title: Successful alteplase bolus administration for a presumed massive pulmonary embolism during cardiopulmonary resuscitation.
abstract: OBJECTIVE
  To describe the case of a patient successfully resuscitated with bolus alteplase for a presumed massive pulmonary embolism (PE) with associated cardiac arrest.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Mission Hospitals, Asheville, NC, USA.
authors.forename: Rathasen
authors.initials: R
authors.lastname: Prom
authors.forename: Ryan
authors.initials: R
authors.lastname: Dull
authors.forename: Bethany
authors.initials: B
authors.lastname: Delk
mesh_terms: D016887:Cardiopulmonary Resuscitation; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: alteplase; arrest; fibrinolysis; pulmonary embolism; resuscitation; reteplase; rtPA; streptokinase; tenecteplase; thrombolysis; urokinase