Clinical

Clinical Practice Guideline Title: Management of Acute Pulmonary Embolism

Ownership: Internal Medicine

Code: RH-CPG/(Internal Medicine)/001

Effective Date: April 2016

Revision Due Date: April 2017

Edition Number: 01

Revision Number: 00

Applies to: Internal Medicine, Emergency,

First Edition Date: April 2016
Cardiology, Pulmonary Medicine, Intensive
Care, Cardiothoracic Surgery, Radiology,
Nursing Department, Pharmacy
1) Clinical Criteria
Patients with clinically suspected or confirmed acute pulmonary embolism should be included in
the clinical pathway of acute pulmonary embolism (PE).
1.1 Guidelines Objectives:
The objectives of the guidelines are
1.1.1 Early diagnosis of acute PE
1.1.2 Proper management in concordance with the international guidelines
1.1.3 Reduction of the 30-day mortality rate and reduction of hospital length of stay
1.1.4 Proper health education of patient with acute PE
1.1.5 Organize the follow-up of patients with acute PE in outpatient clinic
1.1.6 Order follow-up radiological investigation and transthoracic echo on specific
indications
1.1.7 Issue Red Flag card to patients with acute PE on discharge from hospital
1.1.8 Write travel fitness after discharge from hospital on specific criteria
1.2 Clinical Pathway:
To assist physicians from Emergency Medicine, Internal Medicine, Cardiology, Pulmonary
Medicine, Intensive Care to manage acute pulmonary embolism in consistent pathway with
help of multidisciplinary approach with other specialties included in the protocol
1.3 Inclusion Criteria:
1.3.1 Patient age >12 years old
1.3.2 First line physician will assess patients with symptoms and signs suggestive of
acute PE by checking a special screening sheet including the modified wells score.
1.3.3 Initiate the clinical pathway of acute PE if clinically confirmed or highly suspected
1.4 Exclusion Criteria:
1.4.1 Any patient with modified Wells score 4 and normal D-Dimer according to acute
PE screening sheet

Quality & Development Office

Page 1- of -13

2) Protocol
2.1 Definition of Acute PE: Is the presence of filling defect of the pulmonary artery or one of its
branches by thrombus originated in situ or dislodged from the venous vasculature
2.1.1 Definition of Massive PE:
Is acute PE with right ventricular strain which results in shock or hypotension (systolic blood
pressure <90 mm Hg or drop of systolic blood pressure >40 mm Hg from baseline reading which
sustains for >15 minutes) which cannot be explained by other etiologies
2.1.2 Definition of Submassive PE:
Is acute PE with right ventricular strain without hemodynamics compromise
2.2 Definition of Subacute PE: Is PE which may present within days or weeks following the initial
event
2.3 Definition of Chronic PE: Is PE with slowly developing symptoms of pulmonary hypertension
over years
2.4 Protocol of initial evaluation and management of Acute PE:
2.4.1 Any patient with suspected symptoms and signs of acute PE will be evaluated by the physician
from Emergency if the patient is in ED, 1st on-call medical physician if the patient is in the ward,
intensivist if the patient is in ICU by filling the Acute PE Triage Sheet (attachment 1)
2.4.2 Suspected cases of acute PE initial evaluation and management to be at least in high dependency
unit with cardiac monitoring. Provide oxygen to keep pulse oximetry >95%. Give intermittent 500 ml
boluses of crystalloids for any hypotension
2.4.3 Request the following laboratory blood test for all patients with suspected acute PE (available in
the SAM Special Package): CBC, Troponin, Pro BNP, Urea / electrolytes, Creatinine, LFT, PT/INR and
PTT
2.4.3.1 D-Dimer is not required for high risk patients (shock or hypotension)
2.4.3.2 D-Dimer might be elevated in patients with cancer, pregnancy, trauma or surgical cases
2.4.3.3 D-Dimer can be normal in some cases with acute thrombosis
2.4.3.4 D-Dimer will be needed for outpatient follow-up to decide about stopping treatment
2.4.3.5 D-Dimer information above to be highly taken by the assessing physician and radiologist
2.4.4 Request electrocardiogram (ECG) and chest x-ray for all patients with suspected acute PE
2.4.5 Request Arterial Blood Gas (ABG) if patients pulse oximetry is <95% to assess the degree of
hypoxemia and (A-a) gradient

Quality & Development Office

Page 2- of -13

2.4.6 Calculate modified Wells score if acute PE is suspected:

Clinical symptoms of DVT (leg swelling, pain with palpation)

3.0

Other diagnosis less likely than pulmonary embolism

3.0

Heart rate >100/minute

1.5

Immobilization (3 days) or surgery in the previous four weeks

1.5

Previous DVT/PE

1.5

Hemoptysis

1.0

Malignancy

1.0
Probability

Total Score:

Simplified clinical probability assessment (Modified Wells criteria)

>4.0
4.0

PE likely
PE unlikely

2.4.6.1 If modified Wells score is >4, proceed for definite radiological investigation to confirm
acute PE
2.4.6.2 If modified Wells score is 4, request D-Dimer. If D-Dimer is elevated proceed for
definite radiological investigation, otherwise consider another etiology of patient symptoms
2.4.7 Start anticoagulation in all suspected or diagnosed PE unless contraindicated as per the PE triage
sheet instructions
2.4.8 Radiological investigation of acute PE will be as the following:
2.4.8.1 CT pulmonary angiography is the preferred modality. The report will include the location
of filling defects and severity by calculation of right ventricle (RV) diameter/ left ventricle (LV) diameter
ratio. If RV/LV ration is 1, it indicates high-risk acute pulmonary embolism
2.4.8.2 D-Dimer is not required if the patient is high risk probability or modified Wells score >4
2.4.8.3 Timing of the exam is upon agreement between the clinician and the radiologist
2.4.8.4 In case of renal impairment/high creatinine/contrast allergy/metformin and high probability
due to above criteria then ultrasound of both lower limbs to be performed to rule out DVT in Rashid
Hospital radiology department plus V/Q scan to be arrange between the admitting physician and nuclear
medicine unit in Dubai hospital
2.4.8.5 In case of pregnancy and high wells score, the emergency doctor will seek the opinion of
the gynecologist before deciding further investigation. Ultrasound and V/Q scan will be requested choice
2.4.8.6 In case of intravenous contrast precautions or pregnancy and the physician insists on
doing CT, high risk consent should be signed by them before performing the exam
2.4.8.7 When hemodynamic instability is present, proceed for Echocardiography by cardiologist
and Doppler lower limbs by radiologist
2.4.8.8 In case of intravenous contrast study is required for CT pulmonary angiography, adequate
hydration and possible N-Acetylcysteine to be prescribed by ordering physician if there is a risk of
contrast nephropathy according to the clinical judgment

Quality & Development Office

Page 3- of -13

2.4.9 Calculate the Simplified Pulmonary Embolism Severity Index (SPESI) score if acute PE
confirmed or highly suspected. If SPESI score is 1, the 30-day mortality risk is 10.9% and you consider
thrombolysis of the same patient
SIMPLIFIED Acute Pulmonary Embolism Severity Index and Mortality Risk (SPESI score)
Parameter
Age
Cancer
Chronic heart failure
Chronic pulmonary disease
Pulse rate 110/min
Systolic blood pressure <100 mm Hg
Arterial oxyhaemoglobin saturation <90%
Risk Strata (30-day mortality risk)

Simplified version
1 point (if age >80 years)
1 point
1 point
1 point
1 point
1 point
0 point: 1.0%
1 point: 10.9%

2.4.10 Emergency thrombolysis to be administered by privileged ED physician or cardiologist on the

following conditions:
2.4.10.1 Confirmed acute PE and cardiac arrest
2.4.10.2 Suspected acute PE and cardiac arrest if (history is highly suggestive PE + modified
Wells score >4) or cardiologist report of right ventricular strain by echo or radiologist report of deep
venous thrombosis by bedside Doppler lower limb
2.4.11 Activate Acute PE Clinical Pathway (attachment 2) if the diagnosis is confirmed to the concerned
specialty from Internal Medicine, Cardiology
2.5 Protocol of Definitive Management of Acute PE:
2.5.1 Anticoagulation:
2.5.1.1 Anticoagulation with IV heparin alone risk of bleeding is high, invasive procedure is
planned or patient hemodynamics/respiration are unstable
2.5.1.2 Anticoagulation with IV Heparin or SQ LMW Heparin plus Warfarin in the same time if
the patient hemodynamics are stable
2.5.1.3 Non-vitamin K oral anticoagulation (NOAC) will be a better choice for stable patients
and no contraindications
2.5.1.4 Warfarin is contraindicated in pregnancy
2.5.1.5 Consult Hematology team for patients with Heparin Induced Thrombocytopenia (HIT)

Quality & Development Office

Page 4- of -13

2.5.2 Thrombolysis:
2.5.2.1 Calculate early mortality risk of acute pulmonary embolism according to the table below
Early mortality risk for patients with acute pulmonary embolism (For possible thrombolysis)
Early mortality risk

High
Intermediate high
Intermediate low
Low

Risk parameters and scores

Shock or
SPESI 1
hypotension
+
-

+
+
+
-

Signs of RV
Cardiac laboratory
dysfunction on an
biomarker
Imaging test
+
+
Both positive
Either one (or none) positive
Assessment optional; if assessed, both
negative

2.5.2.2 Thrombolysis is indicated in case of hypotension or shock

2.5.2.3 Thrombolysis is better to be given in intermediate-high risk group for early mortality
2.5.2.4 Thrombolysis is not indicated in low risk or low-intermediate risk group for early mortality
2.5.2.5 Thrombolysis will be given according to the protocol of acute PE if no contraindication
(attachment 3)
2.5.2.6 Follow intravenous heparin infusion sliding scale post-thrombolysis (attachment 3)
2.5.2.7 Repeat echo at least 24 hours post-thrombolysis to follow the RV pressure (accept <35 mm Hg)
2.5.2.8 If the patient had failure of thrombolysis in the form of clinical deterioration and RV pressure
rising, consider rescue percutaneous Catheter Directed Thrombolysis (CDT) or Catheter Directed
Thrombus Aspiration by Interventional Radiologist
2.5.2.9 Start oral anticoagulation post-thrombolysis once the patient is stable
2.5.3 Surgical Pulmonary Embolectomy:
2.5.3.1 Embolectomy is indicated in patients with hemodynamically unstable PE in whom thrombolytic
therapy is contraindicated with the availability of cardiac surgeon, cardiopulmonary bypass machine in
the operation room and Extra-Corporeal Membrane Oxygenator (ECMO) in Intensive Care Unit
2.5.3.2 It is also a therapeutic option in those who fail thrombolysis
2.5.3.3 Interventional radiologist can remove emboli by percutaneous catheter aspiration if surgical
embolectomy cannot be done
2.5.4 Inferior Vena Cava (IVC) filter:
2.5.4.1 IVC filter is not routinely recommended
2.5.4.2 To be considered if any absolute contraindications for anticoagulation
2.5.4.3 In patients with acute deep venous thrombosis or PE who are treated with anticoagulants, we
recommend against the use of an IVC filter according to the international guidelines
2.5.4.4 No evidence to support the use of IVC filters in patients with free-floating thrombi in proximal
veins or in those scheduled for systemic thrombolysis, surgical embolectomy, or pulmonary
thromboendarterctomy

Quality & Development Office

Page 5- of -13

3) Algorithm

Quality & Development Office

Page 6- of -13

4) Other Healthcare Provider Role

Responsibility

1. Most Responsible
physician

Cardiology: High or Intermediate-high early mortality risk

patients who will require thrombolysis or Catheter directed
intervention

Quality & Development Office

Page 7- of -13

2. Site of care

Internal Medicine: Intermediate-low or Low early mortality risk

patients who do not need thrombolysis or catheter directed
intervention
Pulmonary Medicine: Acute PE in patients with obstructive
lung disease, interstitial lung disease on immune-suppressive
treatment, lung transplant

3. Triage nurse

High dependency unit: Intermediate-low or Low early mortality

risk patients who do not need thrombolysis or catheter directed
intervention
Coronary Care Unit (CCU): High or Intermediate-high early
mortality risk patients who will require thrombolysis or Catheter
directed intervention
Intensive Care Unit (ICU): Patients post-intubation who are not
candidate for thrombolysis. Patients who require Catheter
directed intervention will be in ICU.
Emergency Department: Preferably in the Resuscitation room
till further management plan is arranged
Assess the vital signs of the patient after initial triaging
Inform the ED physician about the possibility of acute PE

4. ED nurse

Reassess the patient according to the acute PE triage sheet

Connect patient to cardiac monitor
Inserts IV cannula
Provide oxygen to keep SpO2 95%
Inform lab and ECG technician for further investigations

5. ED Physician &
Nurse

Urgent assessment of the patient clinical presentation

Review ECG, asks for CXR and obtain ABG
Calculate modified Wells score for suspected cases
Follow instructions according to the acute PE triage sheet

6. ED Physician

Investigate for acute PE according to triage sheet

Activate acute PE clinical pathway once confirmed or highly
suspected
Consult 1st on-call medical physician to assess patient for low or
intermediate-low risk patients
Consult 1st on-call cardiologist to assess patient for intermediatehigh or high risk patients
Give rescue thrombolysis for confirmed or highly suspected cases
with cardiac arrest in ED

7. 1st Medical on-call

Assess the patient with acute PE on referral according to the

clinical pathway
Inform 2nd or 3rd on-call about the patient
Will accept referrals from the wards in Rashid Hospital and
Trauma Center for suspected cases

Quality & Development Office

Page 8- of -13

8. 1st on-call
Cardiologist

Assess the patient with acute PE on referral according to the

clinical pathway
Inform 2nd or 3rd on-call about the patient

9. CoC or ED nurse
and messenger

Responsible for mobilization of the patient from ED to high

dependency unit or CCU or ICU

10. CCU/ICU/High
dependency ward
Nurse

Reassessment of the patient

Monitoring the patient as per the protocol of CCU/ICU/HDU
Implementation of acute PE clinical pathway

11. General ward

Nurse

Implementation of acute PE clinical pathway

Follow-up anticoagulation treatment with the treating physician
Follow-up patient education on process

12. Dietitian

Review patient diet that might affect anticoagulation

13. Physical medicine

and rehabilitation

Assessment of physical activity with mobilization out of bed on

gradual steps once patient is fit

14. Radiology Staff

CXR on presentation to ED
Arrange CT pulmonary angiogram on maximum of 2 hours

15. Biochemistry

To carry the orders from triaging physician for CBC, Troponin,

Pro BNP, Urea/electrolytes, Creatinine, LFT, PT/INR and PTT as
per the pathway protocol

16. Pharmacy

Dispense the required medications particularly anticoagulation,

thrombolytic after verification of the order as per the acute PE
clinical pathway

17. Case management

Co-ordinate and facilitate the admission and discharge

18. Medical Record

Department

Maintenance of the records and make it available to the treating

physician (as per policy)

19. Experts Panel

Emergency Department: Dr. Firas Annajjar

Internal Medicine: Dr. Salman Abdulaziz
Cardiology: Dr. Khalifa Omar, Dr. Juwairia Al-Ali
ICU: Dr. Mohammed Baqer
Expert panel members will provide medical advice for any case
of acute pulmonary embolism if needed

5) Participant (Patient) Role

5.1 Encourage patient to adhere with the treatment and advices provided during the time of acute illness
and while inpatient until discharge
Quality & Development Office
Page 9- of -13

5.2 Mobilization and bed rest as per orders in the clinical pathway
5.3 Maintain oxygen mask/ nasal prongs as deemed necessary by treating physician
5.4 Maintain ECG monitor cable and BP measuring devices attached
5.5 Be motivated on rehabilitation including healthy life style changes
5.6 Conform with hospitals rules and regulations as per the Patients and Family Bills of Right
Ensure to deposit and offset the bill/payment involved in the treatment and diagnostic procedures
(invasive and non-invasive where applicable) and other payable services provided during hospitalization

6) Patient Reassessment Criteria

6.1 All acute patients in the High Dependency Units/ CCU/ICU will be re-assessed within 24 hours
6.2 Frequent reassessment of unstable patients will be required in accordance to the clinical status
6.3 Reassessment tools include focused history and examination
6.4 Follow up ECG, CXR, Echo and laboratory tests including cardiac biomarkers as needed
6.5 Stable patients in general wards will be re-assessed once in 24hrs as per hospital policy.
6.6 Early discharge (after 48 hours) criteria include:
6.6.1 SPESI score is 0
6.6.2 Normal cardiac markers
6.6.3 Health education is done properly
6.7 The treating physician will fill Acute Pulmonary Thromboembolism Discharge Orders
6.8 The treating physician will provide RED FLAG card and Patient Education Manual about acute PE,
treatment, follow-up
6.9 Travel fitness for cases with Acute Pulmonary Embolism will be provided by treating physician if:
6.9.1 No fitness to fly within the first 4 days of onset
6.9.2 Medical clearance can be in less than 21 days
6.9.3 May travel after 5 days if the patient had stable anticoagulation and normal PAO2 on room air
6.10 Outpatient follow up in Rashid Hospital after 2 weeks from discharge with the following items:
6.10.1 Blood test: CBC, Coagulation profile if needed, D-Dimer, Troponin, Pro-BNP
6.10.2 Thrombophilia study after the first episode of acute PE to be requested only after 4 weeks
from the end of treatment duration according to the clinical assessment
6.10.3 Pulmonary Embolism Radiology study if: recurrent symptoms and signs of pulmonary
embolism, elevated D-Dimer which is persistent or recurrently elevated, right ventricular strain identified
by Echo, or cardiac catheterization
6.10.4 Patients post-thrombolysis or catheter intervention will require echo follow-up on 2 weeks
then 12 weeks interval to assess the pulmonary artery pressure (PAP). If persistent or continuous
elevation of PAP to refer patient to specialized cardiac center for right side cardiac catheterization and
possible pulmonary artery endarterectomy

7) Definitions:
7.1 Definition of Acute PE: is the presence of filling defect of the pulmonary artery or one of its
branches by thrombus originated in situ or dislodged from the venous vasculature
7.1.1 Definition of Massive PE:
is acute pulmonary embolism with right ventricular strain which results in shock or hypotension
(systolic blood pressure <90 mm Hg or drop of systolic blood pressure >40 mm Hg from baseline reading
which sustains for >15 minutes) which cannot be explained by other etiologies
Quality & Development Office
Page 10- of -13

7.1.2 Definition of Submassive PE:

is acute pulmonary embolism with right ventricular strain without hemodynamics compromise
7.2 Definition of Subacute PE: is pulmonary embolism which may present within days or weeks
following the initial event
7.3 Definition of Chronic PE: is pulmonary embolism with slowly developing symptoms of
pulmonary hypertension over years

8) Tools/Attachments Forms:
8.1 Modified Wells score if acute pulmonary embolism is suspected
8.2 Simplified Acute Pulmonary Embolism Severity Index and Mortality Risk (SPESI score)
8.3 Early mortality risk for patients with acute pulmonary embolism (For possible thrombolysis)
8.4 Flow chart for management of acute pulmonary embolism
8.5 Acute Pulmonary Thromboembolism Clinical Pathway
8.6 Acute Pulmonary Embolism Red Flag Card and Patient Education Manual
8.7 Consent form
9) Performance Indicator:
9.1 Compliance of triaging physician on calculation of modified Wells score
9.2 Order time to CT pulmonary angiogram time of 2 hours by radiology technician
9.3 Simplified Acute Pulmonary Embolism Severity Index and Mortality Risk (SPESI score) and Early
mortality risk for patients with acute pulmonary embolism (For possible thrombolysis) by triaging
physician
9.4 Compliance of the treating team on echo indications
9.5 Compliance of the treating team on the clinical pathway
9.6 Reduction of length of stay in hospital
9.7 Reduction of mortality rate
9.6 Proper discharge summary
9.7 Red Flag Card, Patient Education Manual
9.8 Patient Satisfaction Survey
9.9 Regular and well organized long-term follow up plan

10) Search words:

Acute Pulmonary Embolism
Massive Pulmonary Embolism
Submassive Pulmonary Embolism

Quality & Development Office

Page 11- of -13

11) References:

Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest.
2016;149(2):315-352

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2_suppl):7S-47S.

2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart
J. 2014 Nov 14;35(43):3033-69.

Six Months vs Extended Oral Anticoagulation after a First Episode of Pulmonary Embolism the
PADIS-PE Randomized Clinical Trial. JAMA. 2015;314(1):31-40.

Acute Pulmonary Embolism. N Engl J Med 2010;363:266-74.

Management of venous thrombo-embolism: an update. Eur Heart J. 2014 Nov 1;35(41):2855-63

2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2015; 132: S501-S518

Evaluation of Persistent Pulmonary Hypertension after Acute Pulmonary Embolism. CHEST.

2007; 132:780785

Prepared by:

1. Dr. Salman Abdulaziz

Signature:
2. Dr. Laila Hussain
Signature:

Designation: Specialist Senior Registrar

Date: 09/02/2016
Designation: Resident
Date: 09/02/2016
Quality & Development Office
Page 12- of -13

3. Dr. Khalifa Omar Muhammed

Signature:

Designation: Specialist Senior Registrar

Date: 09/02/2016

4. Dr. Usama Al-Bastaki

Designation: Consultant

Signature:

Date: 09/02/2016

Reviewed by:
1. Dr. Jamila Mohammed Bin Adi
Signature:

Designation: Head of General Medicine Department

Date:

Approved by:
1. Dr. Walid Mahmood
Signature:

Designation: Acting Head of Internal Medicine Dept.

RH Medical Affairs Advisory Board
Date:

Reviewed & Acknowledged by:

Signature:

Designation: Head of Quality & Development

Date:

Authorized by:
Dr. Alya Saif Al Mazrouei

Designation: RH CEO

Signature:

Date:

Quality & Development Office

Page 13- of -13