Approach to critical patient
›First 5 minutes workflow
›Continuous monitoring
›Two large bore IV access
›Oxygen to target SpO2 at least 92 percent
›If shock, vasopressor support
›Early bedside echo when unstable
›Testing pathway
›If low risk and PERC negative, no further PE testing
›If low or intermediate risk, D dimer strategy
›If D dimer positive, imaging
›If high risk, direct imaging
Anticoagulation and reperfusion
›Anticoagulation initiation
›If high suspicion and imaging delayed with acceptable bleeding risk, initiate anticoagulation
›If active bleeding or major contraindication, hold anticoagulation and escalate for alternatives
›UFH infusion when high risk or procedures anticipated
›Bolus dosing local protocol dependent
›Infusion titration to aPTT or anti Xa target local protocol dependent
›LMWH example dosing when appropriate
›Enoxaparin 1 mg per kg subcut every 12 hours
›Avoid in severe renal impairment without adjustment
›DOAC initiation when appropriate and stable
›Apixaban 10 mg PO twice daily for 7 days
›Then apixaban 5 mg PO twice daily
›Thrombolysis for massive PE
›Alteplase 100 mg IV over 2 hours for selected patients
›Consider reduced dose protocols local protocol dependent
›Catheter directed therapy and thrombectomy
›Consider when massive PE with thrombolysis contraindicated
›Consider when submassive PE with deterioration despite anticoagulation
Supportive care and monitoring
›Respiratory support
›High flow nasal cannula when escalating oxygen needs
›Intubation risk of hemodynamic collapse in massive PE
›Hemodynamic support
›Norepinephrine first line vasopressor in shock
›Avoid excessive fluid boluses
›Reassessment triggers and timing
›Repeat vitals every 15 to 30 minutes when unstable
›Repeat oxygen requirement trend
›Repeat bedside echo if deterioration
›Escalate if rising lactate or worsening hypotension