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Pulmonary embolism (PE) is a common diagnosis with a low associated mortality rate. More critical variants, such as massive PE, also known as fulminant PE, are characterized by severe hemodynamic instability and have a markedly higher mortality rate. These variants can later develop in previously low to intermediate-risk patients and precipitate cardiac arrest within hours of symptom onset. The high mortality rate associated with massive PE is confounded by the difficulty in identifying patients most at risk of decompensating and a lack of clear treatment guidelines. We present the case of a patient at low to intermediate-high risk upon admission, and after failing systemic thrombolysis, decompensated, and went into cardiac arrest. This article serves to reinforce the need to closely monitor these patients due to the insufficiency of prognostic scores to predict decompensation and highlights the need for further research. We advocate the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as means of stabilization and will discuss various therapeutic alternatives.

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