Today’s pearl is an update about the amount of time to continue a code following the administration of alteplase.
Are the European guidelines in line with current practice?
Back in Pearl #4 (5/17/19), we discussed cardiac arrest dosing of alteplase (tPA). In that pearl, I recommended continuing CPR for at least 15 minutes after the dose to allow time for the drug to circulate and exert its fibrinolytic effect. This was based on several studies and the ACLS guidelines.
The newly released 2019 European Society of Cardiology Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism recommend a longer course of CPR (Konstantinides 2019). In section 6.1.4 on Advanced Life Support in Cardiac Arrest, they write: “The decision to treat for acute PE must be taken early, when a good outcome is still possible. Thrombolytic therapy should be considered; once a thrombolytic drug is administered, cardiopulmonary resuscitation should be continued for at least 60–90 min before terminating resuscitation attempts.” This is also what they recommended in the most recent iteration of the European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac Arrest in Special Circumstances (Truhlar 2015).
There are certainly many factors in play when considering tPA in cardiac arrest. They suggest only using tPA “when a good outcome is still possible.” Earlier is better. Importantly, there are no high-quality data to guide our decision on how long to continue CPR and their recommendation is, therefore, not assigned a class and level of evidence. Based on the American and European guidelines, at least 15 minutes, and up to 90 minutes in the right scenario, are reasonable.