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.
- 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.
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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.
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