Suppose you have a patient in whom you highly suspect a pulmonary embolism (PE) that devolves into PEA arrest while awaiting a CT angiogram. Or, what about a patient with an ECG showing clear STEMI that loses pulses?
Clinical Question:
In the rare situation where fibrinolytics may be indicated in cardiac arrest from PE or Acute Myocardial Infarction (AMI), what’s the dose?
| Citation | Study Design | Condition | Drug | Dose |
| Kurkciyan et al.1 | Retrospective cohort | PE | Alteplase | 100 mg (either two 50 mg boluses OR 15 mg bolus followed by 85 mg over 90 min) |
| Ruiz-Bailen et al.2 | Case series (6 pts) | PE | Alteplase | 50 mg bolus, repeat 50 mg in 30 min |
| Janata et al.3 | Retrospective cohort | PE | Alteplase | 0.6-1.0 mg/kg bolus (up to 100 mg) |
| Sharifi et al.4 | Case series (23 pts) | PE | Alteplase | 50 mg bolus |
| Lederer et al.5 | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg followed by 85 mg over 90 min) |
| Ruiz-Bailen et al.6 | Retrospective cohort | AMI | Alteplase | 100 mg (either two 50 mg boluses OR 15 mg bolus followed by 85 mg over 90 min) |
| Schreiber et al.7 | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg followed by 85 mg over 90 min) |
| Kurkciyan et al.8 | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg followed by 85 mg over 90 min) |
| Bottiger et al.9 | Prospective observational | Nontraumatic cardiac arrest | Alteplase | 50 mg bolus, repeat 50 mg in 30 minutes |
| Abu-Laban et al.10 | RCT | Cardiac arrest from any cause | Alteplase | 100 mg over 15 min |
| Fatovich et al.11 | RCT | Cardiac arrest from any cause | Tenecteplase | 50 mg bolus |
| Bozeman et al.12 | Prospective cohort | Nontraumatic cardiac arrest | Tenecteplase | 0.5 mg/kg bolus |
| Bottiger et al.13 | RCT | Cardiac arrest from any cause | Tenecteplase | 0.5 mg/kg bolus |
| * Table includes only studies which fibrinolytic dose/administration is clearly specified. | ||||
Take Home Points
- The dose of tPA in cardiac arrest is somewhere between 50-100 mg given as a bolus +/- infusion.
- According to the 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, “Ongoing CPR is not an absolute contraindication for fibrinolysis.”
- Some studies suggest allowing 15 minutes of CPR for drug to work.
- Evidence is ‘best’ for PE; data does NOT support for undifferentiated cardiac arrest.
- Anticoagulants, such as heparin, were used in most studies along with the fibrinolytic.
Last updated: Aug 14, 2016
1.
Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535. [PubMed]
2.
Ruiz-Bailén M, Aguayo-de-Hoyos E, Serrano-Córcoles M, et al. Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series. Resuscitation. 2001;51(1):97-101. [PubMed]
3.
Janata K, Holzer M, Kürkciyan I, et al. Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism. Resuscitation. 2003;57(1):49-55. [PubMed]
4.
Sharifi M, Berger J, Beeston P, et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016;34(10):1963-1967. [PubMed]
5.
Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M. Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest. Resuscitation. 2001;50(1):71-76. [PubMed]
6.
Ruiz-Bailén M, Aguayo de, Serrano-Córcoles M, Diáz-Castellanos M, Ramos-Cuadra J, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial infarction requiring cardiopulmonary resuscitation. Intensive Care Med. 2001;27(6):1050-1057. [PubMed]
7.
Schreiber W, Gabriel D, Sterz F, et al. Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation. 2002;52(1):63-69. [PubMed]
8.
Kurkciyan I, Meron G, Sterz F, et al. Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment. J Intern Med. 2003;253(2):128-135. [PubMed]
9.
Böttiger B, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet. 2001;357(9268):1583-1585. [PubMed]
10.
Abu-Laban R, Christenson J, Innes G, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528. [PubMed]
11.
Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313. [PubMed]
12.
Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406. [PubMed]
13.
Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662. [PubMed]
Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP
Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School
@PharmERToxGuy
EM Pharmacist & Toxicologist @MassGeneralEM | Asst Prof @HarvardMed/@EMRES_MGHBWH | @ALiEMteam leadership | Capsules creator, ALiEMU | President, ABAT | #FOAMed
