Confirm, Don’t Conform Toward Thrombolysis in Acute Pulmonary Embolism in Out-of-Hospital Cardiac Arrest

Introduction: Acute pulmonary embolism is a confirmed cause of up to 5% of out-of-hospital cardiac arrest and 5%–13% of unexplained cardiac arrest in patients. However, the true incidence may be much higher, as pulmonary embolism is often clinically underdiagnosed. Thrombolytic therapy is a recognized therapy for pulmonary embolism–associated cardiac arrest but is not routinely recommended during cardiopulmonary resuscitation. Therefore, clinicians should attempt to identify patients with suspected pulmonary embolism. Many point-of care ultrasound protocols suggest diagnosis of pulmonary embolism for cardiac arrest patients. Case presentation: We describe two male patients (60 years and 66 years, respectively) who presented to the emergency department with cardiac arrest within a period of 1 week. With administration of point-of care ultrasound during the ongoing cardiopulmonary resuscitation in both patients, fibrinolytic therapy was initiated under suspicion of cardiac arrest caused by pulmonary embolism. Both patients had return of spontaneous circulation; however, only the second patient, who received fibrinolytic therapy relatively early, was discharged with a good outcome. In this report, we discussed how to diagnose and manage patients with cardiac arrest–associated pulmonary embolism with the help of point-of care ultrasound. We also discuss the different clinical outcomes of the two patients based on the experience of the clinicians and the timing of thrombolytic agent application. Conclusions: If acute pulmonary embolism is suspected in patients with out-of-hospital cardiac arrest, we recommend prompt point-of care ultrasound examination. Point-of care ultrasound may help identify patients with pulmonary embolism during cardiopulmonary resuscitation, leading to immediate treatment, although the clinical outcomes may vary.

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Abstract 199: Pulmonary Embolism and Accidental Hypothermia Have a Favorable Outcome in Cardiac Arrest With PEA Treated by ECPR

Circulation ◽

10.1161/circ.138.suppl_2.199 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Shinichi Ijuin ◽

Akihiko Inoue ◽

Nobuaki Igarashi ◽

Shigenari Matsuyama ◽

Tetsunori Kawase ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Neurological Outcome ◽

Cerebral Performance Category ◽

Accidental Hypothermia ◽

Neurological Outcomes ◽

Good Outcome ◽

Group B ◽

Favorable Neurological Outcome ◽

Hospital Cardiac Arrest

Introduction: We have reported previously a favorable neurological outcome by extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest. However, effects of ECPR on patients with prolonged pulseless electrical activity (PEA) are unclear. We analyzed etiology of patients with favorable neurological outcomes after ECPR for PEA with witness. Methods: In this single center retrospective study, from January 2007 to May 2018, we identified 68 patients who underwent ECPR for PEA with witness. Of these, 13 patients (19%) had good neurological outcome at 1 month (Glasgow-Pittsburgh Cerebral Performance Category (CPC):1-2, Group G), and 55 patients (81%) had unfavorable neurological outcome (CPC:3-5, Group B). We compared courses of treatment and causes/places of arrests between two groups. Results are expressed as mean ± SD. Results: Patient characteristics were not different between the two groups. Time intervals from collapse to induction of V-A ECMO were also not significantly different (Group G; 46.1 ± 20.2 min vs Group B; 46.8 ± 21.7 min, p=0.92). Ten patients achieved favorable neurological outcome among 39 (26%) with non-cardiac etiology. In cardiac etiology, only 3 of 29 patients (9%) had a good outcome at 1 month (p=0.08). In particular, 5 patients of 10 pulmonary embolism, and 4 of 4 accidental hypothermia responded well to ECPR with a favorable neurological outcome. Additionally, 6 of 13 (46%), who had in hospital cardiac arrest, had good outcome, whereas 7 of 55 (15%) who had out of hospital cardiac arrest, had good outcome (p=0.02). Conclusions: In our small cohort of cardiac arrest patients with pulmonary embolism or accidental hypothermia and PEA with witness, EPCR contributed to favorable neurological outcomes at 1 month.

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Percutaneous circulatory support in a patient with cardiac arrest due to acute pulmonary embolism

Clinical Research in Cardiology ◽

10.1007/s00392-012-0481-x ◽

2012 ◽

Vol 101 (12) ◽

pp. 1017-1020 ◽

Cited By ~ 9

Author(s):

Jürgen Leick ◽

Christoph Liebetrau ◽

Sebastian Szardien ◽

Matthias Willmer ◽

Johannes Rixe ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Acute Pulmonary Embolism ◽

Circulatory Support

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Thrombolytic therapy during resuscitation for pulmonary embolism-related out-of-hospital cardiac arrest: perhaps not the ideal solution for everyone

Critical Care ◽

10.1186/s13054-020-2803-0 ◽

2020 ◽

Vol 24 (1) ◽

Author(s):

Patrick M. Honore ◽

Cristina David ◽

Aude Mugisha ◽

Rachid Attou ◽

Sebastien Redant ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Thrombolytic Therapy ◽

Ideal Solution ◽

Hospital Cardiac Arrest ◽

The Ideal

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Massive pulmonary embolism in pregnancy: intra-arrest thrombolysis and resuscitative hysterotomy

BMJ Case Reports ◽

10.1136/bcr-2019-234083 ◽

2020 ◽

Vol 13 (4) ◽

pp. e234083 ◽

Cited By ~ 1

Author(s):

John Edward Ashbridge Taylor ◽

Chen Wen Ngua ◽

Matthew Carwardine

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Massive Pulmonary Embolism ◽

Spontaneous Circulation ◽

Postmortem Examination ◽

Right Heart ◽

Hypoxic Injury ◽

Injury Treatment ◽

Ct Brain ◽

Hospital Cardiac Arrest

Massive pulmonary embolism (PE) is a leading cause of maternal death and may require intra-arrest thrombolysis as well as resuscitative hysterotomy. The case presented is a primigravida in her mid-30s at 28 weeks gestation. The patient presented to the emergency department after out-of-hospital cardiac arrest. Return of spontaneous circulation (ROSC) was achieved but not sustained. Episodic cardiopulmonary resuscitation with epinephrine boluses was required. Resuscitative hysterotomy was performed intra-arrest. Echocardiography revealed a dilated right heart consistent with massive PE and thrombolysis was administered. ROSC was obtained thereafter and output was sustained. Subsequent CT brain revealed irreversible hypoxic injury. Treatment was withdrawn with the support of family. Postmortem examination confirmed massive PE. Thrombolysis can restore and improve cardiovascular status in cardiac arrest caused by massive PE. Thrombolysis is not contraindicated in maternal resuscitation where resuscitative hysterotomy may also be required.

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Thrombolytic therapy for cardiac arrest secondary to acute pulmonary embolism: an oft overlooked strategy

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2015.03.053 ◽

2015 ◽

Vol 33 (6) ◽

pp. 850-851

Author(s):

Anup Katyal ◽

Dayton Dmello ◽

Robert W. Taylor

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Thrombolytic Therapy ◽

Acute Pulmonary Embolism

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Expanding the discussion on fibrinolytic contraindications

Journal of Experimental and Clinical Medicine ◽

10.52142/omujecm.38.4.46 ◽

2021 ◽

Vol 38 (4) ◽

pp. 672-674

Author(s):

Ertan SÖNMEZ ◽

Serdar ÖZDEMİR ◽

Bedia GÜLEN ◽

Bahadır TAŞLIDERE ◽

Ayşe Büşra ÖZCAN

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Cardiac Arrest ◽

Head Trauma ◽

Acute Pulmonary Embolism ◽

Fibrinolytic Therapy ◽

European Resuscitation Council ◽

First Case

The European Resuscitation Council Guidelines recommend the administration of fibrinolytic therapy when acute pulmonary embolism is a known or suspected cause of cardiac arrest. However, contraindications that limit the use of fibrinolytics are sometimes challenged by clinicians, including head trauma in the previous three weeks. We report on the successful use of rescue fibrinolytic therapy on a patient with acute head trauma who had a cardiac arrest in the emergency department as a result of a pulmonary embolism (PE). To the best of our knowledge, this is the first case of successful fibrinolytic therapy for a patient with acute head trauma in the literature.

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Abstract 13076: Refractory Out-of-Hospital Cardiac Arrest in Patients With Pulmonary Embolism and Use of Extracorporeal Membrane Oxygenation: Prague OHCA Study Subanalysis

Circulation ◽

10.1161/circ.144.suppl_2.13076 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Jan Pudil ◽

Jana Smalcova ◽

Ondrej Smid ◽

Daniel Rob ◽

Michaela Hronova ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Extracorporeal Membrane Oxygenation ◽

Primary Outcome ◽

Outcome Data ◽

Membrane Oxygenation ◽

Significant Difference ◽

Initial Settings ◽

Patient Prognosis ◽

Hospital Cardiac Arrest

Introduction: Refractory out-of-hospital cardiac arrest (r-OHCA) in patients with pulmonary embolism (PE) has poor outcome. Data about use of extracorporeal membrane oxygenation (ECMO) in PE are heterogenous and there is minimal evidence for its use in patients presenting with r-OHCA. Hypothesis: To describe in detail profile, initial settings of cardiac arrest (CA) and clinical course of patients with PE presenting with r-OHCA and its specifics in comparison to patients with r-OHCA of other cause. The special attention was paid to the use of ECMO and its potential benefit for patient prognosis. Methods: We reanalyzed subgroup of patients with PE from Prague OHCA study - a randomized control trial evaluating the effect of hyperinvasive approach including the use of ECMO in r-OHCA. Patients characteristics, the specifics of CA settings and the outcome were compared to the patients with other cause of r-OHCA. The neurologically favorable survival was then compared between PE patients randomized to Hyperinvasive and Standard arm of the study. Results: The PE was identified as a cause of CA in 24 (9.4 %) patients in Prague OHCA study. PE patients were more likely women (12 [50 %] vs 32 [13.8 %]) with non-shockable initial rhythm (23 [95.8 %] vs 77 [33.2 %]; P < 0.0001). The CA occurs more frequently after arrival of emergency medical service (14 [58.3 %], vs 22 [9.5 %]; P < 0.0001), had shorter time to hospital admission (median in minutes [IQR], 40 [34.5-57.8] vs 54 [46-64]; P = 0.01) with more severe acidosis at admission (median pH [IQR]; 6.83 [6.75-6.88] vs 6.98 [6.82-7.14] P = 0.0008). The primary outcome of patients with PE - CPC 1 or 2 at 180 days - was significantly worse (2 [8.3 %] vs 66 [28.4 %]; P = 0.049). There was non-significant difference in primary outcome - CPC 1 or 2 at 180 days - between PE patients in Hyperinvasive (12 [50%]) and Standard arm of the study (2 [16.7 %] vs 0; P = 0.24). Conclusion: The initial profile of patients and the settings of CA in patients with r-OHCA and PE differs from patients with other CA cause and their prognosis is significantly worse. The Hyperinvasive approach did not improved outcome in this subgroup of patients.

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Use and clinical outcome of veno-arterial extracorporeal membrane oxygenation in patients with acute pulmonary embolism and cardiopulmonary resuscitation

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.146 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

L Hobohm ◽

I Sagoschen ◽

T Gori ◽

FP Schmidt ◽

T Muenzel ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Mortality Rate ◽

Cardiopulmonary Resuscitation ◽

Acute Pulmonary Embolism ◽

Treatment Strategies ◽

Hospital Death ◽

Systemic Thrombolysis ◽

Va Ecmo ◽

Acute Pe

Abstract Funding Acknowledgements Type of funding sources: None. Background Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with acute pulmonary embolism (PE) and concomitant cardiac arrest with the necessity of cardiopulmonary resuscitation (CPR). Little is known about the use and clinical outcome of veno-arterial (VA)-ECMO and adjunctive treatment strategies in patients with acute PE and CPR. Purpose In this context, we aimed to investigate the use of VA-ECMO alone or after systemic thrombolysis and its impact on in-hospital outcomes of patients with acute PE and CPR. Methods We analyzed data on the characteristics, treatments and in-hospital outcomes for all patients with acute PE (ICD-code I26) and CPR in Germany between the years 2005 and 2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2018, own calculations). Results Between 2005 and 2018, 1,172,354 patients with acute PE (53.5% females) were included in this analysis; of those, 77,196 (6.5%) presented with cardiac arrest and CPR. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority received a combination of thrombolysis + VA-ECMO (n = 165; 0.2%) or singular approach with VA-ECMO treatment alone (n = 588; 0.8%). The overall in-hospital mortality rate of PE patients with cardiac arrest was high with 83.8%. Non-survivors were considerable older than survivors (74 [IQR 63-81] vs. 69 [58-77]). In patients treated with VA ECMO alone the mortality rate was 71.1% and 69.7% when patients received Thrombolysis + VA-ECMO. Patients, who received thrombolysis without VA-ECMO had a higher mortality rate (83.8%). In order to investigate the impact of those different treatment strategies, a multivariate logistic regression analysis (adjusted for age, sex and comorbidities) demonstrated the lowest risk for in-hospital death in patients, who underwent the combination of Thrombolysis + VA-ECMO (OR, 0.61 [95% CI, 0.43-0.86], P = 0.004) or VA-ECMO alone (OR, 0.70 [0.58-0.84], P < 0.001) compared to patients without VA-ECMO and without thrombolysis. Use of thrombolysis alone in patients with PE and CPR lowering the risk regarding in-hospital death as well (OR, 0.95 [0.91-0.99], P = 0.013). Regarding temporal trends, the annual use of VA-ECMO increased from 0 in the year 2005 to the number of 138 in 2018 (ß 6.13 (4.62-6.76); p < 0.001) as well as for the combined treatment Thrombolysis + VA-ECMO (from 0 to 39 [ß 4.28 (3.68-4.89); p < 0.001]). Conclusion Patients with acute PE and CPR had a very high in-hospital mortality rate. Our data suggest, that VA-ECMO alone or after systemic thrombolysis should be considered as an option in this outstanding life-threatening situation to improve in-hospital outcome. Furthermore, our data highlight a marked increase in the number of PE patients treated with VA-ECMO indicating the structural health care progress between 2005 and 2018.

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