What is the epinephrine management in a patient with pulseless electrical activity (PEA) due to pulmonary embolism (PE)?

Epinephrine Management in PE-Related PEA Cardiac Arrest

Administer 1 mg IV/IO epinephrine every 3-5 minutes during ongoing CPR for PEA secondary to pulmonary embolism, while simultaneously pursuing definitive reperfusion therapy with thrombolytics. 1

Standard Epinephrine Protocol

• Give 1 mg epinephrine IV/IO every 3-5 minutes throughout the resuscitation attempt, as recommended by the American Heart Association for all PEA arrests regardless of etiology 1, 2
• Continue high-quality CPR with minimal interruptions in chest compressions while administering epinephrine 1
• There is no defined maximum cumulative dose or number of epinephrine administrations in current guidelines 2

Critical PE-Specific Considerations

The key distinction for PE-induced PEA is that epinephrine alone is insufficient—definitive treatment requires addressing the underlying thrombus:

• Administer thrombolytics emergently during ongoing CPR for suspected or confirmed PE-induced cardiac arrest, as this is reasonable emergency treatment per the American Heart Association 3, 1
• Early systemic thrombolysis is associated with improved outcomes compared to use after failure of conventional ACLS 1
• The 2019 ESC guidelines explicitly state that "epinephrine is used in cardiac arrest" for PE, acknowledging its role in the arrest algorithm 3

Evidence for Thrombolysis in PE-PEA

• A study of 23 patients with PE-induced PEA treated with 50 mg tPA showed 87% long-term survival, with return of spontaneous circulation occurring 2-15 minutes after tPA administration 4
• Thrombolysis during PE-related cardiac arrest significantly increases return of spontaneous circulation (81% vs 43%) compared to standard ACLS alone 5
• Alternative reperfusion options include surgical embolectomy or mechanical thrombectomy if thrombolysis is contraindicated 3, 1

Important Caveats About Epinephrine

While epinephrine is the standard vasopressor, understand its limitations:

• Epinephrine may improve return of spontaneous circulation but does not improve survival to discharge or neurologic outcomes in general cardiac arrest populations 6
• Higher cumulative epinephrine doses are independently associated with worse functional outcomes and increased in-hospital mortality in PEA arrests 7
• Standard-dose epinephrine (not high-dose) is recommended; high-dose epinephrine (0.1-0.2 mg/kg) is not beneficial for routine use 2

Practical Algorithm

1. Immediately begin high-quality CPR and establish vascular access 1
2. Give first dose of epinephrine 1 mg IV/IO as soon as access is obtained 1
3. Administer thrombolytic therapy (e.g., 50 mg tPA IV push or 100 mg rtPA) during ongoing CPR if PE is suspected or confirmed 3, 4, 5
4. Continue epinephrine 1 mg every 3-5 minutes throughout resuscitation 1, 2
5. Prolong resuscitation efforts beyond typical timeframes, as PE-related PEA may respond to thrombolysis even after extended CPR 1, 4

Post-ROSC Management

• If using norepinephrine for post-arrest hemodynamic support in cardiogenic shock from PE, dose at 0.2-1.0 mcg/kg/min to improve RV function and coronary perfusion 3
• Note that norepinephrine is not recommended during the PEA arrest itself—only epinephrine is used during active cardiac arrest 1