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Pulmonary · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Day 6 after knee replacement: sudden pleuritic chest pain and breathlessness; HR 118, BP 104/70, SpO₂ 90%; right calf swollen
Red flags Hypotension or syncope RV dilatation on echo/CT + troponin rise SpO₂ <90% on O₂ Cardiac arrest Differential diagnosis Acute coronary syndrome Pneumonia Pericarditis Aortic dissection Pneumothorax When to admit, call ICU or discharge Admit: Confirmed PE except sPESI 0 with home supportICU: High-risk (shock/arrest) or intermediate-high with deterioration, post-thrombolysisVasopressors: Obstructive shock — noradrenaline, with reperfusionKey points Most PE is treated with anticoagulation alone; lysis is for shock. Low-risk PE (sPESI 0/Hestia negative) can go home within 24 h on a DOAC. Unprovoked PE: limited cancer screening only. Never Use D-dimer to exclude PE in high clinical probability Wait for CTPA before anticoagulating a high-probability patient Give large fluid boluses in RV failure Thrombolyse normotensive low-risk PE Common mistakes D-dimer in high probability Delaying anticoagulation Over-fluid in RV failure Lysis for low-risk PE Disposition and follow-up Low risk → early discharge; intermediate → monitored ward; high risk → ICU with reperfusion.
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