Today’s pearls are about dosing alteplase in cardiac arrest cases.
This can be a tough question in the middle of a critical resuscitation.
There is an overview of the data is available on the Academic Life in EM blog (2013).
- The dose of tPA in cardiac arrest is somewhere between 50-100 mg given as a bolus +/- infusion.
- We generally give 50 mg as an IV push/bolus and often repeat with the other 50 mg in 10-15 minutes, if indicated.
- It may have a better chance of working if given earlier in the resuscitation
- According to the AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, “Ongoing CPR is not an absolute contraindication for fibrinolysis.”
- Some studies suggest allowing at least 15 minutes of CPR for drug to work.
- Evidence is ‘best’ for pulmonary embolism; data does NOT support for undifferentiated cardiac arrest.
- If PE or STEMI is the suspected (or proven) cause, it may have the best chance of working if given earlier in the resuscitation.
- Anticoagulants, such as heparin, were used in most studies along with the fibrinolytic.
Note that the dosing is different in PE or STEMI in the non-arresting patient.