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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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.