What is the dose of Tenecteplase (TNK-tissue plasminogen activator) for a patient in Pulseless Electrical Activity (PEA)?

Tenecteplase Dosing for Pulseless Electrical Activity (PEA) in Suspected or Confirmed Pulmonary Embolism

For PEA cardiac arrest due to confirmed pulmonary embolism, administer tenecteplase as a single weight-based IV bolus using the standard STEMI dosing: 30 mg for <60 kg, 35 mg for 60-69 kg, 40 mg for 70-79 kg, 45 mg for 80-89 kg, and 50 mg for ≥90 kg. 1

Guideline-Based Recommendations

Confirmed PE with PEA Arrest

• Thrombolysis is a reasonable emergency treatment option (Class IIa) for patients with confirmed PE as the precipitant of cardiac arrest. 1
• The 2015 AHA Guidelines explicitly state that thrombolysis can be beneficial even when chest compressions have been provided (Class IIa, LOE C-LD). 1
• Standard contraindications to thrombolysis may be superseded by the need for potentially lifesaving intervention in fulminant PE, given the poor outcomes without clot-directed therapy. 1

Suspected PE with PEA Arrest

• Thrombolysis may be considered when cardiac arrest is suspected to be caused by PE (Class IIb). 1
• There is no consensus on specific inclusion criteria, timing, drug choice, or exact dosing for suspected but unconfirmed PE. 1

Practical Dosing Approach

Standard Weight-Based Dosing

The most validated approach uses the STEMI dosing regimen for tenecteplase: 1

• <60 kg: 30 mg
• 60-69 kg: 35 mg
• 70-79 kg: 40 mg
• 80-89 kg: 45 mg
• ≥90 kg: 50 mg

Alternative Fixed-Dose Approach

• Contemporary accelerated emergency thrombolysis regimens for fulminant PE include alteplase 50 mg IV bolus with an option for repeat bolus in 15 minutes, or single-dose weight-based tenecteplase. 1
• Research evidence supports 50 mg of tenecteplase as IV push in 1 minute during ongoing CPR, which achieved return of spontaneous circulation in 96% of patients (22/23) with PEA due to massive PE. 2

Administration Details

Timing and Method

• Administer as a single IV bolus over 5-10 seconds during ongoing cardiopulmonary resuscitation. 1, 2
• Early administration of systemic thrombolysis is associated with improved resuscitation outcomes compared with use after failure of conventional ACLS. 1
• In the research study, time from CPR initiation to tPA administration was 6.5 ± 2.1 minutes, with return of spontaneous circulation occurring 2-15 minutes after administration. 2

Adjunctive Therapy

• Thrombolytics should be administered with or followed by systemic anticoagulation. 1

Key Clinical Considerations

Patient Selection

• PEA is the presenting rhythm in 36-53% of PE-related cardiac arrests, while primary shockable rhythms are uncommon. 1
• Clinical markers suggesting PE include conventional thromboembolism risk factors, prodromal dyspnea or respiratory distress, and witnessed arrest. 1

Safety Profile

• The research study showed no minor or major bleeding despite chest compression, with 87% survival at 22-month follow-up. 2
• Right ventricular/left ventricular ratio and pulmonary artery systolic pressure showed significant improvement within 48 hours. 2

Common Pitfalls to Avoid

• Do not delay thrombolysis waiting for absolute diagnostic confirmation if clinical suspicion is high and the patient is in cardiac arrest—the mortality benefit outweighs bleeding risk in this scenario. 1
• Do not withhold thrombolysis solely because chest compressions are being performed; this is explicitly supported by guidelines. 1
• Do not use reduced doses in elderly patients for PE-related cardiac arrest (the 50% dose reduction applies only to STEMI in patients >75 years, not to PE). 1