Pulmonary embolism paper reading. Current conclusion of suspected pulmonary embolism patient presented with cardiac arrest and peri-arrest

1. PULMONARY
EMBOLISM
Presenter: Hsu Jin-Yi

2. American Journal of Emergency Medicine 32 (2014) 789–796

3. Resuscitation 82 (2011) 1302–1306
Cardiac OHCA

4. Resuscitation 82 (2011) 1302–1306
Non-cardiac OHCA

5. Hemodynamic unstable
Pulmonary embolism
4%
96%
35%
65%
Low incidence rate but high mortality rate
American Journal of Emergency Medicine 32 (2014) 789–796

6. N Engl J Med 2008;358:1037-52.

7. Curr Cardiol Rev. Feb 2008; 4(1): 49–59

8. Curr Cardiol Rev. Feb 2008; 4(1): 49–59
RV ischemia
LV dysfunction
Cardiac output ➡

9. Curr Cardiol Rev. Feb 2008; 4(1): 49–59

10. Curr Cardiol Rev. Feb 2008; 4(1): 49–59
Thromolytic agent

11. American Journal of Emergency Medicine 32 (2014) 789–796

12. American Journal of Emergency Medicine 32 (2014) 789–796

13. Patient identification

14. N Engl J Med 2008;358:1037-52.
Wells score

15. N Engl J Med 2008;358:1037-52.

16. N Engl J Med 2008;358:1037-52.

17. N Engl J Med 2010;363:266-74

18. N Engl J Med 2010;363:266-74

19. American Journal of Emergency Medicine 2013, 31: 719–721
McConnell's sign

20. RiskBenefit

21. Primary literature review
Included
Thrombolytic therapy in arrest or periarrest patient
Excluded
Case reports, case series, and meta-analyses
if thrombolytic therapy given after ROSC
Primary endpoint
ROSC or mortality
American Journal of Emergency Medicine 32 (2014) 789–796

22. Primary literature review
Thrombolytic therapy in
periarrest
Thrombolytic therapy in
cardiac arrest
Prospective evaluation
Retrospective evaluation
American Journal of Emergency Medicine 32 (2014) 789–796

23. Thrombolytic therapy in
periarrest
Mortality: 0% vs 100%, P = .02
No bleeding
Prospective, randomized, controlled trial
Heparin infusion, n=8
Unstable massive PE
Streptokinase, n = 8
J Thromb Thrombolysis 1995;2:227–9.

24. Thrombolytic therapy in
periarrest
Mortality: 23.8%
SBP from 88 ± 13 to 121±15within2h, P <.05
5 (23%) minor 3 bleeding events
Retrospective review
No control group
Unstable massive PE
t-PA (0.6 mg/kg, maximum dose of 50 mg, infused for
15 min, followed by heparin), n = 21
Am J Emerg Med 2003;21:438–40.

25. Thrombolytic therapy in
periarrest
Mortality: 15% vs 47%, P < .001
Treatment was favored when controlled for age and
comorbidities
Bleeding: not reported
Retrospective database review
No thrombolytic therapy, n = 50840
Unstable massive PE
All patients treated with thrombolytics included, agents
and doses not reported, n = 21390
Am J Med 2012;125:465–70.

26. Am J Med 2012;125:465–70.

27. Thrombolytic therapy in
cardiac arrest ( prospective)
ROSC: 68% vs 44%, P = .26
Survival to CICU: 58%vs 30%, P = .009
Alive at 24 h: 35% vs 22%, P = .171
Survival to discharge: 15%vs 8% control, no P value
Prospective observational trial
Historical matched controls, n = 50
Out-of-hospital cardiac arrest
t-PA (50 mg IVP for 2 min with heparin 5000 units
bolus), n = 40
Lancet 2001;357:1583–5.

28. Thrombolytic therapy in
cardiac arrest ( prospective)
Survival to discharge: 1 patient vs 0 patients, P = .99
No difference in ROSC, hemorrhage, hospital LOS
4 events reported (group unspecified)
Prospective, randomized, placebo controlled trial
Placebo, n = 116
PEA arrest unresponsive to initial therapy
t-PA (100 mg infused for 15 min), n = 117
N Engl J Med 2002;346:1522–8.

29. Thrombolytic therapy in
cardiac arrest ( prospective)
ROSC: 42% vs 6%, P < .05
No difference in survival
Bleeding: None
Prospective, randomized, placebo controlled trial
Placebo n = 16
Out-of-hospital cardiac arrest
Tenecteplase (50 mg as a bolus), n = 19
Resuscitation 2004;61:309–13.

30. Thrombolytic therapy in
cardiac arrest ( prospective)
ROSC: 26% vs 12.4%, P = .004
Survival to ICU: 12% vs 0%, no P value provided
Survival to 24 h: 4% vs 0%, no P value provided
Survival to discharge: 4% vs 0%, no P value provided
Prospective observational trial
Concurrent group of non-traumatic cardiac arrest
Atraumatic cardiac arrest
Tenecteplase (weight-based dosing), n = 50
Resuscitation 2006;69:399–406.

31. Thrombolytic therapy in
cardiac arrest ( prospective)
30 day survival: 14.7% vs 17%, P = .36
No difference in, 24-h survival, or ROSC
ICH: 2.7% vs 0.4%, P <.05
Prospective, randomized, placebo controlled trial
Placebo, n = 525
Witnessed OHCA due to presumed cardiac causes
Tenecteplase (weight-based dosing), n = 525
N Engl J Med 2008;359:2651–62.

32. Thrombolytic therapy in
cardiac arrest ( retrospective)
ROSC: 17 patients (81%) vs 7 patients (33%), P = .03
Survival: 63% (83/132) V.S. 35% (47/133; P < .001)
5 events reported with thrombolytics
Retrospective review
No thrombolytic therapy, n = 21
PE-induced cardiac arrest
t-PA (50 mg bolus or 15 mg bolus followed by 85 mg
infusion for 90 min), n = 21
Arch Intern Med 2000;160:1529–35.

33. Thrombolytic therapy in
cardiac arrest ( retrospective)
ROSC: 70.4% vs 51.0%, P = .001
24h survival: 48% vs 32.9%, P = .003.
Presumptive diagnosis of PE, 57.9% survived 24 hours
and 31.6% survived to discharge
Retrospective review
Matched controls, n=216
Atraumatic OHCA with suspected cardiac origin
t-PA (15 mg bolus followed by 50 mg infused for 30 min
then 35 mg infused for60min),n=108
Resuscitation 2001;50:71–6.

34. Thrombolytic therapy in
cardiac arrest ( retrospective)
ROSC: 67% vs 43%, P = .06
Survival at 24h: 53% vs 23%, P = .01
Survival to discharge: no difference
No difference in 3 major or minor
Retrospective review
No thrombolytics, n = 30
t-PA (0.6-1 mg/kg, max of 100 mg IV push), n = 30
Cardiac arrest secondary to massive PE
Resuscitation 2003;57:49–55.

35. Unstable or arresting patients experiencing
massive PE will likely benefit from
thrombolytic therapy
Patient identification
Risks and benefits of this intervention
Based on the best available information
Contraindications of thrombolytic therapy
Discussion

36. Discussion
CPR ?
Not show a significant difference in outcomes with regard to bleeding
Significantly more intracranial hemorrhages. However, better outcome
Quickly administer the intervention as early administration has
been shown to improve outcomes. (2Hr)
Dosage: not clear.
The authors recommend administration of t-PA as an initial
bolus of 50 mg with a subsequent bolus of an additional 50 mg
if the first dose is unsuccessful

37. American Journal of Emergency Medicine (2009) 27, 84–95
Patient with diagnosis of
pulmonary embolism
Hemodynamically stable?
RV dysfunction?
Fibrinolytic therapy?

38. My opinion
There is still no clear protocol after reading
this article.
Prospective data revealed relatively poor data
( nearly all no difference between two group.)
Prospective data V.S. Retrospective data?

39. Thanks for your attention!

42. N Engl J Med 2008;358:1037-52.

43. N Engl J Med 2014;370:1402-11

44. Curr Opin Crit Care 2012, 18:318 – 325

45. Curr Opin Crit Care 2012, 18:318 – 325

46. Curr Opin Crit Care 2012, 18:318 – 325

47. Curr Opin Crit Care 2012, 18:318 – 325Curr Opin Crit Care 2012, 18:318 – 325

48. American Journal of Emergency Medicine (2009) 27, 84–95
Patient with diagnosis of
pulmonary embolism
Hemodynamically stable?
RV dysfunction?
Fibrinolytic therapy?

49. American Journal of Emergency Medicine (2009) 27, 84–95

50. American Journal of Emergency Medicine (2009) 27, 84–95

51. American Journal of Emergency Medicine 2009, 27: 84–95

52. Am J Respir Crit Care Med 2010, 181: 168-173

53. Am J Respir Crit Care Med 2010, 181: 168-173

54. http://www.ecglibrary.com/pe.php
S1Q3T3

55. American Journal of Emergency Medicine 2013, 31: 719–721
McConnell's sign