Pulmonary embolism

Summary

Pulmonary embolism (PE) is the obstruction of one or more pulmonary arteries by an embolic

solid, fluid, or gas. In the majority of cases, PE is caused by a venous thrombus that originated in
the legs or pelvis and embolized to the lungs via the inferior vena cava. Risk factors include
immobility, inherited hypercoagulability disorders, pregnancy, postpartum period, and
recent surgery. The clinical presentation can range from asymptomatic to obstructive shock,
depending on the extent of pulmonary artery obstruction. Because symptoms are often
nonspecific (e.g., chest pain, coughing, shortness of breath, and tachycardia), PE should be
considered in all patients with acute dyspnea. A tentative diagnosis of PE is usually based on
history and clinical suspicion, then confirmed with CT pulmonary angiography (CTPA). Arterial
blood gas analysis (ABG) may be normal or show low partial oxygen pressure and respiratory
alkalosis. Serum D-dimer test is highly sensitive for PE and can help rule out the diagnosis.
Therapeutic anticoagulation is initiated to prevent further embolic events and to promote the
gradual dissolution of the embolism and any underlying thrombosis. Treatment for massive
PE with hemodynamic instability additionally involves restoring pulmonary perfusion with
thrombolytic agents and/or embolectomy.

See also “Nonthrombotic embolism” and “Deep vein thrombosis.”

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Definition

 Pulmonary embolism (PE): luminal obstruction of one or more pulmonary arteries,

typically due to blood thrombi from deep vein thrombosis (DVT)
 Venous thromboembolism (VTE): an umbrella term that encompasses PE and DVT (see
also “Hypercoagulable states”)
o Recurrent VTE: VTE that recurs in a patient after the completion of the
first 2 weeks of antithrombotic therapy  [1]
o Provoked VTE: VTE in an individual with ≥ 1 risk factor for VTE
 o Unprovoked VTE (idiopathic VTE): VTE in an individual without risk
factors for VTE

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Epidemiology

 Incidence [2]
o ∼ 1–2 venous thromboembolism per 1,000 in the United States per year
o Rises with age
 Sex:
overall ♂ > ♀ but women have a slight increase during the reproductive years [2]
 Mortality: Venous thromboembolism accounts for ∼ 100,000 deaths in the US per
year. [2]

Epidemiological data refers to the US, unless otherwise specified.

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Etiology

 Most common: Deep vein thrombosis (See “Risk factors for VTE.”) [2]

 Causes of nonthrombotic embolism
o Fat embolism
o Air embolism
o Amniotic fluid embolism
o Others: bacterial embolism, pulmonary tumor embolism, pulmonary
cement embolism

PE is FATAL: PE caused by Fat, Air, Thrombus, Amniotic fluid, and Less common, i.e.,

bacterial, tumor, and cement.

Pathophysiology

 Mechanism: thrombus formation (see “Virchow's triad.”) → deep vein thrombosis in

the legs or pelvis (most commonly iliac vein) → embolization to pulmonary
arteries via inferior vena cava  → partial or complete obstruction of pulmonary
arteries  [2]
 Pathophysiologic response of the lung to arterial obstruction  [2]
o Infarction and inflammation of the lungs and pleura
 Causes pleuritic chest pain and hemoptysis
 Leads to surfactant dysfunction → atelectasis → ↓ PaO2  [3]
 Triggers respiratory drive
→ hyperventilation and tachypnea → respiratory
alkalosis with hypocapnia (↓ PaCO2)
o Impaired gas exchange
 Mechanical vessel obstruction → ventilation-
perfusion mismatch  → arterial hypoxemia (↓ PaO2) and
elevated A-a gradient  (See “Diagnostics” below.)
o Cardiac compromise
 Elevated pulmonary artery pressure (PAP) due to blockage
→ right ventricular pressure overload → forward failure with
decreased cardiac output  → hypotension and tachycardia
 Pulmonary vasoconstriction: thromboxane A2, prostaglandins, adenosine, thrombin,
and serotonin secreted by activated platelet and
the thrombus → pulmonary vasoconstriction and bronchospasm [4]
 Saddle thrombus 
o A blood clot (e.g., from deep vein thrombosis) that lodges at the bifurcation
of the pulmonary trunk as it splits into the right and left pulmonary arteries.
o Can obstruct blood flow through the pulmonary arteries and lead to
right heart strain, hemodynamic instability, and/or death.

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Clinical features

 Common features of PE  [5]
o Acute onset of symptoms
o Dyspnea (> 75% of cases) [5]
o Tachycardia and tachypnea (up to 50% of cases) [5]
o Sudden pleuritic chest pain (∼ 20% of cases)  [5]
o Cough and hemoptysis
o Associated features of DVT: e.g., unilaterally painful leg swelling  [6]
 Less common features of PE [5]
o Decreased breath sounds
o Dullness to percussion
o Split S2 
o Low-grade fever
o Rarely, upper abdominal pain [7][8]
 Features of massive PE: (e.g., due to a saddle thrombus)
o Presyncope or syncope
o Jugular venous distension  and Kussmaul sign
o Hypotension and obstructive shock
o Circulatory collapse
 Features of intraoperative PE: all features typically have an abrupt onset [9][10]
o Decrease in EtCO2 (early sign) 
o Decrease in SpO2
o Hypotension
o Tachycardia

Most patients with PE have a grossly normal physical examination; abnormalities heard

on lung auscultation (e.g., wheezes or bilateral rales) often suggest a different cause for the

symptoms. [5]

Consider PE as a differential diagnosis in recurring or progressive dyspnea of uncertain

etiology.
Pretest probability of pulmonary embolism

Overview [11][12]

Estimate pretest probability (PTP) using validated tools and/or clinician gestalt to guide

diagnostic testing.  [11][12][13]

 High PTP of PE
o Modified Wells score > 4
o Original Wells score ≥ 7
o Revised Geneva score > 10
 Intermediate PTP of PE
o Original Wells score 2–6
o Revised Geneva score 4–10
 Low PTP of PE
o Modified Wells score ≤ 4
o Original Wells score < 2
o Revised Geneva score < 4
 Very low PTP of PE: Low PTP of PE plus PERC = 0

Wells criteria for pulmonary embolism  [14]

The Wells score is a diagnostic algorithm for assessing the probability of PE and has been
validated in inpatient and outpatient settings. Use “Wells criteria for DVT” to calculate
the PTP of deep vein thrombosis.

Wells criteria for PE [15][16]

Criteria Points

Clinical symptoms of DVT 3

PE more likely than other diagnoses 3

Previous PE/DVT 1.5
 Wells criteria for PE [15][16]

Criteria Points

Tachycardia (heart rate > 100/min) 1.5

Surgery or immobilization in the past 4 weeks 1.5

Hemoptysis 1

Malignancy  1
Original Wells score (clinical probability) [15]

 Total score 0–1: low probability of PE (6%)

 Total score 2–6:
intermediate probability of PE (23%)
 Total score ≥ 7: high probability of PE (49%)

Modified Wells score (simplified clinical probability) [16]

 Total score ≤ 4: PE unlikely (8%)

 Total score > 4: PE likely (34%)

Revised Geneva score [17] 

The revised Geneva score utilizes objective clinical variables. It has been externally validated
and was initially studied in emergency department outpatients.

Revised Geneva score [15]

Criteria Points

Age > 65 years 1

Prior history of DVT or PE 3

Recent surgery  or fracture of the lower limbs  2

 Revised Geneva score [15]

Criteria Points

Personal history of cancer  2

Unilateral lower limb pain 3

Hemoptysis 2

Heart rate 75–94/min 3

Heart rate ≥ 95/min 5

Pain on palpation of lower limb and unilateral edema 4

Clinical pretest probability

 Total score < 4: low probability of PE (9%)

 Total score 4–10:
intermediate probability of PE (26%)
 Total score > 10: high probability of PE (76%)

Pulmonary embolism rule-out criteria (PERC)  [12][18][19]

Patients with a low PTP of PE and a PERC score of zero have a very low probability of PE and
require no further testing.

Pulmonary embolism rule-out criteria (PERC)

Criteria Points

Age > 50 years 1

Heart rate > 100/min 1

 Pulmonary embolism rule-out criteria (PERC)

Criteria Points

Oxygen saturation < 95%  1

Hemoptysis 1

Estrogen use 1

Prior history of DVT or PE 1

Recent surgery or trauma  in the past 4 weeks 1

Unilateral lower limb edema 1

Clinical pretest probability

 Total score 0: pretest probability < 1%; no further testing needed

 Total score ≥ 1: PE is not ruled out; further testing needed

PERC should only be used in patients with a previously determined low PTP of PE.

The presence of any PERC criteria in a patient with suspected PE necessitates further

testing.

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Diagnostics
Approach [5][20][12]

 Hemodynamically unstable patients: Begin management of massive PE prior to

diagnostic confirmation.  [21]
o Perform bedside echocardiogram and ECG to identify signs of RV
dysfunction.  [21][22]
o Obtain confirmatory imaging (CTPA or V/Q scan) when stable enough
for transport.
 Hemodynamically stable patients (e.g., systolic BP > 90 mm Hg): Assess PTP of
PE.
o Low PTP of PE
 PERC = 0: No further testing for PE is required.
 PERC > 0: Obtain D-dimer.
 Elevated D-dimer: Obtain confirmatory imaging.
 Normal D-dimer: No further testing for PE is
required; consider alternative diagnoses.
o Intermediate PTP of PE: Obtain D-dimer.
 Elevated D-dimer: Obtain confirmatory imaging.
 Normal D-dimer: No further testing for PE is required;
consider alternative diagnoses.
o High PTP of PE: Obtain confirmatory imaging. 
 Confirmed PE: Assess severity using ECG, cardiac biomarkers, and imaging
(e.g., CTPA or echocardiography) [21][23]

Initial evaluation
The initial evaluation of patients with dyspnea and/or chest pain typically includes laboratory
studies, CXR, and ECG. Findings may suggest but do not confirm PE. [5]

D-dimer  [21][12]

 Indications
o Intermediate PTP of PE
 o Low PTP of PE and PERC > 0
 Findings
o Normal levels: < 500 ng/mL
o If ≥ 500 ng/mL: Further testing is required (see below).
o If the patient is > 50 years of age, adjust for age: age x 10 ng/mL = cutoff
value in ng/mL  [12][24]
 Interpretation
o High sensitivity and negative predictive value: A negative D-dimer test
most likely rules out PE. 
o Low specificity: positive results in all forms of fibrinolysis 

Normal D-dimer values usually rule out PE or DVT in patients with a low PTP. A

positive D-dimer is nonspecific, since it may be elevated in any situation in which there is

increased fibrinolysis.

Additional laboratory studies [12]

 Arterial blood gas (ABG) [25][26]

o Often normal 
o Common findings
↑ Alveolar-arterial gradient 

 Hypoxemia (e.g., ↓ SaO2, PaO2 < 80 mm Hg)
 Respiratory alkalosis
 CBC: may show leukocytosis  [27]
 BMP: used to assess renal function 
 Cardiac biomarkers: e.g., troponin, BNP, NT-proBNP (See “Severity assessment”
for interpretation.)

A normal oxygen saturation and/or normal PaO2 do not rule out PE. [5][28]

Chest x-ray  [22]

 Characteristic findings
 o Hampton hump: a wedge-shaped opacity in the peripheral lung with its
base at the thoracic wall; caused by pulmonary infarction and not specific
for PE 
o Westermark sign: an area of lung parenchyma lucency caused by
oligemia secondary to occlusion of blood flow
o Fleischner sign: a prominent pulmonary artery caused by vessel
distention due to a large pulmonary embolus (common in massive PE)
 Nonspecific findings
o Atelectasis
o Pleural effusions 
o Cardiomegaly 

Electrocardiography (ECG) 

 Most common findings [29]

o T-wave inversions or flattening
o Sinus tachycardia 
o Normal ECG
 Predictors of adverse outcomes: See “High-risk ECG findings in PE.”
 Other ECG findings in PE: sinus bradycardia (< 60/min); uncommon)  [30]

Confirmatory imaging

CT pulmonary angiography (CTPA) [22][12][31]

CTPA is the preferred test for the diagnosis of acute PE.  [22]

 Technique: CT chest with bolus IV contrast enhancement of the pulmonary arteries

 Indications
o All patients with a high PTP of PE 
 o Elevated D-dimer in patients with a low or intermediate PTP of PE
 Contraindications
o Renal insufficiency 
o Contrast allergy
o Pregnancy
 Findings
o Direct finding of PE: intraluminal filling defects of pulmonary arteries 
o Pulmonary infarct: opacity with consolidated border; may be
accompanied by pleural effusion
o Evidence of RV dysfunction  [32]

A wedge-shaped infarction with pleural effusion is almost pathognomonic for PE. [22]

Ventilation/perfusion scintigraphy (V/Q scan)  [12][22]

 Technique: comparison of perfusion and ventilation scintigraphy to

identify ventilation-perfusion mismatch 
 Indication: alternative to CTPA in patients with contraindications for iodinated IV
contrast 
 Findings [31][33]
o The absence of perfusion in normally ventilated areas of
the lung (mismatch) suggests PE.
o Discordance between V/Q scan results and the clinical PTP necessitates
further evaluation.

CTPA and V/Q scans have similar sensitivities and specificities for PE, but CTPA is faster

and more readily available. [22]

Pulmonary angiography  [31][22]

 Technique: selective injection of contrast dye into the pulmonary

arteries during fluoroscopic examination
 Indications
o Inconclusive CTPA findings and high level of suspicion for PE
o Candidates for concomitant endovascular treatment, e.g., embolectomy
 Findings: intraluminal filling defects in pulmonary arteries 

Adjunctive imaging

 Lower extremity venous ultrasound [20][12]

o Indications
 Symptoms of deep venous thrombosis  and pulmonary
embolism 
 Contraindications to CTPA (e.g., contrast allergy and renal
insufficiency)
 Pregnancy 
o Findings: e.g., noncompressible deep vein (See “Ultrasound findings of
DVT” for details. 
 High sensitivity for DVT but not for PE
 A negative ultrasound does not rule out PE. [34][35]
 Point-of-care ultrasound (POCUS)  [36][37]
o Location: lungs, heart, and femoral and popliteal veins
o Findings: subpleural consolidations, right ventricular strain,
noncompressible deep vein  [38]
 Magnetic resonance pulmonary angiography: if CTPA or V/Q scan cannot be
performed  [39][22]

The absence of a DVT does not rule out PE, but the presence of a DVT can justify

starting empiric anticoagulation for PE. [38]

Severity assessment [40][21][41]
Signs of RV dysfunction that predict adverse outcomes (e.g., hemodynamic collapse or death)
can be identified clinically, electrically, biochemically, and radiologically (e.g.,
on echocardiography or CTPA). [21][23][41]

ECG and cardiac biomarkers

 High-risk ECG findings in PE [42][43]

o Signs of right heart strain [5]
 SIQIIITIII-pattern  
 New right bundle branch block (incomplete or complete)
 T-wave inversion in anterior precordial leads (V1–V4)
o Sinus tachycardia (> 100/min)
o Atrial fibrillation
o ST elevation in aVR
o Q waves in III and aVF
 Troponin: elevated if myocardial damage has occurred  [44][21]
 B-type natriuretic peptide (BNP) or NT-proBNP: identifies RV strain  [45][21]

↑ BNP is nonspecific but can predict early adverse outcomes in patients with PE. [21]

Echocardiography

 Goal: mostly used for prognosis; can be used as a diagnostic tool in patients too
unstable for confirmatory imaging
 Indications
o Suspected right-heart strain or RV dysfunction
o Critically ill patients with suspected PE
 Findings  [21][22][41]
o Dilatation and hypokinesis of the right ventricle (RV) 
o RV dysfunction
o McConnell sign: akinesia of the mid-free RV wall and hypercontractility
of the apical wall
o Venous reflux with IVC dilation 
 o Tricuspid regurgitation (tricuspid valve insufficiency) 
o ↑ PASP 
o Increased right atrial pressure

The presence or absence of RV dysfunction guides the risk stratification and subsequent

management of hemodynamically stable patients with PE. [23][46]

Identification of underlying pathology

 Evaluation for thrombophilia [47]
o Indicated in younger patients with any of the following
 No or weak risk factors
 Family history
 Recurrence of venous thrombosis
o Timing: after the completion of therapy 
o See “Hypercoagulable states.”
 Evaluation for malignancies: age-appropriate screening studies; See “Preventive
Medicine.” 

Classification

Classification by PE severity [48]

This system guides management using hemodynamic parameters and markers of RV

dysfunction.

 Nonmassive PE
o Stable blood pressure (SBP > 90 mm Hg)
o No RV dysfunction
o Normal cardiac biomarkers
 Submassive PE
 o Stable blood pressure (SBP > 90 mm Hg) PLUS ≥ 1 of the following:
RV dysfunction 

 Evidence of myocardial necrosis (elevated troponin)
 Massive PE: hemodynamic instability (due to right heart failure)
o Systolic BP < 90 mm Hg for > 15 minutes
o Acute decrease in systolic BP ≥ 40 mm Hg
o Hemodynamic support is needed.

Classification by overall PE prognosis [49][50]
This system guides disposition using prognostic risk stratification scores (e.g., PESI or sPESI).

 Low-risk PE: PESI class I–II or sPESI score = 0

 Intermediate-risk PE: PESI class III
 High-risk PE: PESI class ≥ IV or sPESI score ≥ 1

Pulmonary embolism severity index (PESI) and simplified PESI (sPESI)  [49][50]

The PESI and sPESI stratify the 30-day risk of mortality or adverse outcomes based on patient

demographics, comorbidities, and degree of clinical stability.

PESI and sPESI

Points
Criteria
PESI [49] sPESI [50]

Age 1 per year 1 if > 80 years

History of cancer 30 1

Systolic blood pressure < 100 mm

30 1
Hg

Heart rate ≥ 110/min 20 1

O2 saturation on room air < 90% 20 1

Heart failure 10 1 
 PESI and sPESI

Points
Criteria
PESI [49] sPESI [50]

Chronic lung disease 10

Altered mental status 60

Temperature < 96.8°F (< 37°C) 20

Not
Respiratory rate ≥ 30/min 20 considered

Male: 10
Sex
Female: 0

PESI interpretation (30-day mortality rate, inpatient

mortality) [49]

 < 66 points: class I, very low risk (0–1.6%, ≤

1.1%)
 66–85 points: class II, low risk (1.7–3.5%, ≤
1.9%)
 86–105 points: class III, intermediate risk (3.2–
7.1%, ≤ 4.7%)
 106–125 points: class IV, high risk (4.0–11.4%, ≤
7.0%)
 > 125 points: class V, very high risk (10.0–
23.9%, ≤ 17.2%)

sPESI interpretation (30-day mortality) [50]

 0 points: low risk (1%)

 ≥ 1 point: high risk (10.9%)
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Management

General principles [21][51][46]

 Manage unstable patients using the ABCDE approach (see “Management of massive

PE”).
 Provide oxygen therapy for hypoxic patients. 
 Treat PE based on severity and bleeding risk; start empiric anticoagulation for PE if
indicated. 
 Provide analgesia; avoid NSAIDs if possible.
 Consult a pulmonary embolism response team (PERT), if available: A
multidisciplinary team that coordinates the management of patients with PE  [46][52]
 Consider calculating PESI or sPESI score to guide disposition.

Start empiric anticoagulation for PE if clinical suspicion is high unless there is a high risk

of bleeding (e.g., recent surgery, hemorrhagic stroke, active bleeding). [46]

Overview of treatment options by severity

Pulmonary embolism treatment by severity and bleeding risk [23]
[51][46]

Bleeding risk

Low High 

Nonmass  Anticoagulati  Consider a

ive PE
on in most temporary IV
patients C filter. 
 Consider cons
Pulmonary embolism treatment by severity and bleeding risk [23]
[51][46]

Bleeding risk

Low High 

ervative
management o
nly for
patients with
subsegmental 
PE,
no proximal
DVT, and a
low risk of
recurrence
 Outpatient
management
is often
appropriate.

Submass
 Anticoagulati  Consider a
ive PE
on temporary IV
 Consider thro C filter.
mbolysis for  Consider em
PE if high risk bolectomy
for for PE in
decompensati patients at
on (e.g., high risk of
severe RV decompensati
dysfunction) on.
or
deterioration
despite
anticoagulatio
 Pulmonary embolism treatment by severity and bleeding risk [23]
[51][46]

Bleeding risk

Low High 

n.

 Thrombolysis
for
PE followed
by
anticoagulatio  Embolectom
Massive
PE n. y for PE
 Embolectomy
for
PE if thrombo
lysis fails.

Unstable patients

Management of massive PE [21][51][46]

 Hypoxemic respiratory failure: Optimize oxygenation (e.g., using HFNC) and

consider mechanical ventilation.
 Hemodynamic instability
o Consider ≤ 500 mL IV fluid bolus.
o Avoid volume overload. 
o Begin vasopressor or inotrope infusion if the patient remains hypotensive,
e.g., norepinephrine DOSAGE  or dobutamine. DOSAGE  [21]
o Consider temporary mechanical circulatory support.
 Urgent reperfusion
o Begin thrombolysis for PE immediately if there are no
absolute contraindications to thrombolytics for massive PE.
 o If thrombolysis is contraindicated or fails: Consult interventional
radiology or surgery to perform embolectomy for PE. [46]

Avoid volume overload during resuscitation. Aggressive fluid administration can worsen

impaired RV function and further decrease cardiac output. [21]

Management of cardiac arrest due to PE [53]

 Start ACLS  [53]
 Consider POCUS to identify indirect signs of PE.  [53][54][55]
o Subxiphoid view (consider only during pulse check): thin-walled (< 5
mm), dilated RV 
o Lower extremity views: US findings of DVT 
 Consider intra-arrest thrombolytics (e.g., tPA DOSAGE ).  [56][53]
 Consider ECMO. [46][5]

Stable patients [21][23][51]

 Symptomatic nonmassive PE and low-risk submassive PE:

Prescribe anticoagulation for PE if bleeding risk is low.
 High-risk submassive PE: Start anticoagulation for PE and consider thrombolysis
for PE.
 Incidentally discovered PE : Treat the same as symptomatic PE.
 Subsegmental PE : Consider surveillance after ruling out proximal DVT if the risk
of recurrence is low. 
 Recurrent VTE: Consider starting low molecular weight heparin if a direct oral
anticoagulant or vitamin K antagonist was being used prior to recurrence.  [23][57][58]

Disposition [21][23][51]
PESI and sPESI score can be used to help guide disposition.
  Low-risk PE (PESI class I–II or sPESI score = 0)
o Consider outpatient management in consultation with specialists.
o Criteria for outpatient management include:
Hemodynamic stability and adequate room air oxygenation
 Opiates are not required for pain relief.
 Availability of family or social support, easy access to health
care
 No other major comorbidities or reasons for hospitalization
 Intermediate-risk PE or high-risk PE (PESI class ≥ III or sPESI score ≥ 1)
o Hospitalization is required; consult PERT if available.
o ICU admission: commonly necessary for massive PE or patients with
severe RV dysfunction [5]

Anticoagulation

Bleeding risk assessment [59][51][23]

Evaluate a patient's risk for major bleeding and identify contraindications before initiating

anticoagulation. [46]

 See “Risk of major bleeding on anticoagulant therapy in patients with VTE.”   [60][61]

 Contraindications to anticoagulation include : [62][63]
o Significant active bleeding
o Recent high-risk bleeding (e.g., intracranial)
o Recent major surgery
o Severe thrombocytopenia

The benefits of anticoagulation in PE outweigh the bleeding risks in most patients who do

not have an absolute contraindication to anticoagulation. [63]

Empiric anticoagulation for PE [59][21][51][23]

Empiric anticoagulation may be started while waiting for a definitive diagnosis, depending on
the risk of bleeding, the PTP of PE, and the expected timing of the diagnostic study.

 Indications
o High PTP of PE: Initiate in all patients.
o Intermediate PTP of PE: Consider in all patients. 
o Low PTP of PE: only if imaging is expected to be delayed for > 24 hours
 Contraindication: risk of major bleeding on anticoagulant therapy in patients with
VTE
 Choice of medication
o Stable patients: low molecular weight heparin (LMWH) DOSAGE   [59]
o Unstable patients or patients with renal insufficiency: unfractionated
heparin (UFH) DOSAGE  [57]

Initial anticoagulation (first 5–10 days) [23][64][57][51]

The selection of the initial anticoagulant depends on the severity of the PE, patient comorbidities,
and/or planned concurrent treatment. [46]

 LMWH (e.g., enoxaparin DOSAGE ) or fondaparinux DOSAGE   [59][65]

o Preferred over UFH in most patients with normal renal function  [21]
o Anticoagulant of choice for PE in pregnant patients [21]
o LMWH is recommended over UFH for patients with cancer. [66]
 UFH DOSAGE   [64][46]
o Preferred in patients with renal failure
o Preferred if thrombolysis, embolectomy, or mechanical circulatory
support are planned 
o Preferred in patients with unpredictable subcutaneous absorption (e.g.,
patients with obesity, hypoperfusion)
 Initial oral anticoagulation
o Consider as initial therapy for low-risk PE.
o Agents: rivaroxaban DOSAGE  or apixaban DOSAGE  

Long-term anticoagulation (up to 3 months) [51][64][23]

 Direct oral anticoagulant (DOAC)

o Preferred over vitamin K antagonist (VKA) for most patients 
 o No initial parenteral anticoagulation is required
with rivaroxaban DOSAGE  or apixaban DOSAGE
o Initial parenteral anticoagulation is required
with dabigatran DOSAGE  or edoxaban DOSAGE
 VKA: warfarin DOSAGE
o Therapeutic target: INR 2–3 [59]
o Preferred over LMWH when a DOAC cannot be used [64]
 Long-term parenteral anticoagulation with LMWH
o Preferred over VKA in patients with cancer if a DOAC cannot be used [66]
o Preferred in pregnant patients [57]

Extended anticoagulation (> 3 months) [57][51][23]

 Reassess the need for anticoagulation after 3 months, then annually.

 Indications for extended anticoagulation
o Unprovoked PE with a low to moderate risk of bleeding 
o Provoked PE secondary to a chronic risk factor with a low to moderate
risk of bleeding
o Patients with active cancer with any level of bleeding risk [66]

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Reperfusion therapy

Bleeding risk assessment [46]

Evaluate a patient's risk for major bleeding and identify contraindications before

initiating thrombolytics.

 Identify risk factors for bleeding in patients with VTE.

 Evaluate absolute vs. relative contraindications to thrombolysis for PE.
 Carefully consider the risk-benefit ratio of therapy.
 Consider the following interventions to reduce bleeding risk: [63]
o Optimize antihypertensive therapy.
o Stop or minimize the use of antiplatelet medications and NSAIDs.
o Correct reversible renal and/or hepatic disease.
 o Treat potential bleeding sources.

Thrombolysis for PE is associated with a high risk of major bleeding.

Thrombolysis for PE [46][23]

Follow local protocols in consultation with a thrombosis specialist.

Systemic thrombolysis [57][51]

 Procedure: administration of thrombolytic therapy through a peripheral vein

 Indications
o Massive PE (hemodynamic instability and/or right heart failure) with a
low bleeding risk
o Nonmassive PE with a low bleeding risk, if patients deteriorate despite
anticoagulation 
o Cardiac arrest in patients with suspected PE
 Contraindications: See “Contraindications to thrombolysis for PE.” 
 Common thrombolytic agents  [67][5][21]
o Recombinant tissue plasminogen activator (tPA),
e.g., alteplase (preferred) DOSAGE
o Streptokinase DOSAGE
o Urokinase DOSAGE
 Management of anticoagulation [68]
o Discontinue anticoagulation prior to thrombolysis.
o Check aPTT 2 hours after completion of thrombolysis.
o Resume anticoagulation when aPTT is < 2 times the upper limit of
normal.
 Complication: hemorrhage during thrombolytic treatment  [69]

Catheter-directed thrombolysis [70]

 Procedure
o Direct infusion of thrombolytics into the obstructed pulmonary artery via
pulmonary arterial catheter
o May be combined with mechanical or ultrasound fragmentation of
the embolus
  Indication: Alternative to systemic thrombolysis in patients with a high bleeding
risk. 
 Contraindications: See “Contraindications to thrombolysis for PE.”

Contraindications

Contraindications to thrombolysis for pulmonary embolism  [57][21][46]

 Active bleeding
 Prior intracranial hemorrhage
 Ischemic stroke ≤ 3 months ago
Absolute  Recent spinal or brain surgery
contraindications
 Structural intracranial disease 
 Recent head trauma with brain injury or fracture
 Bleeding diathesis

 Uncontrolled hypertension 
 Current anticoagulation use
 Recent nonintracranial bleeding
 Recent surgery, invasive procedure, or trauma
 Ischemic stroke > 3 months ago
Relative  Traumatic CPR
contraindications
 Pregnancy
 Age > 75 years
 Weight < 60 kg
 Pericardial fluid or pericarditis
 Diabetic retinopathy

Embolectomy for PE [46]

 Indications
o Contraindications to thrombolysis for PE in patients with massive PE or
high-risk submassive PE
o Failure of thrombolysis for PE
 Options
 o Surgical embolectomy: removal of the embolus through an incision in
the pulmonary artery
o Endovascular embolectomy: catheter-based thrombus removal [70]

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Acute management checklist

Initial management

 Perform ABCDE assessment.
 Provide analgesia and oxygen therapy as needed.
 Unstable patients (i.e., massive PE): Stabilize, obtain ECG, and consider
bedside echocardiogram and empiric therapy based on bleeding risk.
 Stable patients order initial diagnostic based on PTP of PE.
 Assess bleeding risk on anticoagulation for VTE.
 Consider empiric anticoagulation if the bleeding risk is low.
 Evaluate RV function to determine the severity of PE.
 Consult PERT.

Nonmassive PE

 Low bleeding risk: Start anticoagulation with a DOAC or heparin.

 High bleeding risk: Consider IVC filter placement.
 Consider outpatient management; see “Risk stratification and disposition.”

Submassive PE

 Low bleeding risk: Start anticoagulation with UFH or LMWH.

 High bleeding risk: Consider IVC filter placement.
 Consider thrombolysis for PE in select patients, e.g., those with continued clinical
deterioration.
 Admit to ICU or telemetry.

Massive PE
  Evaluate the need for mechanical ventilation.
 Have a crash cart at the bedside.
 Consider limited IV fluid therapy for hemodynamic support (e.g., 250–500
mL crystalloid fluid IV once).
 Begin vasopressor infusion for hemodynamic support if needed.
 Check for contraindications to thrombolysis for PE.
o No absolute contraindications: Initiate thrombolysis for PE.
o Absolute contraindications: Consult interventional radiology
and/or surgery to perform embolectomy for PE.
 Continuous telemetry and pulse oximetry.
 Transfer to ICU.

Cardiac arrest due to suspected PE

 Start ACLS.
 Consider administration of a reduced dose of tPA.

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Complications

 High risk of recurrence: Without anticoagulant treatment, the risk of recurrence is ∼

10% in the first year and ∼ 5% per year after.  [20]
 Right ventricular failure and secondary pulmonary arterial hypertension
 Sudden cardiac death due to pulseless electrical activity
 Atelectasis (∼ 20% of cases) 
 Pleural effusion
 Pulmonary infarction (∼ 10% of cases)
o Embolisms of smaller segmental arteries can lead to wedge-
shaped hemorrhagic pulmonary infarctions 
o Right ventricular failure, increased bronchial venous pressure, and
preexisting pulmonary diseases increase the risk.
o Patients may present with pneumonia following pulmonary infarction,
detected by peripheral infiltration on chest X-ray (typically wedge-
shaped = Hampton's hump). 
 Arrhythmia
We list the most important complications. The selection is not exhaustive.
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Pathology

 Purpose: distinguishing cause of embolism (See “Etiology”.)

 Histological findings [71]
o Lines of Zahn: alternating layers of platelets mixed with fibrin (light pink
layers) and red blood cells (dark red layers) 
o Only appear premortally (help distinguish a premortal thrombus from a
postmortem one)

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last updated 03/16/2023