TPA in code blue PE arrest

[Dred Pirate]

Just curious what you all do for TPA in cardiac arrest - generally we do 0.6mg/kg up to 50mg as a slow IV push -maybe two survivals out of 15 - pretty poor results. Curious as to if anyone has any more recent literature to support a different dose?

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[sakigt]

Not in CA, but I gave it for massive PE. 100mg total, 10mg bolus with the rest over 2 hours. Heparin drip afterwards with aPTT < 2xULN.
Patient walked out 5 days later.

Ive heard of giving it for CA but the concern is for sternal bleeding after CPR. It was given anyway, didnt work, but it was a hail mary anyway.

The dose youre describing sounds like submassive PE dosing.

 

[Dred Pirate]

no - definitely massive PE leading to CA - the thought is that you give a lower dose because you are pushing it in, with the possibility of repeating it. Yes - a complete hail mary, the thought of "you can't make a dead person more dead". Ya I know the 100mg over 2 hours for a submassive PE - we do that occasionally, although our docs seem to always give lovenox stat then second guess if they should have given TPA, and by that time it is too late.

 

[sakigt]

With our massive PE in CA I think they just did the 10mg bolus and the 2 hours infusion. But I could be wrong, I wasnt there.

"Submassive PE" dose is 50mg. "Massive PE" with hemodynamic instability is the 100mg over 2 hours. "Massive PE" with CA.....

Never heard of pushing TPA, but I found this: http://academiclifeinem.com/whats-the-code-dose-of-tpa/ That matches what youre saying.

My 100mg/2hr dose is from Lexi (Lexi, Jaff 2011)

Found this too about pushing tpa but only for CA: http://emcrit.org/podcasts/fibrinolysis-in-pulmonary-embolism/

Ill have to look more into this 🙂

 

[Mad Jack]

I can only recall TPA being given in a cardiac arrest once in my hospital. It was an ICU patient who had a known PE that subsequently cardiac arrested. The patient lived, so there's that. After multiple arrests no less. It was my last shift of the week, and I gave report right before they coded again. Next time I saw them I was staring at them in awe, my mind completely blown that they were alive after what had to add up to over an hour of CPR and the last ditch resort of TPA. Better yet, the pt was totally neurally intact, extubated, and talkative.

 

[Dred Pirate]

With our massive PE in CA I think they just did the 10mg bolus and the 2 hours infusion. But I could be wrong, I wasnt there.

"Submassive PE" dose is 50mg. "Massive PE" with hemodynamic instability is the 100mg over 2 hours. "Massive PE" with CA.....

Never heard of pushing TPA, but I found this: http://academiclifeinem.com/whats-the-code-dose-of-tpa/ That matches what youre saying.

My 100mg/2hr dose is from Lexi (Lexi, Jaff 2011)

Found this too about pushing tpa but only for CA: http://emcrit.org/podcasts/fibrinolysis-in-pulmonary-embolism/

Ill have to look more into this 🙂

Not to sound like a smart ass - but I see your field is listed as pre-health - undecided - what exactly do you do? (no disrespect) - but if during a code you said we will give it over 2 hours (hell even over 30 minutes) you are gonna get laughed out of the room - trust me.

It is a last ditch effort to try to save a life - usually it doesn't work.

Med Jack - that is impressive - the ones I have seen had less than ideal outcomes - but the fact they were alive at all was impressive, but don't get used to those types of outcomes - or else you will get depressed all to hell when most end up with bad outcomes

 

[Mad Jack]

Not to sound like a smart ass - but I see your field is listed as pre-health - undecided - what exactly do you do? (no disrespect) - but if during a code you said we will give it over 2 hours (hell even over 30 minutes) you are gonna get laughed out of the room - trust me.

It is a last ditch effort to try to save a life - usually it doesn't work.

Med Jack - that is impressive - the ones I have seen had less than ideal outcomes - but the fact they were alive at all was impressive, but don't get used to those types of outcomes - or else you will get depressed all to hell when most end up with bad outcomes

Believe me, I won't get used to it. Like I said, I wrote that guy off as -dead- before I left work that day. This one goes in the "miracle" column, not the "TPA is magic" column. And being intact after a code is always more luck than anything. I've seen people that we coded for over an hour come out fine, and people we've got back after around 10 minutes come out with profound deficits. Definitely just chalking that one up to good fortune.

 

[sakigt]

Not to sound like a smart ass - but I see your field is listed as pre-health - undecided - what exactly do you do? (no disrespect) - but if during a code you said we will give it over 2 hours (hell even over 30 minutes) you are gonna get laughed out of the room - trust me.

It is a last ditch effort to try to save a life - usually it doesn't work.

Med Jack - that is impressive - the ones I have seen had less than ideal outcomes - but the fact they were alive at all was impressive, but don't get used to those types of outcomes - or else you will get depressed all to hell when most end up with bad outcomes

Where did I say that I would run it over 2 hours in a code?

I havent updated my account since I joined many moons ago. But Im a PharmD.

 

[Dred Pirate]

Where did I say that I would run it over 2 hours in a code?

I havent updated my account since I joined many moons ago. But Im a PharmD.

With our massive PE in CA I think they just did the 10mg bolus and the 2 hours infusion. But I could be wrong, I wasnt there.

I interpreted the last line quoted above as saying that - sorry if that is not what you mean

 

[PharmerC]

If PE is suspected during cardiac arrest and no spontaneous return of circulation, will use 50mg iv push. Can be repeated with another 50mg in 15-30 minutes. No positive outcomes as of yet, but the few times I have made this it was kind of a last ditch effort.

 

[njac]

no - definitely massive PE leading to CA - the thought is that you give a lower dose because you are pushing it in, with the possibility of repeating it. Yes - a complete hail mary, the thought of "you can't make a dead person more dead". Ya I know the 100mg over 2 hours for a submassive PE - we do that occasionally, although our docs seem to always give lovenox stat then second guess if they should have given TPA, and by that time it is too late.

You can still give tpa even if you've given the lovenox.

We give 50mg IVP. There are papers that say you can repeat the dose, but frankly I tell my docs/nurses that once we decide to do tPA we've committed to at least 30 minutes of CPR to let it work (you want to see some stink eye from an ER tech? Say that out loud...), and if that doesn't get ROSC, why bother repeating.

 

[njac]

There was a recent study, I can't remember the name, that used lower doses of tPA in massive PE, pre-arrest. I have the info at work. I think their max dose was 50mg and their outcomes were similar to the studies that defined the 100mg over 2 hours.

I think weingart might have discussed it on EMCrit a few months ago.

 

[njac]

Also (sorry, this was the topic of my 1 hour CE presentation as a PGY2) there is TERRIBLE publication bias on this topic.

No one wants to publish when the patient doesn't get ROSC, or gets ROSC and subsequently bleeds out.

But if you read the literature (talking case reports, not the few and far between actual studies), you would be like "hot damn! Why don't we give tPA to every single arrest that has half a chance of being a massive PE? These people walk out of the hospital neurologically intact days later! It just be made with fairy farts and unicorn horns!"

I really only like to use it EARLY (like 2nd round of epi early) in a situation with a super compelling PE story. I want to see a big RV on u/s, recent long flight, recent(ish) surgery (not too recent), OCPs, etc. I'm not sure what our overall success rate has been.

I do know that they gave it one day to a young lady with active ca and mets who I would've been all "hell naw" about doing it on, and she walked out of the hospital. So sometimes our exclusion criteria sucks. She probably would've died if I had been at work that morning and tried to prevent them from using it.

 

[Dred Pirate]

I have seen it used in cardiac arrest probably 15 times - 2 survived to discharge - one with massive neurological damage, one recovered but was soon likely taken out by her liver mets - others, not so good. two that received ROSC bleed out and died -

as far as giving it after givng lovenox - can you give me some resources. If the lovenox was given less than an 1 hour previously we have (takes 2-3 hours to onset) after that aren't you risking masive bleeding?