Oxygen therapy (maintain SpO2 ≥90% unless otherwise indicated)
Hemodynamic support (e.g. IVF, pressors)
Consider gentle fluid challenge of 500ml normal saline bolus to improve cardiac index in select patients
Experimental studies suggest that aggressive volume expansion provides little benefit and may worsen RV function in those with acutely elevated RV afterload and acutely increased<unk>  HTN
Consider gentle fluid challenge of 500ml normal saline bolus to improve cardiac index in select patients
Experimental studies suggest that aggressive volume expansion provides little benefit and may worsen RV function in those with acutely elevated RV afterload and acutely increased<unk>  HTN
Always consider bleeding risk when determining risks/benefits of initiating anticoagulation
Treatment options include any of the following anticoagulations which are indicated for all patients with confirmed<unk>  or high clinical suspicion (do not wait for imaging).
Enoxaparin 1mg/kg SC q12h
Dalteparin 200 IU/kg SC q24h, max 18,000 IU
80 units/kg bolus; then 18 units/kg/hr continuous infusion
Parenteral anticoagulation for 5-10 days; then 150mg twice daily
15mg twice daily for 3 weeks, then 20mg once daily
10mg twice daily for 1 week, then 5mg twice daily
Cannot be administered alone for acute<unk> . Usual starting dose 5mg PO
1st line for most hemodynamically stable patients
Preferred in those with cancer, liver disease, coagulopathy, pregnancy
Short half-life
Preferred if rapid reversal is needed (e.g. considering thrombolytics or with bleeding risk/trauma)
No need for renal dosing
Noninferior to warfarin in reducing DVT and<unk>  
Preferred if parenteral therapy to be avoided
Associated with less bleeding, particularly in elderly patients and those with moderate renal impairment compared to standard treatments 
Preferred if parenteral therapy to be avoided or if history of GI bleeding
Studies show 16% reduction in VTE related death compared to standard therapy 
Preferred in renal disease, history of poor compliance, or history of GI bleed
Severe renal impairment (CrCl <30 mL/min)
Patients with morbid obesity or anasarca may have poor absorption
Use with caution in patients >60yo
Previous history of HIT
Avoid in CAD and in severe renal impairment
Avoid in hepatic disease (Child-Pugh Class B/C)
Avoid in severe hepatic disease and renal impairment
Temporary hypercoagulable state for approx 5 days
Dose adjustments may be necessary in obese patients
Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
Consider interactions with CYP3A4 inhibitors (e.g. -azoles)
Consider interactions with CYP3A4 inhibitors
INR target 2.5
Consider many drug-drug interactions with CYP450 inhibitors or inducers
Duration
3-6 mo, if time limited risk factor (post-op, trauma, estrogen use)
6 mo to life, if idiopathic etiology or recurrent
3-6 mo, if time limited risk factor (post-op, trauma, estrogen use)
6 mo to life, if idiopathic etiology or recurrent
Evaluate for proximal DVT in legs with ultrasound
If low risk for recurrent VTE: Clinical surveillance recommended over anticoagulation (Level 2C evidence)
If high risk for recurrent VTE: anticoagulation recommended over surveillance
If low risk for recurrent VTE: Clinical surveillance recommended over anticoagulation (Level 2C evidence)
If high risk for recurrent VTE: anticoagulation recommended over surveillance
Includes catheter-directed thrombolysis and mechanical thrombus removal without thrombolysis
Still no large prospective cohort or randomized trial evaluating CDT, so limited evidence recommendations from ACCP 2016 are weak
Primary outcome measure in study of 59 patients was improved RV function at 24 hours, but not mortality
Given broad clinical spectrum of intermediate-risk<unk> , CDT can be considered in a subset of patients with following characteristics:
Intermediate-risk<unk>  with more severe degree of RV dysfunction and positive biomarkers
Intermediate-risk<unk>  with severe hypoxemia
High-risk (massive)<unk>  with contraindications to systemic thrombolysis
Complications include major access site bleeding, significant arrhythmias,<unk>  artery dissection, tamponade, worsening hemodynamics
Primary outcome measure in study of 59 patients was improved RV function at 24 hours, but not mortality
Intermediate-risk<unk>  with more severe degree of RV dysfunction and positive biomarkers
Intermediate-risk<unk>  with severe hypoxemia
High-risk (massive)<unk>  with contraindications to systemic thrombolysis
See Thrombolysis for<unk> 
Indications
anticoagulation contraindicated in patient with<unk> 
failure to attain adequate anticoagulation during treatment
anticoagulation contraindicated in patient with<unk> 
failure to attain adequate anticoagulation during treatment
Pulmonary embolism
Acute coronary syndromes 
Pleural effusion
STEMI
Arterial gas embolism
Non-STEMI
Pleuritis
Unstable angina