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Vajifdar F, Badki P. Low-dose tenecteplase during cardiopulmonary resuscitation in massive pulmonary embolism. Int J Emerg Med 2024; 17:82. [PMID: 38961331 PMCID: PMC11223363 DOI: 10.1186/s12245-024-00659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024] Open
Abstract
We report the case of an 18-year-old male who presented to the Emergency Department with sudden onset dyspnea. The patient was intubated on arrival, but suffered a cardiac arrest soon after. Point-of-care echocardiography during cardiopulmonary resuscitation revealed a grossly dilated right atrium and right ventricle, which alerted the Emergency physician to the possibility of massive pulmonary embolism leading to cardiac arrest. Due to no discernible history or risk factors in favour of pulmonary embolism, a decision was taken for thrombolysis with half dose Tenecteplase. Return of spontaneous circulation was achieved 14 min after thrombolysis, with massive pulmonary embolism subsequently being confirmed on CT Pulmonary Angiography.
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Affiliation(s)
- Farzin Vajifdar
- Department of Emergency Medicine, Holy Family Multispecialty Hospital, Mumbai, India.
| | - Parag Badki
- Intensive Care, Holy Family Multispecialty Hospital, Mumba, India
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Thakkar D, Shinde V. Caught in the Clot: A Case Report of Arrested Pulmonary Embolism. Cureus 2024; 16:e61213. [PMID: 38939235 PMCID: PMC11210831 DOI: 10.7759/cureus.61213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Pulmonary embolism (PE) is a life-threatening condition resulting from the obstruction of pulmonary arteries by blood clots, usually originating from deep veins. Symptoms of PE might vary from nothing to sudden death. Clinically, individuals may present very differently. When a diagnosis of PE is suspected, any possible life-saving intervention must be implemented because survival from cardiac arrest following PE is often quite low. Although there are not many randomized controlled trials that provide guidelines for treating suspected PE in cardiac arrest victims, the few published case reports and other minor studies suggest that thrombolysis and other therapies are associated with good outcomes. We report a patient with PE who presented in cardiac arrest with its clinical, electrographic, and radiologic findings, along with the appropriate therapy chosen based on hemodynamic stability. It is important to intervene early to prevent severe complications and improve the patient's outcomes.
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Affiliation(s)
- Dhruvkumar Thakkar
- Emergency Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Varsha Shinde
- Emergency Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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Laher AE, Richards G. Cardiac arrest due to pulmonary embolism. Indian Heart J 2018; 70:731-735. [PMID: 30392514 PMCID: PMC6204441 DOI: 10.1016/j.ihj.2018.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/18/2017] [Accepted: 01/08/2018] [Indexed: 01/21/2023] Open
Abstract
Pulmonary embolism (PE) is a potentially life threatening clinical condition that is fairly non-specific in presentation. Massive pulmonary embolism (PE) without cardiac arrest has been associated with a mortality rate of 30%. However, when cardiac arrest ensues, mortality may be as high as 95%. Since outcomes of cardiac arrest following PE are generally dismal, any available potentially life-saving measure must be instituted when the diagnosis of PE is suspected. Despite a lack of randomized controlled trials guiding the management of suspected PE in the cardiac arrest victim, thrombolysis and other therapies have been associated with good outcomes in the handful of published case reports and other small studies.
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Affiliation(s)
- Abdullah Ebrahim Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg, 2193, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg, 2193, South Africa.
| | - Guy Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg, 2193, South Africa.
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Deng Y, He L, Yang J, Wang J. Serum D-dimer as an indicator of immediate mortality in patients with in-hospital cardiac arrest. Thromb Res 2016; 143:161-5. [DOI: 10.1016/j.thromres.2016.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/19/2016] [Accepted: 03/01/2016] [Indexed: 01/08/2023]
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Yu Y, Zhai Z, Yang Y, Xie W, Wang C. Successful thrombolytic therapy of post-operative massive pulmonary embolism after ultralong cardiopulmonary resuscitation: a case report and review of literature. CLINICAL RESPIRATORY JOURNAL 2015; 11:383-390. [PMID: 26083151 DOI: 10.1111/crj.12332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 01/22/2015] [Accepted: 06/07/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS Cardiac arrest caused by massive pulmonary embolism (PE) is highly refractory to conventional resuscitation. Thrombolytic therapy has been considered to be an effective way to massive PE. METHODS We reported a case of successful thrombolytic therapy of post-operative massive PE after 90-min cardiopulmonary resuscitation (CPR) and reviewed the relevant literature. RESULTS We presented the case of a 48-year-old woman with surgery of varicosis of great saphenous vein who suffered from a massive PE with circulatory arrest refractory to 90 min of aggressive CPR. Thrombolysis was given only as a single dose of 50 mg of recombinant tissue plasminogen activator. Rapid haemodynamic and clinical improvement followed the bolus dose. The patient was discharged later without neurological or other sequelae. An extensive literature search of the PubMed database only identified 11 cases of massive PE with cardiac arrest during the perioperative period with a survival rate was 88.9%. The time period of CPR before thrombolysis or anti-coagulation was 15-90 min. CONCLUSIONS Thrombolytic therapy is useful to achieve the return of spontaneous circulation in the resuscitation of patients with cardiac arrest secondary to massive PE during the perioperative period, even in the prolong resuscitation.
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Affiliation(s)
- Yanxia Yu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
| | - Zhenguo Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,National Clinical Research Center of Respiratory Disease; China-Japan Friendship Hospital. Yinghua Dongjie, Hepingli Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
| | - Wanmu Xie
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
| | - Chen Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,National Clinical Research Center of Respiratory Disease; China-Japan Friendship Hospital. Yinghua Dongjie, Hepingli Beijing, China
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Migneault D, Levine Z, de Champlain F. An unusual presentation of a massive pulmonary embolism with misleading investigation results treated with tenecteplase. Case Rep Emerg Med 2015; 2015:868519. [PMID: 25789181 PMCID: PMC4350959 DOI: 10.1155/2015/868519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/10/2015] [Indexed: 11/18/2022] Open
Abstract
Background. There is no foolproof strategy to identify a pulmonary embolism (PE) in the emergency department, and atypical presentations are common. Negative test results may mislead physicians away from the diagnosis of PE. Objectives. The current report aims to raise awareness of an unusual presentation of massive PE and its diagnosis and management, in the face of limited evidence in the scientific literature. Case Reports. We report the case of a patient with a negative D-Dimer and a negative Computed Tomography contrast angiography of the chest who was diagnosed twenty-seven hours later with a massive PE, as suggested by a bedside echocardiography. The patient was successfully treated with tenecteplase (TNK). Conclusions/Summary. Pulmonary embolism frequently presents atypically and is often a diagnostic challenge. There is limited literature about the treatment of massive PE. Further research on bedside echocardiography for diagnosing PE in unstable patients is warranted. In addition, further study into new thrombolytic agents like tenecteplase in the context of massive and submassive PE is warranted.
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Affiliation(s)
- David Migneault
- Department of Emergency Medicine, Vancouver General Hospital, University of British Columbia, Room 3300 910, West 10th Avenue, Vancouver, BC, Canada V5Z 1M9
| | - Zachary Levine
- Emergency Department, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room B2.117, Montreal, QC, Canada H3G 1A4
| | - François de Champlain
- Emergency Department, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room B2.117, Montreal, QC, Canada H3G 1A4
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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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Prom R, Dull R, Delk B. Successful alteplase bolus administration for a presumed massive pulmonary embolism during cardiopulmonary resuscitation. Ann Pharmacother 2013; 47:1730-5. [PMID: 24259620 DOI: 10.1177/1060028013508644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe the case of a patient successfully resuscitated with bolus alteplase for a presumed massive pulmonary embolism (PE) with associated cardiac arrest. CASE SUMMARY A 54-year-old man presented to the emergency department for evaluation of syncope following recent open reduction and internal fixation of his ankle. On arrival, his condition rapidly deteriorated and progressed to cardiopulmonary arrest. Because of noncompliance with postoperative thromboprophylaxis, there was high suspicion for PE. Following 40 minutes of advanced cardiac life support, empirical alteplase 50 mg was administered intravenously over 2 minutes with return of spontaneous circulation (ROSC) observed 6 minutes later. The diagnosis of PE using computed tomographic angiography was confirmed after fibrinolytic therapy. Although his hospital course was complicated by a gastrointestinal bleed requiring transfusion, he was discharged neurologically intact. DISCUSSION Clinical guidelines recommend fibrinolytic therapy for patients with PE and cardiac arrest. Data from retrospective analyses, case series, and case reports suggest that various fibrinolytic regimens may facilitate ROSC and improve neurologically intact survival without an increased risk of fatal hemorrhage. CONCLUSION The choice of fibrinolytic therapy should be based on hospital availability, with prompt initiation of treatment and incorporation of an intravenous bolus. A reasonable treatment regimen is alteplase 0.6 mg/kg (maximum of 50 mg) or fixed dose of alteplase 50 mg given over 2 to 15 minutes. Resuscitation should be continued for at least 30 minutes, or until ROSC, after fibrinolytic initiation to allow time for the medication to work.
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A Clinically Relevant Rabbit Embolic Stroke Model for Acute Ischemic Stroke Therapy Development: Mechanisms and Targets. Transl Stroke Res 2012. [DOI: 10.1007/978-1-4419-9530-8_27] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Successful treatment of presumed massive pulmonary embolism during cardiac arrest. Am J Emerg Med 2011; 29:132.e3-4. [DOI: 10.1016/j.ajem.2010.01.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 01/31/2010] [Indexed: 11/20/2022] Open
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Perrott J, Henneberry RJ, Zed PJ. Thrombolytics for Cardiac Arrest: Case Report and Systematic Review of Controlled Trials. Ann Pharmacother 2010; 44:2007-13. [DOI: 10.1345/aph.1p364] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe a successful case involving the use of tenecteplase during cardiac arrest for presumed pulmonary embolism (PE) and to systematically review the evidence from controlled trials supporting the efficacy and safety of thrombolysis during cardiac arrest. Case Summary: A 48-year-old male presented to the emergency department with an acute onset of shortness of breath that began approximately 2 hours prior to presentation. Prior to undergoing a computed tomography (CT) scan to rule out PE, the patient went into cardiac arrest, with an initial rhythm of pulseless electrical activity at a rate of 140 beats/min. Cardiopulmonary resuscitation (CPR) was initiated and, due to suspected PE, a bolus dose of tenecteplase 50 mg was administered immediately following a single 1-mg dose of epinephrine. CPR was continued and 4 additional 1-mg doses of epinephrine and three 1-mg doses of atropine were given. After 13 minutes of CPR, return of spontaneous circulation (ROSC) was achieved, with a blood pressure of 144/50 mm Hg. After the patient was stabilized, a CT scan demonstrated extensive bilateral pulmonary emboli in most segmental arteries. He was admitted to the intensive care unit where he was sedated, paralyzed, and treated with induced hypothermia for 24 hours. He was discharged from the hospital 2 weeks later on warfarin, with no noted neurologic deficits. Discussion: A systematic search of MEDLINE (1950-August 2010), Embase (1980-August 2010), and Google Scholar (to August 2010) was conducted to identify prospective controlled trials that investigated the use of thrombolytic medications to treat cardiac arrest. Five trials involving 1544 undifferentiated cases of cardiac arrest were found. Overall, some trials reported an improved rate of ROSC following administration of thrombolytics, but there was no overall mortality reduction in any trial. There was, however, an increased risk of bleeding events following administration of a thrombolytic drug. Conclusions: Controlled trials demonstrate that there is a lack of benefit and potential harm in administering thrombolysis in an undifferentiated patient with cardiac arrest. However, the case we present provides evidence that fibrinolysis may benefit selected patients with cardiac arrest in whom PE is confirmed or in whom there is high index of suspicion of PE.
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Affiliation(s)
- Jerrold Perrott
- Critical Care, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Ryan J Henneberry
- Department of Emergency Medicine, Capital Health, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter J Zed
- Department of Pharmacy and Pharmacotherapeutic Specialist—Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, College of Pharmacy and Department of Emergency Medicine, Dalhousie University
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Abstract
Perioperative bleeding is a major challenge particularly because of increasing clinical use of potent antithrombotic drugs. Understanding current concepts of coagulation is important in determining the preoperative bleeding risk of patients, and in managing hemostatic therapy perioperatively. The serine protease thrombin plays pivotal roles in the activation of additional serine protease zymogens (inactive enzymatic precursors), cofactors, and cell-surface receptors. Thrombin generation is closely regulated to locally achieve rapid hemostasis after injury without causing uncontrolled systemic thrombosis. During surgery, there are major disturbances in coagulation and inflammatory systems because of hemorrhage/hemodilution, blood transfusion, and surgical stresses. Postoperative bleeding often requires allogeneic blood transfusions, which support thrombin generation and hemostasis. However, procoagulant activity and inflammation are increased postoperatively; thus, antithrombotic therapy may be required to prevent perioperative thrombotic complications. There have been significant advances in the management of perioperative hemostasis and thrombosis because of the introduction of novel hemostatic and antithrombotic drugs. However, a limitation of current treatment is that conventional clotting tests do not reflect the entire physiological processes of coagulation making optimal pharmacologic therapy difficult. Understanding the in vivo regulatory mechanisms and pharmacologic modulation of thrombin generation may help control bleeding without potentially increasing prothrombotic risks. In this review, we focus on the regulatory mechanisms of hemostasis and thrombin generation using multiple, simplified models of coagulation.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Kjaergaard B, Kristensen SR, Risom M, Larsson A. A porcine model of massive, totally occlusive, pulmonary embolism. Thromb Res 2009; 124:226-9. [PMID: 19232684 DOI: 10.1016/j.thromres.2009.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Revised: 12/14/2008] [Accepted: 01/21/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND A reliable, animal model of massive, totally occlusive, pulmonary embolism (PE) is lacking. OBJECTIVES To design an animal model of totally occlusive PE and to challenge the model by a plasminogen activator. METHODS In eight anaesthetized pigs (approximately 90 kg) a massive preformed autologous thrombus was injected into the caval vein. One animal was autopsied to assess the extent of injected clot, whereas in the other animals extracorporeal life support (ECLS) was initiated and continued for three hours. These animals received 100 mg rt-PA. Blood gases, coagulation tests, creatine kinase (CK), lactate dehydrogenase (LDH), end-tidal CO2, systemic and pulmonary artery blood pressures and flow were registered. RESULTS All animals went into circulatory arrest within 2 minutes after injection of the thrombus. In the animal where ECLS was not started, autopsy relieved a totally occlusive embolus of the pulmonary artery. The ECLS maintained a systemic blood flow of 6-8 L/min with adequate oxygenation and CO2-removal. However, lactate increased and base-excess became negative. Ddimer increased, fibrinogen decreased, and CK and LDH increased. All seven animals were weaned from ECLS. Despite the rt-PA treatment, the animals had at that time low end tidal CO2/PaCO2 ratio and increased mean pulmonary arterial pressure, suggesting a significant amount of embolic material remaining in the pulmonary artery. CONCLUSION This model of massive, totally occlusive, pulmonary embolism mimics well fatal PE seen in the clinic, and has the potential for use in testing of new therapeutic interventions.
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Affiliation(s)
- Benedict Kjaergaard
- Department of Cardiothoracic Surgery, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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