# Pulmonary Embolism (Referral & Outpatient Triage) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - 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 date: 2026-08 ## Verified against - 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) ## Treatment metadata - Rivaroxaban — 15 mg — oral.solid - Enoxaparin sodium — 100 mg — injection - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text PULMONARY EMBOLISM (REFERRAL & OUTPATIENT TRIAGE) 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) Review status: REVIEWED against 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) (2026-08) 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 Score PERC rule (Pulmonary Embolism Rule-out Criteria) - Can pulmonary embolism be ruled out with no test at all? Score Two-level PE Wells score - Is a pulmonary embolism likely enough to image? Source StatPearls "Acute Pulmonary Embolism" - disease-level clinical article Status traced to the source above 1. RIVAROXABAN [1st line] Adult 15 mg twice daily with food for 21 days, followed by 20 mg once daily with food Peds 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. 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. Caution 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. Egypt REPATOXABAN 15 MG 30 TABS. HORUS FOR PHA... 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 > INSP... 534.00 EGP (12.71/unit) THORMOXIBAN 15 MG 10 F.C. TABS. MEDIZEN PHARM... 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 2. ENOXAPARIN SODIUM [1st line] Adult 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 Peds 1-1.5 mg/kg/dose (Pediatric emergency transfer) 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 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. Caution 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. Egypt CLEXANE 100MG/ML 2 PREFILLED SYRINGES SANOFI 507.00 EGP 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult 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. Caution 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. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)