Admission Orders for Pulmonary Embolism
For patients with confirmed PE, immediately initiate anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran as first-line therapy, or alternatively use LMWH/fondaparinux if parenteral anticoagulation is preferred, while simultaneously performing risk stratification to determine appropriate level of care. 1
Immediate Risk Stratification
Upon admission, classify the patient based on hemodynamic stability:
- High-risk PE (hemodynamically unstable): Systolic BP <90 mmHg or requiring vasopressors
- Intermediate-risk PE: Hemodynamically stable but with evidence of RV dysfunction or elevated biomarkers
- Low-risk PE: Hemodynamically stable, no RV dysfunction, sPESI = 0
Anticoagulation Orders
For Hemodynamically Stable Patients (Intermediate or Low Risk):
Preferred first-line therapy - DOAC monotherapy:
- Apixaban: 10 mg PO BID × 7 days, then 5 mg PO BID
- Rivaroxaban: 15 mg PO BID × 21 days, then 20 mg PO daily
- Edoxaban: Start parenteral anticoagulation first, then 60 mg PO daily (30 mg if CrCl 15-50 mL/min or weight ≤60 kg)
- Dabigatran: Start parenteral anticoagulation first, then 150 mg PO BID
Alternative - Parenteral anticoagulation:
- LMWH (preferred over UFH): Enoxaparin 1 mg/kg SC Q12h or 1.5 mg/kg SC daily
- Fondaparinux: Weight-based dosing (<50 kg: 5 mg; 50-100 kg: 7.5 mg; >100 kg: 10 mg SC daily)
For Hemodynamically Unstable Patients (High-Risk):
- UFH bolus: Weight-adjusted IV bolus (80 units/kg), then continuous infusion (18 units/kg/hr) with aPTT monitoring
- Systemic thrombolysis: Administer immediately (reduces mortality from 3.9% to 2.3%)
- If thrombolysis contraindicated or fails: Surgical pulmonary embolectomy
Critical Contraindications and Caveats
Do NOT use DOACs in:
- Severe renal impairment (CrCl <15-30 mL/min depending on agent)
- Antiphospholipid antibody syndrome (use VKA instead)
- Pregnancy or lactation (use LMWH)
Do NOT routinely:
- Administer thrombolysis to intermediate or low-risk PE patients
- Place IVC filters
- Use rescue thrombolysis unless hemodynamic deterioration occurs on anticoagulation
Monitoring Orders
Baseline laboratory studies:
- CBC with platelets
- PT/INR, aPTT
- Comprehensive metabolic panel (assess renal and hepatic function)
- Troponin and BNP/NT-proBNP (for risk stratification)
- Pregnancy test (women of childbearing age)
Imaging:
- Baseline echocardiogram if intermediate-risk to assess RV function
- Not routinely needed for low-risk patients
Disposition Decision Algorithm
Low-risk patients (sPESI = 0, no RV dysfunction) may be discharged within 24-48 hours or managed as outpatients if:
- No oxygen requirement (SpO2 >94% on room air)
- Heart rate <90-100 bpm
- No active bleeding or high bleeding risk
- Adequate social support and follow-up within 72 hours
- No other medical indication requiring hospitalization
Common pitfall: Even with sPESI = 0, patients with HR 90-109 bpm, SpO2 90-94%, or comorbid conditions are frequently admitted and may benefit from brief observation. 5
Admit all intermediate and high-risk patients for monitoring and potential escalation of therapy. 1
Additional Admission Orders
Supportive care:
- Supplemental oxygen to maintain SpO2 >90%
- Continuous telemetry monitoring for intermediate/high-risk patients
- Fall precautions (anticoagulation bleeding risk)
- DVT prophylaxis NOT needed (already therapeutically anticoagulated)
Consultations:
- Consider Pulmonary Embolism Response Team (PERT) for intermediate-high or high-risk patients
- Cardiology consultation for hemodynamically unstable patients
Duration of Anticoagulation (Document Plan)
- Provoked PE (major transient risk factor): 3 months minimum
- Unprovoked PE or recurrent VTE: Consider indefinite anticoagulation
- Antiphospholipid syndrome: Indefinite VKA therapy
Schedule 3-6 month follow-up to reassess symptoms, consider echocardiography, and evaluate for chronic thromboembolic pulmonary hypertension (CTEPH). 1