PULMONARY EMBOLISM-INDUCED CARDIAC ARREST: 90 MINUTES OF CPR AFTER THROMBOLYTICS

Abstract

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary Embolism (PE) is a common clinical presentation that is typically easy to treat. The problem arises if the PE is considered high-risk, define as presenting with hemodynamic instability. High-risk PE is a life-threatening condition that requires immediate treatment. Treatment of high-risk PE involves parenteral anticoagulation and reperfusion therapy which can include systemic thrombolytics such as tissue plasminogen activator (tPA), catheter-directed treatments, or surgical embolectomy. Here, we describe a case of high-risk PE where tPA was used as a life-saving measure when administered during cardiopulmonary resuscitation (CPR). CASE PRESENTATION: A 63 year old female with no past medical history who presented with progressively worsening shortness of breath over the past four days. Computed tomography pulmonary angiogram revealed saddle embolism with evidence of right heart strain. Patient had pulseless electrical activity arrest while in the emergency room. Code Blue was called and initiated Advanced Cardiovascular Life Support with emergent intubation and CPR. Patient had no absolute contraindication to systemic thrombolytic therapy. Alteplase was given and CPR lasted approximately 90 minutes, at which time return loss of spontaneous circulation was intermittent lost and obtained. Patient was following commands after CPR. Hospitalization course included echocardiogram which demonstrated right ventricular (RV) failure, commencing venoarterial extracorporeal membrane oxygenation (VA-ECMO) for right ventricular support, and continuous renal replacement therapy due to acute tubular necrosis. Fortunately, patient was eventually decannulated off ECMO, kidney function improved, and extubated. She was subsequently discharged to rehab after fifteen days of hospitalization and then discharged home two weeks later. DISCUSSION: The 2019 guidelines by European Society of Cardiology noted the use of systemic thrombolytics as first-line treatment in high-risk PE as a class I recommendation. On the other hand, surgical pulmonary embolectomy is a class I recommendation and catheter-directed treatment is a class II recommendation, but both types of treatment apply to patients with absolute contraindication to systemic thrombolytics. If thrombolytics are administered, the European Resuscitation Council recommends that CPR be continued for at least 60-90 minutes. CONCLUSIONS: In this patient, ECMO intervention is essential because RV failure is the leading cause of death in patients with high-risk PE. This case also demonstrates the importance of prolong CPR after systemic thrombolytics is given in a patient with PE-induced cardiac arrest. REFERENCE #1: Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (Ers). Eur Heart J. 2020;41(4):543-603. REFERENCE #2: Truhlář A, Deakin CD, Soar J, et al. European resuscitation council guidelines for resuscitation 2015: section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201. DISCLOSURES: no disclosure on file for Tyler Boozel; No relevant relationships by Megan Fisher, source=Web Response No relevant relationships by Chun Siu, source=Web Response No relevant relationships by Ashley Vojtek, source=Web Response