[Major pulmonary embolism]

The diagnosis of major pulmonary embolism should be considered in case of acute respiratory distress, particularly in high thrombo-embolic risk situation. Clinical examination, combined with blood gas analysis, electrocardiogram and chest X-ray are generally suggestive of pulmonary embolism but are not sufficient. In patients with shock, hypotension or after cardiac arrest (massive forms), bedside transthoracic echocardiography is the first choice diagnostic test whereas CT-scan should be considered in less severely ill patients. Troponin dosage and measurement of right upon left ventricular diameter ratio (by echocardiography or CT-scan) are mandatory in the prognostic evaluation of submassive forms (i.e. hemodynamically stable patients with right ventricular dysfunction). Thrombolysis is clearly indicated in patients suffering from massive pulmonary embolism and should be discussed in young patients (less than 70 years), with no identified bleeding risk, suffering from submassive form when troponin rate is increased and/or ventricular diameter ratio is over 0.9. Surgical embolectomy should be considered in case of contraindication or failure of thrombolysis.