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Arrest from PE – Do Lytics Help?

January 15, 2020

Written by Clay Smith

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For patients with out-of-hospital cardiac arrest (OHCA) and PE, 30-day survival was greater in those who received thrombolytic therapy than those who did not, but there was no significant improvement in neurologically intact survival.

Why does this matter?
PE is a rare cause of OHCA, around 2.5%. Determining when to use thrombolytic agents in arrest is challenging. Prior history of DVT/PE and non-shockable rhythm are known risks, though these two variables are not sensitive for PE as a cause of arrest. Bedside echo is very helpful in such cases and is recommended by the AHA and ERC. If we suspect PE caused arrest, does it make a difference in outcome to give a thrombolytic during CPR?

More surviveā€¦but not intact
This was a retrospective review of 246 patients with OHCA confirmed to have PE. Of these, 58 received thrombolysis during CPR. Tenecteplase was the most commonly used agent. Overall, 30-day survival was better in those who received thrombolysis vs. those who did not: 16% vs 6%, p = 0.005, respectively; but no improvement in neurologically intact survival: 10% vs 5%; adjusted relative risk, 1.97; 95% CI, 0.70-5.56. Groups were very similar except the lytic patients had longer down time, higher epinephrine dosing, and fewer patients with initial rhythm of asystole. Death from hemorrhage was not greater in the lytic cohort. The study was undoubtedly limited by confounding, being non-randomized and having occasional missing data in the arrest registry. At this point, it is a judgment call whether to give lytics or not for OHCA and suspected PE.

Thrombolysis During Resuscitation for Out-of-Hospital Cardiac Arrest Caused by Pulmonary Embolism Increases 30-Day Survival: Findings From the French National Cardiac Arrest Registry. Chest. 2019 Dec;156(6):1167-1175. doi: 10.1016/j.chest.2019.07.015. Epub 2019 Aug 2.

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