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cardio.post-arrest.pulmonary-embolism-related.v1

PE-related cardiac arrest — peri-arrest thrombolysis + prolonged CPR; embolectomy/ECPR if lysis fails

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Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to cardiac arrest caused by (suspected/confirmed) massive PE producing obstructive-shock PEA arrest, a meaningful minority of non-shockable arrests. KEY DIFFERENCES FROM PARENT: the defining decision is PERI-ARREST THROMBOLYSIS — give a fibrinolytic (alteplase 50 mg IV bolus, or 100 mg/0.6 mg/kg per protocol) when PE is the probable arrest cause and CONTINUE CPR ≥60-90 minutes before considering termination (inverts early-termination calculus; late lysis-mediated ROSC is well described). Alternatives when lysis is contraindicated/failed: surgical embolectomy, catheter-directed therapy, or ECPR (VA-ECMO) at capable centres. Diagnosis is clue-driven during arrest (VTE risk, pre-arrest dyspnoea/syncope, PEA rhythm, dilated under-filled RV on intra-arrest POCUS, ETCO2) — confirmatory CTPA usually only after ROSC. Post-ROSC: transition fibrinolysis → therapeutic UFH, RV-protective haemodynamics (cautious volume, norepinephrine ± dobutamine ± inhaled pulmonary vasodilator, avoid RV-collapsing ventilation), plus the standard post-arrest neuroprotective bundle (TTM, MAP/oxygenation/CO2 targets). Post-lysis bleeding (incl. intracranial/CPR-related) is the major competing risk. PE arrest alone is NOT an ICD indication — treat the clot and anticoagulate. Manifest pointer reuses cardio.post-arrest.core.v1 manifest. Design-brief pointer reuses parent (PE-arrest-specific differences documented inline). PMID list curated to current high-risk-PE / ACLS / post-arrest evidence. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as PE-related cardiac-arrest variant. Sister-differentiated from post-arrest core, non-shockable, and cardiogenic-shock.pe-related.

Entry points (6)

  • vital_abnormality
    PEA / non-shockable arrest in a patient with VTE risk factors (recent surgery, immobilisation, malignancy, known DVT) — presumed massive-PE arrest
    pea_arrest_with_pe_risk_factors
  • symptom
    Sudden severe dyspnoea + syncope immediately preceding collapse — clinical signature of massive PE causing obstructive-shock arrest
    sudden_dyspnoea_syncope_then_collapse
  • imaging
    Intra-arrest POCUS showing an acutely dilated, under-filled right ventricle ± McConnell sign / septal flattening — supports PE as the arrest mechanism
    intra_arrest_pocus_dilated_underfilled_rv
  • history
    Known DVT / recently diagnosed high-risk PE who arrests — peri-arrest reperfusion pathway
    known_dvt_or_high_risk_pe_now_arrested
  • vital_abnormality
    Post-ROSC persistent obstructive shock with echocardiographic RV failure — confirmed/presumed PE-mediated arrest needing reperfusion + RV support
    post_rosc_obstructive_shock_with_rv_failure
  • imaging
    Post-ROSC CTPA confirming central/massive PE as the arrest cause — anchor diagnosis for the PE-arrest pathway
    post_rosc_ctpa_confirmed_massive_pe

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Bleeding risk of peri-arrest thrombolysis and ECPR candidacy are age-modified
  • sex
    demographic • used at CONTEXT
    Pregnancy/peripartum dramatically changes the PE-arrest reperfusion and embolectomy/ECPR calculus
  • vte_risk_factors_and_known_dvt_or_perequired
    history • used at FRAME
    Recent surgery/immobilisation/malignancy/known DVT or diagnosed high-risk PE raise the pretest probability that the arrest is PE-mediated and justify empiric peri-arrest lysis
  • absolute_and_relative_thrombolysis_contraindicationsrequired
    history • used at RED_FLAGS
    Recent intracranial haemorrhage/surgery/trauma, active bleeding — drives the thrombolysis-vs-embolectomy/ECPR decision
  • cardiac_rhythm_during_arrestrequired
    vital • used at ENTRY
    PEA/non-shockable rhythm is typical of obstructive-shock PE arrest and shapes the ACLS pathway
  • end_tidal_co2
    vital • used at INITIAL_WORKUP
    Very low ETCO2 reflects near-absent pulmonary blood flow; a rise can mark ROSC or successful clot lysis during prolonged CPR
  • point_of_care_echocardiographyrequired
    imaging • used at INITIAL_WORKUP
    Intra-arrest/post-ROSC RV assessment (dilated under-filled RV, septal flattening) supports the PE diagnosis when CTPA is not feasible
  • arrest_downtime_and_cpr_qualityrequired
    history • used at RISK_STRATIFICATION
    Total low-flow time + CPR quality inform prolonged-CPR duration after lysis and ECPR candidacy
  • coagulation_and_hemoglobinrequired
    lab • used at BRANCHING_WORKUP
    Baseline coagulation/Hgb for bleeding-risk assessment before/after peri-arrest lysis and for ECPR anticoagulation
  • ctpa_after_rosc
    imaging • used at BRANCHING_WORKUP
    Definitive confirmation of clot burden/location once ROSC achieved and patient stable enough for transport

12-phase flow (11)

  1. 1FRAME
    Arrest mechanism is (suspected/confirmed) massive PE → obstructive shock → PEA arrest. The decisive intervention is peri-arrest reperfusion (thrombolysis ± prolonged CPR, or embolectomy/ECPR), layered onto the standard post-arrest bundle. Generic post-arrest care alone does not relieve the obstructing clot
    inputs: vte_risk_factors_and_known_dvt_or_pe
    advance: PE-arrest mechanism framed + reperfusion question raised
  2. 2ENTRY
    During resuscitation: high-quality CPR, identify non-shockable (PEA) rhythm, run the H&T reversible-cause search with PE high on the list; rapid clue synthesis (pre-arrest dyspnoea/syncope, VTE risk, intra-arrest POCUS)
    inputs: cardiac_rhythm_during_arrest
    actions: post_arrest_care
    advance: PE prioritised among reversible causes during ongoing CPR
  3. 3CONTEXT
    VTE risk factors, known DVT/PE, recent surgery/trauma/bleeding, pregnancy, anticoagulant status, comorbidity + functional baseline (ECPR candidacy), arrest setting and witnessed status
    inputs: age
    advance: context for reperfusion decision complete
  4. 4RED_FLAGS
    Absolute thrombolysis contraindications (recent ICH, intracranial neoplasm, recent CNS surgery/trauma, active major bleeding); refractory arrest; candidacy windows for ECPR/surgical embolectomy; pregnancy
    inputs: absolute_and_relative_thrombolysis_contraindications
    advance: reperfusion-modality contraindications + windows adjudicated
  5. 5INITIAL_WORKUP
    Intra-arrest POCUS (RV dilation/under-filling, septal flattening, IVC), ETCO2 trend, ABG/lactate, point-of-care labs; do NOT delay reperfusion for confirmatory imaging when PE is the probable cause and the patient is arrested
    inputs: point_of_care_echocardiography
    actions: panel.cardiac, panel.abg
    advance: bedside evidence synthesised without delaying reperfusion
  6. 6BRANCHING_WORKUP
    After ROSC (or on ECMO): CTPA to confirm clot burden/location, formal echo for RV function, bilateral leg Doppler, coagulation/Hgb trend, malignancy/provocation review; if still arrested, this branch is deferred until ROSC/ECPR
    inputs: coagulation_and_hemoglobin
    actions: panel.coag, panel.renal
    advance: clot burden + RV status + bleeding status characterised post-ROSC
  7. 7RISK_STRATIFICATION
    Reperfusion modality decision: (1) thrombolysis + prolonged CPR ≥60-90 min if no absolute contraindication; (2) surgical embolectomy or catheter-directed therapy if lysis contraindicated/failed and available; (3) ECPR (VA-ECMO) as a bridge in refractory arrest at capable centres. Weigh downtime, CPR quality, bleeding risk, ECPR candidacy
    inputs: arrest_downtime_and_cpr_quality
    actions: calc.map
    advance: reperfusion modality selected
  8. 8TREATMENT
    If PE is the probable arrest cause and no absolute contraindication: give fibrinolytic during arrest (alteplase 50 mg IV bolus, or 100 mg per protocol, or 0.6 mg/kg) and CONTINUE CPR ≥60-90 min before considering termination. If thrombolysis contraindicated/failed: emergent surgical embolectomy or catheter-directed therapy, or ECPR bridge at capable centres. Post-ROSC: transition to therapeutic UFH (titratable, reversible), RV-protective haemodynamics (cautious volume, norepinephrine ± inotrope/pulmonary vasodilator, lung-protective ventilation avoiding RV-collapsing high intrathoracic pressure), plus the standard post-arrest neuroprotective bundle (TTM, MAP/oxygenation/CO2 targets)
    inputs: absolute_and_relative_thrombolysis_contraindications, arrest_downtime_and_cpr_quality
    advance: reperfusion delivered + post-ROSC anticoagulation/RV support/neuroprotection initiated
  9. 9DISPOSITION
    ICU/CCU (or ECMO unit) with post-arrest + PE expertise; transfer to a PE-response-team / ECMO-capable centre if reperfusion options exceed local capability
    advance: critical-care disposition + escalation pathway documented
  10. 10MONITORING
    Haemodynamics + RV function (serial echo), bleeding surveillance post-lysis (including neuro for ICH), anticoagulation titration, lactate clearance, oxygenation/ventilation targets, neuroprognostication per post-arrest standards, ECMO circuit/limb if on ECPR
    actions: panel.cardiac, panel.coag
    advance: stable on therapeutic anticoagulation with RV recovering, no major bleeding
  11. 11FOLLOWUP
    Continue/transition long-term anticoagulation for the index PE, evaluate provoked-vs-unprovoked and malignancy/thrombophilia, assess for CTEPH risk at follow-up, neurorehabilitation per post-arrest outcome, ICD only if a separate primary-arrhythmic indication (PE arrest itself is not an ICD indication), secondary-prevention + VTE-recurrence plan, family/PE-education
    advance: long-term anticoagulation + CTEPH surveillance + neuro-rehab + recurrence plan documented