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IBSC Massive Pulmonary Embolism Scenario

FOAMfrat is excited to partner with the International Board of Specialty Certifications (IBSC) to release the final social media scenario for 2023. These scenarios aim to spark conversation and encourage providers to dig deeper into critical care topics.

I copied and pasted the storyboard and notes below as we crafted each shot. This will help freezeframe some pertinent moments to help facilitate discussion.

Our scenario starts with an elderly woman driving her husband to the hospital during a snowstorm. The husband is in obvious respiratory distress and hunched over in the vehicle, as shown in the picture below. 

There are some subtle hints that the couple has just returned from vacation. For example, the bobblehead flamingo on the dash and the parking garage receipt are seen on the vehicle floor in the beginning sequence. 

The next shot is them pulling into the emergency entrance of the hospital.


The following sequence includes him being wheeled to a room while a nurse asks how long his shortness of breath has been going on.

The physician will now report that the patient has a massive pulmonary embolism and needs transport “immediately!” I purposely do not give them a ton of lab values here. The report is vague because I want the discussion to include decisions without a solid history and the presence of crashing hemodynamics.

The camera will now pan to the various diagnostic equipment within the patient room. 


BP 50/34      HR 53 (Sinus Brady)         SPO2 86%        ETCO2 24


The patient is intubated, on a mechanical ventilator, and has heparin and levophed currently being infused at the rates shown in the illustration below.



Ventilator settings 


Pinsp 15 cmH2O

PEEP 5 cmH2O

Vte 720 ml

F 18.0

FiO2 100%

The discussion is aimed to be centered on the following topics:

  • Why is this patient bradycardic instead of tachycardic?

  • Should we titrate up the levophed, add another pressor, or both?

  • What ventilator adjustments should be made?

  • Should we start tPA? 

  • Can tPA and Heparin both run at the same time?

  • Is there a role for inhaled pulmonary vasodilators in this patient?

  • What destination capabilities should we consider?

In this episode, Brian King & Shane O'Donnell,l from the FOAMfrat team, join me to discuss several decision points you may encounter.

  1. Risk Stratification & Preparation

  2. Blood Pressure management

  3. Fibrinolytics & Heparin

  4. Ventilator Considerations

  5. Inhaled Pulmonary Vasodilators

Now check out this podcast I did with Shane & Brian discussing the scenario.


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