What is the management approach for a patient in cardiac arrest suspected to have a pulmonary embolism (PE)?

Management of Cardiac Arrest Due to Suspected Pulmonary Embolism

In cardiac arrest with suspected pulmonary embolism (PE), thrombolysis should be administered immediately, with alteplase 50 mg IV bolus during CPR, as this intervention can significantly improve chances of return of spontaneous circulation and survival. 1

Initial Management Algorithm

1. Continue standard CPR protocols

   • Maintain high-quality chest compressions
   • Follow standard ACLS protocols for cardiac arrest
   • Consider PE as a potential reversible cause (one of the "H's and T's") 1

2. Thrombolytic therapy administration

   • For confirmed PE:
     • Administer alteplase 50 mg IV bolus 1
     • Reassess after 30 minutes 1
     • Consider repeat bolus if needed 1
   • For suspected PE:
     • Thrombolysis may still be considered (Class IIb, LOE C-LD) 1
     • Standard contraindications to thrombolysis may be superseded by the need for potentially lifesaving intervention 1, 2

3. Post-ROSC management (if achieved)

   • Initiate anticoagulation (typically 3 hours after thrombolysis) 1
   • Implement post-cardiac arrest care including treatment of hypoxemia and hypotension 1
   • Consider therapeutic hypothermia if patient remains comatose 1

Evidence Supporting Thrombolysis in PE-Related Cardiac Arrest

Thrombolysis in PE-related cardiac arrest is supported by multiple guidelines and studies:

• The American Heart Association (2015) gives a Class IIa recommendation for thrombolysis in confirmed PE causing cardiac arrest 1
• Early administration of thrombolysis is associated with better outcomes compared to use after failure of conventional ACLS 1, 2
• Systemic thrombolysis is associated with increased rates of ROSC in observational studies 2, 3

Alternative Treatment Options

When thrombolysis is not feasible or unsuccessful, consider:

• Surgical embolectomy - reasonable emergency option for confirmed PE (Class IIa, LOE C-LD) 1
• Mechanical embolectomy - reasonable emergency option for confirmed PE (Class IIa, LOE C-LD) 1
• Extracorporeal membrane oxygenation (ECMO) - may be considered in specialized centers for prolonged cardiac arrest due to massive PE 4

Important Clinical Considerations

• Recognition of PE as cause of arrest: PE often presents as PEA (pulseless electrical activity) arrest 2
• Diagnostic confirmation: While ideal, confirmation should not delay treatment in highly suspicious cases 1
• Survival outcomes: Despite intervention, cardiac arrest due to PE carries high mortality (approximately 90%) 5
• Bleeding risk: The risk of bleeding with thrombolysis during CPR is present but should not prevent treatment given the high mortality without intervention 1, 3

Thrombolytic Dosing Options

• Alteplase: 50 mg IV bolus (with option to repeat in 15 minutes) 1
• Tenecteplase: Single weight-based dose (an alternative to alteplase) 1, 6

While the evidence for thrombolysis in cardiac arrest due to PE is largely observational, the potential benefit in this otherwise fatal condition justifies its use when PE is confirmed or strongly suspected as the cause of arrest.