From the Guidelines
The recommended dose of alteplase for pulmonary embolism (PE) during cardiac arrest is 50 mg administered as an IV bolus, with an option for repeat bolus in 15 minutes, as supported by the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1. This dose is based on the understanding that systemic thrombolysis is associated with return of spontaneous circulation (ROSC) and short-term survival in PE-related cardiac arrest, as observed in nonrandomized observational studies 1. Key considerations for this treatment approach include:
- The dose of 50 mg is a commonly used regimen in emergency thrombolysis for fulminant PE, and may be repeated after 15 minutes if necessary 1.
- Early administration of systemic thrombolysis is associated with improved resuscitation outcomes compared with use after failure of conventional ACLS 1.
- Thrombolytic therapy increases bleeding risk, so recent surgery, trauma, or active bleeding are relative contraindications that must be weighed against the immediate life-threatening situation.
- Preparation for potential bleeding complications is crucial, including having blood products available and monitoring closely if ROSC is achieved.
From the Research
Dose of Alteplase in Pulmonary Embolism during Cardiac Arrest
- The dose of alteplase (tissue-like plasminogen activator) in pulmonary embolism (PE) during cardiac arrest is often administered as a bolus, with the most common dose being 50 mg 2, 3, 4.
- In some cases, a double bolus of 50 mg alteplase may be administered 20 minutes apart during cardiopulmonary resuscitation (CPR) for persistent hemodynamic compromise guided by bedside echocardiogram 3.
- The median cumulative alteplase dose was significantly higher in patients who had return of spontaneous circulation (ROSC) than those who did not (90.6 and 69.4 mg, respectively; p = 0.03) 2.
- A study also reported a median dose of alteplase administered as 100 mg 5.
- A reasonable treatment regimen is alteplase 0.6 mg/kg (maximum of 50 mg) or fixed dose of alteplase 50 mg given over 2 to 15 minutes 4.
Administration and Outcomes
- The administration of alteplase during cardiac arrest due to suspected or confirmed pulmonary embolism (PE) has been associated with improved outcomes, including return of spontaneous circulation (ROSC) and survival to hospital discharge 2, 4.
- However, the use of thrombolytic therapy during cardiac arrest is controversial, and the decision to administer alteplase should be made on a case-by-case basis, considering the high suspicion for pulmonary embolism as the cause of arrest and the availability of thrombolytic therapy 5.