Algorithm
- ABC; O₂ to target SpO₂; assess shock / RV strain signs.
- Risk stratify (hemodynamic instability vs intermediate/low).
- If high suspicion + shock: consider bedside echo / empiric reperfusion pathway per local PE protocol — do not delay.
- Anticoagulate when PE likely and bleeding risk acceptable (LMWH/UFH/DOAC per pathway).
- CTPA when stable enough; V/Q if CT contraindicated.
- Massive PE with shock: thrombolysis / catheter / surgical embolectomy — specialist decision.
- Investigate precipitant; early ambulatory pathway only if low risk and local protocol allows.
Red flags
- • Hypotension / syncope
- • Contraindication to anticoagulation
- • Right-heart strain with deterioration
Medications by step
Anticoagulation
- LMWH or UFH (prefer UFH if thrombolysis possible / unstable) · SC / IV
Per local weight-based protocol
Reperfusion
- Systemic thrombolysis (e.g. alteplase) — specialist only · IV
Per ESC / local PE protocol
References
- • ESC Guidelines — Acute pulmonary embolism (2019)
Updated: July 2026