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Acute pulmonary embolus with visible right heart thrombus in transit

A 29-year-old woman presented to our emergency department with syncope, acute chest pain and circulatory collapse. She had a tachycardia of 135 bpm, blood pressure of 77/55 mm Hg and a profound metabolic acidosis (pH 7.07, lactate 10, base excess-20). A 12-lead ECG (figure 1) showed sinus tachycardia with right axis deviation, large p waves and poor R wave progression across the chest leads, suggestive of acute right heart strain. …