Intra-cardiac arrest thrombolysis in the pre-hospital setting: four cases worth considering

Abstract

Background: It has been estimated that over 400 000 people have an out-of-hospital cardiac arrest (OHCA) annually in the United States and Europe combined, of whom fewer than 10% survive to hospital discharge. In up to 70% of cases OHCA is caused by underlying acute coronary disease or pulmonary embolism, and as such the benefits of thrombolytic therapy during resuscitation attempts have been explored without there being a clear conclusion. This paper presents a case series of four victims of OHCA who received thrombolysis, with adjunctive antithrombotic therapy, in the pre-hospital phase of their treatment. Three of these were attended by a critical care paramedic (CCP)—a paramedic with advanced training in emergency care—who received online physician support. The other victim was attended by paramedics and a physician who is experienced in pre-hospital emergency care. Discussion: Although there is much debate about the efficacy of routine administration of thrombolytic therapy during OHCA, cases such as those featured in this paper indicate a need for clinicians to consider the merits of pre-hospital thrombolysis (PHT) based on individual patient characteristics and the circumstances leading to their presenting condition. Conclusions: Lives can be saved with the timely administration of intra-arrest PHT but candidates should be selected with great care. This may be best delivered in systems where clinicians at scene are supported by expert medical advice, allowing clinicians to recognise and treat this small but important group of survivors.