Pulmonary Embolism (in Adults)

Wells/YEARS approach


Major risk factors for PE


  • Major abdominal / pelvic / knee surgery
  • Post-op intensive care


  • Late pregnancy, Caesarian section
  • Puerperium

Lower limb problems

  • Fracture, Varicose veins


  • Abdominal / pelvic
  • Advanced / metastatic

Reduced mobility

  • Hospitalisation
  • Institutional care


  • Previous proven VTE

Management probable massive PE

Massive PE likely if:

  • Collapse/hypotension and
  • Unexplained hypoxia, and
  • Engorged neck veins, and
  • Right ventricular gallop (often)


Alteplase dose

For patients >65kg a total dose of 100mg should be administered in 2 hours as follows:
10mg as an IV bolus over 1-2 minutes, followed by an IV infusion of 90mg over 2 hours

For patients <65kg the total dose should not exceed 1.5mg/kg as follows:
10mg as an IV bolus over 1-2 minutes, followed by remainder of dose as an IV infusion over 2 hours

Post thrombolysis

  • Thrombolysis should be immediately followed by unfractionated heparin
    • Give bolus UFH 5000 units (unless earlier/on therapeutic LMWH)
    • Then 1000 U per hour and ajust to aPTT at 2.0-2.5 times the upper limit of normal
    • If already given LMWH, delay IV heparin for 12 hours and reassess (with aPTT)
  • Contraindications to thrombolysis should be reconsidered in life-threatening PE
  • Out -of-hospital cardiac arrest patients with PE rarely recover
  • Thromboilysed cases should be discussed with the respiratory team on call

Management Proven VTE

Provoked PE

Anticoagulate for 3 months (after the provoking trigger resolved).

Unprovoked PE

Increased risk of occult malignancy so:

  • Ask about personal or family history of malignancy and symptoms concerning for underlying malignancy e.g. weight loss, bleeding, altered bowel habit etc
  • A thorough physical exam: including breast and PR
  • Ensure age appropriate screening is up to date
  • Check FBC, ESR, LFT, U&E, CXR, Ca++, urinalysis and CXR
  • Men > 40 - request PSA
  • The need for further investigation (endoscopy, imaging etc.) should be guided by findings from the history and exam and results from the initial blood tests (ISTH 2017, NICE 2020)
  • Unprovoked (SPESI 0) should be reviewed by an EM Senior and treated with an explanation of their situation, a prescription for Rivaroxaban (x3 months [15mg Bd x21days then 20mg OD x70 days]) and a referral letter to Haematology OPD for review. If in CUH, please warn the patient that the waiting list for (under-resourced) Haematology OPD in CUH may be many weeks. Please copy the GP in all correspondence

Content by - Dr Íomhar O' Sullivan. Last review Dr √ćomhar O' Sullivan 1/12/22.