Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest

Böttiger, Bernd W.; Arntz, Hans-Richard; Chamberlain, Douglas; Bluhmki, Erich; Belmans, Ann; Danays, Thierry; Carli, Pierre; Adgey, Jennifer; Bode, Christoph; Wenzel, Volker

doi:10.1056/nejmoa070570

Cited by 335 publications

(187 citation statements)

References 35 publications

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“…The results did not show an improvement in 30-day survival for all patients, but cases with pulmonary embolism did benefit from early thrombolysis. 8 In a smaller case series and retrospective analysis of patients with pulmonary embolism undergoing CPR, 9 the patient outcomes support thrombolytic therapy when pulmonary embolism is highly suspected. Our patient had known risk factors, including a history of knee surgery with immobilisation, as well as oral contraceptive use.…”

Section: Discussionmentioning

confidence: 99%

Use of computed tomography and mechanical CPR in cardiac arrest to confirm pulmonary embolism: a case study

Schubert¹,

Kanz

Linsenmaier

et al. 2015

CJEM

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Precise therapeutic decision-making is vital in managing out-of-hospital cardiac arrest. We present an interesting approach where suspected pulmonary embolism could be confirmed by early computed tomography in cardiac arrest. Chest compressions were performed automatically by mechanical devices also during the acquisition of computed tomography data and subsequent thrombolysis. RÉSUMÉLa précision des décisions relatives au traitement est d'importance « vitale » dans la prise en charge des arrêts cardiaques extrahospitaliers. Sera présentée ici une intervention intéressante, qui a permis de confirmer, par une tomodensitométrie (TDM) précoce, une embolie pulmonaire présumée chez une patiente en état d'arrêt cardiaque. Les compressions thoraciques, réalisées automatiquement par un appareil mécanique se sont poursuivies durant l'acquisition des données de la TDM et le traitement thrombolytique qui s'en est suivi.

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Section: Discussionmentioning

confidence: 99%

Use of computed tomography and mechanical CPR in cardiac arrest to confirm pulmonary embolism: a case study

Schubert¹,

Kanz

Linsenmaier

et al. 2015

CJEM

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“…For the majority of patients affected, fibrinolysis is therefore a pathophysiologically well-founded therapeutic option whose effectiveness has been shown in animal experiments (10,11). However, the positive results of several smaller prospective studies (12,13), case series studies (14,15) and one meta-analysis (16) on pre-hospital fibrinolysis in the case of OHCA could not be confirmed in a large randomised-controlled multicentre study (Thrombolysis in Cardiac Arrest, TROICA) where tenecteplase (TNK) was used (17). Possible reasons for this discrepancy between the TROICA and earlier studies include smaller effects of fibrinolysis if applied early during the course of resuscitation, differing proportions of patients with causal pulmonary embolism, lack of anti-coagulation and anti-aggregation co-medication and generally insufficient perfusion pressure during cardiopulmonary resuscitation (CPR) (17).…”

Section: Introductionmentioning

confidence: 94%

Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention

Luiz

Wilhelms

Madler

et al. 2017

Experimental and Therapeutic Medicine

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Abstract. Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.

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“…O estudo TROICA (Thrombolysis in Cardiac Arrest) 482 , interrompido por problemas de segurança, está contraindicando seu uso na ressuscitação cardiopulmonar. Porém, alguns relatos de administração de trombolíticos na parada cardiorrespiratória após infarto do miocárdio ou embolia pulmonar maciça têm evidenciado resultados animadores, mesmo quando esta terapêutica é utilizada como recurso extremo após falha nas medidas habituais e com ressuscitação prolongada 483,484 .…”

Section: -Terapia Trombolítica Na Parada Cardiorrespiratóriaunclassified

Diretrizes

2009

Arq. Bras. Cardiol.

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-Atendimento pré-hospitalarO interesse no atendimento pré-hospitalar do infarto agudo do miocárdio (IAM) teve início na década de 1960, devido ao grande número de óbitos que ocorriam antes que os paciente chegassem ao hospital.A maioria das mortes por IAM ocorre nas primeiras horas de manifestação da doença, sendo 40%-65% dos casos na primeira hora e, aproximadamente, 80% nas primeiras 24 horas [1][2][3] . Assim, a maior parte das mortes por IAM acontece fora do ambiente hospitalar, geralmente desassistidas pelos médicos 4 . A modalidade mais frequente de parada cardiorrespiratória nas primeiras horas do IAM é a fibrilação ventricular 3 . -Período pré-hospitalar.O período pré-hospitalar compreende dois momentos: a) do início dos sintomas (geralmente dor torácica aguda) até a decisão de procurar atendimento; b) da decisão de procurar atendimento até a chegada ao hospital.No infarto agudo do miocárdio com elevação do segmento ST (IAMCST), o tempo desde o início dos sintomas (oclusão da artéria coronária) até a instituição do tratamento (reperfusão química ou mecânica) é diretamente proporcional à ocorrência de eventos clinicamente relevantes. Esse tempo é fator fundamental para o benefício do tratamento, tanto imediato quanto tardio 5 .No entanto, sabe-se que a fase pré-hospitalar (em ambos os momentos descritos) é caracterizada por ser demorada, especialmente em pacientes idosos, do sexo feminino e com baixa condição socioeconômica 4 . Alguns fatores estão relacionados ao aumento desse tempo tão precioso (Quadro 1.1.1.1) 6 . O componente pré-hospitalar no atraso do atendimento ao paciente com dor torácica é de tal magnitude que, na prática clínica, apenas cerca de 20% destes pacientes chegam ao setor de emergência com até duas horas após o início dos sintomas 7 . -Medidas na fase pré-hospitalarApesar da significativa redução da mortalidade hospitalar do IAM nas últimas décadas 8,9 , houve pouco avanço no conhecimento sobre a epidemiologia e o tratamento na fase pré-hospitalar. É notória a necessidade de mudanças nesse cenário, embora poucas sejam as evidências geradas para este fim.A abordagem do paciente com suspeita de síndrome coronária aguda em ambiente extra-hospitalar deve, idealmente, ser feita por profissional de saúde, com realização de uma história clínica direcionada, investigando as características dos sintomas atuais (momento do início, tempo de duração, qualidade, intensidade, relação com o esforço e repouso) e a presença de doença coronária estabelecida (angina prévia). Algumas características são reconhecidamente determinantes para a manifestação atípica de um evento coronariano e devem ser lembradas quando um indivíduo for abordado na fase pré-hospitalar, por mascararem o quadro de IAM (Tabela 1.1.2.1) [10][11][12] .O eletrocardiograma executado no local de atendimento e interpretado por um médico habilitado (na ambulância ou em local remoto) mostrou ser um método que reduz em 34% o tempo porta-agulha e em 18% o tempo porta-balão, além de proporcionar maiores taxas de tempo porta-balão ideal (men...

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Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest

Abstract: When tenecteplase was used without adjunctive antithrombotic therapy during advanced life support for out-of-hospital cardiac arrest, we did not detect an improvement in outcome, in comparison with placebo. (ClinicalTrials.gov number, NCT00157261.)

Cited by 335 publications

References 35 publications

Use of computed tomography and mechanical CPR in cardiac arrest to confirm pulmonary embolism: a case study

Use of computed tomography and mechanical CPR in cardiac arrest to confirm pulmonary embolism: a case study

Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention

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