The 2026 American Heart Association/American College of Cardiology pulmonary embolism guideline sets out a severity-based framework and a range of reperfusion strategies, including catheter-directed and mechanical therapies that most regional intensive care units in Australia cannot deliver on site. For the lowest-risk and the most severe high-risk patients, management is largely determined by severity and is similar wherever the patient presents. The difficult group is the patient with intermediate-high or early high-risk pulmonary embolism who may deteriorate but does not yet warrant immediate thrombolysis, and who often carries a bleeding risk that thrombolysis would worsen. The absence of on-site advanced therapy matters most for this group. The guideline helps here by setting out the available therapies and their limits and by defining when to involve a tertiary centre. Systemic thrombolysis remains the only on-site reperfusion option for a regional unit, and for the deteriorating patient without prohibitive bleeding risk, it is a reasonable choice consistent with current best-available evidence. We set out how a regional unit might reason through these decisions and offer a management table as one worked example. The table is a local adaptation and has not been prospectively validated.