What is the management of cardiac arrest secondary to Acute Pulmonary Embolism (APE)?

Management of Cardiac Arrest Secondary to Acute Pulmonary Embolism

For cardiac arrest caused by acute pulmonary embolism, immediately initiate high-quality CPR with plans for systemic thrombolysis as the primary definitive treatment, administered as early as possible during resuscitation (alteplase 50 mg IV bolus), and prepare for prolonged resuscitation efforts of at least 60-90 minutes before considering termination of efforts. 1

Immediate Resuscitation Protocol

• Begin high-quality CPR immediately upon recognition of pulseless electrical activity (PEA), which is the presenting rhythm in 36-53% of PE-related cardiac arrests 1
• Administer epinephrine 1 mg IV every 3-5 minutes during ongoing CPR 1
• Commit to extended CPR duration of 60-90 minutes minimum before terminating resuscitation attempts, as PE-related arrests have better outcomes with prolonged efforts compared to other causes of cardiac arrest 1

Definitive Treatment: Systemic Thrombolysis

Thrombolysis is the most rapidly deployable and recommended definitive treatment for PE-related cardiac arrest. 1

Dosing Regimen for Cardiac Arrest

• Alteplase 50 mg IV bolus, with option for repeat 50 mg bolus in 15 minutes if needed 1
• Alternative: Single-dose weight-based tenecteplase 1
• Do NOT use standard thrombolytic dosing (100 mg over 2 hours) in the cardiac arrest setting 1

Critical Considerations for Thrombolysis

• Administer early during CPR, as early administration is associated with improved resuscitation outcomes compared to use after failure of conventional ACLS 1
• Standard contraindications may be superseded by the need for potentially lifesaving intervention, given the 65-90% mortality associated with fulminant PE 1
• Ongoing CPR is NOT a contraindication to thrombolysis—the risk of bleeding must be weighed against near-certain mortality without clot-directed therapy 1
• Thrombolysis can be considered even without definitive PE confirmation in witnessed arrest with high clinical suspicion and PEA rhythm (Class IIb recommendation) 1

Features Supporting PE as Cause of Arrest

• Conventional thromboembolism risk factors present 1
• Prodromal dyspnea or respiratory distress 1
• Witnessed arrest 1

Alternative Definitive Treatments

Surgical or Percutaneous Mechanical Embolectomy

• Should be considered when thrombolysis is contraindicated or has failed 2
• Surgical pulmonary embolectomy is a Class I recommendation for high-risk PE when thrombolysis is contraindicated or unsuccessful 2
• Percutaneous catheter-directed treatment is a Class IIa recommendation in the same scenarios 2
• No comparative data exist to recommend one strategy over another 1
• Feasibility under uncontrolled CPR conditions is not well established 1

ECMO (Extracorporeal Cardiopulmonary Resuscitation)

• May be considered as rescue therapy when conventional CPR fails (Class IIb recommendation) 2, 1
• Should be combined with surgical embolectomy or catheter-directed treatment in patients with PE and refractory circulatory collapse or cardiac arrest 2
• Recent data suggest VA-ECMO alone or combined with embolectomy or thrombolysis offers survival advantages compared to thrombolysis alone in PE patients with cardiac arrest 3
• Case series report 83% successful ECMO weaning and 67% 30-day survival when ECMO combined with anticoagulation 4

Post-Resuscitation Anticoagulation

Initial Anticoagulation After ROSC

• Unfractionated heparin (UFH) with weight-adjusted bolus should be initiated without delay 2
• UFH dosing: 80 U/kg bolus followed by 18 U/kg/h infusion 2
• Adjust subsequent doses using aPTT-based nomogram targeting 1.5-2.3 times control 2

Post-Stabilization Anticoagulation

• After hemodynamic stabilization, continue anticoagulation as for intermediate- or low-risk PE 2
• LMWH or fondaparinux is preferred over UFH for most stable patients 2

Post-Resuscitation Ventilation Management

Ventilator Settings

• Maintain tidal volume of 6-8 mL/kg predicted body weight to reduce ventilator-associated lung injury 2
• Target normocapnia: PaCO2 40-45 mm Hg or ETCO2 35-40 mm Hg 2
• Avoid routine hyperventilation with hypocapnia (Class III recommendation), as it may worsen global brain ischemia through excessive cerebral vasoconstriction 2
• Avoid excessive tidal volumes that increase intrathoracic pressure and contribute to hemodynamic instability 2

Sedation After ROSC

• Use intermittent or continuous sedation/analgesia for intubated patients with coma or respiratory dysfunction 2
• Administer cautiously with daily interruptions, titrated to desired effect 2
• Shorter-acting medications that can be given as bolus or continuous infusion are preferred 2

Hemodynamic Support

• Norepinephrine and/or dobutamine should be considered in patients with high-risk PE (Class IIa recommendation) 2

Critical Pitfalls to Avoid

1. Do NOT prematurely terminate resuscitation—PE-related cardiac arrest requires 60-90 minutes minimum of CPR as outcomes can be favorable with appropriate intervention 1

2. Do NOT delay thrombolysis waiting for definitive confirmation—in witnessed arrest with high clinical suspicion and PEA rhythm, early empiric thrombolysis may be justified given dismal prognosis without intervention 1

3. Do NOT withhold thrombolysis due to ongoing CPR—thrombolysis can be beneficial even during chest compressions, and bleeding risk must be weighed against near-certain mortality 1

4. Do NOT use standard thrombolytic dosing—use accelerated emergency dosing (alteplase 50 mg bolus, not 100 mg over 2 hours) 1

5. Do NOT hyperventilate the patient after ROSC—this worsens cerebral ischemia and hemodynamic instability 2