Clinical Practice and Cases in Emergency Medicine

Introduction: High-risk pulmonary embolism (PE) is an uncommon but potentially reversible cause of out-of-hospital cardiac arrest, frequently presenting as pulseless electrical activity (PEA). Early identification and multidisciplinary intervention are critical, yet confirmatory imaging is often delayed. Current guidelines recommend consideration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in specialized centers when high-risk PE is suspected and the patient presents with cardiogenic shock or cardiac arrest. 

Case Report: We describe a 50-year-old woman with a remote history of deep vein thrombosis who arrested after acute-onset dyspnea. Emergency medical services documented PEA arrest and initiated advanced cardiac life support. On arrival to the emergency department (ED), the patient remained in PEA arrest without cardiac motion on point-of-care ultrasound. Pulmonary embolism was strongly suspected but could not be confirmed, and VA-ECMO was initiated within 42 minutes of arrest. Pulmonary angiography confirmed massive bilateral PE, followed by mechanical thrombectomy using a catheter-directed device. Extracorporeal membrane oxygenation support continued for four days before successful decannulation, and the patient was discharged on hospital day 17 to a rehabilitation facility with a Cerebral Performance Category score 1, indicating excellent neurological function. 

Conclusion: This case illustrates the potential for favorable neurologic and functional outcomes in cardiac arrest associated with high-risk PE when VA-ECMO is implemented early as a bridge to definitive therapy. In resource-rich settings, rapid ED-based activation of extracorporeal cardiopulmonary resuscitation protocols and access to catheter-directed thrombectomy may represent an optimal strategy for improving survival and neurologic recovery in patients with PEA arrest that may be related to high-risk PE.