Thrombolytics for Cardiac Arrest: Case Report and Systematic Review of Controlled Trials

Frequency of Medical Reversal Among Published Randomized Controlled Trials Assessing Cardiopulmonary Resuscitation (CPR)

OBJECTIVE

To characterize what proportion of all randomized controlled trials (RCTs) among patients experiencing cardiac arrest find that an established practice is ineffective or harmful, that is, a medical reversal.

METHODS

We reviewed a database of all published RCTs of cardiac arrest patient populations between 1995 and 2014. Articles were classified on the basis of whether they tested a new or existing therapy and whether results were positive or negative. A reversal was defined as a negative RCT of an established practice. Further review and categorization were performed to confirm that reversals were supported by subsequent systematic review, as well as to identify the type of medical practice studied in each reversal. This study was conducted from October 2017 to June 17, 2019.

RESULTS

We reviewed 92 original articles, 76 of which could be conclusively categorized. Of these, 18 (24%) articles examined a new medical practice, whereas 58 (76%) tested an established practice. A total of 18 (24%) studies had positive findings, whereas 58 (76%) reached a negative conclusion. Of the 58 articles testing existing standard of care, 44 (76%) reversed that practice, whereas 14 (24%) reaffirmed it.

CONCLUSION

Reversal of cardiopulmonary resuscitation practices is widespread. This investigation sheds new light on low-value practices and patterns of medical research and suggests that novel resuscitation practices have low pretest probability and should be empirically tested with rigorous trials before implementation.

Thrombolysis during Extended Cardiopulmonary Resuscitation for Autoimmune-Related Pulmonary Embolism

Massive pulmonary embolism (MPE) is one of the potentially reversible causes of cardiac arrest and pulseless electrical activity. At present, a fear of lethal haemorrhage makes thrombolytic therapy prohibitive during cardiopulmonary resuscitation. Blood hypercoagulability in autoimmune disorders (such as autoimmune haemolytic anaemia) carries a risk of MPE. Prompt diagnosis is critical for timely thrombolytic intervention. We reported a 23-year-old female with 10 years medical history of autoimmune haemolytic anaemia developed cardiac arrest in our emergency intensive care unit. Electrocardiogram and echocardiogram findings indicated the possibility of MPE, so fibrinolytic therapy with alteplase was administered along with prolonged cardiopulmonary resuscitation. Her neurological recovery was generally good, and no major bleeding occurred. MPE was confirmed by computed tomography pulmonary angiography afterwards. We regard that once there is presumptive diagnosis of MPE, initiating early thrombolysis during cardiopulmonary resuscitation may be considered. (Hong Kong j.emerg.med. 2016;23:180-185)

Pulmonary embolism with cardiac arrest: a STEMI patient's unexpected course

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.

Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention

Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.

Does Thrombolysis Have a Place in the Cardiopulmonary Resuscitation of Patients With Acute Pulmonary Embolism? A Case of Successful Thrombolysis During Pulmonary Embolism Induced Cardiopulmonary Arrest

OBJECTIVE

Pulmonary embolism often causes cardiac arrest. When this occurs, thrombolytic therapy is not routinely administered. There are multiple reasons for this, including difficulty with rapidly adequately diagnosing the embolus, the lack of good data supporting the use of thrombolytics during resuscitation, the belief that thrombolytic therapy is ineffective once a patient has already arrested, the difficulty of obtaining thrombolytics at the bedside rapidly enough to administer during a code, and the increased risks of bleeding, particularly with ongoing chest compressions. In this case report, we present a patient who was successfully treated with thrombolytic therapy during pulmonary embolism-induced cardiopulmonary arrest and discuss the role of thrombolytics in cardiopulmonary resuscitation.

DESIGN

Case report.

SETTING

Surgical ICU in a comprehensive cancer center.

PATIENT

A 56-year-old man who developed hypotension, dyspnea, hypoxia, and pulseless electrical activity 10 days after resection of a benign colon lesion with a right hemicolectomy and primary end-to-end anastomosis.

INTERVENTIONS

After a rapid bedside echocardiogram suggesting pulmonary embolus, thrombolytic therapy was administered during cardiopulmonary resuscitative efforts.

MEASUREMENTS AND MAIN RESULTS

The patient had a return of spontaneous circulation and showed improvement in repeat echocardiographic imaging. He had a prolonged course in the ICU and hospital, but eventually made an essentially complete clinical recovery.

CONCLUSION

As bedside echocardiographic technology becomes more rapidly and readily available, the rapid diagnosis of pulmonary embolism and use of thrombolytics during cardiopulmonary resuscitation may need to be more routinely considered a potential therapeutic adjunctive measure.

Coagulation profiles of unexpected DCDD donors do not indicate a role for exogenous fibrinolysis

It has been suggested that vascular stasis during cardio-circulatory arrest leads to the formation of microvascular thrombi and the viability of organs arising from donation after circulatory determination of death (DCDD) donors may be improved through the application of fibrinolytic therapy. Our aim was to comprehensively study the coagulation profiles of Maastricht category II DCDD donors in order to determine the presence of coagulation abnormalities that could benefit from fibrinolytic therapy. Whole blood from potential DCDD donors suffering out-of-hospital cardiac arrest was sampled after declaration of death in the emergency department, and rotational thromboelastomeric analysis was performed. Between July 2012 and December 2013, samples from 33 potential DCDD donors were analyzed. All patients demonstrated hyperfibrinolysis (HF), as reflected by maximum clot lysis of 98-100% in all cases, indicating that there is no role for additional fibrinolytic therapy in this setting. As well, we observed correlations between thromboelastomeric lysis parameters and maximum hepatic transaminase levels measured in potential donors and renal artery flows measured during ex situ hypothermic oxygenated machine perfusion, indicating that further studies on the utility of thromboelastometry to evaluate organ injury and perhaps even viability in unexpected DCDD may be warranted.

Benefits of thrombolytics in prolonged cardiac arrest and hypothermia over its bleeding risk

A 52-year-old non-smoking Caucasian male, who was admitted to our emergency room after he was found unconscious in the bathroom, went into cardiac arrest requiring prolonged cardiopulmonary resuscitation (CPR) and hypothermia therapy. Cardiac catheterization showed non-obstructive coronary arteries and further bedside echocardiogram suggested probable pulmonary embolism (PE) as an underlying cause of cardiac arrest. Although thrombolytic therapy is an effective therapy for PE, it is not routinely given during prolonged CPR for its life- threatening bleeding complications. Many reported cases have suggested a beneficial effect of empiric thrombolytic in cardiac arrest, but unrelated to duration of resuscitation and adjuvant treatments that imposes bleeding risk. We suspect that tissue plasminogen activator (tPA) should be promptly given to prolonged cardiac arrest patients, even when bleeding risk is high with the concurrent hypothermia treatment, keeping the benefits over risk strategy. Our patient received thrombolytic, tPA and showed remarkable clinical, physiological and radiographical improvement.

A case of survival after cardiac arrest and 3½ hours of resuscitation

Although survival rates after cardiac arrest remain low, new techniques are improving patients' outcomes. We present the case of a 40-year-old man who survived a cardiac arrest that lasted approximately 3½ hours. Resuscitation was performed with strict adherence to American Heart Association/American College of Cardiology Advanced Cardiac Life Support guidelines until bedside extracorporeal membrane oxygenation could be placed. A hypothermia protocol was initiated immediately afterwards. The patient had a full neurologic recovery and was bridged from dual ventricular assist devices to a total artificial heart. On hospital day 160, he underwent orthotopic heart and cadaveric kidney transplantation. On day 179, he was discharged from the hospital in ambulatory condition. To our knowledge, this is the only reported case in which a patient survived with good neurologic outcomes after a resuscitation that lasted as long as 3½ hours. Documented cases of resuscitation with good recovery after prolonged arrest give hope for improved overall outcomes in the future.

Management dilemmas in acute pulmonary embolism

Background

Physicians treating acute pulmonary embolism (PE) are faced with difficult management decisions while specific guidance from recent guidelines may be absent.

Methods

Fourteen clinical dilemmas were identified by physicians and haematologists with specific interests in acute and chronic PE. Current evidence was reviewed and a practical approach suggested.

Results

Management dilemmas discussed include: sub-massive PE, PE following recent stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or catheter-based therapy, failure to respond to initial thrombolysis, PE in pregnancy, right atrial thrombus, role of caval filter insertion, incidental and sub-segmental PE, differentiating acute from chronic PE, early discharge and novel oral anticoagulants.

Conclusion

The suggested approaches are based on a review of the available evidence and guidelines and on our clinical experience. Management in an individual patient requires clinical assessment of risks and benefits and also depends on local availability of therapeutic interventions.

Successful alteplase bolus administration for a presumed massive pulmonary embolism during cardiopulmonary resuscitation

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.

Aortic intramural hematoma and hepatic artery pseudoaneurysm: unusual complication following resuscitation

We present a case of a 71-year-old woman with an unusual complication of aortic intramural hematoma and hepatic artery pseudoaneurysm following cardiopulmonary resuscitation and thrombolysis done for sudden cardiopulmonary arrest and pulmonary embolism. Patient was on Warfarin treatment for a prior history of pulmonary embolism and experienced recurrent cardiac arrests, which finally resolved after intravenous administration of thrombolytic agents. However, follow-up computed tomographic angiography revealed descending aortic intramural hematoma with intramural blood pool and concomitant liver laceration with hepatic artery pseudoaneurysm. The patient received transcatheter embolization for the hepatic injury with careful follow-up for the aortic injury and was later discharged in a stable condition. Follow-up with subsequent computed tomographic angiography at a regular interval over 1 month shows near complete resolution of the intramural hematoma. The purpose of this report is to describe the rare complication of cardiopulmonary resuscitation and thrombolysis in the form of concomitant injuries of the aorta and liver. Although the use of thrombolytic agents in patients with pulmonary embolism and cardiac arrest is still a matter of debate, this case report supports the concept that thrombolysis has a role in restoring cardiopulmonary circulation, especially in recurrent cardiac arrests resulting from pulmonary embolism. On the other hand, this case also highlights the increased association of the bleeding-related complication as a result of vigorous efforts of cardiopulmonary resuscitation. Aggressive management with interventional radiology for hepatic pseudoaneurysm and conservative management of the aortic intramural hematoma resulted in favorable outcome for our patient.

Hyperfibrinolysis is common in out-of-hospital cardiac arrest: results from a prospective observational thromboelastometry study

BACKGROUND

Cardiocirculatory arrest (CCA) activates procoagulant pathways. It has also been reported to inhibit fibrinolysis, resulting in fibrin deposition and further impairment of blood flow. Until now, no studies have used whole-blood viscoelastic tests to characterize coagulation and the impact of fibrinolysis in out-of-hospital cardiac arrest (OHCA).

METHODS

Patient with established OHCA who underwent cardiopulmonary resuscitation (CPR) were enrolled. Blood samples were obtained immediately after placement of an intravenous line at the scene, for full blood cell count, standard coagulation tests and rotational thromboelastometric (ROTEM(®)) analyses. Patients with return of spontaneous circulation (ROSC) were compared to non-ROSC patients.

RESULTS

Fifty-three patients (median age 67 years, interquartile range: 56-73 years) were included in the study. ROSC was established in 25 patients. Prothrombin time index (PTI) was significantly lower and activated partial thromboplastin time (aPTT) was significantly prolonged in non-ROSC patients compared to ROSC patients. Clotting time (CT) in the extrinsically activated ROTEM test (EXTEM) was significantly longer in non-ROSC versus ROSC patients. For the remaining EXTEM parameters, there were no significant differences between ROSC and non-ROSC patients. Hyperfibrinolysis (maximum lysis>15% according to ROTEM test results) was observed in 19 patients (35.8%). There was no difference between ROSC and non-ROSC patients in the incidence of hyperfibrinolysis.

CONCLUSIONS

PTI, aPTT and EXTEM CT revealed significant differences between ROSC and non-ROSC patients. Hyperfibrinolysis according to ROTEM test results was much more common than previously assumed. Routine use of fibrinolytic therapy in all patients with prolonged CPR cannot therefore be recommended.