Pulmonary embolism management

Initial ABCDE assessment

Follow usual ABCDE approach if critically ill.

Investigations

• Confirm/exclude diagnosis
  • D-Dimer if low PE Wells score
  • CTPA (or V/Q scan if CTPA contraindicated)
• Other tests
  • ECG may show: tachycardia; RV strain, i.e. T-wave inversion in right precordial and inferior leads; RBBB; right axis deviation; S₁Q₃T₃; RA enlargement, i.e. P pulmonale; RV dilation, i.e. dominant R in V1
  • CXR may show: wedge infarcts; regional oligaemia; enlarged pulmonary artery; effusion
  • Echocardiogram: right ventricular dysfunction/dilation
  • Troponin: higher mortality risk if raised
• Consider looking for cause if unprovoked PE 
  • Malignancy: undertake history, examination and basic blood tests (FBC, U&Es, LFTs, coagulation screen); further investigations only if relevant symptoms/signs
  • Antiphospholipid syndrome: check antiphospholipid antibodies if antiphospholipid syndrome suspected
  • Hereditary thrombophilia: consider testing if first-degree relative also has DVT or PE

Management algorithm

Calculate the PE Wells score to predict the likelihood of PE. This score takes into account risk factors (recent surgery/immobility, previous VTE, cancer), symptoms of VTE (DVT symptoms, HR, haemoptysis), and the likelihood of alternative diagnosis (Wells et al. 2001).

Reference: NICE ‘NG158 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing’ 2020

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Therapeutic anticoagulant options

Thrombolysis and other interventions

• ‘High-risk’ PE (persistent hypotension, obstructive shock or cardiac arrest) → immediate thrombolysis 
• ‘Intermediate-risk’ PE (haemodynamically stable, but with RV dysfunction and/or myocardial necrosis) → consider heparin infusion initially, so thrombolysis can be given more safely if patient develops high-risk features 

NB: thrombolysis is followed by an unfractionated heparin infusion. If thrombolysis is contraindicated or fails, other options such as surgical embolectomy or percutaneous catheter-directed treatment can be considered.

Reference: European Society of Cardiology ‘Guidelines for the diagnosis and management of acute pulmonary embolism’ 2019

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