Pulmonary angiography during cardiopulmonary resuscitation

Thrombolysis during cardiopulmonary resuscitation in fulminant pulmonary embolism: a review

OBJECTIVE

To review current knowledge on thrombolysis in patients with fulminant pulmonary embolism (FPE) who need cardiopulmonary resuscitation (CPR).

DATA SOURCES

The bibliography for the study was compiled through a search of different databases between 1966 and 2000. References cited in the articles selected were also reviewed.

STUDY SELECTION

The selection criteria included all reports published on thrombolysis, pulmonary embolism, and CPR, from case reports and case series to controlled studies.

DATA SYNTHESIS

Very few studies evaluated thrombolysis in cases of FPE that required CPR and most of these were clinical case reports and case series with a low level of scientific evidence. There has been no clinical trial to address this issue.

CONCLUSIONS

FPE can frequently produce cardiac arrest, which has an extremely high mortality despite application of the usual CPR measures. The administration of thrombolytic therapy during CPR could help to reduce the mortality, although it has classically been contraindicated. There are no published clinical trials or other high-grade studies that evaluated the efficacy and safety of this approach. From the few existing studies, it can be inferred that thrombolysis may be efficacious and safe for patients with FPE who need CPR. However, a clinical trial is required to provide evidence of value for sound clinical decision-making.

Bolus injection of thrombolytic agents during cardiopulmonary resuscitation for massive pulmonary embolism

Thrombolytic therapy has proved to be efficacious in the treatment of massive and fulminant pulmonary embolism (PE), but thrombolysis has been considered as contraindicated during cardiopulmonary resuscitation (CPR). This review on the administration of thrombolytic agents in patients who have suffered massive PE necessitating CPR summarises 14 anecdotal reports and three case series involving 34 patients. The case series revealed an overall initial survival rate of 55-100% following bolus administration of thrombolytic agents. In general, bleeding complications were managed conservatively. The establishment of the diagnosis may be feasible using echocardiography or bedside angiography during CPR. However, therapeutic measures should be taken without delay; the patient's history and the clinical picture may thus be the only diagnostic criteria. Even where myocardial infarction is misinterpreted as PE during CPR, bolus injection of a thrombolytic agent can be an appropriate therapeutic option. An alternative may be mechanical catheter fragmentation of the thrombus with subsequent local thrombolysis. Surgery may be restricted to hospitals with ready access to extracorporeal circulation. We conclude that early administration of thrombolytic agents during PE necessitating CPR may help to reduce mortality. We favour the administration of urokinase (2- to 3,000,000-U bolus) or rt-PA.