›Enoxaparin 1.5 mg/kg subcutaneously once daily for stable patients
›Or enoxaparin 1 mg/kg subcutaneously every 12 hours
›Renal dosing adjustment if CrCl <30 mL/min
›Direct oral anticoagulants (DOACs)
›Rivaroxaban 15 mg twice daily with food for 21 days, then 20 mg daily
›Apixaban 10 mg twice daily for 7 days, then 5 mg twice daily
›Preferred over LMWH-warfarin for most patients
›Class I recommendation from AHA/ESC
›Unfractionated heparin IV for massive PE
›80 units/kg IV bolus then 18 units/kg/hour infusion
›aPTT target 60 to 100 seconds
›Preferred when thrombolysis possible or renal failure
›Systemic thrombolysis for massive PE
›Alteplase 100 mg IV over 2 hours
›Reserved for hemodynamically unstable massive PE
›Absolute contraindications: active bleeding, recent surgery, prior hemorrhagic stroke
›Relative contraindications: recent major surgery, ischemic stroke within 3 months
›Class I recommendation for hemodynamic collapse
›Cardiology consultation prior when feasible
›ICU care mandatory post-thrombolysis
Treatment of pericarditis
›Anti-inflammatory for acute pericarditis
›Ibuprofen 600 mg orally three times daily
›Taper over 4 weeks
›Gastroprotection with PPI
›Colchicine adjunct (Class I recommendation)
›0.5 mg twice daily for weight >70 kg
›0.5 mg once daily for weight <=70 kg
›Duration 3 months for first episode
›Reduces recurrence rate from 37% to 17%
›Aspirin alternative (preferred post-MI pericarditis)
›500 to 1000 mg orally every 8 hours
›Taper over 4 weeks
›Corticosteroids for pericarditis
›Second-line: reserved for NSAID failure or contraindication
›Prednisone 0.25 to 0.5 mg/kg/day
›Slow taper over weeks to months
›Increased recurrence risk with early steroid use
Treatment of pneumothorax
›Spontaneous pneumothorax management
›Small primary spontaneous pneumothorax
›<2 cm rim on CXR in stable patient
›Observation with supplemental oxygen
›Supplemental oxygen accelerates reabsorption
›Large or symptomatic pneumothorax
›Needle aspiration: 14 to 16G catheter at second intercostal space midclavicular line
›Or small-bore chest drain insertion
›ACEP Level B recommendation for aspiration as first-line
›Tension pneumothorax
›Immediate needle decompression before imaging
›14G catheter second ICS midclavicular line or fourth/fifth ICS anterior axillary line
›Followed by definitive chest drain
Antibiotic therapy for pleural infection
›Empiric antibiotics for parapneumonic pleuritis
›Community-acquired pleural infection
›Amoxicillin-clavulanate 875/125 mg orally twice daily for mild
›Ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours for inpatient
›Ampicillin-sulbactam 3 g IV every 6 hours as alternative
›Hospital-acquired or resistant organism risk
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours for MRSA risk
›AUC-guided vancomycin monitoring preferred
›Duration
›3 weeks minimum for pleural infection
›4 to 6 weeks if abscess or empyema
›Chest drain for empyema and complicated effusion
›Indications for drainage
›Frank pus on aspiration
›pH <7.2 or glucose <3.3 mmol/l
›Positive Gram stain or culture
›Intrapleural fibrinolytics for loculated empyema
›Alteplase 10 mg plus DNase 5 mg intrapleurally twice daily for 3 days
›Reduces surgical intervention rate
›Class IIa evidence from MIST-2 trial
Treatment for autoimmune pleuritis
›SLE pleuritis management
›Mild pleuritis
›NSAIDs as first-line
›Hydroxychloroquine 200 to 400 mg daily
›Maintenance disease control
›Moderate to severe pleuritis
›Prednisone 0.5 to 1 mg/kg/day
›Taper once symptomatic improvement achieved
›Immunosuppressive therapy for refractory cases
›RA pleuritis
›NSAIDs for symptomatic relief
›Short-course corticosteroids if significant effusion
›Disease-modifying therapy optimization
›Rheumatology referral
›Methotrexate or biologic agents per rheumatology guidance