Section 1
The 60-Second Resuscitation Card (First 5 Minutes)
0:00
Immediate Bedside Action
High-Flow Oxygenation & Strictly Avoid Positive-Pressure Intubation
Exact Dosing, Equipment & Mixing
Apply HFNC (40–60 L/min, FiO₂ 1.0) or Non-Rebreather Mask (15 L/min) to target SpO₂ ≥ 94%.
Establish two 18G peripheral IVs.
Avoid RSI/Intubation unless apneic or in cardiac arrest.
Establish two 18G peripheral IVs.
Avoid RSI/Intubation unless apneic or in cardiac arrest.
Physiological & Mechanical Objective
Reverses hypoxic pulmonary vasoconstriction (HPV), acutely lowering Pulmonary Vascular Resistance (PVR) and right ventricular (RV) afterload without increasing intrathoracic pressure.
Ref
[1]
0:30
Immediate Bedside Action
Multi-Organ POCUS (RUSH / Cardiac / Compression US) & 12-Lead ECG
Exact Dosing, Equipment & Mixing
Phased-array probe (2–5 MHz) for Apical 4-Chamber / Parasternal Short-Axis views + High-frequency linear probe (5–10 MHz) for 2-point femoral/popliteal DVT compression.
Physiological & Mechanical Objective
Identifies acute RV pressure overload (RV:LV ratio > 1.0, McConnell sign, septal flattening/"D-sign", distended IVC > 2.1 cm). Finding a proximal DVT in a crashing patient confirms massive PE at the bedside (100% specificity for treatment initiation) when unstable for CTPA.
Ref
[1,2]
1:30
Immediate Bedside Action
Hemodynamic Stabilization: Micro-Fluid Challenge vs. Early Norepinephrine
Exact Dosing, Equipment & Mixing
If Hypotensive (SBP < 90 mmHg) & IVC Collapsible: Give strictly ≤ 250–500 mL balanced crystalloid over 15 min (ZERO fluids if IVC is plethoric/non-collapsing).
First-Line Vasopressor: Norepinephrine 0.05–0.5 mcg/kg/min (2–30 mcg/min) IV to target MAP ≥ 65–75 mmHg.
Add Inotrope if Low CO persists: Dobutamine 2–10 mcg/kg/min IV.
First-Line Vasopressor: Norepinephrine 0.05–0.5 mcg/kg/min (2–30 mcg/min) IV to target MAP ≥ 65–75 mmHg.
Add Inotrope if Low CO persists: Dobutamine 2–10 mcg/kg/min IV.
Physiological & Mechanical Objective
Prevents fatal RV overdistension and leftward interventricular septal shift (which crushes LV preload). Norepinephrine increases systemic aortic root diastolic pressure (↑ RCA perfusion gradient to the ischemic RV) while providing β-mediated RV inotropy.
Ref
[1]
3:00
Immediate Bedside Action
Immediate Parenteral Anticoagulation
Exact Dosing, Equipment & Mixing
Massive (High-Risk) / Thrombolysis Candidate: Unfractionated Heparin (UFH) 80 units/kg IV bolus (Max 5,000–10,000 units), followed by 18 units/kg/hr infusion.
Submassive (Intermediate-Risk) / Stable (CrCl ≥ 30 mL/min): Enoxaparin (LMWH) 1 mg/kg SC q12h.
Submassive (Intermediate-Risk) / Stable (CrCl ≥ 30 mL/min): Enoxaparin (LMWH) 1 mg/kg SC q12h.
Physiological & Mechanical Objective
Accelerates Antithrombin III (AT-III) activity by 1,000-fold to immediately halt thrombin (Factor IIa) and Factor Xa propagation on the saddle/mainstem thrombus, allowing endogenous plasminogen to begin fibrinolysis.
Ref
[1]
5:00
Immediate Bedside Action
Systemic Thrombolysis & PERT / VA-ECMO Activation
Exact Dosing, Equipment & Mixing
Massive PE (Shock SBP < 90 mmHg): Alteplase (tPA) 100 mg IV over 2 hours (or 10 mg IV bolus + 90 mg over 2 hr; Half-Dose 50 mg if < 65 kg).
Cardiac Arrest (PEA): Alteplase 50 mg IV bolus over 1–2 min (repeat 50 mg in 15 min if no ROSC) or Tenecteplase (TNK) 0.5 mg/kg IV push (Max 50 mg); continue CPR for 60–90 min. Activate PERT & VA-ECMO.
Cardiac Arrest (PEA): Alteplase 50 mg IV bolus over 1–2 min (repeat 50 mg in 15 min if no ROSC) or Tenecteplase (TNK) 0.5 mg/kg IV push (Max 50 mg); continue CPR for 60–90 min. Activate PERT & VA-ECMO.
Physiological & Mechanical Objective
Converts fibrin-bound plasminogen into plasmin, cleaving cross-linked fibrin meshes within the pulmonary arterial tree to rapidly drop PVR, unload the RV, and restore left atrial filling.
Ref
[1,3,4]
| Time | Immediate Bedside Action | Exact Dosing, Equipment & Mixing | Physiological & Mechanical Objective | Ref |
|---|---|---|---|---|
| 0:00 | High-Flow Oxygenation & Strictly Avoid Positive-Pressure Intubation | Apply HFNC (40–60 L/min, FiO₂ 1.0) or Non-Rebreather Mask (15 L/min) to target SpO₂ ≥ 94%. Establish two 18G peripheral IVs. Avoid RSI/Intubation unless apneic or in cardiac arrest. | Reverses hypoxic pulmonary vasoconstriction (HPV), acutely lowering Pulmonary Vascular Resistance (PVR) and right ventricular (RV) afterload without increasing intrathoracic pressure. | [1] |
| 0:30 | Multi-Organ POCUS (RUSH / Cardiac / Compression US) & 12-Lead ECG | Phased-array probe (2–5 MHz) for Apical 4-Chamber / Parasternal Short-Axis views + High-frequency linear probe (5–10 MHz) for 2-point femoral/popliteal DVT compression. | Identifies acute RV pressure overload (RV:LV ratio > 1.0, McConnell sign, septal flattening/"D-sign", distended IVC > 2.1 cm). Finding a proximal DVT in a crashing patient confirms massive PE at the bedside (100% specificity for treatment initiation) when unstable for CTPA. | [1,2] |
| 1:30 | Hemodynamic Stabilization: Micro-Fluid Challenge vs. Early Norepinephrine | If Hypotensive (SBP < 90 mmHg) & IVC Collapsible: Give strictly ≤ 250–500 mL balanced crystalloid over 15 min (ZERO fluids if IVC is plethoric/non-collapsing). First-Line Vasopressor: Norepinephrine 0.05–0.5 mcg/kg/min (2–30 mcg/min) IV to target MAP ≥ 65–75 mmHg. Add Inotrope if Low CO persists: Dobutamine 2–10 mcg/kg/min IV. | Prevents fatal RV overdistension and leftward interventricular septal shift (which crushes LV preload). Norepinephrine increases systemic aortic root diastolic pressure (↑ RCA perfusion gradient to the ischemic RV) while providing β-mediated RV inotropy. | [1] |
| 3:00 | Immediate Parenteral Anticoagulation | Massive (High-Risk) / Thrombolysis Candidate: Unfractionated Heparin (UFH) 80 units/kg IV bolus (Max 5,000–10,000 units), followed by 18 units/kg/hr infusion. Submassive (Intermediate-Risk) / Stable (CrCl ≥ 30 mL/min): Enoxaparin (LMWH) 1 mg/kg SC q12h. | Accelerates Antithrombin III (AT-III) activity by 1,000-fold to immediately halt thrombin (Factor IIa) and Factor Xa propagation on the saddle/mainstem thrombus, allowing endogenous plasminogen to begin fibrinolysis. | [1] |
| 5:00 | Systemic Thrombolysis & PERT / VA-ECMO Activation | Massive PE (Shock SBP < 90 mmHg): Alteplase (tPA) 100 mg IV over 2 hours (or 10 mg IV bolus + 90 mg over 2 hr; Half-Dose 50 mg if < 65 kg). Cardiac Arrest (PEA): Alteplase 50 mg IV bolus over 1–2 min (repeat 50 mg in 15 min if no ROSC) or Tenecteplase (TNK) 0.5 mg/kg IV push (Max 50 mg); continue CPR for 60–90 min. Activate PERT & VA-ECMO. | Converts fibrin-bound plasminogen into plasmin, cleaving cross-linked fibrin meshes within the pulmonary arterial tree to rapidly drop PVR, unload the RV, and restore left atrial filling. | [1,3,4] |
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