This patient has developed shock related to PE, and thrombolytic therapy, such as alteplase, is often recommended in the absence of known contraindications. There is insufficient evidence to recommend any specific thrombolytic therapy over another. Dopamine is a vasoconstricting agent that may help to augment mean arterial blood pressure, but it does not offer an advantage over norepinephrine, which this patient is already receiving. Tirofiban is an antiplatelet glycoprotein IIb/IIIa inhibitor indicated in the treatment of acute coronary syndrome; it has no role in treating venous thromboembolic disease. Warfarin and argatroban are acceptable alternatives to heparin for treating thromboembolic disease but are no more effective than heparin and are not indicated for massive PE.
- IV alteplase 100 mg over 2 hours.
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