Expanding the discussion on fibrinolytic contraindications

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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Return of spontaneous circulation in patients with out-of-hospital cardiac arrest caused by pulmonary embolism using early point-of-care ultrasound and timely thrombolytic agent application: Two case reports

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907920964136 ◽

2020 ◽

pp. 102490792096413

Author(s):

Su Yeong Pyo ◽

Gwan Jin Park ◽

Sang Chul Kim ◽

Hoon Kim ◽

Suk Woo Lee ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Acute Pulmonary Embolism ◽

Thrombolytic Agent ◽

Point Of Care ◽

Fibrinolytic Therapy ◽

Spontaneous Circulation ◽

Point Of Care Ultrasound ◽

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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Unique ECG Findings in Acute Pulmonary Embolism: STE with Reciprocal Changes and Pathologic Q Wave

Case Reports in Critical Care ◽

10.1155/2018/7865894 ◽

2018 ◽

Vol 2018 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Amanda Grant-Orser ◽

Brennan Ballantyne ◽

Wael Haddara

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Case Report ◽

Acute Pulmonary Embolism ◽

Pulseless Electrical Activity ◽

Spontaneous Circulation ◽

Presumptive Diagnosis ◽

Coronary Syndrome ◽

First Case ◽

Pulmonary Angiogram

A 68-year-old male presented to the emergency department with retrosternal chest pain, presyncope, and then a pulseless electrical activity cardiac arrest. An ECG prior to his arrest revealed ST elevations in leads V1–V3, Q waves in lead V2, and reciprocal ST depressions in the lateral and inferior leads. He received thrombolytic therapy for a presumptive diagnosis of ST elevation myocardial infarction. Return of spontaneous circulation was achieved and he underwent a coronary angiogram. No critical disease was found and his left ventriculogram showed normal contraction. His ongoing metabolic acidosis and dependence on an intra-aortic balloon pump, despite adequate cardiac output, prompted a CT pulmonary angiogram which showed multiple segmental filling defects. He was treated for a pulmonary embolism and was discharged 5 days later. Acute pulmonary embolism (APE) has variable clinical presentations. To our knowledge, this is the first case report of an APE presenting with these ECG findings suggestive of myocardial ischemia. In this case report, we discuss the underlying physiological mechanisms responsible and offer management suggestions for emergency department and critical care physicians to better expedite the treatment of APE mimicking acute coronary syndrome on ECG.

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Overcoming barriers to outpatient management of emergency department patients with acute pulmonary embolism

Academic Emergency Medicine ◽

10.1111/acem.14210 ◽

2021 ◽

Author(s):

David R. Vinson ◽

Dustin G. Mark ◽

Dustin W. Ballard

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Outpatient Management ◽

Emergency Department Patients

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136 Impact of Electronic Clinical Decision Support on Initial Site of Care for Emergency Department Patients With Acute Pulmonary Embolism

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2016.08.148 ◽

2016 ◽

Vol 68 (4) ◽

pp. S54 ◽

Cited By ~ 2

Author(s):

D.R. Vinson ◽

D.W. Ballard ◽

D.G. Mark ◽

D.M. Yealy ◽

M.E. Reed ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Decision Support ◽

Clinical Decision Support ◽

Acute Pulmonary Embolism ◽

Clinical Decision ◽

Emergency Department Patients ◽

Electronic Clinical Decision Support

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Acute Pulmonary Embolism in Emergency Department Patients Despite Therapeutic Anticoagulation

Western Journal of Emergency Medicine ◽

10.5811/westjem.2018.1.35586 ◽

2018 ◽

Vol 19 (3) ◽

pp. 510-516 ◽

Cited By ~ 5

Author(s):

Michelle Liu ◽

Dustin Ballard ◽

Jie Huang ◽

Adina Rauchwerger ◽

Mary Reed ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Therapeutic Anticoagulation ◽

Emergency Department Patients

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Value of the Delta Neutrophil Index for Predicting 28-Day Mortality in Patients With Acute Pulmonary Embolism in the Emergency Department

Shock ◽

10.1097/shk.0000000000001027 ◽

2018 ◽

Vol 49 (6) ◽

pp. 649-657 ◽

Cited By ~ 7

Author(s):

Taeyoung Kong ◽

Yoo Seok Park ◽

Hye Sun Lee ◽

Sinae Kim ◽

Jong Wook Lee ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Delta Neutrophil Index

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Treatment of Pulmonary Embolism: a Decade of Experience

Ukrainian journal of cardiovascular surgery ◽

10.30702/ujcvs/19.3505/038046-049 ◽

2019 ◽

pp. 46-49

Author(s):

A. Nikonenko ◽

S. Matvieiev ◽

V. Osaulenko ◽

S. Nakonechniy

Keyword(s):

Pulmonary Embolism ◽

Outpatient Treatment ◽

Acute Pulmonary Embolism ◽

High Efficiency ◽

Oral Anticoagulants ◽

Fibrinolytic Therapy ◽

Major Life ◽

Life Threatening Illness ◽

The World ◽

Life Threatening

Pulmonary embolism (PE) is a major life-threatening illness which remains one of the main causes of sudden death throughout the world. The analysis of diagnosis and treatment of 472 patients with acute pulmonary embolism for a period of 10 years was performed. High efficiency of diagnosis using multispiral computer angiopulmonography (MSCT APG) has been established, thus this method completely supersedes the traditional selective angiopulmonography. Seventeen (3.6 %) patients died due to PE recurrence, another 8 (1.7 %) patients died due to the bleeding after using fibrinolytics and anticoagulants, and 14 (2.9 %) died due to progression of organs failure. This emphasizes the need to improve measures aimed to prevent PE recurrence and identify sources of possible bleeding and refrain from aggressive fibrinolytic therapy. The use of differentiated approach to the treatment with thrombolytic therapy and anticoagulants enabled to achieve recovery in 433 (91.7 %) patients who were discharged for outpatient treatment. New oral anticoagulants were prescribed to 94 (21.7 %) patients after discharge.

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Family history of venous thromboembolism predicts the diagnosis of acute pulmonary embolism in the emergency department

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2018.01.023 ◽

2018 ◽

Vol 36 (9) ◽

pp. 1550-1554 ◽

Cited By ~ 2

Author(s):

Christopher Kelly ◽

Chad Agy ◽

Margaret Carlson ◽

Jacob Steenblik ◽

Joseph Bledsoe ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Family History ◽

Acute Pulmonary Embolism ◽

History Of

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Abstract 17285: Trends and Outcomes of Fibrinolytic Therapy in Patients With Pulmonary Embolism and Metastatic Cancer

Circulation ◽

10.1161/circ.138.suppl_1.17285 ◽

2018 ◽

Vol 138 (Suppl_1) ◽

Author(s):

Gbolahan O Ogunbayo ◽

Robert Pecha ◽

Naoki Misumida ◽

Karam Ayoub ◽

Dustin Hillerson ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Metastatic Cancer ◽

Temporal Trends ◽

Multivariable Analysis ◽

Fibrinolytic Therapy ◽

Primary Diagnosis ◽

Predictors Of Mortality ◽

History Of ◽

Baseline Characteristics

Introduction: Pulmonary embolism in the setting of cancer portends a poor prognosis. There is limited data on the use and outcomes of fibrinolytic therapy (FT) in this subgroup of patients. This study describes temporal trends and outcomes of the use of FT among these patients. Hypothesis: The use of FT in patients with metastatic cancer and acute pulmonary embolism is associated with higher mortality Methods: Using the NIS database, we extracted patients with metastatic cancer admitted with a primary diagnosis of acute pulmonary embolism from January 2010 to December 2014. Using weighted data we analyzed the trends of FT in these patients. For analysis of outcomes, we performed a propensity score matching (match tolerance.01) of patients with PE and FT. After matching, we compared baseline characteristics and inpatient outcomes of patients with PE who underwent FT with those that did not. Or primary outcome was mortality. We performed a multivariable regression analysis with mortality as our outcome. We also described predictors of mortality in patients that underwent FT. Results: Of the 65,882 patients with metastatic cancer admitted with a primary diagnosis of PE, 946 (1.4%) underwent fibrinolytic therapy. There was a significant trends of increase in the use of FT in this cohort of patients, increasing from 0.9% in 2010 to 2.1% in 2014. After exclusions 666 were included in the propensity match and all were matched. Both groups were well matched with regards to baseline characteristics. Patients with FT were less likely to be Caucasian or have anemia. The use of FT was more common in teaching hospitals. Patients in the FT arm were more likely to have cardiac arrest, respiratory failure and acute renal failure. There was no difference in rates of bleeding or blood transfusion. Mortality was significantly higher in the FT arm (24% vs. 1.6%, p<.01). In multivariable analysis, FT was independently associated with mortality (OR 8.35, 95% CI 2.2-32.94; p<.01). Among patients with metastatic cancer and acute PE that underwent FT, independent predictors of mortality were Obesity (OR 4.51, 95% CI 1.35-15.03; p=.02), history of coagulopathy (OR 6.71, 95% CI 1.35-33.46; p=.02), current tobacco abuse (OR 3.26, 95% CI 1.04-10.21; p=.04) and a history of anticoagulant use (OR 2.21, 95% CI 1.02-4.82; p=.046). Conclusions: Fibrinolytic therapy in patients with metastatic cancer and acute pulmonary embolism is associated with increase mortality. The clinical benefits expected from the use fibrinolytic therapy in these patients should be weighed against the risks.

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