Acute Pulmonary Embolism & Right Heart Strain

Resuscitation Quick Ribbon (First 2 Minutes)

Massive PE Thrombolysis:Alteplase (tPA) 100 mg IV infusion over 2 hours; in arrest, 50 mg IV push over 2 min

Therapeutic Anticoagulation:Enoxaparin 1 mg/kg SC q12h OR Heparin 80 U/kg IV bolus + 18 U/kg/h infusion

DOAC (Low-Risk PE):Apixaban 10 mg PO BID x 7 days OR Rivaroxaban 15 mg PO BID x 21 days

Fluid Caution:Limit IV fluids to <= 500 mL; excessive volume worsens RV ischemia and bowing of septum

Bottom-Line Clinical Pearl

Pulmonary embolism triage is driven by hemodynamics, not clot burden. Massive PE = sustained hypotension (SBP < 90 mmHg for > 15 min), requiring immediate systemic thrombolysis (Alteplase 100 mg IV over 2 hours, or 50 mg push in arrest). Submassive PE = normotensive but with evidence of RV dysfunction (elevated troponin/BNP or RV dilation on POCUS/CT), requiring immediate therapeutic anticoagulation (LMWH or unfractionated heparin) and close monitoring for decompensation.

1. Risk Stratification: Massive vs. Submassive vs. Low-Risk

Classification	Blood Pressure	Biomarkers (Troponin/BNP)	RV Dysfunction (Echo/CT)	Primary ED Treatment
Massive PE	Hypotension: SBP < 90 mmHg or drop >= 40 mmHg > 15m	Positive	Positive (Severe RV failure)	Systemic Thrombolysis (Alteplase) or Catheter Embolectomy
Submassive PE	Normotensive (SBP >= 90)	Positive (Troponin or BNP)	Positive (RV/LV ratio > 0.9)	Immediate therapeutic anticoagulation (Heparin/LMWH), ICU admission
Low-Risk PE	Normotensive	Negative	Negative (Normal RV)	Anticoagulation (DOAC), consider safe outpatient discharge via PESI score