Pulmonary Embolism

Risk stratify using the Wells PE score. Score >4: PE likely — CTPA immediately. Score ≤4: PE unlikely — D-dimer; if positive, CTPA. Massive PE (haemodynamic instability) requires immediate thrombolysis or catheter-directed therapy.

NICE Two-Level PE Pathway

The pathway

1 · Wells PE score

Clinical signs of DVT (+3)
No alternative diagnosis (+3)
HR >100 (+1.5)
Immobilisation/surgery in 4 weeks (+1.5)
Previous VTE (+1.5)
Haemoptysis (+1)
Active malignancy (+1)

>4 = PE likely.

2 · Immediate investigations

ABG
ECG (sinus tachycardia commonest; S1Q3T3 in massive PE)
CXR
CTPA if Wells >4 or D-dimer positive.

3 · Oxygen

High-flow O₂ to correct hypoxaemia. Target SpO₂ >94%.

4 · Anticoagulation

Start immediately if high clinical suspicion and no contraindication. Do NOT wait for CTPA confirmation in massive PE.

5 · Haemodynamic support

Cautious IV fluid challenge 500ml (RV is preload-dependent)
Vasopressors (noradrenaline) via ITU if shocked.

6 · Massive PE

SBP <90 or >40mmHg drop → systemic thrombolysis: alteplase 10mg IV bolus then 90mg over 2h
Or surgical embolectomy if contraindicated.

7 · Long-term

DOAC for 3 months minimum (NG158), then a review of whether to continue
Extended treatment if unprovoked, or while cancer remains active
No routine thrombophilia screen — NG158: not while anticoagulation continues, and not after a provoked VTE at all
Antiphospholipid testing only in unprovoked VTE when stopping is being considered — the reviewing team's call
A screen sent while anticoagulated is hard to interpret anyway

Drugs

Drug	Dose	Route	Notes
Apixaban	10mg BD for 7 days then 5mg BD	PO	First-line DOAC for PE. No bridging required.
Rivaroxaban	15mg BD with food for 21 days then 20mg OD	PO	Alternative first-line DOAC.
LMWH (enoxaparin)	1.5mg/kg OD or 1mg/kg BD	SC	Use if DOAC not suitable (e.g. cancer-associated VTE, pregnancy).
Alteplase	10mg IV bolus then 90mg over 2h	IV	Massive PE only. Stop anticoagulation during infusion.
Unfractionated heparin	80 units/kg bolus then 18 units/kg/hr	IV	Use in massive PE before/after thrombolysis.

When to escalate

Haemodynamic instability (massive PE) — immediate thrombolysis discussion,Intermediate-high risk (sPESI ≥1, or PESI class III–V, WITH both RV dysfunction on echo/CTPA and a raised troponin) — HDU monitoring,Contraindication to anticoagulation,PE in pregnancy — contact obstetrics and haematology

Reference: NICE NG158 / ESC PE Guidelines 2019

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