3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

Inferior Q waves in lead II, III, and aVF

Collapse all sections REGISTER LOG IN

Identifying the underlying cause

Evaluation for thrombophilia [32]

Indicated in younger patients with any of the following

No or weak risk factors

Family history
Recurrence of venous thrombosis

Timing: after the completion of therapy

See “Hypercoagulable states.”
Evaluation for malignancies: age-appropriate screening studies

Treatment

Approach

1. Stabilize the patient and provide supportive care.

Pulseless patient with suspected PE: Start ACLS and consider administration of thrombolytics
[33][34]
(e.g., tPA ). .

2. Assess bleeding risk (see risk factors for bleeding in patients with VTE).
3. Consider empiric parenteral anticoagulation while awaiting a definitive diagnosis.

4. Risk stratify the patient based on prognostic models (see risk stratification of pulmonary embolism).
[35]
5. Consult pulmonary embolism response team (PERT), if available.

6. Initiate therapy based on risk stratification and bleeding risk.

Massive PE: thrombolytic therapy or embolectomy

Submassive and nonmassive PE: anticoagulation or IVC filter

Supportive care

Hemodynamic support: in patients with hypotension and obstructive shock [36]

IV fluids
Gentle bolus (e.g., normal saline ≤ 500 mL)

Avoid volume overload, which may be harmful in cases of right ventricular strain

Consider vasopressors (norepinephrine is most commonly used) if there is no improvement

following fluid administration.

Respiratory support
https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 11/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

Oxygen supplementation in patients with SpO2 < 90% [36]

Collapse all sections REGISTER LOG IN
For patients with respiratory failure: airway management and/or mechanical ventilation

Analgesics: for patients with pain

See pain management.

Avoid NSAIDs if patient receiving anticoagulation or thrombolytics

Consider one of the following:

Morphine
Oxycodone

Hypervolemia can be harmful if right ventricle strain is present.

Assessment of bleeding risk

There are currently no scoring systems with sufficient prediction outcomes for the bleeding risk from
anticoagulant therapy in patients with PE. The HAS-BLED score is sometimes used but it was
designed and validated for anticoagulant therapy in patients with atrial fibrillation. See risk factors for
bleeding in patients with VTE. [37]

Empiric parenteral anticoagulation for pulmonary embolism

Indications: consider starting empiric anticoagulation in patients awaiting a definitive diagnosis,

depending on the risk of bleeding, the pretest probability of PE, and the expected timing of the
[34][36]
diagnostic study ;

Low probability of PE and diagnostic study is expected to be delayed > 24 hours [34]

Intermediate probability of PE and diagnostic study is expected to be delayed > 4 hours [34]

High probability of PE

Absolute contraindication: high bleeding risk

Choice of medication [34][36]

[34]
Stable patients: LMWH
[38]
Unstable patients or patients with renal insufficiency: UFH

An absolute contraindication for empiric anticoagulation is a high risk of bleeding (e.g.,

recent surgery, hemorrhagic stroke, active bleeding).

Risk stratification of pulmonary embolism

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 12/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

Collapse
Risk categories based on the risk of adverse outcomes [39][40] all sections REGISTER LOG IN

Massive pulmonary embolism (high-risk PE)

Persistent hypotension (shock)

Right ventricular failure

Submassive pulmonary embolism (intermediate-risk PE)

Stable blood pressure (SBP > 90 mm Hg)

Right ventricular dysfunction or evidence of myocardial necrosis

Nonmassive pulmonary embolism (low-risk PE)

Normotensive
No right ventricular dysfunction

Normal cardiac biomarkers

[41][42]
Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI)
The Pulmonary Embolism Severity Index stratifies the risk of mortality or adverse outcomes and is
used to assist in decisions on inpatient vs. outpatient management.

PESI and sPESI

Criteria Points

PESI [41] sPESI [42]

Age 1 per year 1 if > 80 years

History of cancer 30 1

Systolic blood pressure < 100 mm Hg 30 1

Heart rate ≥ 110/min 20 1

O saturation on room air < 90% 20 1

Heart failure 10 1

Chronic lung disease 10

Altered mental status 60 Not considered

Temperature < 96.8°F (< 37°C) 20

Respiratory rate ≥ 30/min 20

Sex Male: 10
Female: 0

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 13/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

PESI and sPESI

Collapse all sections REGISTER LOG IN

Criteria Points

PESI [41] sPESI [42]

PESI interpretation (30-day mortality rate, inpatient mortality) [41]

< 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) [42]

0 points: low risk (1%)

≥ 1 point: high risk (10.9%)

Treatment of massive pulmonary embolism

Initiate directed therapy based on bleeding risk and the presence of any contraindications to
thrombolytic therapy in massive pulmonary embolism.

Low bleeding risk: systemic thrombolytic therapy

High bleeding risk: catheter-directed thrombolytic therapy

If thrombolytic therapy is contraindicated or unsuccessful: embolectomy

Thrombolytic therapy in pulmonary embolism

Systemic thrombolysis [38]

Indications
Massive PE causing right heart failure associated with hypotension and a low bleeding risk

Nonmassive PE if the patient deteriorates after the initiation of anticoagulation but has not yet
developed hypotension and has a low bleeding risk

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 14/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

Contraindications: See contraindications to thrombolytic therapy in massive pulmonary embolism

Collapse all sections REGISTER LOG IN
below.

Procedure: thrombolysis, preferably with recombinant tissue-type plasminogen activator (tPA),

e.g., alteplase

Most commonly systemic infusion via peripheral IV catheter [38]

Thrombolytic agents

tPA (alteplase)
Streptokinase

Urokinase

In patients receiving anticoagulation [43]

Discontinue anticoagulation prior to thrombolysis

Check aPTT 2 hours after completion of thrombolysis.

Resume anticoagulation when aPTT is < 2 times the upper normal limit.
[44]
Complication: risk of hemorrhage during thrombolytic treatment

Catheter-directed thrombolysis [38]

Indication: patients with persistent hypotension who have high bleeding risk, obstructive shock,
and/or failed systemic thrombolysis

Contraindications: See contraindications to thrombolytic therapy in massive pulmonary embolism

below.

Procedure: ultrasound-assisted direct infusion of thrombolytics into pulmonary artery via

pulmonary arterial catheter

Contraindications to thrombolysis

Contraindications to thrombolytic therapy in massive pulmonary embolism [38]

Absolute contraindications Presence of structural intracranial disease

Prior intracranial hemorrhage

Ischemic stroke ≤ 3 months ago

Active bleeding

Recent spinal or brain surgery

Recent brain injury or head trauma with fracture

Bleeding diathesis

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 15/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

Contraindications to thrombolytic therapy in massive pulmonary embolism [38]

Collapse all sections REGISTER LOG IN

Relative contraindications Systolic blood pressure > 180 mm Hg

Diastolic blood pressure > 110 mm Hg

Recent nonintracranial bleeding

Recent surgery

Recent invasive procedure

Ischemic stroke > 3 months ago

Current anticoagulation use

Traumatic CPR

Pericardial fluid or pericarditis

Diabetic retinopathy
Pregnancy

Age > 75 years

Body weight < 60 kg

Embolectomy in pulmonary embolism [34]

Indication: : treatment of last resort when thrombolysis is contraindicated or unsuccessful

Procedure: surgical embolectomy (removal of an embolus by opening up an artery with an incision)

or catheter-based thrombus removal

Treatment of nonmassive pulmonary embolism and submassive pulmonary

embolism
Initiate directed therapy based on the bleeding risk on anticoagulation for VTE.

Low to moderate bleeding risk: anticoagulation for pulmonary embolism

High bleeding risk (anticoagulation is contraindicated): Consider IVC filter. [34]

Anticoagulation for pulmonary embolism [34][38][40][45]

Initial parenteral anticoagulation (first 5–10 days): not required if long-term anticoagulation is
planned with rivaroxaban or apixaban [38]
[34][40]
Low molecular weight heparin (LMWH) (e.g., enoxaparin ) or fondaparinux ;

Preferred in patients with normal renal function

LMWH is especially preferred in patients with cancer.
[45]
Unfractionated heparin (UFH) ;

In patients with renal failure

In patients with inadequate subcutaneous absorption (i.e., obesity)

In patients who might still require thrombolysis

Long-term anticoagulation (up to 3 months)

DOAC: preferred over VKA in the general population

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 16/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

No initial parenteral anticoagulation required: rivaroxaban or apixaban

Collapse all sections REGISTER LOG IN
Initial parenteral anticoagulation required: dabigatran or edoxaban

Vitamin K antagonist (warfarin; , target INR 2–3): If DOAC cannot be given, VKA is preferred
[45]
over LMWH.

LMWH: preferred in cancer patients and pregnant women

Reassessment of need for anticoagulation

After 3 months of anticoagulation, then annually

Indications for extended anticoagulation [38]

Unprovoked PE with a low to moderate risk of bleeding

Patients with cancer with any level of bleeding risk

Specific populations [38]

Recurrent VTE
Assess for true recurrence, medication compliance, and underlying malignancy.

If on VKA or DOAC, switch to LMWH at least temporarily (usually at least for 1 month).

If there is a recurrence while on LMWH, increase the dose by one-quarter to one-third.

Subsegmental PE

If there is a low risk for recurrence , anticoagulation is not necessary.

Otherwise, initiate anticoagulation.

Ultrasound of lower extremities to rule out proximal DVT.

Low-risk PE based on risk stratification (see risk stratification of pulmonary embolism)

Patients with adequate home circumstances may be treated at home or discharged early (after 5
days of treatment).

Acute management checklist

Initial management

Hemodynamic support in patients with hypotension

Supplemental oxygen as needed

Analgesics

Consult Pulmonary Embolism Response Team (PERT). [35]

Nonmassive and submassive pulmonary embolism

Assess bleeding risk and consider empiric parenteral anticoagulation while awaiting definitive
diagnosis.

If bleeding risk is low to moderate, start anticoagulation (see anticoagulation for pulmonary
embolism).

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 17/23
3/15/22, 8:34 PM Pulmonary embolism - Knowledge @ AMBOSS

If bleeding risk is high, consider IVC filter placement.

Collapse all sections REGISTER LOG IN
Consider continuous pulse oximetry and/or continuous telemetry.
In select patients with very low-risk PE (e.g., sPESI = 0): Consider outpatient therapy.

In patients with subsegmental PE with low risk of recurrent VTE: Consider clinical surveillance only.

Massive pulmonary embolism

Evaluate need for mechanical ventilation.

Have a crash cart at the bedside.

Check for contraindications to thrombolytic therapy in massive pulmonary embolism.

If there are no absolute contraindications: Initiate thrombolytic therapy in pulmonary embolism.

If thrombolytic therapy is ineffective or absolute contraindications are present: Consult

interventional radiology and/or surgery for embolectomy (see embolectomy in pulmonary
embolism).

Continuous telemetry and pulse oximetry

Transfer to ICU.

Pulseless patient with suspected PE

Start ACLS.
Consider administration of reduced dose of tPA.

Complications

High risk of recurrence: Without anticoagulant treatment, the risk of recurrence is ∼ 10% in the first
[5]
year and ∼ 5% per year after.
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)

Embolisms of smaller segmental arteries can lead to wedge-shaped hemorrhagic
pulmonary infarctions

Right ventricular failure, increased bronchial venous pressure, and preexisting pulmonary
diseases increase the risk.

Patients may present with pneumonia following pulmonary infarction, detected by peripheral
infiltration on chest X-ray (typically wedge-shaped = Hampton's hump).

Arrhythmia

https://www.amboss.com/us/knowledge/Pulmonary_embolism/ 18/23