An evidence-based tool to guide the identification and outpatient treatment of patients with low-risk pulmonary embolism.
- Untreated substance use disorder
- Dysregulated psychiatric disease
- Lack of ability to follow up (e.g. transportation)
- Lack of ability to obtain medications (e.g. no insurance)
- Any other condition that the physician deems as high risk for noncompliance
- RV:LV ratio >1
- Main pulmonary artery PE or saddle PE
- Clot visualized in the heart
- Echocardiogram should be considered if CTPA shows evidence of right ventricular strain (e.g. RV:LV ratio >1)
- Right ventricular hypokinesis
- Bowing of the intraventricular septum (i.e. D-sign)
- Clot visualized in the heart
- Troponin elevated
- Lower extremity venous imaging should be considered when a patient has leg pain, swelling, redness, or evidence of venous distension
- DVT in iliofemoral vein
- Evidence of phlegmasia cerulea or alba dolens
- New right heart strain pattern, including;
- Right bundle branch block
- Deep T wave inversions in anterior precordial leads
- S1Q3T3 pattern
- New onset atrial fibrillation
- Active bleeding
- Previous clinically significant bleeding including: Bleeding in a critical area or organ (e.g. intracranial, intraspinal, intraocular, retroperitoneal, intraarticular, pericardial, intramuscular with compartment syndrome, hemoptysis, airway bleeding), or other bleeding requiring intervention.
- Recent major surgery
- Recent major trauma (including closed head injury without bleeding)
- Recent stroke
- Malignancy in a critical site (e.g. intracranial, spinal, ocular, oropharyngeal, retroperitoneal)
- Thrombocytopenia (platelet count <75,000)
- Cirrhosis or severe alcohol use disorder
- High risk of falling
- Use of medications that interact with anticoagulants or significantly increase risk of bleeding
- LMWH: enoxaparin sodium (Lovenox), 1 mg/kg SC twice daily or dalteparin sodium (fragmin), 200 IU/kg SC daily
- Fondaparinux: 5 mg (body weight <50 kg), 7.5 mg (50 to 100 kg), or 10 mg (>100 kg) SC once daily
- A "Med to Bed" or similar programs whereby patients are discharged with their medications in-hand
- The patient's pharmacy may be able to confirm that the anticoagulant is covered by their insurance, without the need for a prior authorization
- A "starter pack" of a DOAC can assist patients in successfully transitioning their dose at week 1 or 3
Developed by the ACEP Expert Panel on Low-Risk Pulmonary Embolism
and Low-Risk Deep Vein Thrombosis
Reviewed by the ACEP Clinical Resource Review Committee
Christopher Kabrhel MD, MPH, FACEP, FAAEM (chair) Anna Marie Chang, MD Jackeline Hernandez-Nino, MD Alice M. Mitchell, MD, FACEP Rachel Rosovsky, MD, MPH David R. Vinson, MD, FACEP Stephen J. Wolf, MD, FACEP
Jerry Anderson Riane V. Gay, MPA, CAE Liz Muth
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