Double Bolus Alteplase Therapy during Cardiopulmonary Resuscitation for Cardiac Arrest due to Massive Pulmonary Embolism Guided by Focused Bedside Echocardiography

Successful Intraosseous Thrombolysis in the Management of a Massive Pulmonary Embolism With Cardiac Arrest

We describe the successful cardiopulmonary resuscitation of a patient with massive pulmonary embolism who received thrombolysis via the intraosseous route. This case also demonstrates survival without apparent long-term sequelae despite extreme metabolic acidosis. In the context of pulmonary embolism, this has not been widely reported in the existing literature. A 22-year-old woman suffered a prolonged cardiac arrest secondary to pulmonary embolism in a hospital corridor following short hospital admission for medical termination of pregnancy. A point-of-care echocardiogram showed a grossly dilated right ventricle indicative of pulmonary embolism. Due to severe peripheral vasoconstriction, intravenous access proved difficult, and the decision was made to deliver intraosseous thrombolysis. Initial blood gas analysis showed a profound acidosis due to alternating return of spontaneous circulation and further loss of output. Because of her prolonged "low-flow" state, she was deemed unsuitable for extracorporeal membrane oxygenation. Despite the poor prognosis, the decision was made to continue with resuscitation in light of a reversible pathology. She was successfully discharged from the hospital after a short intensive care stay with no long-term complications. This case demonstrates successful thrombolysis through an intraosseous route, with a good outcome despite poor prognostic factors. Early thrombolysis and continuous cardiopulmonary resuscitation in massive pulmonary embolism are imperative to survival in cardiac arrest.