Management of the Patient With Fulminant Pulmonary Embolism Undergoing Cardiopulmonary Resuscitation

  • Fabian Spöhr
  • Bernd W. Böttiger
Chapter
Part of the Contemporary Cardiology book series (CONCARD)

Abstract

Patients with cardiac arrest after fulminant pulmonary embolism (PE) have a very poor prognosis. Conventional cardiopulmonary resuscitation (CPR) is frequently unsuccessful because it does not treat the underlying condition. Although thrombolysis is an effective therapeutic option for patients with acute PE, this treatment has traditionally been withheld during CPR because of the anticipated risk of severe hemorrhagic complications associated with chest compressions. This chapter focuses on the mechanisms of action of thrombolytic therapy during CPR after acute PE on the basis of experimental and clinical data. In fact, most data suggest a significant improvement of overall and neurological outcome in patients receiving thrombolysis during CPR after massive PE. Although the use of thrombolytics is indeed associated with an increased incidence of hemorrhagic complications in this setting, critical bleeding complications are rare and do not seem to outweigh the potential benefits of this therapeutic option. Therefore, thrombolytic therapy should not be withheld in patients suffering cardiac arrest after massive PE, particularly if conventional CPR has failed to show immediate success and other treatment options (e.g., surgical embolectomy) are not available.

Key Words

Cardiac arrest cardiopulmonary resuscitation massive pulmonary embolism thrombolysis outcome 
This is a preview of subscription content, log in to check access.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Courtney DM, Sasser HC, Pincus CL, Kline JA. Pulseless electrical activity with witnessed arrest as a predictor of sudden death from massive pulmonary embolism in outpatients. Resuscitation 2001;49:265–272.PubMedCrossRefGoogle Scholar
  2. 2.
    Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med 2000;160:1529–1535.PubMedCrossRefGoogle Scholar
  3. 3.
    Böttiger B W, Bach A, Böhrer H, Martin E. Acute thromboembolism of the lung. Clinical picture—pathophysiology—diagnosis—therapy. Anaesthesist 1993;42:55–73.PubMedGoogle Scholar
  4. 4.
    Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest 1995;108:978–981.PubMedGoogle Scholar
  5. 5.
    Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002;121:877–905.PubMedCrossRefGoogle Scholar
  6. 6.
    Böttiger BW, Böhrer H, Bach A, Motsch J, Martin E. Bolus injection of thrombolytic agents during cardiopulmonary resuscitation for massive pulmonary embolism. Resuscitation 1994;28:45–54.PubMedCrossRefGoogle Scholar
  7. 7.
    Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004;110:588–636.PubMedCrossRefGoogle Scholar
  8. 8.
    Van de Werf F, Ardissino D, Betriu A, et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2003;24:28–66.PubMedCrossRefGoogle Scholar
  9. 9.
    Padosch SA, Motsch J, Böttiger BW. Thrombolysis during cardiopulmonary resuscitation. Anaesthesist 2002;51:516–532.PubMedCrossRefGoogle Scholar
  10. 10.
    Hossmann KA. Ischemia-mediated neuronal injury. Resuscitation 1993;26:225–235.PubMedCrossRefGoogle Scholar
  11. 11.
    Böttiger BW, Martin E. Thrombolytic therapy during cardiopulmonary resuscitation and the role of coagulation activation after cardiac arrest. Curr Opin Crit Care 2001;7:176–183.PubMedCrossRefGoogle Scholar
  12. 12.
    Gando S, Nanzaki S, Morimoto Y, Kobayashi S, Kemmotsu O. Out-of-hospital cardiac arrest increases soluble vascular endothelial adhesion molecules and neutrophil elastase associated with endothelial injury. Intensive Care Med 2000;26:38–44.PubMedCrossRefGoogle Scholar
  13. 13.
    Mossakowski MJ, Lossinsky AS, Pluta R, Wisniewski HM. Abnormalities of the blood-brain barrier in global cerebral ischemia in rats due to experimental cardiac arrest. Acta Neurochir Suppl (Wien) 1994;60:274–276.Google Scholar
  14. 14.
    Fischer M, Böttiger BW, Popov-Cenic S, Hossmann KA. Thrombolysis using plasminogen activator and heparin reduces cerebral no-reflow after resuscitation from cardiac arrest: an experimental study in the cat. Intensive Care Med 1996;22:1214–1223.PubMedCrossRefGoogle Scholar
  15. 15.
    Böttiger BW, Motsch J, Böhrer H, et al. Activation of blood coagulation after cardiac arrest is not balanced adequately by activation of endogenous fibrinolysis. Circulation 1995;92:2572–2578.PubMedGoogle Scholar
  16. 16.
    Gando S, Kameue T, Nanzaki S, Nakanishi Y. Massive fibrin formation with consecutive impairment of fibrinolysis in patients with out-of-hospital cardiac arrest. Thromb Haemost 1997;77:278–282.PubMedGoogle Scholar
  17. 17.
    Böttiger BW, Böhrer H, Böker T. Platelet Factor 4 release in patients undergoing cardiopulmonary resuscitation: can reperfusion be impaired by platelet aggregation? Acta Anaesthesiol Scand 1996;40:631–635.PubMedGoogle Scholar
  18. 18.
    Gando S, Kameue T, Nanzaki S, Igarashi M, Nakanishi Y. Platelet activation with massive formation of thromboxane A2 during and after cardiopulmonary resuscitation. Intensive Care Med 1997;23:71–76.PubMedCrossRefGoogle Scholar
  19. 19.
    Newman DH, Greenwald I, Callaway CW. Cardiac arrest and the role of thrombolytic agents. Ann Emerg Med 2000;35:472–480.PubMedGoogle Scholar
  20. 20.
    Köhle W, Pindur G, Stauch M, Rasche H. Hochdosierte Streptokinasetherapie bei fulminanter Lungenarterienembolie. Anaesthesist 1984;33:469.Google Scholar
  21. 21.
    Scholz KH, Hilmer T, Schuster S, Wojcik J, Kreuzer H, Tebbe U. Thrombolysis in resuscitated patients with pulmonary embolism. Dtsch Med Wochenschr 1990;115:930–935.PubMedGoogle Scholar
  22. 22.
    Ballew KA, Philbrick JT, Caven DE, Schorling JB. Predictors of survival following in-hospital cardiopulmonary resuscitation. A moving target. Arch Intern Med 1994;154:2426–2432.PubMedCrossRefGoogle Scholar
  23. 23.
    Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569–576.PubMedCrossRefGoogle Scholar
  24. 24.
    Böttiger BW, Grabner C, Bauer H, et al. Long term outcome after out-of-hospital cardiac arrest with physician staffed emergency medical services: the Utstein style applied to a midsized urban/suburban area. Heart 1999;82:674–679.PubMedGoogle Scholar
  25. 25.
    Silfvast T. Cause of death in unsuccessful prehospital resuscitation. J Intern Med 1991;229:331–335.PubMedCrossRefGoogle Scholar
  26. 26.
    Spaulding CM, Joly LM, Rosenberg A, et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 1997;336:1629–1633.PubMedCrossRefGoogle Scholar
  27. 27.
    Klefisch F, Gareis R, Störk T, Möckel M, Danne O. Pröklinische ultima-ratio Thrombolyse bei therapierefraktbrer kardiopulmonaler Reanimation. Intensivmedizin 1995;32:155–162.Google Scholar
  28. 28.
    Böttiger BW, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet 2001;357:1583–1585.PubMedCrossRefGoogle Scholar
  29. 29.
    Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M. Recombinanttissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest. Resuscitation 2001;50:71–76.PubMedCrossRefGoogle Scholar
  30. 30.
    Abu-Laban RB, Christenson JM, Innes GD, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med 2002;346:1522–1528.PubMedCrossRefGoogle Scholar
  31. 31.
    Böttiger BW, Padosch SA, Wenzel V, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med 2002;17:1281–1282.CrossRefGoogle Scholar
  32. 32.
    Spöhr F, Arntz HR, Bluhmki E, et al. International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: the Thrombolysis in Cardiac Arrest (TROICA) Study. Eur J Clin Invest 2005;35:315–323.PubMedCrossRefGoogle Scholar
  33. 33.
    Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac resuscitation. Chest 1987;92:287–291.PubMedCrossRefGoogle Scholar
  34. 34.
    Bedell SE, Fulton EJ. Unexpected findings and complications at autopsy after cardiopulmonary resuscitation (CPR). Arch Intern Med 1986;146:1725–1728.PubMedCrossRefGoogle Scholar
  35. 35.
    Nagel EL, Fine EG, Krischer JP, Davis JH. Complications of CPR. Crit Care Med 1981;9:424.PubMedCrossRefGoogle Scholar
  36. 36.
    Spöhr F, Böttiger BW. Safety of thrombolysis during cardiopulmonary resuscitation. Drug Saf 2003;26:367–379.PubMedCrossRefGoogle Scholar
  37. 37.
    Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Lancet 1994;343:311–322.Google Scholar
  38. 38.
    Kanter DS, Mikkola KM, Patel SR, Parker JA, Goldhaber SZ. Thrombolytic therapy for pulmonary embolism. Frequency of intracranial hemorrhage and associated risk factors. Chest 1997;111:1241–1245.PubMedGoogle Scholar
  39. 39.
    Böttiger BW, Spöhr F. The risk of thrombolysis in association with cardiopulmonary resuscitation: no reason to withhold this causal and effective therapy. J Intern Med 2003;253:99–101.PubMedCrossRefGoogle Scholar
  40. 40.
    Kürkciyan I, Meron G, Sterz F, et al. Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment. J Intern Med 2003;253:128–135.PubMedCrossRefGoogle Scholar
  41. 41.
    Horstkotte D, Heintzen M, Strauer B. Combined mechanical and thrombolytic reopening of the lungstream-track with massive lung-arterial-embolism. Intensivmedizin 1990;27:124–132.Google Scholar
  42. 42.
    Siebenlist D, Gattenlöhner W. Fibrinolysis with rt-PA for fulminant pulmonary thromboembolism. Intensivmedizin 1990;27:302–305.Google Scholar
  43. 43.
    Böttiger BW, Reim SM, Diezel G. Successful treatment of a fulminant pulmonary embolism using a high-dose bolus injection of urokinase during cardiopulmonary resuscitation. Anasthesiol Intensivmed Notfallmed Schmerzther 1991;26:29–36.PubMedGoogle Scholar
  44. 44.
    Hopf HB, Flossdorf T, Breulmann M. Rekombinanter Gewebeplasminogenaktivator (rt-PA) zur Notfallbehandlung der perioperativen lebensbedrohlichen Lungenembolie (Stadium IV). Anaesthesist 1991;40:309–314.PubMedGoogle Scholar
  45. 45.
    Sigmund M, Rubart M, Vom Dahl J, Uebis R, Hanrath P. Successful treatment of massive pulmonary embolism by combined mechanical and thrombolytic therapy. J Interv Cardiol 1991;4:63–68.PubMedCrossRefGoogle Scholar
  46. 46.
    Westhoff-Bleck M, Gulba D, Claus G, Rafflenbeul W, Lichtlein P. Lysetherapie bei protrahierter kardiopulmonaler Reanimation: Nutzen und Komplikationen. Z Kardiol 1991;80:139.Google Scholar
  47. 47.
    Scheeren TW, Hopf HB, Peters J. Intraoperative thrombolysis with rt-PA in massive pulmonary embolism during venous thrombectomy. Anösthesiol Intensivmed Notfallmed Schmerzther 1994;29:440–445.CrossRefGoogle Scholar
  48. 48.
    Ruiz-Bailen M, Aguayo-de-Hoyos E, Serrano-Corcoles MC, et al. Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series. Resuscitation 2001;51:97–101.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc., Totowa, NJ 2007

Authors and Affiliations

  • Fabian Spöhr
    • 1
  • Bernd W. Böttiger
    • 2
    • 3
  1. 1.Department of AnesthesiologyRuprecht Karls UniversityHeidelbergGermany
  2. 2.European Resuscitation CouncilGermany
  3. 3.Department of AnesthesiologyRuprecht Karls UniversityHeidelbergGermany

Personalised recommendations