Red flags
- Haemodynamic instability (massive PE)
- RV dysfunction on echo/troponin (submassive)
- Cardiac arrest with dilated RV
First steps
- ABCDE + O₂ to SpO₂ >94%
- Wells score + PERC
- IV access, ECG
Key investigations
- Wells + D-dimer (low-risk)
- CTPA if intermediate/high risk
- V/Q if CTPA contraindicated (renal, pregnancy)
- Troponin, BNP, echo (RV strain)
Differentials
- ACS
- Pneumonia
- Pneumothorax
- Aortic dissection
Initial management
- Anticoagulate: LMWH bridge then DOAC (apixaban 10 BD × 7 d, rivaroxaban 15 BD × 21 d)
- Massive PE: systemic tPA 100 mg IV over 2 h + heparin
- Submassive: consider catheter-directed thrombolysis
- IVC filter only if OAC contraindicated
Referral
- Respiratory/haematology for anticoagulation
- Interventional radiology for catheter thrombolysis
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