Transfer Criteria for Large Pulmonary Embolism with Stable Hemodynamics
Transfer hemodynamically stable patients with large pulmonary embolism to a higher-level care facility when they demonstrate severe right ventricular dysfunction on echocardiography, evidence of clinical deterioration (new hemodynamic instability, worsening respiratory failure), or when your facility lacks advanced interventional capabilities (catheter-directed therapy or surgical embolectomy) that may become urgently needed. 1
Primary Transfer Indications
Immediate Transfer Required
Hemodynamic deterioration despite initial management – Any development of shock (systolic BP <90 mmHg), persistent hypotension, or need for vasopressor support mandates urgent transfer to intensive care units in centers equipped for thrombectomy 1
Severe right ventricular dysfunction on point-of-care echocardiography – Right ventricular enlargement or dysfunction identified by bedside ultrasound indicates high-risk features requiring transfer to tertiary centers with advanced interventional capabilities 1
Clinical evidence of adverse prognosis including:
Facility-Based Transfer Considerations
Lack of advanced interventional capabilities – If your facility cannot provide catheter embolectomy, surgical embolectomy, or extracorporeal membrane oxygenation (ECMO), transfer should be considered for patients with large PE who may deteriorate, particularly if contraindications to fibrinolysis exist 1
Absence of 24/7 critical care monitoring – Patients with large PE require continuous ECG and hemodynamic monitoring; transfer to facilities with intensive care capabilities is recommended if this is unavailable 1
Patients Who Can Remain at Current Facility
Stable patients with large PE can be managed at non-tertiary centers when:
- Hemodynamics remain truly stable (normal blood pressure, heart rate <110 bpm, adequate perfusion) 1, 2
- Only minor RV dysfunction without clinical worsening 1
- Adequate monitoring and anticoagulation capabilities exist 1
- No contraindications to anticoagulation that would necessitate advanced interventions 1
Transfer to emergency departments or chest pain units (rather than intensive care) is appropriate for stable patients with suspected or confirmed PE who lack high-risk features 1
Critical Pitfalls to Avoid
Do not delay transfer while pursuing extensive diagnostic workup – The time lag to confirm massive PE should be kept as short as possible; rely on bedside tests and clinical probability rather than transferring unstable patients to radiology 3
Recognize that "stable" hemodynamics can deteriorate rapidly – More than 1 in 5 patients with PE at tertiary centers are transfers, and transferred patients have higher PE-related mortality (38.5% vs 9.4%), suggesting some patients are transferred too late 4
Ensure safe transfer conditions – Only appropriately trained and equipped ambulance crews should transfer these patients, with continuous ECG monitoring, oxygen saturation monitoring, and intravenous access maintained during transport 1
Pre-Transfer Stabilization
Before transfer, initiate:
- Immediate anticoagulation with unfractionated heparin (70 IU/kg IV bolus) without waiting for confirmatory imaging if clinical suspicion is high 1
- Oxygen therapy targeting saturation >94% 1
- Continuous monitoring with ECG and pulse oximetry 1
- Intravenous access for medication administration during transport 1
Activate the receiving facility's PE response team (PERT) or interventional services during transfer so that catheter-directed therapy, surgical embolectomy, or ECMO can be immediately available upon arrival if needed 1, 5
Transfer Coordination
Institutions with expertise in advanced PE intervention should be identified in advance, with explicit criteria and procedures for transfer agreed upon 1. A plan should be in place for expedited transfers, as delays worsen outcomes in patients who ultimately require advanced therapies 1, 4.