A 35-year-old woman with no significant medical history is evaluated in the emergency department after collapsing（晕倒） while shopping. Shortly after initial assessment, she loses pulses and requires cardiopulmonary resuscitation (CPR). CPR is continued and, after 1 mg epinephrine and endotracheal intubation, she has return of spontaneous circulation. She is stable for 5 minutes and then has another cardiac arrest, responding again to CPR and 1 mg of epinephrine. Her vital signs are: blood pressure 88/52 mm Hg, heart rate 115 beats/min, temperature 37.3°C (99.1°F), and respiratory rate 14 breaths/min. Emergency medical personnel report that, while on the scene, the patient’s friend said that they had just returned from a trip to South America and had partaken of illicit（不正当） drug use there. The clinician performs a quick bedside echocardiogram, which shows moderate right ventricular hypokinesis（运动减退） and dilation with end-diastolic diameter 32 mm in parasternal view（胸骨旁）.
Which of the following is the most appropriate next step in management?
A. Emergent chemistry panel with creatinine level
B. Emergent chest CT with angiography
C. Heparin weight-based bolus followed by continuous infusion
D. Alteplase, 10 mg IV bolus, followed by 90 mg over 2 hours
E. Emergent ventilation/perfusion scan
答案解析：
这种表现最符合大面积肺栓塞(PE)。出现PE的患者具有广泛的临床严重程度。虽然一些患者有明显的血流动力学崩溃和心脏骤停，但其他患者在另一种疾病检查期间偶然发现无症状PE。当患者出现疑似急性PE时，初始复苏治疗应侧重于氧合和稳定。有多种程度的治疗；治疗计划应相对于就诊情况为患者量身定制。复苏治疗范围从辅助供氧到呼吸机支持、血流动力学支持、抗凝和/或纤维蛋白溶解。纤维蛋白溶解剂在急性PE中的应用仍然是一个有争议的话题。大多数人同意心脏骤停和血流动力学不稳定伴收缩压低于90 mmHg是溶栓的指征。随着床旁超声检查的使用增加，现在有一种辅助诊断，也可能决定治疗。如果患者血流动力学不稳定，超声心动图显示右心扩张和功能障碍，一旦排除绝对禁忌症，下一步应该是溶栓治疗。关于超声心动图显示右心室功能不全的稳定患者的适当治疗仍存在争议。该患者已经发生了两次心脏骤停，并且对于证实性CT太不稳定；因此需要开始溶栓治疗。
正确答案：D
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