Pulmonary embolismMANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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644 items

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01Approach to the Critical Patient/attcp52

Immediate priorities

›Unstable PE resuscitation

›Airway and breathing

›Oxygen target SpO2 92% to 96%

›High flow nasal cannula for persistent hypoxemia

›Noninvasive ventilation caution for RV failure and hypotension

›Intubation trigger refractory hypoxemia or airway protection

›Circulation and shock

›Shock definition SBP <90 mmHg for 15 minutes or vasopressor requirement not due to arrhythmia hypovolemia sepsis

›Large bore IV access x2

›Cardiac monitor and defibrillator pads for peri arrest risk

›Norepinephrine first line vasopressor in PE shock

›Vasopressin adjunct for refractory hypotension

›Dobutamine for low cardiac output with adequate BP

›Fluid bolus small 250 mL increments for preload optimization

›Avoid large volume fluids worsening RV dilation

›Immediate diagnostic and activation

›POCUS for RV dilation and alternative shock etiologies

›If suspected massive PE and no immediate CT access systemic thrombolysis pathway

›Activate PE response team when available

›Early ICU consult for shock or escalating oxygen

Risk stratification and time critical decisions

›Early risk phenotype

›High risk massive

›Persistent hypotension or shock

›Cardiac arrest

›Refractory hypoxemia with impending collapse

›Intermediate risk submassive

›Normotension with RV dysfunction on echo or CT

›Elevated troponin or BNP or NT proBNP

›sPESI or PESI not low risk

›Low risk

›Normotension

›No RV dysfunction

›Negative troponin

›Low risk by sPESI or PESI

›Bleeding risk screen before thrombolysis

›Prior intracranial hemorrhage

›Known intracranial neoplasm or AVM

›Ischemic stroke within 3 months

›Suspected aortic dissection

›Active bleeding or major recent surgery

Key concepts

›Pathophysiology core

›Pulmonary arterial obstruction increases PVR

›RV pressure overload

›RV dilation and septal shift

›Reduced LV preload and cardiogenic shock

›VQ mismatch and dead space ventilation

›Hypoxemia disproportionate to CXR findings

›Respiratory alkalosis early

›Clinical coding alignment

›ICD-10 I26.99 pulmonary embolism without acute cor pulmonale

›ICD-10 I26.02 pulmonary embolism with acute cor pulmonale

›SNOMED CT pulmonary embolism concept

02History/hx53

Presentation patterns and triggers

›Symptom cluster

›Dyspnea

›Sudden onset

›Exertional intolerance

›Pleuritic chest pain

›Worse with inspiration

›Localized lateral pain

›Cough

›Hemoptysis

›Syncope or near syncope

›Suggests high risk PE

›Leg symptoms

›Unilateral swelling

›Calf pain

›Timeline

›Onset time and progression

›Minutes to hours abrupt symptoms

›Days progressive dyspnea

›Recent immobilization

›Long travel within 4 weeks

›Bed rest more than 3 days

Risk factors and provoking conditions

›VTE risk profile

›Prior DVT or PE

›Anticoagulant adherence

›Prior thrombophilia evaluation

›Recent surgery or trauma

›Orthopedic surgery within 12 weeks

›Major surgery within 4 weeks

›Malignancy

›Active treatment

›Metastatic disease

›Estrogen exposure

›Combined oral contraceptives

›Hormone therapy

›Pregnancy and postpartum

›Postpartum within 6 weeks

›Medical illness

›Heart failure

›COPD exacerbation

›Nephrotic syndrome

›Thrombophilia context

›Family history unprovoked VTE

›Recurrent pregnancy loss

›Alternative diagnosis cues

›Fever and sputum suggests pneumonia

›Tearing pain suggests aortic dissection

›Wheeze and triggers suggest asthma

PITFALLS

›Missed PE patterns

›Normal chest x ray with severe dyspnea

›Isolated syncope in older adults

›Mild tachycardia and anxiety appearance

›Atypical epigastric or shoulder pain

›Coexisting pneumonia and PE

03Physical Exam/exam47

Vitals and general appearance

›Hemodynamic and respiratory clues

›Tachycardia

›Persistent HR >100

›New atrial fibrillation

›Tachypnea

›RR >20

›Work of breathing

›Hypoxemia

›SpO2 <90% on room air

›Increasing oxygen requirement

›Hypotension

›SBP <90 mmHg

›Narrow pulse pressure

›Fever

›Low grade possible with PE

›High fever suggests infection

›Shock exam

›Altered mental status

›Confusion

›Somnolence

›Skin perfusion

›Cool clammy extremities

›Delayed capillary refill

Cardiopulmonary and extremities

›Chest exam

›Lung auscultation

›Clear lungs common

›Focal crackles possible with infarct or effusion

›Pleural effusion signs

›Decreased breath sounds at base

›Dullness to percussion

›Cardiac exam

›JVP elevation

›Suggests RV strain

›Right heart findings

›Loud P2

›Tricuspid regurg murmur

›DVT exam

›Unilateral leg swelling

›Calf circumference difference

›Pitting edema

›Tenderness along deep venous system

›Popliteal region tenderness

›Medial thigh tenderness

PITFALLS

›Exam limitations

›Absence of leg findings does not exclude PE

›Clear lungs does not exclude PE

›Normal SpO2 does not exclude small PE

04Differential Diagnosis/ddx38

Life threatening cardiopulmonary causes

›Chest pain and dyspnea emergencies

›Acute coronary syndrome

›ICD-10 I21 acute MI

›ICD-10 I20.0 unstable angina

›Aortic dissection

›ICD-10 I71.0

›Tension pneumothorax

›ICD-10 J93.0

›Cardiac tamponade

›ICD-10 I31.4

›Severe asthma or COPD exacerbation

›ICD-10 J45.901

›ICD-10 J44.1

›Pneumonia with sepsis

›ICD-10 J18.9

›ICD-10 A41.9

Common mimics and distinguishing clues

›Pulmonary and pleural

›Pneumonia

›Fever and consolidation on imaging

›Pleurisy or viral syndrome

›Upper respiratory symptoms

›Pulmonary edema

›Bilateral crackles and B lines

›Cardiac rhythm and failure

›SVT or atrial fibrillation with RVR

›Palpitations predominant

›Acute decompensated heart failure

›Orthopnea and edema

›Anxiety and hyperventilation

›Panic attack

›Paresthesias and carpopedal spasm

›Normal risk profile

›Noncardiopulmonary

›Anemia

›Pallor and low hemoglobin

›Metabolic acidosis

›Kussmaul breathing

›Elevated lactate or ketones

05Laboratory Tests/lt42

Core labs for risk and safety

›Initial lab set

›Complete blood count for anemia and baseline platelets

›Hemoglobin for alternative diagnosis and bleed risk

›Platelets for heparin safety and HIT baseline

›Electrolytes and renal function for anticoagulant choice

›Creatinine for DOAC dosing and contrast planning

›Potassium and magnesium for arrhythmia risk

›Liver tests for DOAC considerations

›Significant hepatic impairment limits DOAC use

›Coagulation tests for baseline and thrombolysis planning

›INR baseline

›aPTT baseline

›Pregnancy test for reproductive age

›Management and imaging pathway changes

Biomarkers and severity markers

›Cardiac injury and RV strain markers

›High sensitivity troponin

›Elevation supports intermediate risk classification

›Normal value supports low risk phenotype

›BNP or NT proBNP

›Elevation supports RV strain and worse prognosis

›Hypoperfusion markers

›Lactate

›Elevated value suggests shock physiology

›Serial trend for resuscitation response

›Blood gas when severe respiratory distress

›Arterial blood gas

›Early respiratory alkalosis common

›Rising PaCO2 suggests fatigue and impending failure

›PaO2 in mmHg for severity tracking

D dimer use constraints

›D dimer principles

›High sensitivity for ruling out PE in low pretest probability

›Negative result supports exclusion when appropriate pathway used

›Poor specificity in hospitalized or older patients

›Positive result does not confirm PE

›Age adjusted threshold for patients over 50 years

›Threshold age times 10 micrograms per liter FEU

›YEARS adjusted approach supported in selected patients

›Higher threshold when no YEARS items

PITFALLS

›Lab interpretation errors

›Normal troponin does not exclude PE

›Elevated troponin may reflect ACS or demand ischemia

›D dimer not appropriate in high pretest probability

06Diagnostic Tests/dt91

Scoring Systems

›Pretest probability and rule out pathways

›Wells criteria for PE

›Clinical signs DVT

›PE most likely diagnosis

›HR >100

›Immobilization or surgery within 4 weeks

›Prior DVT or PE

›Hemoptysis

›Malignancy active

›Interpretation two tier PE unlikely 4 or less

›Interpretation three tier low moderate high

›Revised Geneva score

›Age risk factors and clinical findings weighted

›Interpretation low intermediate high probability

›PERC rule for very low risk patients

›Age under 50

›HR under 100

›SpO2 95% or higher

›No unilateral leg swelling

›No hemoptysis

›No recent surgery or trauma

›No prior DVT or PE

›No estrogen use

›All negative allows no D dimer in low gestalt risk

›YEARS criteria

›Clinical signs DVT

›Hemoptysis

›PE most likely

›D dimer threshold 1000 micrograms per liter FEU when none present

›D dimer threshold 500 micrograms per liter FEU when any present

›Prognosis and disposition tools

›PESI score

›Class I to V mortality risk

›Low class supports outpatient consideration

›sPESI score

›Age over 80

›Cancer

›Chronic cardiopulmonary disease

›HR 110 or higher

›SBP under 100

›SpO2 under 90

›Score 0 low risk

›Hestia criteria for outpatient eligibility

›No need for oxygen to keep SpO2 above threshold

›No high bleeding risk

›No severe pain needing IV opioids

›No medical or social reason for admission

MRI

›MRI pulmonary angiography

›Use cases

›Contrast allergy or radiation avoidance when CT not feasible

›Selected centers with expertise

›Limitations

›Limited availability in ED workflows

›Motion artifact and longer acquisition time

›Less validated than CTPA

›CT pulmonary angiography

›First line imaging in most patients

›High diagnostic accuracy for central and segmental PE

›Alternative diagnoses identification

›Contraindications and cautions

›Severe iodinated contrast allergy

›Renal failure with high risk contrast nephropathy

›Pregnancy with individualized risk benefit

›Interpretation additions

›RV to LV ratio on CT for RV strain

›Clot burden location main lobar segmental subsegmental

›Guideline alignment

›ACEP Level B support for validated pathways combining pretest probability and D dimer to avoid unnecessary imaging

›ACEP Level C caution against D dimer use in high pretest probability

Ultrasound

›Bedside ultrasound applications

›Lower extremity compression ultrasound

›Proximal DVT finding supports VTE diagnosis

›Positive proximal DVT may allow treatment without CTPA in selected unstable patients

›Negative study does not exclude PE

›Cardiac POCUS

›RV dilation and hypokinesis

›Interventricular septal flattening

›McConnell sign low specificity

›TAPSE reduction suggests RV dysfunction

›Pericardial effusion assessment for alternative shock

›Lung ultrasound

›Peripheral wedge shaped pleural based consolidations possible infarct

›Diffuse B lines suggests pulmonary edema alternative

›Formal echocardiography

›RV dysfunction assessment

›RV size and function

›Tricuspid regurg and estimated PA pressure

›Indications

›Shock with suspected PE

›Intermediate risk stratification

›Persistent hypoxemia and unclear diagnosis

07Disposition/dispo44

Level of care and admission decisions

›ICU indications

›Hemodynamic instability

›Vasopressor requirement

›Persistent SBP <90 mmHg

›Escalating respiratory support

›High flow nasal cannula

›Noninvasive ventilation

›Mechanical ventilation

›Planned thrombolysis or thrombectomy

›Systemic thrombolysis monitoring

›Catheter directed therapy monitoring

›Significant RV dysfunction

›Echo RV failure with elevated biomarkers

›Stepdown or telemetry indications

›Intermediate risk PE

›RV dysfunction with normotension

›Positive troponin or BNP

›New arrhythmia

›Atrial fibrillation

Outpatient management pathway

›Discharge eligibility

›Low risk by sPESI 0 or PESI low class

›No RV dysfunction

›Negative troponin

›Hestia criteria met

›No active bleeding or high bleed risk

›Creatinine allows chosen anticoagulant

›Reliable follow up within 24 to 72 hours

›Adequate home support and ability to obtain medication

›Discharge process requirements

›First anticoagulant dose in ED when feasible

›Documented plan for next dose timing

›Clear return precautions and medication education

›Bleeding symptoms

›Recurrent dyspnea or syncope

›Follow up coordination

›Primary care or thrombosis clinic

›Evaluation for provoking factors and cancer screening when appropriate

Transfer criteria

›Advanced therapy capability need

›Catheter directed thrombolysis availability

›Persistent shock or deterioration

›Surgical embolectomy availability

›Contraindication to thrombolysis with massive PE

›ECMO capability

›Refractory arrest or shock despite maximal therapy

08Treatment/t151

Supportive and monitoring

›Initial supportive care

›Oxygen and ventilation

›Nasal cannula titration to target SpO2

›High flow nasal cannula for severe hypoxemia

›Avoid excessive PEEP in RV failure if intubated

›Hemodynamics

›Norepinephrine infusion for hypotension

›Fluid bolus 250 mL crystalloid reassess after each bolus

›Consider dobutamine for low output with stable BP

›Analgesia

›Acetaminophen for pleuritic pain

›Opioid small doses for severe pain with respiratory caution

›Monitoring

›Continuous pulse oximetry

›Cardiac telemetry

›Serial vitals and mental status

›Repeat lactate for shock response

Anticoagulation

›Anticoagulation strategy

›Start immediately when PE strongly suspected and bleeding risk acceptable

›Do not delay for imaging in high clinical suspicion with acceptable bleed risk

›Unfractionated heparin preferred in high risk or planned procedures

›Rapid titration and short half life

›Reversal with protamine available

›Low molecular weight heparin preferred in stable patients and cancer

›Predictable dosing

›Lower HIT risk

›DOAC preferred for many low risk and intermediate risk stable patients

›No bridging required for apixaban or rivaroxaban

›Avoid in pregnancy and certain severe renal or hepatic disease

›Unfractionated heparin IV

›Bolus and infusion dosing

›Bolus 80 units per kg IV

›Omit bolus if high bleeding risk

›Infusion 18 units per kg per hour IV

›aPTT titration per institutional protocol

›Anti Xa monitoring alternative where used

›Monitoring and complications

›Platelets every 2 to 3 days for HIT risk during days 4 to 14

›Major bleeding surveillance

›Enoxaparin

›Standard dosing

›1 mg per kg SC every 12 hours

›Use actual body weight dosing

›Alternative once daily 1.5 mg per kg SC daily in selected patients

›Renal impairment

›If CrCl <30 mL per minute 1 mg per kg SC daily

›Obesity considerations

›Consider anti Xa monitoring in extremes of weight per local protocol

›Fondaparinux

›Weight based dosing

›Under 50 kg 5 mg SC daily

›50 to 100 kg 7.5 mg SC daily

›Over 100 kg 10 mg SC daily

›Renal contraindication

›Avoid if CrCl <30 mL per minute

›Apixaban

›Acute VTE dosing

›10 mg PO twice daily for 7 days

›Then 5 mg PO twice daily

›Extended therapy option after 6 months 2.5 mg PO twice daily in selected patients

›Contraindications and cautions

›Avoid in pregnancy

›Caution severe hepatic disease

›Rivaroxaban

›Acute VTE dosing

›15 mg PO twice daily for 21 days

›Then 20 mg PO daily with food

›Extended therapy option 10 mg PO daily in selected patients

›Contraindications and cautions

›Avoid in pregnancy

›Caution significant renal impairment

›Dabigatran and edoxaban

›Parenteral lead in requirement

›5 to 10 days of heparin or LMWH before starting

›Dabigatran dosing

›150 mg PO twice daily after parenteral lead in

›Edoxaban dosing

›60 mg PO daily after parenteral lead in

›30 mg PO daily if CrCl 15 to 50 mL per minute or weight 60 kg or less

›Warfarin

›Indications

›Mechanical heart valve

›Antiphospholipid syndrome high risk profile

›Severe renal failure limiting DOAC

›Bridging

›Overlap with heparin or LMWH for at least 5 days

›INR therapeutic 2.0 to 3.0 for 24 hours before stopping bridge

Reperfusion and advanced therapies

›Systemic thrombolysis

›Indication

›Massive PE with shock or cardiac arrest and no absolute contraindication

›Alteplase regimen

›100 mg IV over 2 hours

›Consider heparin management per institutional protocol

›Cardiac arrest alternative regimen

›50 mg IV bolus may be used in some protocols

›Contraindications

›Prior intracranial hemorrhage

›Known intracranial structural lesion

›Ischemic stroke within 3 months

›Suspected aortic dissection

›Active bleeding

›Evidence level framing

›Class I recommendation for thrombolysis in high risk PE with shock in major society guidelines

›Class IIb consideration in selected deteriorating intermediate risk with low bleeding risk

›Catheter directed therapy

›Indications

›Massive PE with high bleeding risk for systemic thrombolysis

›Intermediate high risk with clinical deterioration

›Approaches

›Catheter directed thrombolysis lower dose alteplase per local protocol

›Mechanical thrombectomy devices when available

›Monitoring

›ICU or procedural recovery setting

›Access site bleeding surveillance

›Surgical embolectomy

›Indications

›Massive PE with contraindication to thrombolysis

›Failed thrombolysis with persistent shock

›Requirements

›Cardiothoracic surgery availability

›Immediate transfer if candidate

›ECMO

›Indications

›Refractory cardiogenic shock

›Cardiac arrest as bridge to reperfusion therapy

›Care context

›Specialized center management

IVC filter

›IVC filter considerations

›Indication

›Acute VTE with absolute contraindication to anticoagulation

›Not routine use

›No benefit in most anticoagulated patients

›Retrieval plan

›Document timeline for removal when anticoagulation feasible

Duration and etiology guided therapy

›Treatment duration framework

›Provoked PE transient risk factor

›Minimum 3 months anticoagulation

›Unprovoked PE

›Consider extended therapy based on bleeding risk and patient values

›Active cancer associated PE

›Extended therapy while cancer active or treatment ongoing

›Recurrent VTE

›Indefinite therapy consideration

›Etiology evaluation

›Transient provoking factors documentation

›Surgery immobility estrogen travel

›Cancer screening age appropriate

›Focused evaluation for concerning symptoms

›Thrombophilia testing

›Avoid during acute event and while on anticoagulants

›Consider hematology referral for unprovoked young age or strong family history

09Special Populations/sp42

Pregnancy

›Pregnancy and postpartum management

›Diagnostic pathway modifications

›Pregnancy adapted clinical probability tools where used

›D dimer limitations with rising baseline during pregnancy

›Compression ultrasound first line if leg symptoms

›VQ scan or CTPA based on local expertise and radiation considerations

›Anticoagulation

›LMWH first line

›Enoxaparin 1 mg per kg SC every 12 hours

›Anti Xa monitoring consideration in extremes of weight or renal disease

›Avoid DOAC

›Placental transfer concerns and limited safety data

›Warfarin avoidance during pregnancy

›Teratogenic risk especially first trimester

›Thrombolysis and massive PE

›Life saving use may be considered for maternal shock

›Multidisciplinary obstetrics anesthesia ICU involvement

Geriatric

›Older adult considerations

›Presentation differences

›Syncope and delirium more common

›Baseline dyspnea confounds symptoms

›D dimer strategy

›Age adjusted threshold improves specificity

›Anticoagulation risks

›Higher bleeding risk assessment

›Renal dosing adjustments for DOAC and LMWH

›Disposition

›Lower threshold for admission due to comorbidity and social supports

Pediatrics

›Pediatric PE

›Risk factors

›Central venous catheter

›Congenital heart disease

›Cancer

›Thrombophilia

›Diagnostics

›Pediatric adapted imaging with radiation minimization

›D dimer performance less established

›Anticoagulation

›Weight based heparin or LMWH per pediatric protocol

›Hematology consultation recommended

›Disposition

›Admission typical for monitoring and etiologic evaluation

10Background/b34

Epidemiology

›Population burden

›VTE includes DVT and PE

›PE accounts for significant cardiovascular mortality

›Provoked versus unprovoked distribution

›Many events associated with transient risk factors

›Recurrence risk

›Highest in first weeks to months after event

Pathophysiology

›Thrombus formation and embolization

›Venous stasis hypercoagulability endothelial injury triad

›Surgery and immobility drive stasis

›Cancer and estrogen drive hypercoagulability

›Embolus lodging in pulmonary arteries

›Mechanical obstruction

›Vasoconstriction mediated by hypoxia and mediators

›RV failure cascade

›Increased RV afterload

›RV dilation and ischemia

›Reduced LV filling

›Cardiogenic shock and arrest

Therapeutic Considerations

›Anticoagulation rationale

›Prevent clot propagation and new emboli

›Does not immediately dissolve existing clot

›Endogenous fibrinolysis over time

›Symptom improvement over days to weeks

›Reperfusion rationale

›Rapid reduction in obstruction and RV afterload

›Thrombolysis risk bleeding tradeoff

›Catheter and surgical options for selected patients

›Alternative when thrombolysis contraindicated

›Guideline concept framing

›Class I anticoagulation for confirmed PE without contraindication

›Class I reperfusion for high risk PE with shock when eligible

›Class IIa catheter based reperfusion when thrombolysis contraindicated or fails in experienced centers

›Class IIb rescue thrombolysis in deteriorating intermediate risk with low bleeding risk

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Pulmonary embolism discharge instructions

›Diagnosis explanation

›Blood clot in lung blood vessels

›Treated with blood thinner medication

›Anticoagulant instructions

›Take exactly as prescribed

›Do not skip doses

›Do not double dose if a dose is missed unless instructed

›New medication and supplement check with clinician or pharmacist

›Bleeding precautions

›Avoid high injury risk activities

›Soft toothbrush and electric razor

›Watch for black stools red urine vomiting blood severe bruising

›Return to ED now

›Trouble breathing worsening

›Chest pain new or worsening

›Fainting or near fainting

›Coughing blood

›Severe headache weakness vision or speech change

›Uncontrolled bleeding

›Follow up plan

›Appointment within 24 to 72 hours if outpatient start

›Clot clinic or primary care follow up within 1 week

›Discuss duration of anticoagulation and provoking factors

›Lifestyle and prevention

›Keep moving avoid prolonged immobility

›Hydration during travel

›Compression stockings use only if advised

12References/r22

Guidelines and evidence sources

›Core guidelines

›European Society of Cardiology guideline on acute pulmonary embolism latest edition

›Risk stratification using PESI or sPESI and RV biomarkers

›Reperfusion for high risk PE with shock

›American College of Chest Physicians antithrombotic therapy guideline for VTE latest edition

›DOAC preferred over warfarin in many noncancer patients

›Treatment duration framework provoked versus unprovoked

›American Heart Association scientific statement on PE management

›Definitions massive submassive low risk

›Role of catheter based therapies and PERT models

›ACEP clinical policy on suspected VTE in ED

›Pretest probability plus D dimer pathways to reduce imaging

›PERC use in low risk patients

›Decision tools and validation

›Wells score original derivation and validation studies

›Pretest probability stratification for PE

›PERC derivation and validation studies

›Very low risk exclusion without testing

›YEARS studies

›Reduced imaging with adjusted D dimer thresholds

›PESI and sPESI validation

›Mortality risk prediction and outpatient selection

Learn More: Pulmonary embolism→

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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