PE Response Team Data Collection Form
The PE Data Collection Form is designed to capture essential clinical, procedural, and outcome data for patients undergoing interventions for pulmonary embolism. Please follow the instructions below to ensure accurate and complete data entry.
Organization information
Name of person completing this form
First Name
Last Name
Organization/Site
Email
example@example.com
Patient Information
Age
Gender
Female
Male
Non-binary
Did not disclose
Date of Procedure:
-
Month
-
Day
Year
Date
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Clinical Presentation
Risk Stratification
Yes
No
RV Strain
Troponin Elevated (HS Troponin >50)
Syncope Event
Hypotension (SBP < 90)
Hypotension (low BP 90-100)
Need for Pressors
O2 Sat <90%
Vital Signs on Presentation
Measurments
Blood pressure
Heart rate
Oxygen saturation (O₂ Sat)
Number of Pressors (binary)
Findings: RV/LV ratio on CT scan
Troponin levels
Presence of RV dysfunction based on echocardiogram
Yes
No
Presence of DVT (Deep Vein Thrombosis)
Yes
No
Type of anticoagulant used
Heparin
Lovenox
Other
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Procedural Data
Treatment Used
Thrombectomy
Catheter Directed Thrombolysis
IV Thrombolysis
Full-Dose Lytics
Half-Dose Lytics
Other
Device Used
EKOS
Penumbra
Inari
Other
Specify the agent used for thrombolytics
tPA
TNK
Other
Hemodynamics Measured
Yes
No
PA Pressure
RA Pressure
Cardiac Index
Hemodynamic Data Measurements
Pre Procedure
Post Procedure
RA Pressure
PA Pressure
Mean PA
Cardiac index
Requirement for mechanical circulatory support
Yes
No
Cardiogenic Shock (cardiac index <2.2)
Yes
No
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Outcomes
In-Hospital Mortality
Yes
No
Cause of death, if applicable
PE
Other
Recurrent PE (within 30 days)
Yes
No
Bleeding Events
Major bleeding (e.g., BARC 3–5 or TIMI major bleeding classification)
None
Source of bleed:
ICU Admission
Yes
No
ICU Lenth of Stay (if applicable):
Post-Procedure Therapy
Coumadin
Eliquis
Xarelto
Other
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Adverse Events
Any additional adverse events not otherwise specified?
Submit
Should be Empty: