Pleuritic pain, dyspnea, tachycardia, hypoxia
ABCDE O₂, IV access, monitoring; empirical anticoagulation if high suspicion; if shocked → resuscitate + thrombolysis pathway.
Calculators: wpe
Low probability → D-dimer to exclude. Otherwise → CT angiogram (V/Q if contrast/renal issue)
High suspicion + delay → start anticoagulation empirically (heparin = LMWH efficacy)
Maintenance: DOAC (apixaban) or warfarin
Massive PE + heart strain / hypotension → thrombolytics
Decision tree Haemodynamically unstable (massive PE)?
Yes Resuscitate + thrombolysis (or embolectomy if lysis contraindicated)
No High clinical probability (Wells)?
No D-dimer → if positive, CTPA; anticoagulate if confirmed
Order set Wells score D-dimer (low pretest) / CTPA ECG, troponin ABG Anticoagulate empirically if high suspicion Escalate / ICU Hypotension / RV strain (massive PE) Needs thrombolysis / embolectomy Refractory hypoxia Criteria Admit Confirmed/high-suspicion PE
ICU Massive PE, RV strain, post-thrombolysis
Vasopressors Obstructive shock (with thrombolysis/embolectomy)
Discharge Stable, anticoagulated, PESI low-risk, follow-up
Clinical detail — differentials, red flags, pitfalls, disposition Red flags Hypotension/RV strain (massive) Syncope Refractory hypoxia Differentials ACS Pneumonia Pericarditis Aortic dissection Common mistakes D-dimer in high pretest probability Delaying anticoagulation Disposition & follow-up Anticoagulate; massive → thrombolysis; risk-stratify (PESI).
Discharge package Medications Anticoagulation (duration per provocation)
Follow-up Anticoagulation review; thrombophilia only if indicated
Warning symptoms Chest pain, breathlessness, leg swelling, bleeding
💊 Treatment detail — doses & preparation Apixaban DOAC (anti-Xa)
Dose 5 mg BD (2.5 mg BD if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥133). PE/DVT: 10 mg BD ×7 d then 5 mg BD
Preparation 2.5/5 mg tablets (crushable)
Monitor Bleeding, renal function; no routine monitoring
Rivaroxaban DOAC (anti-Xa)
Dose PE/DVT: 15 mg BD ×21 d then 20 mg OD with food. AF: 20 mg OD (15 mg if CrCl 15–49)
Preparation 10/15/20 mg tablets; take 15/20 mg with food
Monitor Bleeding, renal function
Enoxaparin LMW heparin
Dose Treatment: 1 mg/kg SC q12h (or 1.5 mg/kg OD). Prophylaxis: 40 mg SC OD
Preparation Pre-filled syringes 20–150 mg; inject SC abdomen, do not expel air bubble
Monitor Anti-Xa if renal failure/pregnancy; platelets (HIT); renal dosing
Alteplase (tPA) thrombolytic
Dose Stroke: 0.9 mg/kg (max 90 mg) — 10% bolus, 90% over 1 h. Massive PE: 100 mg over 2 h (or 50 mg bolus in arrest)
Preparation Reconstitute 50 mg vial with 50 mL sterile water (1 mg/mL); dedicate a line
Monitor BP <185/110 before stroke lysis; neuro exam q15 min ×2 h; no antiplatelets ×24 h
📖 ESC / ACCP VTE Reviewed July 2026