Massive PE with shock (sustained hypotension): this is high-risk PE. Discuss immediate thrombolysis (or embolectomy) and start anticoagulation unless an absolute bleeding contraindication.
Two-level Wells (higher weight items)
- Clinical DVT signs (3), PE the most likely diagnosis (3)
- HR over 100 (1.5), immobilisation or surgery (1.5), previous VTE (1.5)
- Haemoptysis (1), active malignancy (1)
- 4 or less: PE unlikely; over 4: PE likely
Investigation
- PE likely (over 4): CTPA; if delayed, give interim anticoagulation
- PE unlikely (4 or less): D-dimer; if positive, CTPA
- Pregnancy: do not use D-dimer or Wells; chest X-ray then CTPA or V/Q per pathway
Low risk (sPESI 0)
- Stable, no RV strain
- Consider outpatient treatment
- DOAC first line
Intermediate
- RV strain on CT or echo
- Raised troponin or BNP
- Admit and monitor
High risk (massive)
- Sustained hypotension or shock
- Thrombolysis or embolectomy
- Anticoagulate unless contraindicated
PE pathway
1
1. Stabilise
Oxygen to target saturations, careful fluids (cautious bolus if RV strain). Analgesia. ECG and chest X-ray to look for alternatives.
Oxygen to target saturations, careful fluids (cautious bolus if RV strain). Analgesia. ECG and chest X-ray to look for alternatives.
↓
2
2. Anticoagulate
DOAC first-line (apixaban or rivaroxaban) when PE confirmed, or as interim treatment if scan is delayed and suspicion is high. LMWH in pregnancy or active cancer; LMWH or UFH if thrombolysis likely.
DOAC first-line (apixaban or rivaroxaban) when PE confirmed, or as interim treatment if scan is delayed and suspicion is high. LMWH in pregnancy or active cancer; LMWH or UFH if thrombolysis likely.
↓
3
3. Risk stratify
sPESI for severity. High-risk (shock): thrombolysis. Low-risk sPESI 0: consider outpatient treatment. Intermediate: admit and monitor.
sPESI for severity. High-risk (shock): thrombolysis. Low-risk sPESI 0: consider outpatient treatment. Intermediate: admit and monitor.
↓
4
4. Cause and duration
At least 3 months anticoagulation. Review provoked vs unprovoked. Consider cancer and thrombophilia assessment for unprovoked PE.
At least 3 months anticoagulation. Review provoked vs unprovoked. Consider cancer and thrombophilia assessment for unprovoked PE.
Signs of RV strain
- Hypotension or syncope
- Raised troponin or BNP
- RV dilatation on CT or echo, S1Q3T3 on ECG
Pitfalls
- Using D-dimer or Wells in pregnancy
- Waiting for the scan before anticoagulating a high-probability PE
- Aggressive fluids worsening RV failure
- Missing high-risk PE needing thrombolysis
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026