Thrombolytics for PE in Cardiac Arrest

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Lauren Igneri
Lauren Igneri
Critical care pharmacist and proud Rutgers University graduate. Enjoys rock climbing, cycling, travel, and lively discussions on the finer points of pharmacokinetics and critical care over a beer with friends.

The Pre-brief

Massive pulmonary embolism (PE) is the cause of unexplained cardiac arrest in 5% to 13% of patients. Patients with massive PE who progress to cardiac arrest have a 65-90% mortality rate.

Since the ability to perform confirmatory diagnostic testing is limited in the setting of cardiac arrest, providers often must make the determination to treat massive PE based on clinical judgment. The updated 2020 AHA Adult Advanced Life Support recommendations suggest the administration of thrombolytic therapy for cardiac arrest when PE is the suspected cause, which is unchanged from 2015.

While these recommendations are based on a very low-certainty level of evidence, thrombolytic therapy has been shown to significantly improve 30-day survival. 

There is discordant evidence whether thrombolytics improve the attainment of ROSC, survival at 24-hours, and survival to hospital discharge.

Both tenecteplase and alteplase have been evaluated in the setting of cardiac arrest

  • Tenecteplase weight-based dose (range 30 mg-50 mg) via IV push over 5-10 seconds, then continue CPR for at least 30 minutes after drug administration.
  • Alteplase 50 mg IV push over 2 minutes, then continue CPR for at least 15 minutes. If ROSC not achieved, repeat dosing with additional CPR can be considered.

The Debrief

  • Massive PE is a known and treatable cause of cardiac arrest.
  • If there is moderate to high suspicion for PE, thrombolytic therapy should be considered.

References

  1. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132(suppl 2):S501-S518.

  2. Summers K, Schultheis J, Raiff D, Dahhan T. Evaluation of rescue thrombolysis in cardiac arrest secondary to suspected or confirmed pulmonary embolism. Ann Pharmacother. 2019; 53: 711-5.

  3. Berg KM, Soar J, Andersen LW, et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2020; 142(suppl 1):S92-139.

  4. Böttiger BW, Arntz H-R, Chamberlain DA, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008; 359(25): 2651-2662.

  5. Böttiger BW, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet. 2001; 357:1583-5.

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