Fatal intrathoracic haemorrhage after cardiopulmonary resuscitation and treatment with streptokinase and heparin

Thrombolysis as a Therapeutic Modality in Cardiac Arrest

Introduction

In recent years, thrombolysis has emerged as a potentially promising treatment for cardiac arrest. Patients with cardiac arrests from myocardial infarction or pulmonary embolism, as well as out-of-hospital cardiac arrests, were reported to have improvement in both survival and neurologic outcome after being treated with thrombolysis. This paper aims to review the available literature on the use of thrombolysis in cardiac arrest.

Method

Study of papers from PubMed literature search for all articles with terms related to thrombolysis and cardiac arrest in title or abstract.

Results

Thrombolytics are thought to act by lysing both macroscopic clots and microthrombi, particularly in the cerebral microcirculation, thus alleviating or reversing post-arrest cerebral no-reflow. Their use in cardiac arrest has been restrained by concerns over their safety after cardiopulmonary resuscitation, in particular bleeding-related complications, although these concerns seem to have been misplaced.

Conclusions

Thrombolysis for cardiac arrest is likely to be most efficacious in a pre-hospital environment, and future research should be directed to this setting.

Safety of thrombolysis during cardiopulmonary resuscitation

The prognosis is generally poor for patients who experience a cardiac arrest. The most common causes of sudden cardiac arrest are massive pulmonary embolism (PE) and acute myocardial infarction (MI). While thrombolysis is a first-line treatment option in massive PE and acute MI, cardiopulmonary resuscitation (CPR) has been regarded as a relative contraindication for thrombolysis because of the anticipated bleeding risk caused by traumatic cardiocompressions. However, an increasing number of case reports and clinical studies on thrombolysis during and after CPR highlight an increased frequency of the return of spontaneous circulation and a better neurological outcome of surviving patients. These effects are mainly due to the thrombolysis of macroscopic blood clots and the amelioration of microcirculatory reperfusion. This article reviews case reports and clinical studies of thrombolysis during and shortly after CPR in order to estimate the risk of severe bleeding events caused by CPR in association with thrombolysis compared with CPR without thrombolysis. Although thrombolysis per se can cause severe and potentially fatal haemorrhage, there is no evidence that severe bleeding events occur more often when thrombolysis is combined with cardiocompressions. In addition, by far the majority of bleeding complications can be treated effectively. Thus, in many cases, the possible benefit of thrombolysis during CPR seems to outweigh the potential risks. However, there may be a publication bias in some case reports and studies towards reporting successful rather than unsuccessful CPRs. In addition, not enough controlled clinical trials have yet been conducted. Therefore, data from large randomised, multicentre studies are needed to definitely answer the question of the relationship between safety and efficacy of this promising treatment option. We conclude that the currently available data do not indicate that thrombolysis contributes to a significant increase in bleeding complications when administered during CPR.

Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest

OBJECTIVE

To investigate the safety and efficacy of thrombolytic treatment for an acute myocardial infarction (AMI) immediately after resuscitation in the out-of-hospital setting.

DESIGN

Retrospective.

SETTING

A middle-sized urban city (population 540000) served by a single emergency medical system using a tiered response with physicians in field.

PATIENTS AND METHODS

Sixty-eight patients with an initial diagnosis of AMI who received thrombolytic treatment in an out-of-hospital setting after cardiac arrest and cardiopulmonary resuscitation (CPR) between January 1st 1994 and December 31st 1998. An ECG and the myocardial enzymes (CK, CK-MB, Troponin-T) were used to diagnose AMI. Myocardial reperfusion was assessed by resolution of the ST-segment elevation. Side effects and complications were studied. The quality of secondary survival was evaluated. The Utstein style was used for a uniform style of reporting the cardiac arrest data.

RESULTS

The accuracy of prehospital diagnosis was found to be excellent. Retrospective analysis revealed that thrombolytic therapy had been appropriately administered in 64 (94%) of the 68 patients actually treated. Reperfusion was achieved in 71% of the patients. Haemorrhagic complications were few, and included intracranial haemorrhage (one patient), gastrointestinal bleeding (two patients), bleeding from the puncture site (one patient) and epistaxis (one patient). The incidence of hypotension during streptokinase infusion was 22%. Sixty-three (93%) of the patients were admitted alive to the hospital, with 36 subsequently surviving to discharge.

CONCLUSIONS

Thrombolytic treatment is a safe and effective treatment in AMI even after out-of-hospital cardiopulmonary resuscitation.

Unusual bleeding complications of thrombolytic therapy after cardiopulmonary resuscitation. Three case reports

The authors present three case reports retrospectively casting doubt on the benefit of thrombolysis after external cardiac massage.

Liver rupture after cardiopulmonary resuscitation in a patient receiving thrombolytic therapy

A patient with an acute myocardial infarction had to be resuscitated due to recurring ventricular fibrillation. After stabilisation, she received thrombolytic treatment with anistreplase. Fourteen hours later, clinical signs of hemoperitoneum developed and the diagnosis of liver rupture was made. After abdominal surgery and coronary revascularisation, the subsequent clinical course was uncomplicated. The literature on liver trauma after CPR as well as thrombolysis in association with CPR is reviewed. This observation suggests that there are no convincing arguments to withhold thrombolytic therapy in acute myocardial infarction after CPR in the absence of gross trauma. We stress that a high degree of clinical alertness is necessary to diagnose this life-threatening condition because of its frequent subacute evolution in patients that are per se hemodynamically unstable.

Early management of acute myocardial infarction: thrombolysis, angioplasty, and adjunctive therapies

Early identification and treatment, including administration of intravenous thrombolytics, coronary angioplasty, and adjunctive therapies, has been shown to benefit patients who present with acute myocardial infarction. However, only a small percentage of these patients receive such therapies because of late presentation, associated risks, and controversies around certain myocardial infarct subsets. The logistics involved in carrying out these treatments have resulted in unnecessary prehospital and in-hospital delays. These issues make essential the availability of a streamlined protocol that should be updated at regular intervals to ensure that these time-dependent therapies are more routinely and rapidly utilized. This article discusses these topics in conceptual format and provides a ready-to-use protocol.

Streptokinase and facial haematoma

We report two cases of facial haematoma following streptokinase therapy. This is an important complication as it can have fatal consequences. Early recognition and close monitoring are essential as emergency intervention may be required.

Thrombolysis in acute myocardial infarction following prolonged cardiopulmonary resuscitation

Thrombolytic therapy was administered to a 64-year-old man with an acute anterolateral myocardial infarction who had received cardiopulmonary resuscitation (CPR) for 24 minutes. At the time of thrombolytic therapy, the patient was alert and without clinical or radiographic evidence of injury. The patient developed a retroperitoneal hematoma related to femoral line placement, as well as subcutaneous bruising of the anterior chest wall; both were self-limited. No long- term morbidity developed, and the myocardial infarction was aborted. The use of thrombolytic therapy for patients with acute myocardial infarction who have received CPR is reviewed. In the absence of clinical or radiographic evidence of trauma from CPR, patients with acute myocardial infarction should not be excluded from receiving thrombolytic therapy solely because of having had CPR or the duration of CPR.

Thrombolysis following pre-hospital cardiopulmonary resuscitation

Forty-eight patients were discharged from hospital following successful resuscitation from out-of-hospital ventricular fibrillation. Sixteen of these patients received intravenous thrombolytic therapy on admission to hospital. There were 3 significant bleeding complications and 2 cases of inappropriate administration of streptokinase. One of the patients that did not receive thrombolysis also had a significant bleeding complication of cardiopulmonary resuscitation. Patients admitted to hospital following resuscitation should only receive thrombolytic therapy when there is overwhelming electrocardiographic evidence of acute myocardial infarction, and even then with caution.

Acute myocardial infarction. An updated protocol for thrombolytic therapy

Only a small percentage of patients who have acute myocardial infarction receive the benefit of intravenous thrombolytic therapy, often because logistics result in unnecessary pre-hospital and in-hospital delays. Dr Selig therefore recommends that a streamlined protocol be available and that it be updated at regular intervals to ensure that this time-dependent therapy is more routinely utilized.

Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction

Prolonged external cardiac massage is often regarded as a contraindication for thrombolytic therapy because of the risk of fatal hemorrhage. The influence of cardiopulmonary resuscitation on complications of thrombolytic bleeding was assessed analyzing data of all patients with myocardial infarction admitted to our clinic during the 10-year period between 1978 and 1987. From the total of 2,147 patients with acute myocardial infarction, 590 received thrombolytic therapy (intracoronary in 229, intravenous in 400). Of these, 43 patients underwent prolonged cardiopulmonary resuscitation and received thrombolysis within a time interval of less than 24 hours. In 21 patients, resuscitation was performed within a short period of time (5 minutes to 20 hours) after thrombolysis (10 intracoronary, 10 intravenous, 1 intravenous + intracoronary) had been initiated; 9 of these patients survived (43%). In the other 22 patients, thrombolytic therapy was initiated during ongoing resuscitation (n = 6: intravenous in 5, intravenous + intracoronary in 1) or in the early phase (10 to 120 minutes) after successful resuscitation (n = 16: intracoronary in 10, intravenous in 4, intravenous + intracoronary in 2). From this group, 14 patients survived (in-hospital mortality 36%). The mean duration of cardiopulmonary resuscitation was 36 +/- 32 minutes (range 4 to 120). Autopsy studies were performed in 16 of 20 decreased patients. Bleeding complications occurred in 8 of 43 patients. No case of bleeding was directly related to cardiocompression despite the often traumatic procedure with rib fractures verified in 17 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolytic therapy in acute myocardial infarction following prolonged cardiopulmonary resuscitation

Thrombolytic therapy was administered to a 49-year-old woman with an acute anterior wall myocardial infarction after having prolonged cardiopulmonary resuscitation for 13 minutes. On admission, there was no clinical or radiographic evidence of gross trauma. There was no significant morbidity and the patient recovered to a completely functional status. The literature of thrombolytic therapy after cardiopulmonary resuscitation is reviewed. In the absence of gross trauma from cardiopulmonary resuscitation, thrombolytic therapy in acute myocardial infarction should not necessarily be excluded because of the duration of resuscitation. Further experience with such patients will shed additional light on efficacy and safety.

Extensive subcutaneous bleeding after cardiopulmonary resuscitation and thrombolytic therapy

A patient with acute myocardial infarction, complicated by pre-hospital cardiac arrest, was treated with anistreplase, heparin and aspirin following resuscitation. She developed a large lower lip haematoma and extensive bruising over the chest wall ten hours after thrombolytic therapy. A blood transfusion was required.