Medical

Massive PE / RV failure

Before / During / After / Pitfalls

Before

• Intubation can precipitate collapse; optimize RV preload/afterload strategy and call critical care early.
• Use oxygenation/vasopressor/inotrope strategy per local protocol; keep peri-arrest rescue plan ready.
• Avoid hypoxia, hypercarbia, and acidosis when possible; they worsen pulmonary vascular resistance.

During

• Gentle transition to PPV; avoid excessive PEEP and high intrathoracic pressure.
• Have pressors running/ready and resuscitation team prepared.
• Consider thrombolysis/embolectomy pathway depending on context.

After

• Reassess RV shock, EtCO2, MAP, lactate/perfusion.
• Use ventilator settings that protect RV physiology.
• Continue definitive PE/RV failure management.

Pitfalls

• Treating as a routine hypoxic airway.
• High PEEP/pressures worsening RV output.
• Underestimating peri-intubation arrest risk.