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Feltes J, Popova M, Hussein Y, Pierce A, Yamane D. Thrombolytics in Cardiac Arrest from Pulmonary Embolism: A Systematic Review and Meta Analysis. J Intensive Care Med 2024; 39:477-483. [PMID: 38037310 DOI: 10.1177/08850666231214754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND During cardiopulmonary resuscitation, intravenous thrombolytics are commonly used for patients whose underlying etiology of cardiac arrest is presumed to be related to pulmonary embolism (PE). METHODS We performed a systematic review and meta-analysis of the existing literature that focused on the use of thrombolytics for cardiac arrest due to presumed or confirmed PE. Outcomes of interest were return of spontaneous circulation (ROSC), survival to hospital discharge, neurologically-intact survival, and bleeding complications. RESULTS Thirteen studies with a total of 803 patients were included in this review. Most studies included were single-armed and retrospective. Thrombolytic agent and dose were heterogeneous between studies. Among those with control groups, intravenous thrombolysis was associated with higher rates of ROSC (OR 2.55, 95% CI = 1.50-4.34), but without a significant difference in survival to hospital discharge (OR 1.41, 95% CI = 0.79-2.41) or bleeding complications (OR 2.21, 0.95-5.17). CONCLUSIONS Use of intravenous thrombolytics in cardiac arrest due to confirmed or presumed PE is associated with increased ROSC but not survival to hospital discharge or change in bleeding complications. Larger randomized studies are needed. Currently, we recommend continuing to follow existing consensus guidelines which support use of thrombolytics for this indication.
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Affiliation(s)
- Jordan Feltes
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Margarita Popova
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Yasir Hussein
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ayal Pierce
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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2
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Cruz G, Pedroza S, Giraldo M, Peña AD, Calderón CA, Quintero IF. Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review. BMC Anesthesiol 2023; 23:415. [PMID: 38110877 PMCID: PMC10726619 DOI: 10.1186/s12871-023-02370-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/03/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Intraoperative pulmonary embolism (PE) with cardiac arrest (CA) represents a critical and potentially fatal condition. Available treatments include systemic thrombolysis, catheter-based thrombus fragmentation or aspiration, and surgical embolectomy. However, limited studies are focused on the optimal treatment choice for this critical condition. We present a case series and an updated review of the management of intraoperative CA secondary to PE. METHODS A retrospective review of patients who developed high-risk intraoperative PE was performed between June 2012 and June 2022. For the updated review, a literature search on PubMed and Scopus was conducted which resulted in the inclusion of a total of 46 articles. RESULTS A total of 196 174 major non-cardiac surgeries were performed between 2012 and 2022. Eight cases of intraoperative CA secondary to high-risk PE were identified. We found a mortality rate of 75%. Anticoagulation therapy was administered to one patient (12.5%), while two patients (25%) underwent thrombolysis, and one case (12.5%) underwent mechanical thrombectomy combined with thrombus aspiration. Based on the literature review and our 10-year experience, we propose an algorithm for the management of intraoperative CA caused by PE. CONCLUSION The essential components for adequate management of intraoperative PE with CA include hemodynamic support, cardiopulmonary resuscitation, and the implementation of a primary perfusion intervention. The prompt identification of the criteria for each specific treatment modality, guided by the individual patient's characteristics, is necessary for an optimal approach.
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Affiliation(s)
- Gustavo Cruz
- Departamento de anestesiología, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia.
| | - Santiago Pedroza
- Centro de investigaciones clínicas, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Miller Giraldo
- Departamento de cardiología y hemodinamia, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Alvaro D Peña
- Departamento de cirugía cardiovascular, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Camilo A Calderón
- Departamento de cardiología, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Ivan F Quintero
- Departamento de anestesiología, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
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3
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Liu W, Liu LN, Lin CW, Wang HY, Wang XD. Successful Recovery After Prolonged Cardiopulmonary Resuscitation and Rescue Thrombolytics in a Patient with Cardiac Arrest Secondary to Presumed Massive Pulmonary Embolism. Risk Manag Healthc Policy 2021; 14:4253-4256. [PMID: 34703337 PMCID: PMC8523905 DOI: 10.2147/rmhp.s317205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022] Open
Abstract
We present the case of a 60-year-old woman who suddenly suffered a witnessed cardiac arrest and did not achieve return of spontaneous circulation despite being given 150-minute ultra-long cardiopulmonary resuscitation (CPR). During CPR, pulmonary embolism was suspected and was eventually diagnosed based on refractory pulseless electrical activity, elevated serum D-dimmer, and a markedly enlarged right ventricle chamber. After rescue thrombolytic alteplase therapy, the patient was successfully resuscitated and had a good neurological recovery.
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Affiliation(s)
- Wei Liu
- Department of Emergency, Aerospace Center Hospital (Peking University Aerospace School of Clinical Medicine), Beijing, 100049, People's Republic of China
| | - Li-Na Liu
- Department of Emergency, Aerospace Center Hospital (Peking University Aerospace School of Clinical Medicine), Beijing, 100049, People's Republic of China
| | - Cai-Wei Lin
- Department of Emergency, Aerospace Center Hospital (Peking University Aerospace School of Clinical Medicine), Beijing, 100049, People's Republic of China
| | - Hao-Yu Wang
- Department of Radiology, Aerospace Center Hospital (Peking University Aerospace School of Clinical Medicine), Beijing, 100049, People's Republic of China
| | - Xu-Dong Wang
- Department of Emergency, Aerospace Center Hospital (Peking University Aerospace School of Clinical Medicine), Beijing, 100049, People's Republic of China
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4
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Rivera-Morales MD, Wu JC, Dub L, Ganti L. Rare Presentation of Deep Vein Thrombosis and Submassive Pulmonary Emboli Due to Hypercoagulable State With Supratherapeutic Anticoagulation. Cureus 2021; 13:e17300. [PMID: 34552835 PMCID: PMC8449517 DOI: 10.7759/cureus.17300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/05/2022] Open
Abstract
We present a case of an elderly male with multiple co-morbidities, including atrial fibrillation on warfarin and recently diagnosed left lower extremity deep vein thrombosis (DVT), who presented to the emergency department for dyspnea. He was found to be hypoxic and mildly hypotensive. He was diagnosed with submassive pulmonary emboli (PE) despite having a supratherapeutic international normalized ratio (INR). In this case report, the clinical presentation, diagnostic workup, and management of this patient are discussed.
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Affiliation(s)
- Mark D Rivera-Morales
- Emergency Medicine, University of Central Florida Hospital Corporation of America (HCA) Healthcare Graduate Medical Education Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA.,Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Jesse C Wu
- Emergency Medicine, University of Central Florida Hospital Corporation of America (HCA) Healthcare Graduate Medical Education Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA.,Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Larissa Dub
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA.,Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA.,Emergency Medicine, University of Central Florida Hospital Corporation of America (HCA) Healthcare Graduate Medical Education Consortium Emergency Medicine Residency Program of Greater Orlando, Orlando, USA
| | - Latha Ganti
- Emergency Medicine, Envision Physician Services, Plantation, USA.,Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA.,Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA.,Emergency Medicine, University of Central Florida Hospital Corporation of America (HCA) Healthcare Graduate Medical Education Consortium Emergency Medicine Residency Program of Greater Orlando, Olrando, USA
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5
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Welle SR, Harrison MF. Massive Pulmonary Embolism Causing Cardiac Arrest Managed with Systemic Thrombolytic Therapy: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931215. [PMID: 34228699 PMCID: PMC8272940 DOI: 10.12659/ajcr.931215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/31/2021] [Accepted: 05/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Approximately 290 000 cases of in-hospital cardiac arrest occur annually, the majority of which are due to cardiac or respiratory causes. Cardiac arrest due to acute pulmonary embolism (PE) is associated with a 90% incidence of mortality and, if identified, it can be treated with systemic thrombolytics. Here, we describe a case in which the outcome for such an event was favorable. CASE REPORT A 66-year-old woman was admitted with multiple rib and left ankle fractures due to accidental trauma. Before undergoing orthopedic surgery, she experienced a cardiac arrest with pulseless electrical activity, which was witnessed. She had refractory hypoxia and hypotension following intubation and a brief initial return of spontaneous circulation (ROSC) before a second cardiac arrest. A 100-mg bolus dose of systemic thrombolytic therapy was promptly administered, with rapid achievement of sustained ROSC. The results of a subsequent electrocardiogram, echocardiogram, and computed tomography scan further supported the diagnosis of acute PE with right heart strain. Supportive care in the Intensive Care Unit resulted in full neurological recovery and she was discharged to a physical rehabilitation facility 12 days after her cardiac arrest. CONCLUSIONS Systemic thrombolytic therapy is beneficial for cardiac arrest due to acute PE.
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Affiliation(s)
- Stephanie R. Welle
- Department of Intensive Care (Critical Care), Mayo Clinic Health System, Mankato, MN, USA
| | - Michael F. Harrison
- Department of Intensive Care (Critical Care), Mayo Clinic Health System, Mankato, MN, USA
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
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6
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Karami M, Mandigers L, Miranda DDR, Rietdijk WJR, Binnekade JM, Knijn DCM, Lagrand WK, den Uil CA, Henriques JPS, Vlaar APJ. Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care 2021; 64:245-254. [PMID: 34049258 DOI: 10.1016/j.jcrc.2021.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/21/2020] [Accepted: 03/14/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND To examine whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) improves survival of patients with acute pulmonary embolism (PE). METHODS Following the PRISMA guidelines, a systematic search was conducted up to August 2019 of the databases: PubMed/MEDLINE, EMBASE and Cochrane. All studies reporting the survival of adult patients with acute PE treated with VA-ECMO and including four patients or more were included. Exclusion criteria were: correspondences, reviews and studies in absence of a full text, written in other languages than English or Dutch, or dating before 1980. Short-term (hospital or 30-day) survival data were pooled and presented with relative risks (RR) and 95% confidence intervals (95% CI). Also, the following pre-defined factors were evaluated for their association with survival in VA-ECMO treated patients: age > 60 years, male sex, pre-ECMO cardiac arrest, surgical embolectomy, catheter directed therapy, systemic thrombolysis, and VA-ECMO as single therapy. RESULTS A total of 29 observational studies were included (N = 1947 patients: VA-ECMO N = 1138 and control N = 809). There was no difference in short-term survival between VA-ECMO treated patients and control patients (RR 0.91, 95% CI 0.71-1.16). In acute PE patients undergoing VA-ECMO, age > 60 years was associated with lower survival (RR 0.72, 95% CI 0.52-0.99), surgical embolectomy was associated with higher survival (RR 1.96, 95% CI 1.39-2.76) and pre-ECMO cardiac arrest showed a trend toward lower survival (RR 0.88, 95% CI 0.77-1.01). The other evaluated factors were not associated with a difference in survival. CONCLUSIONS At present, there is insufficient evidence that VA-ECMO treatment improves short-term survival of acute PE patients. Low quality evidence suggest that VA-ECMO patients aged ≤60 years or who received SE have higher survival rates. Considering the limited evidence derived from the present data, this study emphasizes the need for prospective studies. PROTOCOL REGISTRATION PROSPERO CRD42019120370.
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Affiliation(s)
- Mina Karami
- Heart Center; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Loes Mandigers
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wim J R Rietdijk
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan M Binnekade
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Daniëlle C M Knijn
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wim K Lagrand
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Corstiaan A den Uil
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - José P S Henriques
- Heart Center; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Hailu K, Allen B, Pagan-Valentin S, Schissler K. Use of fibrinolytics for the management of massive pulmonary embolism in a patient with a history of subdural hemorrhage. Am J Emerg Med 2021; 47:339.e1-339.e3. [PMID: 33750664 DOI: 10.1016/j.ajem.2021.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/27/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Management of massive pulmonary embolism in patients with hemodynamic instability encompasses the use of fibrinolytics. Use of fibrinolytic therapy is currently recommended in this patient population by ACCP, AHA, and EHA if treatment benefit outweighs the risk of bleeding. There is currently no data challenging or exploring the risk of using fibrinolytic therapy for the management of massive PE in patients with a history of intracranial hemorrhage. CASE PRESENTATION A 38-year old female with suspected massive pulmonary embolism was admitted with a chief complaint of chest pain and right leg pain. Shortly after a confirmatory CT of bilateral PE, the patient had multiple cardiac arrests along with severe shock that led to a general agreement among the team to proceed with IV and then catheter-directed TPA as well as thrombectomy. Following fibrinolytic therapy, the patient was started on a heparin drip along with epinephrine for hemodynamic support. CT chest angiography showed the resolution of emboli following treatment with the fibrinolytic agent. CT of the head taken approximately 24 h post tPA initiation was used to rule out intracranial hemorrhage or other complications resulting from tPA administration. CONCLUSION In patients with a history of intracranial hemorrhage, catheter guided fibrinolytic and thrombectomy may be effective treatment options of massive pulmonary embolism.
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Affiliation(s)
- Kirubel Hailu
- Department of Pharmacy, Ascension St. Vincent's, Jacksonville, FL, United States of America.
| | - Bryan Allen
- Department of Pharmacy, Ascension St. Vincent's, Jacksonville, FL, United States of America
| | - Sylma Pagan-Valentin
- Department of Pharmacy, Baptist Health Beaches, Jacksonville, FL, United States of America
| | - Keith Schissler
- Department of Pharmacy, Baptist Health Beaches, Jacksonville, FL, United States of America
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8
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International Survey of Thrombolytic Use for Treatment of Cardiac Arrest Due to Massive Pulmonary Embolism. Crit Care Explor 2020; 2:e0132. [PMID: 32695997 PMCID: PMC7314323 DOI: 10.1097/cce.0000000000000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objectives This survey sought to characterize the national prescribing patterns and barriers to the use of thrombolytic agents in the treatment of pulmonary embolism, with a specific focus on treatment during actual or imminent cardiac arrest. Design A 19-question international, cross-sectional survey on thrombolytic use in pulmonary embolism was developed, validated, and administered. A multivariable logistic regression was conducted to determine factors predictive of utilization of thrombolytics in the setting of cardiac arrest secondary to pulmonary embolism. Setting International survey study. Subjects Physicians, pharmacists, nurses, and other healthcare professionals who were members of the Society of Critical Care Medicine. Interventions None. Measurements and Main Results Thrombolytic users were compared with nonusers. Respondents (n = 272) predominately were physicians (62.1%) or pharmacists (30.5%) practicing in an academic medical center (54.8%) or community teaching setting (24.6%). Thrombolytic users (n = 177; 66.8%) were compared with nonusers (n = 88; 33.2%) Thrombolytic users were more likely to work in pulmonary/critical care (80.2% thrombolytic use vs 59.8%; p < 0.01) and emergency medicine (6.8% vs 3.5%; p < 0.01). Users were more likely to have an institutional guideline or policy in place pertaining to the use of thrombolytics in cardiac arrest (27.8% vs 13.6%; p < 0.01) or have a pulmonary embolism response team (38.6% vs 19.3%; p < 0.01). Lack of evidence supporting use and the risk of adverse outcomes were barriers to thrombolytic use. Working in a pulmonary/critical care environment (odds ratio, 2.36; 95% CI, 1.24-4.52) and comfort level (odds ratio, 2.77; 95% CI, 1.7-4.53) were predictive of thrombolytic use in the multivariable analysis. Conclusions Most survey respondents used thrombolytics in the setting of cardiac arrest secondary to known or suspected pulmonary embolism. This survey study adds important data to the literature surrounding thrombolytics for pulmonary embolism as it describes thrombolytic user characteristic, barriers to use, and common prescribing practices internationally.
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9
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Thrombolysis During Resuscitation for Out-of-Hospital Cardiac Arrest Caused by Pulmonary Embolism Increases 30-Day Survival. Chest 2019; 156:1167-1175. [DOI: 10.1016/j.chest.2019.07.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/18/2022] Open
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Abstract
OBJECTIVES Pulmonary embolism is a rarely reported and potentially treatable cause of cardiac arrest in children and adolescents. The objective of this case series is to describe the course of five adolescent patients with in-hospital cardiac arrest secondary to pulmonary embolism. DESIGN Case series. SETTING Single, large academic children's hospital. PATIENTS All patients under the age of 18 years (n = 5) who experienced an in-hospital cardiac arrest due to apparent pulmonary embolism from August 1, 2013, to July 31, 2017. INTERVENTIONS All five patients received systemic thrombolytic therapy (IV tissue plasminogen activator) during cardiac arrest or periarrest during ongoing resuscitation efforts. MEASUREMENTS AND MAIN RESULTS Five adolescent patients, 15-17 years old, were treated for pulmonary embolism-related cardiac arrests during the study period. These accounted for 6.3% of all children and 25% of adolescents (12-17 yr old) receiving at least 5 minutes of in-hospital cardiopulmonary resuscitation during the study period. All five had venous thromboembolism risk factors. Two patients had known, extensive venous thrombi at the time of cardiac arrest, and one was undergoing angiography at the time of arrest. The diagnoses of pulmonary embolism were based on clinical suspicion, bedside echocardiography (n = 4), and low end-tidal CO2 levels relative to arterial CO2 values (n = 5). IV tissue plasminogen activator was administered during cardiopulmonary resuscitation in three patients and after the return of spontaneous circulation, in the setting of severe hemodynamic instability, in the other two patients. Four of five patients were successfully resuscitated and survived to hospital discharge. CONCLUSIONS Pulmonary embolism was recognized as the etiology of multiple adolescent cardiac arrests in this single-center series and may be more common than previously reported. Recognition, high-quality cardiopulmonary resuscitation, and treatment with thrombolytic therapy resulted in survival in four of five patients.
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11
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Peppard SR, Parks AM, Zimmerman J. Characterization of alteplase therapy for presumed or confirmed pulmonary embolism during cardiac arrest. Am J Health Syst Pharm 2019; 75:870-875. [PMID: 29880524 DOI: 10.2146/ajhp170450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The dosing and administration of alteplase in cardiac arrest due to suspected or confirmed pulmonary embolism (PE) are characterized. METHODS This multicenter, retrospective, cohort study evaluated adult patients who received alteplase during PE-induced cardiac arrest at 16 medical centers. Outcomes analyzed included alteplase dosing characteristics, cardiopulmonary resuscitation survival, time to return of spontaneous circulation (ROSC), documented occurrence of major or minor bleeding, intensive care unit and hospital length of stay, and survival to discharge. RESULTS A total of 35 patients were included in the analysis. Forty-six percent of patients received alteplase by a bolus-only dosing strategy. The most common bolus-only alteplase dose was 50 mg. Patients in the bolus-only group had a significantly shorter mean time from cardiac arrest onset to alteplase administration (15.1 minutes) compared with both the infusion-only group (46.4 minutes) and the bolus-with-infusion group (48.0 minutes) (p = 0.006). The mean cumulative alteplase dose was significantly higher in patients who had ROSC than those who did not (90.6 and 69.4 mg, respectively; p = 0.03). Although there was a significant difference in the cardiac arrest survival between groups, there was no difference between dosing strategies and the attainment of ROSC, and survival to hospital discharge. CONCLUSION Among patients receiving alteplase for presumed or confirmed PE during cardiac arrest, the most common treatment was administration of a single 50-mg bolus of the thrombolytic agent. This treatment was received by all survivors of cardiac arrest.
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Affiliation(s)
- Sarah R Peppard
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, WI .,Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI.
| | - Ann M Parks
- Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI.,Department of Pharmacy, Aurora Health Care, Milwaukee, WI
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12
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Oh YN, Oh DK, Koh Y, Lim CM, Huh JW, Lee JS, Jung SH, Kang PJ, Hong SB. Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review. Acute Crit Care 2019; 34:148-154. [PMID: 31723920 PMCID: PMC6786667 DOI: 10.4266/acc.2019.00500] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 12/12/2022] Open
Abstract
Background Although extracorporeal membrane oxygenation (ECMO) has been used for the treatment of acute high-risk pulmonary embolism (PE), there are limited reports which focus on this approach. Herein, we described our experience with ECMO in patients with acute high-risk PE. Methods We retrospectively reviewed medical records of patients diagnosed with acute high-risk PE and treated with ECMO between January 2014 and December 2018. Results Among 16 patients included, median age was 51 years (interquartile range [IQR], 38 to 71 years) and six (37.5%) were male. Cardiac arrest was occurred in 12 (75.0%) including two cases of out-of-hospital arrest. All patients underwent veno-arterial ECMO and median ECMO duration was 1.5 days (IQR, 0.0 to 4.5 days). Systemic thrombolysis and surgical embolectomy were performed in seven (43.8%) and nine (56.3%) patients, respectively including three patients (18.8%) received both treatments. Overall 30-day mortality rate was 43.8% (95% confidence interval, 23.1% to 66.8%) and 30-day mortality rates according to the treatment groups were ECMO alone (33.3%, n=3), ECMO with thrombolysis (50.0%, n=4) and ECMO with embolectomy (44.4%, n=9). Conclusions Despite the vigorous treatment efforts, patients with acute high-risk PE were related to substantial morbidity and mortality. We report our experience of ECMO as rescue therapy for refractory shock or cardiac arrest in patients with PE.
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Affiliation(s)
- You Na Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: A two center observational study. Resuscitation 2019; 136:8-13. [DOI: 10.1016/j.resuscitation.2018.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/28/2018] [Accepted: 12/10/2018] [Indexed: 11/22/2022]
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14
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Summers K, Schultheis J, Raiff D, Dahhan T. Evaluation of Rescue Thrombolysis in Cardiac Arrest Secondary to Suspected or Confirmed Pulmonary Embolism. Ann Pharmacother 2019; 53:711-715. [DOI: 10.1177/1060028019828423] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | - Doug Raiff
- Duke University Hospital, Durham, NC, USA
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15
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Mongodi S, Luperto M, Roldi EM, Orlando A, Iotti GA, Mojoli F. Ultrasound Diagnosis of Cardiac Arrest in a Patient With Hematologic Disease. Chest 2019; 155:e9-e12. [DOI: 10.1016/j.chest.2018.08.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/25/2018] [Accepted: 08/27/2018] [Indexed: 10/27/2022] Open
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Resuscitation group should be a part of all pulmonary thromboembolism risk stratifications. Am J Emerg Med 2018; 37:151-152. [PMID: 29731346 DOI: 10.1016/j.ajem.2018.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 11/23/2022] Open
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18
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Wada T. Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome. Front Med (Lausanne) 2017; 4:156. [PMID: 29034235 PMCID: PMC5626829 DOI: 10.3389/fmed.2017.00156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/11/2017] [Indexed: 01/08/2023] Open
Abstract
Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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19
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Abstract
We describe the successful use and complications of bolus-dose alteplase to treat strongly suspected pulmonary embolism (PE) with cardiac arrest in a patient initially presenting as ST-elevation myocardial infarcation (MI). Case description is followed by a review of the indications, safety, and dosing of systemic thrombolytic therapy for high-risk PE in the emergency department (ED). Diagnostic and therapeutic approach to PE in critically ill patients is also considered, including the potential utility of point-of-care ultrasound (PoCUS) in the ED.
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20
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Yang J, Zhao LX, Li CS, Tong N, Xiao HL, An L. Variations of Postresuscitation Lung Function after Thrombolysis Therapy in a Cardiac Arrest Porcine Model Caused by Pulmonary Thromboembolism. Chin Med J (Engl) 2017; 130:1475-1480. [PMID: 28584212 PMCID: PMC5463479 DOI: 10.4103/0366-6999.207481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Study of lung function in survivor from cardiac arrest (CA) caused by pulmonary thromboembolism (PTE) was rare. The aim of this study was to investigate the variations of postresuscitation lung function after thrombolysis treatment in a CA porcine model caused by PTE. METHODS After 2 min of untreated CA, pigs of 10-12 weeks with a weight of 30 ± 2 kg (n = 24) were treated with recombinant human tissue plasminogen activator (50 mg). Cardiopulmonary resuscitation (CPR) and ventilation were initiated after drug administration. Pulmonary function and arterial blood gas parameters were measured at baseline, return of spontaneous circulation (ROSC) immediately, and 1 h, 2 h, 4 h, and 6 h after ROSC. RESULTS The dynamic lung compliance decreased significantly at ROSC immediately and 1 h after ROSC compared to baseline (21.86 ± 2.00 vs. 26.72 ± 2.20 ml/mmHg and 20.38 ± 1.31 vs. 26.72 ± 2.20 ml/mmHg, respectively; P < 0.05; 1 mmHg = 0.133 kPa). Compared with baseline, airway resistance increased significantly at ROSC immediately and 1 h after ROSC (P < 0.05). Respiratory index also increased after ROSC and showed significant differences among baseline, ROSC immediately, and 2 h after ROSC (P < 0.05). Oxygen delivery decreased at ROSC immediately compared to baseline (P < 0.05). The oxygenation index decreased significantly at any time after ROSC compared to baseline (P < 0.05). Extravascular lung water index and pulmonary vascular permeability index (PVPI) showed significant differences at ROSC immediately compared to baseline and 1 h after ROSC (P < 0.05); PVPI at ROSC immediately was also different from 6 h after ROSC (P < 0.05). Ventilation/perfusion ratios increased after ROSC (P < 0.05). Histopathology showed fibrin effusion, bleeding in alveoli, and hemagglutination in pulmonary artery. CONCLUSIONS Lung function remains abnormal even after CPR with thrombolysis therapy; it is essential to continue anticoagulation and symptomatic treatment after ROSC.
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Affiliation(s)
- Jun Yang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing 100020, China
| | - Lian-Xing Zhao
- Department of Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, China
| | - Chun-Sheng Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing 100020, China
| | - Nan Tong
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing 100020, China
| | - Hong-Li Xiao
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing 100020, China
| | - Le An
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing 100020, China
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21
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Thrombolytic therapy delay is independent predictor of mortality in acute pulmonary embolism at emergency service. Kaohsiung J Med Sci 2016; 32:572-578. [DOI: 10.1016/j.kjms.2016.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/13/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
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Thrombolytic Therapy by Tissue Plasminogen Activator for Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:67-74. [DOI: 10.1007/5584_2016_106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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23
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Sharifi M, Berger J, Beeston P, Bay C, Vajo Z, Javadpoor S. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the "PEAPETT" study). Am J Emerg Med 2016; 34:1963-1967. [PMID: 27422214 DOI: 10.1016/j.ajem.2016.06.094] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/07/2016] [Accepted: 06/29/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Pulseless electrical activity (PEA) during cardiac arrest portends a poor prognosis. There is a paucity of data in the use of thrombolytic therapy in PEA and cardiopulmonary arrest due to confirmed pulmonary embolism (PE). We evaluated the outcome of low-dose systemic thrombolysis with tissue plasminogen activator (tPA) in patients presenting with PEA due to PE. METHODS During a 34-month period, we treated 23 patients with PEA and cardiopulmonary arrest due to confirmed massive PE. All patients received 50 mg of tPA as intravenous push in 1 minute while cardiopulmonary resuscitation was ongoing. The time from initiation of cardiopulmonary resuscitation to administration of tPA was 6.5 ± 2.1 minutes. RESULTS Return of spontaneous circulation occurred in 2 to 15 minutes after tPA administration in all but 1 patient. There was no minor or major bleeding despite chest compression. Of the 23 patients, 2 died in the hospital, and at 22 ± 3 months of follow-up, 20 patients (87%) were still alive. The right ventricular/left ventricular ratio and pulmonary artery systolic pressure dropped from 1.79 ± 0.27 and 58.10 ± 7.99 mm Hg on admission to 1.16 ± 0.13 and 40.25 ± 4.33 mm Hg within 48 hours, respectively (P< .001 for both comparisons). There was no recurrent venous thromboembolism or bleeding during hospitalization or at follow-up. CONCLUSION Rapid administration of 50 mg of tPA is safe and effective in restoration of spontaneous circulation in PEA due to massive PE leading to enhanced survival and significant reduction in pulmonary artery pressures.
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Affiliation(s)
- Mohsen Sharifi
- Arizona Cardiovascular Consultants & Vein Clinic, Mesa, AZ; A.T. Still University, Mesa, AZ.
| | | | | | | | - Zoltan Vajo
- Arizona Cardiovascular Consultants & Vein Clinic, Mesa, AZ
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24
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Which out-of-hospital cardiac arrest patients should be thrombolysed? Am J Emerg Med 2016; 34:916-7. [DOI: 10.1016/j.ajem.2016.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/20/2022] Open
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25
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Newman J, Park D, Manetta F. Extracorporeal membrane oxygenation for failed tPA therapy of pulmonary embolism. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/2055552016633964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Pulmonary embolism may cause cardiac arrest secondary to obstruction of blood flow. Traditional treatment strategies include anticoagulation, thrombolysis, and mechanical extraction. Some advocate for support with extra corporeal membrane oxygenation; however, surgical therapies are contraindicated following thrombolytics. Methods: We describe the emergent use of peripheral extra corporeal membrane oxygenation following thrombolytic therapy for a saddle pulmonary embolism associated with multiple episodes of cardiac arrest. Results: The patient was stabilized with peripheral extra corporeal membrane oxygenation, anticoagulated and subsequently weaned from extra corporeal membrane oxygenation without any major bleeding complications. Conclusion: The administration of thrombolytics should not be a contraindication for extra corporeal membrane oxygenation in patients with massive pulmonary embolism associated with hemodynamic instability.
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Affiliation(s)
- Joshua Newman
- Hofstra North Shore-LIJ School of Medicine, Hofstra University, Hempstead, NY, USA
| | - David Park
- Department of Cardiovascular and Thoracic Surgery, Southside Hospital, Bay Shore, NY, USA
| | - Frank Manetta
- Hofstra North Shore-LIJ School of Medicine, Hofstra University, Hempstead, NY, USA
- Department of Cardiovascular and Thoracic Surgery, Southside Hospital, Bay Shore, NY, USA
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26
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Yousuf T, Brinton T, Ahmed K, Iskander J, Woznicka D, Kramer J, Kopiec A, Chadaga AR, Ortiz K. Tissue Plasminogen Activator Use in Cardiac Arrest Secondary to Fulminant Pulmonary Embolism. J Clin Med Res 2016; 8:190-5. [PMID: 26858790 PMCID: PMC4737028 DOI: 10.14740/jocmr2452w] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2016] [Indexed: 11/12/2022] Open
Abstract
Background Tissue plasminogen activator (tPA) is used emergently to dissolve thrombi in the treatment of fulminant pulmonary embolism. Currently, there is a relative contraindication to tPA in the setting of traumatic or prolonged cardiopulmonary resuscitation > 10 minutes because of the risk of massive hemorrhage. Methods Our single-center, retrospective study investigated patients experiencing cardiac arrest (CA) secondary to pulmonary embolus. We compared the effectiveness of advanced cardiac life support with the administration of tPA vs. the standard of care consisting of advanced cardiac life support without thrombolysis. The primary endpoint was survival to discharge. Secondary endpoints were return of spontaneous circulation (ROSC), major bleeding, and minor bleeding. Results We analyzed 42 patients, of whom 19 received tPA during CA. Patients who received tPA were not associated with a statistically significant increase in survival to discharge (10.5% vs. 8.7%, P = 1.00) or ROSC (47.4% vs. 47.8%, P = 0.98) compared to the control group. We observed no statistically significant difference between the groups in major bleeding events (5.3% in the tPA group vs. 4.3% in the control group, P = 1.00) and minor bleeding events (10.5% in the tPA group vs. 0.0% in the control group, P = 0.11). Conclusion This study did not find a statistically significant difference in survival to discharge or in ROSC in patients treated with tPA during CA compared to patients treated with standard therapy. However, because no significant difference was found in major or minor bleeding, we suggest that the potential therapeutic benefits of this medication should not be limited by the potential for massive hemorrhage. Larger prospective studies are warranted to define the efficacy and safety profile of thrombolytic use in this population.
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Affiliation(s)
- Tariq Yousuf
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Taylor Brinton
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Khansa Ahmed
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Joy Iskander
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Daniel Woznicka
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Jason Kramer
- Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Adam Kopiec
- Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Amar R Chadaga
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Kathia Ortiz
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
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Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Donnino MW. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S501-18. [PMID: 26472998 DOI: 10.1161/cir.0000000000000264] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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28
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Madsen PH, Hess S. Symptomatology, Clinical Presentation and Basic Work up in Patients with Suspected Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:33-48. [DOI: 10.1007/5584_2016_104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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29
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Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest. Case Rep Emerg Med 2015; 2015:367295. [PMID: 26664765 PMCID: PMC4664787 DOI: 10.1155/2015/367295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/27/2015] [Accepted: 10/28/2015] [Indexed: 12/29/2022] Open
Abstract
More than 70% of cardiac arrest cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is a recognised therapy for both AMI and PE, its indiscriminate use is not routinely recommended during cardiopulmonary resuscitation (CPR). We present a case describing the successful use of double dose thrombolysis during cardiac arrest caused by pulmonary embolism. Notwithstanding the relative lack of high-level evidence, this case suggests a scenario in which recombinant tissue Plasminogen Activator (rtPA) may be beneficial in cardiac arrest. In addition to the strong clinical suspicion of pulmonary embolism as the causative agent of the patient's cardiac arrest, the extremely low end-tidal CO2 suggested a massive PE. The absence of dilatation of the right heart on subxiphoid ultrasound argued against the diagnosis of PE, but not conclusively so. In the context of the circulatory collapse induced by cardiac arrest, this aspect was relegated in terms of importance. The second dose of rtPA utilised in this case resulted in return of spontaneous circulation (ROSC) and did not result in haemorrhage or an adverse effect.
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30
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Gao JP, Ying KJ. Thrombolysis during extended cardiopulmonary resuscitation for autoimmune-related pulmonary embolism. World J Emerg Med 2015; 6:153-6. [PMID: 26056548 DOI: 10.5847/wjem.j.1920-8642.2015.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 01/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Massive pulmonary embolism (MPE) and acute myocardial infarction are the two most common causes of cardiac arrest (CA). At present, lethal hemorrhage makes thrombolytic therapy underused during cardiopulmonary resuscitation, despite the potential benefits for these underlying conditions. Hypercoagulability of the blood in autoimmune disorders (such as autoimmune hemolytic anemia) carries a risk of MPE. It is critical to find out the etiology of CA for timely thrombolytic intervention. METHODS A 23-year-old woman with a 10-year medical history of autoimmune hemolytic anemia suffered from CA in our emergency intensive care unit. ECG and echocardiogram indicated the possibility of MPE, so fibrinolytic therapy (alteplase) was successful during prolonged resuscitation. RESULTS Neurological recovery of the patient was generally good, and no fatal bleeding developed. MPE was documented by CT pulmonary angiography. CONCLUSIONS A medical history of autoimmune disease poses a risk of PE, and the causes of CA (such as this) should be investigated etiologically. A therapy with alteplase may be used early during cardiopulmonary resuscitation once there is presumptive evidence of PE. Clinical trials are needed in this setting to study patients with hypercoagulable states.
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Affiliation(s)
- Jian-Ping Gao
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Ke-Jing Ying
- Department of Respiratory and Critical Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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31
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Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk. J Emerg Med 2015; 48:771-80. [DOI: 10.1016/j.jemermed.2014.12.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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32
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Katyal A, Dmello D, Taylor RW. Thrombolytic therapy for cardiac arrest secondary to acute pulmonary embolism: an oft overlooked strategy. Am J Emerg Med 2015; 33:850-1. [PMID: 25843791 DOI: 10.1016/j.ajem.2015.03.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- Anup Katyal
- Critical Care Medicine, Mercy Clinic and Hospital Saint Louis, St. Louis, MO 63141
| | - Dayton Dmello
- Pulmonary, Critical Care and Sleep Medicine, Mercy Clinic and Hospital, St. Louis, MO 63141.
| | - Robert W Taylor
- Critical Care Medicine, Mercy Clinic and Hospital Saint Louis, St. Louis, MO 63141
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Wu JP, Gu DY, Wang S, Zhang ZJ, Zhou JC, Zhang RF. Good neurological recovery after rescue thrombolysis of presumed pulmonary embolism despite prior 100 minutes CPR. J Thorac Dis 2015; 6:E289-93. [PMID: 25590010 DOI: 10.3978/j.issn.2072-1439.2014.12.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/13/2014] [Indexed: 12/18/2022]
Abstract
We reported the case of a 70-year-old man who was admitted to neurologic wards for recurrent syncope for 3 years. Unfortunately, just 2 hours after his admission, he suddenly collapsed and failed to return of spontaneous circulation (ROSC) after a 100-minute standard cardiopulmonary resuscitation (CPR). Fortunately, he was timely suspected to have pulmonary embolism (PE) based on his sedentary lifestyle, elevated D-dimer and markedly enlarged right ventricle chamber on bedside echocardiography. After a rescue thrombolytic alteplase therapy, he was successfully resuscitated and good neurological recovery was achieved.
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Affiliation(s)
- Jiang-Ping Wu
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Dan-Yan Gu
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Sheng Wang
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Zhen-Jun Zhang
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jian-Cang Zhou
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Rui-Feng Zhang
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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