• Shortness of breath
• BP about 60/40 mmHg
• Pulse about 140/min
• SpO₂ about 65%
• Patient described as clinically very ill, with altered behavior/orientation possibly noted
• A call/referral to the Medicine Department

• Keep the patient resting, preferably upright if breathing is easier.
• Do not let them walk or exert themselves.
• Do not give food or drink if drowsy, confused, or severely breathless.
• Bring this note and all current medicines to the hospital.

Immediate emergency actions - clinician/ED team

1. Activate emergency help
   • Call senior emergency/ICU/anaesthesia and cardiology or a PE-response team if available.
   • Continuous ECG, BP, SpO₂ monitoring, defibrillator pads, two large-bore IV lines.
   • Transfer only by ambulance and only with monitoring/resuscitation capability.
2. ABC resuscitation
   • Give high-concentration oxygen and support ventilation.
   • Obtain ABG/VBG, glucose, ECG, CBC, coagulation profile, renal function, troponin, lactate, and group-and-crossmatch.
   • Avoid unnecessary sedation.
   • Avoid intubation if possible because induction and positive-pressure ventilation can abruptly reduce venous return and precipitate cardiovascular collapse in massive PE. If unavoidable, it should be performed by an experienced airway team with vasopressor support ready. Oxygen is essential in shock/hypoxemia from PE. Murray & Nadel's Textbook of Respiratory Medicine, pp. 1876-1877.
3. Support circulation
   • Start a vasopressor, usually norepinephrine, for hypotension/shock.
   • Give only small, cautious fluid boluses if there is evidence of low filling, then reassess. Large fluid volumes can worsen right-ventricular dilatation and failure.
   • Consider an inotrope such as dobutamine only in an ICU setting when there is low cardiac output despite adequate pressure.
4. Bedside confirmation without delaying resuscitation
   • Bedside echocardiography for acute RV dilatation/failure, clot-in-transit, or alternative diagnoses.
   • Compression ultrasound of legs for DVT.
   • CTPA if the patient becomes stable enough for transport.
   • In a patient in shock, bedside tests may be imperfect and emergency treatment may be necessary before definitive proof. Murray & Nadel's Textbook of Respiratory Medicine, p. 1877.
5. Start anticoagulation if no active major bleeding
   • In unstable patients, IV unfractionated heparin is generally preferred because it can be adjusted or stopped rapidly if thrombolysis, catheter intervention, or surgery is needed.
   • Do not delay treatment solely while awaiting CT when clinical probability is very high and bleeding risk is acceptable. Anticoagulation should begin immediately in suspected PE while confirmatory testing is pending. Goldman-Cecil Medicine, p. 805.
6. Urgent reperfusion therapy
   • For massive PE with shock, persistent hypotension, or peri-arrest deterioration, systemic thrombolysis is usually the first reperfusion option if there is no major contraindication.
   • If thrombolysis is contraindicated, has failed, or bleeding risk is unacceptable, urgently consider catheter-directed therapy/mechanical thrombectomy or surgical embolectomy, depending on local expertise.
   • The current multidisciplinary ACC/AHA acute PE guideline summary identifies anticoagulation plus escalation to systemic thrombolysis, catheter-based therapy, thrombectomy, or embolectomy according to severity.
7. If cardiac arrest occurs
   • Start high-quality ALS/CPR immediately.
   • Treat PE as a reversible cause.
   • The arrest team may give thrombolysis when PE is strongly suspected, following local protocol, and continue resuscitation for a prolonged period when appropriate.

Do not do

• Do not manage this at home or in a routine outpatient setting.
• Do not give a large unmonitored fluid load.
• Do not delay emergency escalation for D-dimer or CT in a shocked patient.
• Do not administer thrombolysis without assessing for major bleeding risks, such as active bleeding, prior intracranial hemorrhage, recent major brain/spinal surgery or trauma, or suspected aortic dissection.