PE, tamponade and aortic emergencies

PE risk stratification and thrombolysis

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Stratify acute PE by haemodynamics, sPESI, RV dysfunction and troponin (ESC 2019 and AHA/ACC 2026 categories), and choose anticoagulation, thrombolysis or advanced therapy.

Definition
High-risk PE (ESC) / AHA-ACC category E = cardiac arrest, obstructive shock (SBP < 90 mmHg or vasopressors with end-organ hypoperfusion) or persistent hypotension (SBP < 90 or fall ≥ 40 mmHg for > 15 min). Intermediate risk = sPESI ≥ 1 or RV dysfunction/troponin; intermediate-high = both RV dysfunction AND raised troponin.

At the bedside

Timed steps
  1. 1

    Suspect and stabilise

    0 min

    Sudden dyspnoea, pleuritic pain, syncope, hypoxaemia, tachycardia; risk factors (post-op, immobilisation, cancer, pregnancy/postpartum, OCP). Oxygen; avoid intubation if possible (induction can cause arrest).

  2. 2

    Unstable: bedside echo

    < 15 min

    If shock and CT not immediately feasible: bedside echo showing RV dilatation (RV/LV > 1), McConnell sign, D-shaped LV, or a clot-in-transit justifies treatment as high-risk PE. Look for DVT with compression ultrasound.

  3. 3

    Stable: confirm

    Wells/Geneva probability; D-dimer (age-adjusted: age x 10 mcg/L if > 50 years) for low/intermediate probability; CTPA if high probability or positive D-dimer. Start anticoagulation while waiting if probability is high.

  4. 4

    Stratify

    sPESI (age > 80, cancer, chronic cardiopulmonary disease, HR ≥ 110, SBP < 100, SpO2 < 90%: 1 point each). Then RV on CT/echo and troponin: both positive = intermediate-high; one or none = intermediate-low; sPESI 0 and both normal = low risk.

  5. 5

    High risk (category E): reperfuse

    Immediately

    UFH bolus + systemic thrombolysis (alteplase 100 mg over 2 h). If contraindicated or failed: catheter-directed therapy or surgical embolectomy. Cardiac arrest from PE: alteplase 0.6 mg/kg (max 50 mg) over 15 min, continue CPR 60-90 min; consider ECMO.

  6. 6

    Intermediate-high: anticoagulate and watch

    LMWH (or UFH if thrombolysis likely) and monitor in HDU/ICU for 48-72 h. Routine primary thrombolysis is NOT recommended (PEITHO). Rescue thrombolysis or catheter therapy if haemodynamic decompensation.

  7. 7

    Low and intermediate-low

    Anticoagulation with LMWH or a DOAC (rivaroxaban/apixaban); early discharge for low risk if home circumstances allow.

Systemic thrombolysis (high-risk PE)

Alteplase (rt-PA)

IV
Dose
100 mg over 2 h; arrest 0.6 mg/kg (max 50 mg) over 15 min

Hold UFH during infusion; restart when aPTT < 2x upper limit.

Thrombolysis alternative (off-label)

Tenecteplase

IV bolus
Dose
30-50 mg by weight band (5 mg per 10 kg from 30 mg at < 60 kg)
Worked example
72 kg: 40 mg (8 mL of 5 mg/mL) single bolus

Low-cost thrombolytic

Streptokinase

IV
Dose
1.5 million IU over 2 h

Anticoagulation when reperfusion may be needed

Unfractionated heparin

IV
Dose
80 units/kg bolus then 18 units/kg/h
Preparation
25,000 units in 50 mL NS = 500 units/mL
Target
aPTT 1.5-2.5x control
Worked example
70 kg: 5,600 units bolus, then 1,260 units/h = 2.5 mL/h
Open infusion calculator

Preferred anticoagulant if stable

Enoxaparin (LMWH)

SC
Dose
1 mg/kg every 12 h
Worked example
70 kg: 70 mg SC twice daily

PE risk classes (ESC 2019) and AHA/ACC 2026 categories

RiskShock/hypotensionsPESI ≥ 1RV dysfunction + troponinApprox. AHA/ACC categoryTreatment
HighYes(+)(+)E (E1 shock, E2 arrest)Thrombolysis or advanced therapy
Intermediate-highNoYesBoth positiveC-DAnticoagulate, monitor, rescue reperfusion
Intermediate-lowNoYesOne or noneCAnticoagulate, ward
LowNoNoNeither (optional)A-BAnticoagulate, early discharge

AHA/ACC 2026 categories are approximated; see the guideline for the subcategory definitions (C1-C3, D1-D2, E1-E2).

Contraindications to thrombolysis (ESC 2019)

TypeContraindication
AbsolutePrevious haemorrhagic stroke or stroke of unknown origin
AbsoluteIschaemic stroke in previous 6 months
AbsoluteCNS neoplasm
AbsoluteMajor trauma, surgery or head injury in previous 3 weeks
AbsoluteBleeding diathesis or active bleeding
RelativeTIA < 6 months, oral anticoagulation, pregnancy/first postpartum week, non-compressible puncture, traumatic CPR, refractory hypertension (SBP > 180), advanced liver disease, infective endocarditis, active peptic ulcer
Red flag · call your senior now
PE with syncope, SpO2 < 90%, lactate > 2 mmol/L or rising vasopressor needs: high risk of collapse, involve senior/PERT now.
Red flag
Intubating a PE patient in shock can cause cardiac arrest: preoxygenate, use haemodynamically stable induction (low-dose ketamine), have noradrenaline running, avoid high PEEP.
Pitfall
Giving full-dose thrombolysis to normotensive intermediate-risk patients: PEITHO showed fewer decompensations but more haemorrhagic strokes and no mortality benefit.
Pitfall
Large fluid boluses in RV failure: they worsen RV dilatation and septal shift.
Pearl
In India streptokinase and tenecteplase are cheaper and more available than alteplase; agree a hospital PE thrombolysis protocol in advance.
Pearl
The 2026 AHA/ACC guideline recommends LMWH over UFH for most patients needing parenteral anticoagulation and multidisciplinary PE response teams for categories C-E.

Calculators for this topic

Wells score for PE

Pre-test probability of pulmonary embolism.

Shock index

Heart rate ÷ systolic BP.

Infusion rate from per-kg-per-hour dose

Pump rate for drugs dosed per kg per hour (insulin U/kg/h, midazolam mg/kg/h, propofol mg/kg/h, fentanyl mcg/kg/h, dexmedetomidine mcg/kg/h).

Infusion rate from mcg/kg/min

Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).

References

  1. 1

    Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society. Eur Heart J 2020;41:543-603.

  2. 2

    Creager MA, et al (writing committee). 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. J Am Coll Cardiol 2026.

  3. 3

    Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism (PEITHO). N Engl J Med 2014;370:1402-11.

  4. 4

    Jimenez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010;170:1383-9.

  5. 5

    Harjola VP, Mebazaa A, Celutkiene J, et al. Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the ESC. Eur J Heart Fail 2016;18:226-41.

Test yourself

Module quiz · score 70% to complete the module

Next

Acute right ventricular failure

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.