Which step is appropriate for suspected massive PE with shock?

• A. Anticoagulation alone
• B. Observation
• C. Emergent systemic thrombolysis or embolectomy
• D. Treat with diuretics

Answer: (C)

When a massive pulmonary embolism causes shock, the body’s forward blood flow is acutely compromised by a large clot blocking the pulmonary arteries, leading to rapid right‑sided strain and systemic hypoperfusion. The priority is rapid reperfusion to dissolve or remove the clot and restore circulation, which is best achieved with emergent systemic thrombolysis; if thrombolysis is not possible or fails, emergent surgical or catheter‑directed embolectomy is pursued. Anticoagulation alone won’t resolve the obstruction quickly enough to reverse shock, and observation or diuretics don’t address the underlying clot and can worsen the situation. Reperfusion therapy, used promptly, offers the best chance to rapidly improve hemodynamics and survival in this scenario, keeping in mind bleeding risks and any contraindications.