Who to Consult for Suspected Pulmonary Embolism
For suspected PE, immediately contact a consultant physician (attending/senior physician) if the patient is deteriorating or has signs of massive PE, while stable patients can be managed by senior trainees (ST3+) or designated advanced practitioners with consultant backup available. 1
Immediate Consultation Requirements
Massive/High-Risk PE (Requires Immediate Consultant Contact)
Contact a consultant immediately if the patient presents with any combination of: 1
- Systolic blood pressure <90 mm Hg or requiring vasopressors
- Cardiac arrest or deteriorating hemodynamic status
- Collapse/hypotension with unexplained hypoxia
- Engorged neck veins
- Right ventricular gallop
These patients require urgent decisions about thrombolysis (50 mg alteplase IV), surgical embolectomy, or catheter-directed interventions—decisions that mandate consultant-level expertise. 1
Multidisciplinary Team Consultation (Pulmonary Embolism Response Team)
For intermediate-high risk PE or when interventional treatment is being considered, activate a Pulmonary Embolism Response Team (PERT) if available at your institution. 2 This team should include:
- Interventional cardiology
- Interventional radiology
- Cardiac surgery
- Cardiac imaging specialists
- Critical care/intensive care physicians
The PERT model helps determine optimal intervention strategy (catheter-directed fibrinolysis, ultrasound-assisted thrombolysis, mechanical thrombectomy, or surgical embolectomy) for complex cases. 2
Stable Patient Management
Who Can Manage Initially
For hemodynamically stable patients with suspected PE, the following clinicians can initiate workup and treatment: 1
- Senior trainees (ST3 or above; ST4 in Emergency Medicine)
- Staff grade or substantive career grade physicians
- Advanced nurse practitioners or clinical nurse specialists designated for this role
- However, consultant review is required prior to discharge on an outpatient pathway 1
When to Seek Specialist Advice
Seek specialist consultation in the following scenarios: 1
- High clinical probability with negative CTPA (consider further VTE imaging or pulmonary angiography)
- Indeterminate imaging results requiring interpretation
- Subsegmental PE findings (discuss with radiologist to avoid false-positive misdiagnosis) 1
- Pregnant or postpartum patients (requires consultant review AND discussion with maternity services) 1
- Patients with intermediate-risk PE (PESI class III) being considered for early discharge 1
Specialty-Specific Consultations
Respiratory Medicine/Pulmonology
Each hospital should have at least one physician with special interest in pulmonary embolism for expert clinical advice when necessary. 1 This specialist should be consulted for:
- Complex diagnostic dilemmas
- Recurrent PE despite adequate anticoagulation
- Follow-up of PE patients (should be performed by clinicians with special interest in VTE) 1
- Suspected chronic thromboembolic pulmonary hypertension (CTEPH) 1
Hematology
Consult hematology for:
- Suspected thrombophilic disorders in patients with idiopathic or recurrent PE 1
- Heparin-induced thrombocytopenia (HIT) concerns 3
- Complex anticoagulation decisions in patients with bleeding risk
Obstetrics/Maternal-Fetal Medicine
All pregnant and postpartum women with suspected or confirmed PE must be discussed with maternity services prior to discharge. 1
Common Pitfalls to Avoid
- Don't delay consultant contact in deteriorating patients while completing diagnostic workup—massive PE requires immediate senior decision-making about reperfusion therapy 1, 4
- Don't discharge intermediate-risk patients without consultant review, even if they meet low-risk criteria on scoring systems, as age and cancer may artificially elevate scores 1
- Don't manage pregnant patients with PE without obstetric consultation—standard risk scores (PESI/sPESI) don't apply in pregnancy 1
- Don't assume junior staff can make discharge decisions alone—consultant or designated senior review is mandatory before outpatient management 1