Alteplase Dosing in Cardiac Arrests

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.


Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

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