Evaluation of Systemic Thrombolytic Treatment in the Emergency Service in Unstable and Resuscitated Patients Due to Massive Pulmonary Embolism

Öz

Background: PE accounts for 3% of out-of-hospital cardiac arrest. In this case, treating patients with thrombolysis during resuscitation has been associated with better survival. Objective: The aim of this study is to evaluate the use of systemic thrombolytic in unstable and/or resuscitated patients who are evaluated in the red area in emergency service practice and who are diagnosed with massive pulmonary embolism with bedside examinations. Methods: This prospective study was designed on 17 patients who were transferred as unstable to the emergency service of a tertiary hospital by Emergency Health Services and/or who needed resuscitation due to non-shockable fatal rhythm disorder on admission and who underwent systemic thrombolysis due to the diagnosis of pulmonary embolism during resuscitation. Results: Of the 17 patients included in the study, 52.9% were discharged and improvement was detected in unstable vital findings in 47.1% patients after thrombolysis. Of the bedside examinations performed on admission, ECG showed T wave negativity at V1-4 deviations and P-pulmonale in 41.2% patients and ECHO showed right ventricle dilatation indicating right ventricle dysfunction in 82.4% patients. CTPA taken after stabilization showed thrombus at bilateral pulmonary artery in 88.2% patients. Conclusion: Cardiopulmonary arrest caused by PE is a life-threatening condition that requires urgent systemic thrombolysis. Patients who are evaluated as unstable or in need of resuscitation in the emergency service should be diagnosed quickly as a result of examinations performed at bed-side and thrombolytic treatment should be started.

Anahtar Kelimeler

• Emergency,
• Pulmonary Embolism,
• Massive,
• Trombolytic Treatment

Kaynakça

1. 1- Wilbur J, Shian B. Deep venous thrombosis and pulmonary embolism: Current therapy. Am Fam Physician. 2017; 95: 295–302.
2. 2- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola V-P, 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: 543-603.
3. 3- Javaudin F, Lascarrou JB, Esquina H, Baert V, Hubert H, Leclere B, et al. Improving identification of pulmonary embolism-related out-of-hospital cardiac arrest to optimize thrombolytic therapy during resuscitation. Crit Care. 2019; 23: 409.
4. 4- Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132: 444-64.
5. 5- Cohen AT, Dobromirski M, Gurwith MM. Managing pulmonary embolism from presentation to extended treatment. Thromb Res 2014; 133: 139-48.
6. 6- Konstantinides SV, Barcos S, Lankeit M, Meyer G. Management of Pulmonary Embolism: An Update. J Am Coll Cardiol 2016; 67: 976-90.
7. 7- Greco F, Misuraca G, Serafini O, Guzzo D, Plastina F. Thrombolytic therapy during cardiopulmonary resuscitation for acute massive pulmonary embolism. A case report. Minerva Cardioangiol. 2001; 49: 433-6.
8. 8- Javaudin F, Lascarrou JB, Le Bastard Q, Bourry Q, Latour C, Carvalho HD, et al. 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; 156: 1167-75.

9. 9- Summers K, Schultheis J, Raiff D, Dahhan T. Evaluation of Rescue Thrombolysis in Cardiac Arrest Secondary to Suspected or Confirmed Pulmonary Embolism. Ann Pharmacother. 2019; 53: 711-5.
10. 10- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola V-P, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019; 54. pii: 1901647.
11. 11- Prom R, Dull R, Delk B. Successful Alteplase Bolus Administration for a Presumed Massive Pulmonary Embolism During Cardiopulmonary Resuscitation. Ann Pharmacother. 2013; 47: 1730-5.
12. 12- Sharifi M, Berger J, Beeston P, Bay C, Vajo Z, Javadpoor S; “PEAPETT” Investigators. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016; 34: 1963-7.
13. 13- Bauer MP, Vliegen HW, Huisman MV. Massive pulmonary embolism with cardiac arrest after an intracardiac electrophysiological study: a strong case for venous thromboprophylaxis. Blood Coagul Fibrinolysis. 2006; 17: 57-8.
14. 14- Pala S, Kahveci G, Bozok S. Acute massive pulmonary embolism with hemodynamic compromise treated successfully with thrombolytic therapy. Clin Appl Thromb Hemost. 2009; 15: 708-10.
15. 15- Er F, Nia AM, Gassanov N, Caglayan E, Erdmann E, Hoppe UC. Impact of rescue-thrombolysis during cardiopulmonary resuscitation in patients with pulmonary embolism. PLoS One. 2009; 4: e8323.
16. 16- Close MD, Cherkas D. Successful treatment of presumed massive pulmonary embolism during cardiac arrest. Am J Emerg Med. 2011; 29: 132 e3-e4.
17. 17- Landy C, Plancade D, Gagnon N, Schaeffer E, Nadaud J, Favier JC. Complication of intraosseous administration of systemic fibrinolysis for a massive pulmonary embolism with cardiac arrest. Resuscitation. 2012; 83: e149-50.
18. 18- Bailen MR, Cuadra JA, Aguayo De, Hoyos E. Thrombolysis during cardiopulmonary resuscitation in fulminant pulmonary embolism: a review. Crit Care Med. 2001; 29: 2211-9.
19. 19- Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl): e419S-e496S.
20. 20- Piazza G, Goldhaber SZ. Fibrinolysis for acute pulmonary embolism. Vasc Med. 2010; 15: 419-28.
21. 21- Goldhaber SZ, Agnelli G, Levine MN. Reduced dose bolus alteplase vs conventional alteplase infusion for pulmonary embolism thrombolysis: an international multicenter randomized trial. The Bolus Alteplase Pulmonary Embolism Group. Chest. 1994; 106: 718-24.
22. 22- Zhang Z, Zhai ZG, Liang LR, Liu FF, Yang YH, Wang C. Lower dosage of recombinant tissue-type plasminogen activator (rt-PA) in the treatment of acute pulmonary embolism: a systematic review and meta-analysis. Thromb Res. 2014; 133: 357-63.
23. 23- 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: 1214-23.
24. 24- Böttiger BW, Martin E. Thrombolytic therapy during cardiopulmonary resuscitation and the role of coagulation activation after cardiac arrest. Curr Opin Crit Care. 2001; 7: 176-83.
25. 25- Spöhr F, Böttiger BW. Thrombolytics in CPR. Current advantages in cardiopulmonary resuscitation. Minerva Anestesiol. 2005; 71: 291-6.