This handout is for pe-related cardiac arrest — peri-arrest thrombolysis + prolonged cpr; embolectomy/ecpr if lysis fails. Your care team identified this based on: pea / non-shockable arrest in a patient with vte risk factors (recent surgery, immobilisation, malignancy, known dvt) — presumed massive-pe arrest.
Other reasons your team may use this plan: sudden severe dyspnoea + syncope immediately preceding collapse — clinical signature of massive pe causing obstructive-shock arrest; intra-arrest pocus showing an acutely dilated, under-filled right ventricle ± mcconnell sign / septal flattening — supports pe as the arrest mechanism; known dvt / recently diagnosed high-risk pe who arrests — peri-arrest reperfusion pathway.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| alteplase | 50 mg IV bolus during arrest (alternatives: 100 mg per standard protocol, or 0.6 mg/kg over ~15 min), then CONTINUE CPR ≥60-90 min | IV | one-time (per protocol) | 2020 AHA ACLS / 2019 ESC PE — fibrinolysis for presumed PE arrest with prolonged CPR; late ROSC after clot lysis is well described |
| tenecteplase | weight-based IV bolus per protocol (single-bolus convenience in arrest) | IV | one-time | Single-bolus fibrinolytic alternative used in peri-arrest PE where rapid administration is advantageous (ESC PE high-risk pathway) |
| heparin (unfractionated) | post-ROSC therapeutic IV infusion, weight-based, aPTT/anti-Xa titrated (start/resume after lysis per bleeding assessment) | IV | continuous | 2019 ESC PE — UFH preferred post-arrest: titratable, reversible, supports embolectomy/ECPR transitions and bleeding control |
| norepinephrine | IV infusion titrated to MAP ≥65 (post-arrest target individualised) | IV | continuous | First-line vasopressor for PE obstructive shock — maintains coronary/RV perfusion pressure; ESC PE high-risk haemodynamic support |
| dobutamine | IV infusion 2-10 mcg/kg/min for RV inotropic support (with a vasopressor to offset vasodilation) | IV | continuous | Augments RV contractility in PE-related RV failure; combine with norepinephrine to maintain systemic pressure (ESC PE) |
| Inhaled pulmonary vasodilator (e.g., inhaled nitric oxide/epoprostenol) | inhaled, titrated for refractory RV failure / severe hypoxaemia post-ROSC | inhaled | continuous | Selectively lowers RV afterload without systemic hypotension as a bridge while reperfusion takes effect |
| Surgical embolectomy / catheter-directed therapy | emergent if thrombolysis contraindicated or failed and expertise available | N/A | once | 2019 ESC PE — embolectomy/catheter-directed therapy for high-risk PE when lysis is contraindicated/fails at capable centres |
| ECPR (veno-arterial ECMO) | VA-ECMO bridge in refractory PE arrest at ECMO-capable centres (bridge to embolectomy/lysis/recovery) | N/A | continuous bridge | ELSO/ESC — ECPR provides circulatory support during refractory PE arrest, buying time for clot resolution or definitive embolectomy |
| AVOID early termination of resuscitation after peri-arrest lysis | Do NOT terminate before ≥60-90 min of CPR once a fibrinolytic is given for presumed PE arrest | N/A | N/A | 2020 AHA ACLS — lysis-mediated ROSC can be delayed; premature termination forfeits salvageable patients |
| AVOID aggressive volume loading + RV-collapsing ventilation | Avoid large fluid boluses and high mean airway/intrathoracic pressures that worsen RV distension/collapse | N/A | N/A | Overfilling a pressure-overloaded RV and high intrathoracic pressure precipitate RV collapse and re-arrest; cautious volume + RV-protective ventilation (ESC PE) |
Plan: PE-related arrest — peri-arrest fibrinolysis + prolonged CPR ≥60-90 min; surgical embolectomy / catheter-directed therapy / ECPR if lysis contraindicated or failed; post-ROSC therapeutic UFH + RV support (2020 AHA ACLS; 2019 ESC PE)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: 2020 AHA ACLS / ILCOR + 2019 ESC Acute PE Guideline + 2025 AHA post-cardiac-arrest care / ERC-ESICM 2021 + ELSO ECPR guidance