What is the management for cardiac arrest secondary to pulmonary embolism (PE)?

Management of Cardiac Arrest Secondary to Pulmonary Embolism

For confirmed PE causing cardiac arrest, immediately administer systemic thrombolysis (alteplase 50 mg IV bolus with option for repeat in 15 minutes, or weight-based tenecteplase), surgical embolectomy, or mechanical embolectomy as reasonable emergency treatment options, with thrombolysis remaining beneficial even after chest compressions have been provided. 1

Immediate Resuscitation Approach

Standard ACLS with PE-Specific Modifications

• Begin high-quality CPR immediately, as pulseless electrical activity (PEA) is the presenting rhythm in 36-53% of PE-related cardiac arrests, while primary shockable rhythms are uncommon 1
• Administer epinephrine 0.01 mg/kg (typically 1 mg) every 3-5 minutes during CPR 2
• Extend CPR duration to at least 60-90 minutes before terminating resuscitation attempts in PE-related arrest, as prolonged efforts are more likely successful 1

Definitive Treatment Selection

For confirmed PE:

• Thrombolysis is the most rapidly deployable option and should be administered early—early administration is associated with improved resuscitation outcomes compared to use after failure of conventional ACLS 1
• Standard contraindications to thrombolysis may be superseded by the need for potentially lifesaving intervention, given the 65-90% mortality associated with fulminant PE 1
• Surgical or percutaneous mechanical embolectomy are alternatives when available, though no comparative data exist to recommend one strategy over another 1

Thrombolytic Dosing Regimens

Accelerated emergency dosing for fulminant PE:

• Alteplase 50 mg IV bolus with option for repeat bolus in 15 minutes, OR 1
• Single-dose weight-based tenecteplase 1
• Administer with or followed by systemic anticoagulation 1

Evidence Considerations

The 2015 AHA Guidelines note that one RCT showed no difference in overall survival with tenecteplase versus placebo during CPR, but in the subgroup with suspected PE (37 patients), 2 of 15 patients (13.3%) survived with tenecteplase compared to 0 of 22 (0%) with placebo 1. While this did not reach statistical significance, it suggests potential benefit 1. More recent meta-analysis demonstrates thrombolysis is associated with higher rates of ROSC (OR 2.55) but without significant difference in survival to hospital discharge 3.

Suspected PE Without Confirmation

For suspected but unconfirmed PE:

• Thrombolysis may be considered when cardiac arrest is suspected to be caused by PE (Class IIb recommendation) 1
• Look for conventional thromboembolism risk factors, prodromal dyspnea or respiratory distress, and witnessed arrest as features associated with PE-related cardiac arrest 1
• No evidence supports or refutes empiric thrombolysis effectiveness in unconfirmed PE, but the poor prognosis without intervention may justify treatment 1

Advanced Rescue Therapies

Extracorporeal Support

• ECPR (extracorporeal cardiopulmonary resuscitation) may be reasonable as rescue therapy when conventional CPR fails 1
• VA-ECMO can provide circulatory and oxygenation support while definitive clot removal is achieved 4
• Case series demonstrate 83% successful ECMO weaning and 67% 30-day survival when ECPR is used with anticoagulation for PE-related cardiac arrest 4

Mechanical Embolectomy

• Surgical or percutaneous mechanical embolectomy have been reported successful in limited series, though feasibility under uncontrolled CPR conditions is not well established 1
• Selection should be based on timing, available expertise, and patient location, as no clear benefit of one approach over another has been demonstrated 1

Critical Pitfalls to Avoid

Do not prematurely terminate resuscitation: PE-related cardiac arrest requires prolonged CPR efforts (60-90 minutes minimum) as outcomes can be favorable with appropriate intervention 1

Do not delay thrombolysis for confirmation: In witnessed arrest with high clinical suspicion and PEA rhythm, early empiric thrombolysis may be justified given the dismal prognosis without intervention 1

Do not withhold thrombolysis due to ongoing CPR: Thrombolysis can be beneficial even when chest compressions have been provided, and the risk of bleeding must be weighed against near-certain mortality without clot-directed therapy 1

Do not use standard thrombolytic dosing: Accelerated emergency dosing regimens (alteplase 50 mg bolus, not standard 100 mg over 2 hours) are appropriate for cardiac arrest 1

Bleeding Risk Considerations

• Meta-analysis shows no significant difference in bleeding complications with thrombolysis during PE-related cardiac arrest (OR 2.21,95% CI 0.95-5.17) 3
• Retrospective studies demonstrate low rates of major bleeding (5.3%) and minor bleeding (10.5%) with tPA during cardiac arrest 5
• The potential therapeutic benefits should not be limited by concerns for massive hemorrhage given the otherwise fatal prognosis 5