Unexpected bilateral massive pulmonary embolism

A 59-year-old woman with a past history of rheumatoid arthritis arrived in our Emergency Department via ambulance. Her husband stated she had suddenly "appeared very strange" whilst preparing to go out for the afternoon, but could not identify specific symptoms. Physical examination showed her to have sinus tachycardia and tachypnea, but little else of note. Her oxygen saturations however rapidly dropped when she was taken off high-flow oxygen. Her D-dimer assay was markedly elevated, and urgent computed tomographic pulmonary angiography (CTPA) was performed (Figures 1 and 2). This showed large emboli (black arrows) in both the left (Figure 1) and right (Figure 2) pulmonary arteries (white arrows), with a saddle embolus noted on the right. Following the CTPA, she developed signs and symptoms of obstructive shock, requiring urgent thrombolysis using tenectaplase and admission to the intensive care unit. Her hospital stay was complicated by a lower respiratory tract infection, but she was discharged 17 days after her admission.