Suppose you have a patient in whom you highly suspect a pulmonary embolism (PE) that devolves into PEA arrest while awaiting a CT angiogram. Or, what about a patient with an ECG showing clear STEMI that loses pulses?
Clinical Question:
In the rare situation where fibrinolytics may be indicated in cardiac arrest from PE or Acute Myocardial Infarction (AMI), what’s the dose?
| Citation | Study Design | Condition | Drug | Dose |
| Kurkciyan et al.1 | Retrospective cohort | PE | Alteplase | 100 mg (either two 50 mg boluses OR 15 mg bolus followed by 85 mg over 90 min) |
| Ruiz-Bailen et al.2 | Case series (6 pts) | PE | Alteplase | 50 mg bolus, repeat 50 mg in 30 min |
| Janata et al.3 | Retrospective cohort | PE | Alteplase | 0.6-1.0 mg/kg bolus (up to 100 mg) |
| Sharifi et al.4 | Case series (23 pts) | PE | Alteplase | 50 mg bolus |
| Lederer et al.5 | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg followed by 85 mg over 90 min) |
| Ruiz-Bailen et al.6 | Retrospective cohort | AMI | Alteplase | 100 mg (either two 50 mg boluses OR 15 mg bolus followed by 85 mg over 90 min) |
| Schreiber et al.7 | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg followed by 85 mg over 90 min) |
| Kurkciyan et al.8 | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg followed by 85 mg over 90 min) |
| Bottiger et al.9 | Prospective observational | Nontraumatic cardiac arrest | Alteplase | 50 mg bolus, repeat 50 mg in 30 minutes |
| Abu-Laban et al.10 | RCT | Cardiac arrest from any cause | Alteplase | 100 mg over 15 min |
| Fatovich et al.11 | RCT | Cardiac arrest from any cause | Tenecteplase | 50 mg bolus |
| Bozeman et al.12 | Prospective cohort | Nontraumatic cardiac arrest | Tenecteplase | 0.5 mg/kg bolus |
| Bottiger et al.13 | RCT | Cardiac arrest from any cause | Tenecteplase | 0.5 mg/kg bolus |
| * Table includes only studies which fibrinolytic dose/administration is clearly specified. | ||||
Take Home Points
- The dose of tPA in cardiac arrest is somewhere between 50-100 mg given as a bolus +/- infusion.
- According to the 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, “Ongoing CPR is not an absolute contraindication for fibrinolysis.”
- Some studies suggest allowing 15 minutes of CPR for drug to work.
- Evidence is ‘best’ for PE; data does NOT support for undifferentiated cardiac arrest.
- Anticoagulants, such as heparin, were used in most studies along with the fibrinolytic.
Last updated: Aug 14, 2016
1.
Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535. [PubMed]
2.
Ruiz-Bailén M, Aguayo-de-Hoyos E, Serrano-Córcoles M, et al. Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series. Resuscitation. 2001;51(1):97-101. [PubMed]
3.
Janata K, Holzer M, Kürkciyan I, et al. Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism. Resuscitation. 2003;57(1):49-55. [PubMed]
4.
Sharifi M, Berger J, Beeston P, et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016;34(10):1963-1967. [PubMed]
5.
Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M. Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest. Resuscitation. 2001;50(1):71-76. [PubMed]
6.
Ruiz-Bailén M, Aguayo de, Serrano-Córcoles M, Diáz-Castellanos M, Ramos-Cuadra J, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial infarction requiring cardiopulmonary resuscitation. Intensive Care Med. 2001;27(6):1050-1057. [PubMed]
7.
Schreiber W, Gabriel D, Sterz F, et al. Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation. 2002;52(1):63-69. [PubMed]
8.
Kurkciyan I, Meron G, Sterz F, et al. Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment. J Intern Med. 2003;253(2):128-135. [PubMed]
9.
Böttiger B, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet. 2001;357(9268):1583-1585. [PubMed]
10.
Abu-Laban R, Christenson J, Innes G, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528. [PubMed]
11.
Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313. [PubMed]
12.
Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406. [PubMed]
13.
Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662. [PubMed]
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