| Accuracy | |
| Valid for practice | |
| True to literature | |
| Overall quality |
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Clinical Question
In the rare situation where fibrinolytics may be indicated in cardiac arrest from PE or Acute Myocardial Infarction (AMI), what's the dose?
Citation | Study Design | Condition | Drug | Dose |
Kurkciyan I, et al. Arch Intern Med 2000; 160:1529-35. | Retrospective cohort | PE | Alteplase | 100 mg (either two 50 mg boluses or 15 mg bolus followed by 85 mg over 90 min) |
Ruiz-Bailen M, et al. Resuscitation 2001; 51:97-101. | Case series | PE | Alteplase | 50 mg bolus, repeat 50 mg in 30 min |
Janata K, et al. Resuscitation 2003; 57:49-55. | Retrospective cohort | PE | Alteplase | 0.6-1.0 mg/kg bolus (up to 100 mg) |
Lederer W, et al. Resuscitation 2001; 50:71-6. | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg bolus followed by 85 mg over 90 min) |
Ruiz-Bailen M, et al. Intensive Care Med 2001; 27:1050-7. | Retrospective cohort | AMI | Alteplase | 100 mg (either two 50 mg boluses or 15 mg bolus followed by 85 mg over 90 min) |
Schreiber W, et al. Resuscitation 2002; 52:63-9. | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg bolus followed by 85 mg over 90 min) |
Kurkciyan I, et al. J Intern Med 2003; 253:128-35. | Retrospective cohort | AMI | Alteplase | 100 mg (15 mg bolus followed by 85 mg over 90 min) |
Bottiger BW, et al. Lancet 2001; 357:1583-5. | Prospective observational | Nontraumatic cardiac arrest | Alteplase | 50 mg bolus, repeat 50 mg in 30 min |
Abu-Laban RB, et al. N Engl J Med 2002; 346:1522-8. | RCT | Cardiac arrest from any cause | Alteplase | 100 mg over 15 min |
Fatovich DM, et al. Resuscitation 2004; 61:309-13. | RCT | Cardiac arrest from any cause | Tenecteplase | 50 mg bolus |
Bozeman WP, et al. Resuscitation 2006; 69:399-406. | Prospective cohort | Nontraumatic cardiac arrest | Tenecteplase | 0.5 mg/kg bolus |
Bottiger BW, et al. N Engl J Med 2008; 359:2651-62. | RCT | Cardiac arrest from any cause | Tenecteplase | 0.5 mg/kg bolus |
Take Home Points
- The dose of tPA in cardiac arrest is somewhere between 50-100 mg given as a bolus +/- infusion.
- According to the 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, "Ongoing CPR is not an absolute contraindication for fibrinolysis."
- Some studies suggest allowing 15 minutes of CPR for drug to work.
- Evidence is 'best' for PE; data does not support for undifferentiated cardiac arrest.
- Anticoagulants, such as heparin, were used in most studies along with the fibrinolytic.
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Excellent review of the literature. I think the key here is, if you clinically suspect PE as the culprit, it is really the only diagnosis that seems to benefit from lytics peri-arrest. That being said physicians need to remember that MI/ACS is the number one killer, followed by PE is the number two killer for out of hospital arrest. Great post, great topic for discussion.
ReplyDeleteThe data for PE is definitely there in the peri-arrest patient. The arresting STEMI patient should also be receiving this therapy. After all, the current AHA guidelines do consider thrombolytic therapy for STEMI to be appropriate if primary PCI is not readily available. I am not sending a coding patient to the cath lab. Yes, they need the intervention, but after they have been resuscitated. I personally use the 50 mg dose for PE and 100 mg for STEMI, both doses given over approximately 15 minutes. This is not the therapy for the undifferentiated arrest patient.
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