In a patient who is in cardiac arrest (coding) due to a massive pulmonary embolism, what is the immediate management?

Immediate Management of Massive Pulmonary Embolism in Cardiac Arrest

In a patient coding from confirmed massive pulmonary embolism, immediately administer alteplase 50 mg IV bolus during ongoing CPR, with the option to repeat after 15 minutes if no return of spontaneous circulation (ROSC) occurs. 1, 2

Critical Action Steps During Active CPR

Thrombolytic Administration

• Give alteplase 50 mg as an intravenous bolus immediately while continuing high-quality chest compressions 1, 2
• Repeat the 50 mg bolus after 15 minutes if ROSC has not been achieved 1, 2
• Do not discontinue heparin that was previously initiated when giving the bolus 2
• Thrombolysis can be beneficial even when chest compressions have been provided (Class IIa, LOE C-LD) 1

Alternative Dosing Regimens

• Single-dose weight-based tenecteplase is an acceptable alternative 1, 2
• These accelerated regimens are specifically designed for fulminant PE with cardiac arrest 1

Evidence Supporting Early Thrombolysis

• Early administration of systemic thrombolysis is associated with improved resuscitation outcomes compared with use after failure of conventional ACLS 1, 2
• Systemic thrombolysis is associated with ROSC and short-term survival in PE-related cardiac arrest in observational studies 1
• Without clot-directed therapy, mortality for fulminant PE ranges from 65% to 90% 1, 2

Disregard Standard Contraindications

Standard contraindications to thrombolysis should be superseded by the need for potentially lifesaving intervention in cardiac arrest from massive PE. 1, 2

• Recent intracranial surgery, hemorrhagic stroke, and other typical absolute contraindications become relative in this setting 1, 2, 3, 4
• The mortality without thrombolysis far exceeds bleeding risks 2, 3
• Case reports document successful outcomes with thrombolysis despite recent hemorrhagic CVA and intracranial surgery 3, 4

Alternative Interventions (When Available)

Surgical or Mechanical Embolectomy

• Surgical embolectomy and percutaneous mechanical embolectomy are reasonable emergency treatment options (Class IIa, LOE C-LD) 1
• These should be considered when thrombolysis is contraindicated or has failed 5
• The feasibility of embolectomy under uncontrolled CPR conditions is not well established 1

Extracorporeal Support

• ECPR (extracorporeal cardiopulmonary resuscitation) may be considered in centers with capability 1, 6, 7
• ECMO can provide hemodynamic support and facilitate surgical embolectomy 5, 6, 7
• VA-ECMO is preferred for cardiac arrest scenarios 7

Management of Suspected (Unconfirmed) PE

Thrombolysis may be considered when cardiac arrest is suspected to be caused by PE (Class IIb, LOE C-LD), though this recommendation is weaker than for confirmed PE. 1

• Features suggesting PE-related arrest include: conventional thromboembolism risk factors, prodromal dyspnea, witnessed arrest, and pulseless electrical activity as presenting rhythm 1
• No consensus exists on inclusion criteria for suspected PE 1

Post-ROSC Management

If ROSC is Achieved

• Continue anticoagulation with unfractionated heparin 5
• If the 100 mg/2-hour infusion regimen is used post-ROSC, discontinue heparin during infusion and restart after 3 hours when aPTT is <2 times upper limit of normal 2
• Provide hemodynamic support with vasopressors (norepinephrine) and/or dobutamine as needed 5
• Avoid aggressive fluid resuscitation as it may worsen right ventricular function 5

Common Pitfalls to Avoid

• Do not delay thrombolysis waiting for angiographic confirmation—echocardiography, CTPA, or high clinical probability is sufficient 2
• Do not withhold thrombolysis due to relative contraindications—in massive PE with cardiac arrest, the benefit outweighs bleeding risks 1, 2, 3
• Do not use conventional ACLS alone—early thrombolysis improves outcomes compared to delayed administration after failed conventional resuscitation 1, 2
• Do not use standard 100 mg/2-hour infusion during active CPR—the 50 mg bolus regimen is specifically designed for cardiac arrest 1, 2

Prognostic Considerations

• Pulseless electrical activity is the presenting rhythm in 36% to 53% of PE-related cardiac arrests 1
• Primary shockable rhythms are uncommon in PE-related arrest 1
• Less than 5% of patients with acute PE progress to cardiac arrest, but this subset has extremely high mortality without aggressive intervention 1