A fictional 57-year-old becomes acutely breathless four days after hip surgery. CTPA confirms pulmonary embolism; troponin is elevated and echocardiography shows right-ventricular dysfunction. Blood pressure is 101/64 mmHg without clinical shock.
Listen for the assumption.
The troponin and right-ventricular changes mean I should thrombolyse immediately.
They mark increased risk, but the patient is currently haemodynamically stable and has just had major surgery. What does current UK guidance say about routine systemic thrombolysis?
It should not be offered while haemodynamically stable. I will anticoagulate appropriately, monitor closely and agree a rescue plan now.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Persistent tachycardia
- Elevated troponin and right-ventricular dysfunction
- Recent major orthopaedic surgery increases bleeding risk
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
Use an appropriate monitored setting, trend haemodynamics and oxygenation, and define exactly what would trigger immediate escalation.
Avoid relying on a single systolic-pressure cut-off. Assess shock, persistent hypotension, trajectory, right-heart strain and bleeding risk together.
I will document anticoagulation, monitoring frequency, escalation triggers and the named team for rescue reperfusion decisions.
What must remain explicit.
- Follow the current local PE and anticoagulation pathway.
- Escalate any shock, persistent hypotension, syncope or worsening oxygen requirement immediately.
- Make reperfusion decisions with senior multidisciplinary expertise.
Where reasoning fails.
- Routine thrombolysis while stable
- Calling the case low risk because blood pressure is preserved
- No rescue plan
Confirmed PE with haemodynamics [trend], oxygen requirement [trend], RV/biomarker findings [summary], bleeding risks [details], anticoagulation [drug/time] and rescue triggers/decision-makers [plan].
What escalation trigger would make you call the PE response team before overt shock?