Intraosseous administration of thrombolysis in out-of-hospital massive pulmonary thromboembolism

Abstract

Pulmonary thromboembolism has an incidence of more than 69/100 000 population but may be underdiagnosed because of the non-specific character of its symptoms and difficult differential diagnosis. The prognosis is worse if the pulmonary thromboembolism is massive and associated with haemodynamic instability, whereupon mortality rises to over 50%. Cardiogenic shock supervenes and cardiopulmonary arrest is often inevitable. This emergency can only be prevented by aggressive therapy with thrombolytic agents. The case history is described of a 25-year-old woman in cardiogenic shock leading to prehospital cardiac arrest in which intravenous access was impossible. Resuscitation drugs were given by the intraosseous route and, with a suspected diagnosis of massive pulmonary thromboembolism, it was decided to start thrombolysis by the same route before transport to hospital. The treatment was a complete success, and the patient was discharged from hospital with no sequelae after 39 days.

Successful Alteplase Bolus Administration for a Presumed Massive Pulmonary Embolism During Cardiopulmonary Resuscitation

“…3 Published cases revealed good or intact neurological status for the majority of survivors, even in cases of prolonged CPR up to 90 minutes and delayed fibrinolytic administration up to 60 minutes. 4,14,15,[18][19][20][21][23][24][25][27][28][29]33,35,37 These findings are consistent with experimental studies that showed that fibrinolytics may reduce the cerebral no-reflow phenomenon and improve microcirculatory reperfusion. 40,41 The occurrence of major bleeding complications (total, intracranial, and fatal) is a serious concern of fibrinolysis during CPR.…”

“…Streptokinase, urokinase, tenecteplase, and reteplase have successfully resuscitated patients in such situations. [25][26][27][28][29]33,36 Streptokinase and urokinase, like alteplase, are both FDA approved for treating acute PE and are typically infused over 12 to 24 hours; however, bolus administration was used in the PE-associated cardiac arrest cases. 7,38 Tenecteplase and reteplase, in contrast, do not carry an FDA-indication for but have been investigated in acute PE.…”

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

“…Given the difficulty in securing access in this patient, the decision was made to thrombolyse via an intraosseous (IO) line inserted into the proximal left tibia, which was secured rapidly prior to cannulation of the external jugular vein. This case lends further weight to suggesting that the administration of thrombolysis during cardiac arrest via the IO route is safe where venous access is difficult [14,15]. Whilst there are potential risks of inducing hemorrhage, air emboli, fractures, and tissue necrosis [16], it was felt that the potential benefits outweighed the risks of administration in this critically unwell patient.…”

Salvage intraosseous thrombolysis and extracorporeal membrane oxygenation for massive pulmonary embolism

“…There are two descriptions of massive PE management with intraosseous thrombolysis. [ 3 5 ] In both cases, tissue plasminogen activator, administered as a weight-adjusted bolus, provided adequate thrombolytic therapy. Intraosseous thrombolysis has also been reported in the setting of acute ST-segment elevation myocardial infarction.…”

“…There are three previous reports of successful intraosseous thrombolysis, with two being in the setting of PE. [ 3 4 5 ] There have been no previous reports of intraosseous thrombolysis in combination with ECMO therapy for massive PE.…”