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cardio.post-arrest.pulmonary-embolism-related.v1PRODUCTION
cardio.post-arrest.pulmonary-embolism-related.v1

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

cardiologyacuteadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

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

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PE-arrest mechanism framed + reperfusion question raised

Patient inputs (10)

Baseline coagulation/Hgb for bleeding-risk assessment before/after peri-arrest lysis and for ECPR anticoagulation

Bleeding risk of peri-arrest thrombolysis and ECPR candidacy are age-modified

PEA/non-shockable rhythm is typical of obstructive-shock PE arrest and shapes the ACLS pathway

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

Intra-arrest/post-ROSC RV assessment (dilated under-filled RV, septal flattening) supports the PE diagnosis when CTPA is not feasible

Recent intracranial haemorrhage/surgery/trauma, active bleeding — drives the thrombolysis-vs-embolectomy/ECPR decision

Total low-flow time + CPR quality inform prolonged-CPR duration after lysis and ECPR candidacy

Definitive confirmation of clot burden/location once ROSC achieved and patient stable enough for transport

Pregnancy/peripartum dramatically changes the PE-arrest reperfusion and embolectomy/ECPR calculus

Very low ETCO2 reflects near-absent pulmonary blood flow; a rise can mark ROSC or successful clot lysis during prolonged CPR

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalseverepresumed_pe_arrest_candidate_for_peri_arrest_thrombolysis
    PEA arrest with strong PE clues (VTE risk, pre-arrest dyspnoea/syncope, dilated under-filled RV on POCUS) and no absolute thrombolysis contraindication — give fibrinolytic and continue CPR ≥60-90 minutes
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethrombolysis_contraindicated_in_pe_arrest
    PE-mediated arrest with an absolute thrombolysis contraindication (recent ICH/CNS surgery/trauma, active major bleeding) — escalate to surgical embolectomy / catheter-directed therapy / ECPR
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_pe_arrest_ecpr_window
    Refractory PE arrest not responding to ACLS ± lysis in a potential ECPR candidate at an ECMO-capable centre — time-critical VA-ECMO decision
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_lysis_major_or_intracranial_haemorrhage
    Major bleeding (including intracranial) after peri-arrest fibrinolysis — the principal competing risk of the thrombolysis strategy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_post_rosc_rv_failure_obstructive_shock
    Post-ROSC persistent obstructive shock with echocardiographic RV failure despite initial reperfusion — residual clot burden requiring escalation and RV-protective management
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: pe_arrest_peri_arrest_thrombolysis_prolonged_cpr_then_embolectomy_or_ecpr
Selected axis "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)" by default fallback (first axis)
  • alteplase
    first line
    fibrinolytic
    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)
    triggers: presumed_or_confirmed_pe_arrest_no_absolute_contraindication
    2020 AHA ACLS / 2019 ESC PE — fibrinolysis for presumed PE arrest with prolonged CPR; late ROSC after clot lysis is well described
    rxcui 8410
  • tenecteplase
    second line
    fibrinolytic
    weight-based IV bolus per protocol (single-bolus convenience in arrest) • IV • one-time
    triggers: pe_arrest_bolus_fibrinolytic_preferred_alteplase_unavailable
    Single-bolus fibrinolytic alternative used in peri-arrest PE where rapid administration is advantageous (ESC PE high-risk pathway)
    rxcui 259280
  • heparin (unfractionated)
    first line
    unfractionated_heparin
    post-ROSC therapeutic IV infusion, weight-based, aPTT/anti-Xa titrated (start/resume after lysis per bleeding assessment) • IV • continuous
    triggers: post_rosc_pe_anticoagulation, thrombolysis_contraindicated_anticoagulate_and_pursue_embolectomy
    2019 ESC PE — UFH preferred post-arrest: titratable, reversible, supports embolectomy/ECPR transitions and bleeding control
    rxcui 235473
  • norepinephrine
    first line
    vasopressor
    IV infusion titrated to MAP ≥65 (post-arrest target individualised) • IV • continuous
    triggers: post_rosc_obstructive_shock_rv_failure
    First-line vasopressor for PE obstructive shock — maintains coronary/RV perfusion pressure; ESC PE high-risk haemodynamic support
    rxcui 7512
  • dobutamine
    add on
    inotrope
    IV infusion 2-10 mcg/kg/min for RV inotropic support (with a vasopressor to offset vasodilation) • IV • continuous
    triggers: post_rosc_low_output_rv_failure
    Augments RV contractility in PE-related RV failure; combine with norepinephrine to maintain systemic pressure (ESC PE)
    rxcui 3616
  • Inhaled pulmonary vasodilator (e.g., inhaled nitric oxide/epoprostenol)
    add on
    pulmonary_vasodilator
    inhaled, titrated for refractory RV failure / severe hypoxaemia post-ROSC • inhaled • continuous
    triggers: refractory_post_rosc_rv_failure_or_severe_hypoxaemia
    Selectively lowers RV afterload without systemic hypotension as a bridge while reperfusion takes effect
  • Surgical embolectomy / catheter-directed therapy
    rescue
    mechanical_reperfusion
    emergent if thrombolysis contraindicated or failed and expertise available • N/A • once
    triggers: thrombolysis_contraindicated, failed_thrombolysis_persistent_obstructive_shock
    2019 ESC PE — embolectomy/catheter-directed therapy for high-risk PE when lysis is contraindicated/fails at capable centres
  • ECPR (veno-arterial ECMO)
    rescue
    mechanical_circulatory_support
    VA-ECMO bridge in refractory PE arrest at ECMO-capable centres (bridge to embolectomy/lysis/recovery) • N/A • continuous bridge
    triggers: refractory_pe_arrest_ecpr_candidate_capable_centre
    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
    contraindication substitute
    decision_rule
    Do NOT terminate before ≥60-90 min of CPR once a fibrinolytic is given for presumed PE arrest • N/A • N/A
    triggers: fibrinolytic_administered_for_pe_arrest
    2020 AHA ACLS — lysis-mediated ROSC can be delayed; premature termination forfeits salvageable patients
  • AVOID aggressive volume loading + RV-collapsing ventilation
    contraindication substitute
    do_not_use
    Avoid large fluid boluses and high mean airway/intrathoracic pressures that worsen RV distension/collapse • N/A • N/A
    triggers: post_rosc_rv_failure
    Overfilling a pressure-overloaded RV and high intrathoracic pressure precipitate RV collapse and re-arrest; cautious volume + RV-protective ventilation (ESC PE)

outpatient playbook — drug actions (2)

  1. 1. long-term anticoagulation per recurrence risk
    rxcui 1364430
    apixaban 5 mg BID → 2.5 mg BID extended if indicated (or per agent / LMWH in cancer) • PO/SC • per agent
    trigger: Ongoing VTE-recurrence risk
    ESC PE — duration individualised to provocation/recurrence risk
  2. 2. no chronic cardiac antiarrhythmic solely for the PE arrest
    none — PE arrest alone is not an ICD/antiarrhythmic indication • N/A • N/A
    trigger: PE-mediated arrest without separate arrhythmic substrate
    Treat the clot + anticoagulate; arrhythmic prophylaxis only for an independent indication

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: PEA / non-shockable arrest in a patient with VTE risk factors (recent surgery, immobilisation, malignancy, known DVT) — presumed massive-PE arrest; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**PE-related cardiac arrest — peri-arrest thrombolysis + prolonged CPR; embolectomy/ECPR if lysis fails** (cardio.post-arrest.pulmonary-embolism-related.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)**.
1. 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) (fibrinolytic, first line) — 2020 AHA ACLS / 2019 ESC PE — fibrinolysis for presumed PE arrest with prolonged CPR; late ROSC after clot lysis is well described
2. tenecteplase weight-based IV bolus per protocol (single-bolus convenience in arrest) IV one-time (fibrinolytic, second line) — Single-bolus fibrinolytic alternative used in peri-arrest PE where rapid administration is advantageous (ESC PE high-risk pathway)
3. heparin (unfractionated) post-ROSC therapeutic IV infusion, weight-based, aPTT/anti-Xa titrated (start/resume after lysis per bleeding assessment) IV continuous (unfractionated_heparin, first line) — 2019 ESC PE — UFH preferred post-arrest: titratable, reversible, supports embolectomy/ECPR transitions and bleeding control
4. norepinephrine IV infusion titrated to MAP ≥65 (post-arrest target individualised) IV continuous (vasopressor, first line) — First-line vasopressor for PE obstructive shock — maintains coronary/RV perfusion pressure; ESC PE high-risk haemodynamic support
5. dobutamine IV infusion 2-10 mcg/kg/min for RV inotropic support (with a vasopressor to offset vasodilation) IV continuous (inotrope, add on) — Augments RV contractility in PE-related RV failure; combine with norepinephrine to maintain systemic pressure (ESC PE)
6. Inhaled pulmonary vasodilator (e.g., inhaled nitric oxide/epoprostenol) inhaled, titrated for refractory RV failure / severe hypoxaemia post-ROSC inhaled continuous (pulmonary_vasodilator, add on) — Selectively lowers RV afterload without systemic hypotension as a bridge while reperfusion takes effect
7. Surgical embolectomy / catheter-directed therapy emergent if thrombolysis contraindicated or failed and expertise available N/A once (mechanical_reperfusion, rescue) — 2019 ESC PE — embolectomy/catheter-directed therapy for high-risk PE when lysis is contraindicated/fails at capable centres
8. ECPR (veno-arterial ECMO) VA-ECMO bridge in refractory PE arrest at ECMO-capable centres (bridge to embolectomy/lysis/recovery) N/A continuous bridge (mechanical_circulatory_support, rescue) — ELSO/ESC — ECPR provides circulatory support during refractory PE arrest, buying time for clot resolution or definitive embolectomy
9. 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 (decision_rule, contraindication substitute) — 2020 AHA ACLS — lysis-mediated ROSC can be delayed; premature termination forfeits salvageable patients
10. 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 (do_not_use, contraindication substitute) — Overfilling a pressure-overloaded RV and high intrathoracic pressure precipitate RV collapse and re-arrest; cautious volume + RV-protective ventilation (ESC PE)

Setting playbook (outpatient) — Long-term VTE secondary prevention, CTEPH surveillance, neuro-functional follow-up, recurrence-risk-based anticoagulation duration
11. long-term anticoagulation per recurrence risk apixaban 5 mg BID → 2.5 mg BID extended if indicated (or per agent / LMWH in cancer) PO/SC per agent — Ongoing VTE-recurrence risk (ESC PE — duration individualised to provocation/recurrence risk)
12. no chronic cardiac antiarrhythmic solely for the PE arrest none — PE arrest alone is not an ICD/antiarrhythmic indication N/A N/A — PE-mediated arrest without separate arrhythmic substrate (Treat the clot + anticoagulate; arrhythmic prophylaxis only for an independent indication)

Non-pharmacologic actions:
- CTEPH surveillance
- Neuro-rehab continuation
- VTE-recurrence + lifestyle counselling
- Family education if heritable thrombophilia found

AVOID / contraindication checks:
- Absolute_thrombolysis_contraindication_recent_ich_cns_surgery_trauma_active_major_bleeding
- Pursue_embolectomy_or_ecpr_if_thrombolysis_contraindicated_or_failed
- Avoid_termination_before_60_to_90_min_cpr_after_peri_arrest_lysis
- Avoid_aggressive_volume_and_rv_collapsing_ventilation_in_rv_failure
- Post_rosc_ufh_preferred_titratable_reversible
- Decision:peri_arrest_fibrinolysis_if_pe_is_probable_arrest_cause_and_no_absolute_contraindication
- Decision:continue_cpr_at_least_60_to_90_min_after_lysis
- Decision:ecpr_bridge_for_refractory_arrest_at_capable_centres
- Decision:layer_standard_post_arrest_neuroprotective_bundle_ttm_map_oxygen_co2
- Decision:pe_arrest_alone_is_not_an_icd_indication_treat_the_clot_and_anticoagulate
- Decision:transition_fibrinolysis_to_therapeutic_anticoagulation_post_rosc_after_bleeding_assessment
- Decision:transfer_to_pe_response_team_or_ecmo_centre_if_beyond_local_capability

Monitoring

Regimen monitoring:
- haemodynamics and serial rv function echo post rosc
- bleeding surveillance post lysis including neuro for intracranial haemorrhage
- anticoagulation titration aptt or anti xa on ufh
- lactate clearance and oxygenation ventilation targets
- etco2 trend during prolonged cpr as rosc lysis marker
- post arrest neuroprognostication per standard bundle
- ecmo circuit and limb perfusion if on ecpr

Setting (outpatient) monitoring:
- Anticoagulation adherence/bleeding
- Annual CTEPH-symptom screen
- Neuro-functional follow-up

Follow-up plan: 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
- Close-out criterion: long-term anticoagulation + CTEPH surveillance + neuro-rehab + recurrence plan documented

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term VTE secondary prevention, CTEPH surveillance, neuro-functional follow-up, recurrence-risk-based anticoagulation duration

Disposition criteria:
- Indefinite thrombosis-clinic follow-up; duration tied to recurrence risk; CTEPH pathway if it develops

Escalation triggers (move to higher acuity):
- Recurrent VTE → extend/intensify anticoagulation
- Confirmed CTEPH → PEA-surgery/BPA referral
- Neuro-decline → re-evaluate

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] PEA arrest with strong PE clues (VTE risk, pre-arrest dyspnoea/syncope, dilated under-filled RV on POCUS) and no absolute thrombolysis contraindication — give fibrinolytic and continue CPR ≥60-90 minutes
- [SEVERE] PE-mediated arrest with an absolute thrombolysis contraindication (recent ICH/CNS surgery/trauma, active major bleeding) — escalate to surgical embolectomy / catheter-directed therapy / ECPR
- [SEVERE] Refractory PE arrest not responding to ACLS ± lysis in a potential ECPR candidate at an ECMO-capable centre — time-critical VA-ECMO decision

Citations

- 2020 AHA ACLS / ILCOR + 2019 ESC Acute PE Guideline + 2025 AHA post-cardiac-arrest care / ERC-ESICM 2021 + ELSO ECPR guidance [PMID:33081529](https://pubmed.ncbi.nlm.nih.gov/33081529/)
- Cited evidence (PMID 31504429) [PMID:31504429](https://pubmed.ncbi.nlm.nih.gov/31504429/)
- Cited evidence (PMID 33773825) [PMID:33773825](https://pubmed.ncbi.nlm.nih.gov/33773825/)
- Cited evidence (PMID 36325905) [PMID:36325905](https://pubmed.ncbi.nlm.nih.gov/36325905/)
- Cited evidence (PMID 19038880) [PMID:19038880](https://pubmed.ncbi.nlm.nih.gov/19038880/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2020 AHA ACLS / ILCOR + 2019 ESC Acute PE Guideline + 2025 AHA post-cardiac-arrest care / ERC-ESICM 2021 + ELSO ECPR guidance — PMID:33081529
  • Cited evidence (PMID 31504429) — PMID:31504429
  • Cited evidence (PMID 33773825) — PMID:33773825
  • Cited evidence (PMID 36325905) — PMID:36325905
  • Cited evidence (PMID 19038880) — PMID:19038880