code dose of tpa

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?

CitationStudy DesignConditionDrugDose
Kurkciyan et al.1Retrospective cohortPEAlteplase100 mg (either two 50 mg boluses OR 15 mg bolus followed by 85 mg over 90 min)
Ruiz-Bailen et al.2Case series (6 pts)PEAlteplase50 mg bolus, repeat 50 mg in 30 min
Janata et al.3Retrospective cohortPEAlteplase0.6-1.0 mg/kg bolus (up to 100 mg)
Sharifi et al.4Case series (23 pts)PEAlteplase50 mg bolus
Lederer et al.5Retrospective cohortAMIAlteplase100 mg (15 mg followed by 85 mg over 90 min)
Ruiz-Bailen et al.6Retrospective cohortAMIAlteplase100 mg (either two 50 mg boluses OR 15 mg bolus followed by 85 mg over 90 min)
Schreiber et al.7Retrospective cohortAMIAlteplase100 mg (15 mg followed by 85 mg over 90 min)
Kurkciyan et al.8Retrospective cohortAMIAlteplase100 mg (15 mg followed by 85 mg over 90 min)
Bottiger et al.9Prospective observationalNontraumatic cardiac arrestAlteplase50 mg bolus, repeat 50 mg in 30 minutes
Abu-Laban et al.10RCTCardiac arrest from any causeAlteplase100 mg over 15 min
Fatovich et al.11RCTCardiac arrest from any causeTenecteplase50 mg bolus
Bozeman et al.12Prospective cohortNontraumatic cardiac arrestTenecteplase0.5 mg/kg bolus
Bottiger et al.13RCTCardiac arrest from any causeTenecteplase0.5 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

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

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Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

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Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

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