Rethinking Prehospital Fluid Resuscitation for Massive Pulmonary Embolism A Narrative Literature Review
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Abstract
Background: Massive pulmonary embolism (PE) is characterized by sustained hypotension and right ventricular (RV) dysfunction, resulting in high morbidity and mortality. Although these patients present hemodynamically unstable, hypotension arises from obstructive shock rather than hypovolemia. Despite this, fluid resuscitation (FR) remains common in prehospital care, and its role in massive PE remains controversial.
Objective: This review aimed to evaluate the efficacy of FR in adult patients with massive PE, with consideration of its implications for prehospital care.
Methods: A narrative literature review was conducted in April 2026 using Ovid MEDLINE and EMBASE (1950–April 2026). Due to the paucity of prehospital data, both human and animal studies examining any form of fluid therapy in massive PE were included. Non–peer-reviewed literature, unrelated conditions, and systematic reviews were excluded. Nine peer-reviewed studies met inclusion criteria.
Results: Fluid administration in massive PE was associated with worsened RV dysfunction, reduced cardiac output (CO), and increased hemodynamic instability. In contrast, alternative interventions, including positive inotropes and diuretic therapy (DT), were associated with improved RV function, stroke volume (SV), and hemodynamic stability.
Conclusion: The available evidence, although derived largely from animal, retrospective, and hospital-based studies, suggests routine FR in hypotensive patients with massive PE may exacerbate RV failure and compromise CO. Prehospital management should therefore consider strategies that support RV function and hemodynamic stability. These findings support reconsideration of FR as a primary intervention in massive PE and highlight the need for evidence-informed prehospital guidelines.
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