Ep 203 Intermediate Risk Pulmonary Embolism Risk Stratification, Management and Algorithm

A 30-year-old woman rolls into your resuscitation bay looking very dyspneic on a non-rebreather, clammy with a heart rate of 135 bpm. She takes oral contraceptives, has had a sudden syncopal episode, and now lies in the stretcher struggling. Her blood pressure is 100/60 and she is hypothermic with a temp of 35.7°C. Her ECG and PoCUS suggest right heart strain. CTPA confirms a saddle pulmonary embolism (PE). But she’s not hypotensive… yet. So, what’s next? How do you predict which intermediate-risk patients will suddenly deteriorate? What role do biomarkers, imaging, and hemodynamics play in decision-making? Should she receive anticoagulation alone, or is thrombolysis warranted? When should you consider catheter-directed or surgical interventions? This case focuses us to think critically about risk stratification and early interventions in PE. Not all patients fit neatly into classification boxes, making clinical judgment crucial. Join Dr. Lauren Westafer, Dr. Justin Morgenstern, Dr. Bourke Tillman and Anton as they explore the key decision points, pitfalls, and lifesaving strategies for managing intermediate-risk PE in the ED...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Sara Brade, edited by Anton Helman April, 2025

Cite this podcast as: Helman, A. Morgenstern, J. Tillmann, B. Westafer, L. Intermediate Risk Pulmonary Embolism Risk Stratification, Management and Algorithm. Emergency Medicine Cases. Month, 2024. https://emergencymedicinecases.com/intermediate-risk-pulmonary-embolism-risk-stratification-management. Accessed September 14, 2025

Résumés EM CasesPulmonary embolism risk categories

PE severity exists on a spectrum, ranging from low-risk cases to cardiac arrest. Patients who fall in the intermediate-risk category are particularly challenging because they represent a heterogenous group with varying degrees of severity and risk for clinical deterioration.

The European Society of Cardiology (ESC) classifies PE severity into four categories:



Low-risk patients do not require oxygen, show no signs of RV dysfunction, and have normal biomarkers.

Intermediate-low risk patients have either elevated biomarkers OR RV dysfunction but not both.

Intermediate-high risk patients exhibit both elevated biomarkers AND RV dysfunction.

High-risk patients have prolonged hypotension (systolic BP 2-5L nasal prongs to maintain oxygen saturation.

Although non-invasive ventilation (NIV) may exacerbate RV dysfunction, it can be beneficial for patients with concurrent conditions like COPD or CHF.

Fluids in management of pulmonary embolism



Pitfall: Excess IV fluids is likely worsen RV dysfunction and should be avoided whenever possible.



Systemic thrombolysis or catheter-directed procedure for intermediate-risk pulmonary embolism?

Systemic thrombolysis or catheter-directed procedures should be considered in the intermediate high-risk patient after high risk feature assessment and answering the questions: is the pulmonary embolism accounting for the entire clinical picture? Is the patient dynamic? What is their bleeding risk? Is there a clot in transit?

Thrombolytics can be administered systemically or via catheter devices. Catheter-directed therapy delivers a smaller thrombolytic dose directly to the clot, potentially reducing intracranial bleeding risk. However, high-quality RCTs are lacking, and available studies are industry-funded, lack comparison groups, and focus on disease-oriented outcomes only.

For intermediate-high risk patients without contraindications to thromboly...