Case Report: tPA Bolus Treatment for a Peri-Arrest Patient with Massive Pulmonary Embolism

Background: Each year approximately 100,000 patients die of pulmonary emboli (PE). The most deadly types are massive PEs, which the American Heart Association (AHA) defines as emboli that cause hemodynamic instability. Although massive PEs only constitutes 4%-5% of patients with PEs, these emboli carry very high inhospital mortalities (58%) and require emergent treatment. Prior studies and meta-analysis has shown that thrombolysis is appropriate in massive PE and decreases mortality. Accordingly, the AHA, European Society of Cardiology and American College of Chest Physicians all consider thrombolysis as first-line treatment for massive PE. In spite of this, many hospitals in the US have policies stating thrombolytics cannot be given until the patient is in arrest. The case below highlights the importance of early intervention. Case: This is the case of a 56 year-old man who was three weeks post-op from a knee replacement surgery and presented to a Baltimore emergency department (ED) with a massive PE. The patient presented in a state of periarrest in which he was both hypotensive and hypoxic. After a bedside assessment, including ultrasound and an EKG, he was administered 100 mg of tissue Plasminogen Activator (tPA) in divided doses. He had a remarkable response and recovery and his course did not require intubation or vasopressors.