Massive PE – Initial resuscitation Fluid - conservative strategy Rarely helpful (venous pressure generally already excessively high) Don’t give fluid unless evidence of low filling pressure (e.g. small IVC or collapsed jugular veins) Pressor - aggressive strategy Epinephrine good front - line agent, titrate for MAP > 65 mm Vasopressin as second - line agent Inhaled pulmonary vasodilators Epoprostanol or nitric oxide – whatever you can get fastest. If refractory may consider combination of nitric oxide plus epoprostanol. Thrombolysis No contraindication: 100 mg alteplase. Relative contraindication & actively dying: 100 mg alteplase. Relative contraindication & stabilized: may start with 50 mg alteplase. Other PE - directed therapies (tPA failure/contraindication) Interventional radiology clot extraction (e.g. FlowTriever) Cardiothoracic surgical extraction VA ECMO - Internet Book of Critical Care, by @PulmCrit