Clinical reference

Pulmonary Embolism (Referral & Outpatient Triage)

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources2 sources

Egyptian National Drug Formulary - Blood Disorder Medications 2025 (enoxaparin monograph) · RIVAROXABAN US prescribing information, Dosage and Administration (DailyMed SetID e62f23c6-89f2-4179-95dc-5732401b3f93)

Verified against3 documents

Egyptian National Drug Formulary - Blood Disorder Medications 2025 (enoxaparin monograph)
RIVAROXABAN US prescribing information, Dosage and Administration (DailyMed SetID e62f23c6-89f2-4179-95dc-5732401b3f93)
Acute Pulmonary Embolism - disease-level clinical article (pulmonary-embolism-referral-clinical.txt)

Verified date2026-08

Presentation reference

Is it this?

Reference only, to read alongside your own examination.

Symptoms — what the patient reports (7)

Untreated, three in ten die; treated in time, fewer than one in ten. The whole value is in catching it early
The usual complaints: breathlessness, pain on breathing in, cough, coughing blood, near-fainting and fainting [breathlessness · cough · syncope]
A big central clot gives sudden severe breathlessness; a small peripheral one gives mild breathlessness that passes [breathlessness]
Where the heart or lungs were already bad, worsening breathlessness may be the only clue there is [breathlessness]
Chest pain in a central clot can come from the strained right ventricle, and then it mimics a heart attack or a dissection [chest pain]
It can also present as a new arrhythmia such as atrial fibrillation, as a faint, or as collapse [arrhythmia · collapse · syncope]
A large clot can produce few symptoms or none, so ask about the risk factors rather than waiting to be impressed

Signs — what you find (8)

Fast breathing and a fast pulse are the common findings, and neither one is specific [tachypnoea]
Look at the calf: calf tenderness, swelling, redness, a palpable cord, or swollen feet [calf pain · leg swelling · redness]
In the chest, crackles or quiet breath sounds on one side [crackles]
Signs that pressure in the lung circuit is high: raised neck veins, a loud second sound, a right-sided gallop, a heave at the left sternal edge [raised JVP]
A massive clot fails the right ventricle acutely: distended neck veins, a heave, a third sound, blue lips and shock [cyanosis · raised JVP · shock]
If a fast pulse suddenly turns slow, or a broad complex rhythm appears, shock is arriving - do not wait for it [shock]
Suspect it in anyone with low blood pressure and full neck veins once infarct, tamponade and tension pneumothorax are excluded [hypotension · ischaemia]
It causes roughly one sudden cardiac arrest in twelve [sudden cardiac arrest]

Tests (12)

Score the probability first, with Wells or Geneva, then let that score decide what the imaging means
Low oxygen you cannot explain, with a clear chest film, should raise the suspicion by itself
A normal D-dimer makes a clot unlikely - that is the whole strength of the test
A raised D-dimer proves nothing and must never be used to confirm the diagnosis
Over the age of 50 use an age-adjusted threshold: the age in years multiplied by ten
The ECG changes are not specific - a fast rate, ST and T changes, the S1Q3T3 pattern, right heart strain, new partial right bundle branch block
The chest film is usually normal; its job is to exclude the other causes of sudden breathlessness
CT pulmonary angiography is the test of choice, seeing down to the subsegmental arteries
A negative scan excludes it only when your own probability was low or moderate; if you thought it likely, it misses four in ten
Contrast may be unsafe in dye allergy or poor kidneys - a V/Q scan is the alternative
In pregnancy the V/Q scan is preferred, provided the chest film is clear
Troponin and BNP do not diagnose it; they say how badly the right ventricle is struggling

If not this — what else fits (7)

Acute coronary syndrome, or stable angina
Pericarditis, or heart failure
An underlying cancer, which both mimics it and causes it
A cardiac arrhythmia in its own right
Pneumonia, or inflammation of the lung from another cause
Pneumothorax - sudden breathlessness with pain on one side
A simple faint, which is the trap when the only event was a collapse

Scores

PERC rule (Pulmonary Embolism Rule-out Criteria) — Can pulmonary embolism be ruled out with no test at all?
Two-level PE Wells score — Is a pulmonary embolism likely enough to image?

SourceStatPearls "Acute Pulmonary Embolism" - disease-level clinical article

Presentation findings are traced to the source above.

RIVAROXABAN

1st line

Strength15 mg

Formoral.solid

Adult dose and duration

15 mg twice daily with food for 21 days, followed by 20 mg once daily with food

Paediatric dose

Urgent pediatric emergency transfer required

Choice

Alternatives. Rivaroxaban is oral and needs no injection or bridging, which is what makes outpatient management of a pulmonary embolism possible at all.

Dose source

RIVAROXABAN US prescribing information, Dosage and Administration (DailyMed SetID e62f23c6-89f2-4179-95dc-5732401b3f93)

Why

Rivaroxaban is a direct factor Xa inhibitor that anticoagulates the patient to stop the pulmonary embolism from propagating while emergency hospital referral and imaging are arranged.

Cautions

Requires immediate emergency hospital referral for hemodynamic risk stratification and CTPA imaging.
Must take with meals to ensure reliable bio-availability.
Contraindicated in severe renal failure (CrCl <15 mL/min).
Not recommended acutely as an alternative to unfractionated heparin in patients with PE who present with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy.

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
REPATOXABAN 15 MG 30 TABS.	HORUS FOR PHARMACEUTICAL PRODUCTS > EVA PHARMA	360.00 EGP (12.00/unit)
RIVAFLOWVA 15 MG 20 F.C. TABS.	GYPTO PHARMA	254.00 EGP (12.70/unit)
RIVAROSPIRE 15 MG 42 F.C.TABS.	SEDICO > INSPIRE PHARMACEUTICAL COMPANY	534.00 EGP (12.71/unit)
THORMOXIBAN 15 MG 10 F.C. TABS.	MEDIZEN PHARMACEUTICAL INDUSTRIES	130.00 EGP (13.00/unit)
VAXATO 15 MG 30 TABS.	RAMEDA	390.00 EGP (13.00/unit)
XANOXIBAN 15 MG 50 F.C. TABS.	HIKMA PHARMA	855.00 EGP (17.10/unit)
XARELTO 15 MG 14 F.C. TAB.	BAYER HEALTHCARE	589.00 EGP (42.07/unit)
RIVABEDAX 15 MG 30 ODT	AVERROES PHARMA	390.00 EGP

ENOXAPARIN SODIUM

1st line

Strength100 mg

Forminjection

Adult dose and duration

1.5 mg/kg SC once daily (uncomplicated, low VTE recurrence risk) or 1 mg/kg SC twice daily (obesity, symptomatic PE, cancer, recurrent VTE, or proximal iliac thrombosis) - initial emergency stabilization

Paediatric dose

1-1.5 mg/kg/dose (Pediatric emergency transfer)

Dose by weight
3kg	3-4.5 mg/dose
4kg	4-6 mg/dose
5kg	5-7.5 mg/dose
6kg	6-9 mg/dose
7kg	7-10.5 mg/dose
8kg	8-12 mg/dose
9kg	9-13.5 mg/dose
10kg	10-15 mg/dose
11kg	11-16.5 mg/dose
12kg	12-18 mg/dose
13kg	13-19.5 mg/dose
14kg	14-21 mg/dose
15kg	15-22.5 mg/dose
16kg	16-24 mg/dose
17kg	17-25.5 mg/dose
18kg	18-27 mg/dose
19kg	19-28.5 mg/dose
20kg	20-30 mg/dose
21kg	21-31.5 mg/dose
22kg	22-33 mg/dose
23kg	23-34.5 mg/dose
24kg	24-36 mg/dose
25kg	25-37.5 mg/dose
26kg	26-39 mg/dose
27kg	27-40.5 mg/dose
28kg	28-42 mg/dose
29kg	29-43.5 mg/dose
30kg	30-45 mg/dose
31kg	31-46.5 mg/dose
32kg	32-48 mg/dose
33kg	33-49.5 mg/dose
34kg	34-51 mg/dose
35kg	35-52.5 mg/dose
36kg	36-54 mg/dose
37kg	37-55.5 mg/dose
38kg	38-57 mg/dose
39kg	39-58.5 mg/dose
40kg	40-60 mg/dose
41kg	41-61.5 mg/dose
42kg	42-63 mg/dose
43kg	43-64.5 mg/dose
44kg	44-66 mg/dose
45kg	45-67.5 mg/dose
46kg	46-69 mg/dose
47kg	47-70.5 mg/dose
48kg	48-72 mg/dose
49kg	49-73.5 mg/dose
50kg	50-75 mg/dose

Dose source

Egyptian National Drug Formulary - Blood Disorder Medications 2025 (enoxaparin monograph)

Why

Enoxaparin is a low-molecular-weight heparin that potentiates antithrombin to inhibit factor Xa, providing rapid parenteral anticoagulation for pulmonary embolism while urgent hospital transfer is arranged; it is an alternative to oral rivaroxaban when a parenteral route is preferred.

Cautions

Urgent tertiary care emergency transfer is mandatory.
Monitor closely for acute hemodynamic collapse or right ventricular strain.
Which regimen: 1.5 mg/kg once daily is for an uncomplicated patient at low risk of recurrence. Use 1 mg/kg twice daily in obesity, symptomatic PE, cancer, recurrent VTE, or proximal iliac thrombosis.
Severe renal impairment (creatinine clearance 15-30 mL/min): reduce to 1 mg/kg ONCE daily. Below 15 mL/min it is not recommended. Enoxaparin accumulates when clearance falls and the consequence is bleeding.

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
CLEXANE 100MG/ML 2 PREFILLED SYRINGES	SANOFI	507.00 EGP

REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)

1st line

Dose source

Acute Pulmonary Embolism - disease-level clinical article (pulmonary-embolism-referral-clinical.txt)

Why

Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen.

Cautions

RED FLAG - Hemodynamic instability is explicitly defined as SBP <90 mmHg, a drop >=40 mmHg from baseline, or a need for vasopressors, and it marks the pathway needing thrombolysis or hospital-level reperfusion rather than routine anticoagulation and transfer.
RED FLAG - PESI/sPESI risk stratification is the tool that decides who is low-risk enough for outpatient management (rivaroxaban) and who needs hospital care (transfer on enoxaparin).
RED FLAG - In hemodynamically stable patients with only low clinical suspicion of PE, anticoagulation should generally wait for imaging rather than being started empirically.

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.