Thrombolytics for pulmonary embolism - Revision history

Rossdonaldson1: /* Administration */

2026-04-08T20:10:18Z

Administration

← Older revision		Revision as of 20:10, 8 April 2026
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	**''Continue CPR for at least 15 minutes after lytic administration''		**''Continue CPR for at least 15 minutes after lytic administration''
	**[[Alteplase]] (tPA): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg) ('''first line''')		**[[Alteplase]] (tPA): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg) ('''first line''')
	**[[Tenecteplase]] (TNK): 50 mg bolus (or 0.5 mg/kg bolus) (~~'''~~second line; not FDA approved for PE)<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>		**[[Tenecteplase]] (TNK): 50 mg bolus (or 0.5 mg/kg bolus) (second line; not FDA approved for PE)<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>

	===Related Instructions===		===Related Instructions===

Rossdonaldson1: /* Administration */

2026-04-08T20:09:54Z

Administration

← Older revision		Revision as of 20:09, 8 April 2026
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	*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>		*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>
	**''Continue CPR for at least 15 minutes after lytic administration''		**''Continue CPR for at least 15 minutes after lytic administration''
	**[[Alteplase]]: 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg) ('''first line''')		**[[Alteplase]] (tPA): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg) ('''first line''')
	**[[Tenecteplase]] (TNK): 50 mg ~~IV/IO over 2 min~~ (0.6 mg/kg ~~if <70 kg~~),<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>		**[[Tenecteplase]] (TNK): 50 mg bolus (or 0.5 mg/kg bolus) ('''second line; not FDA approved for PE)<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>

	===Related Instructions===		===Related Instructions===

Rossdonaldson1: /* Administration */

2026-04-08T19:54:18Z

Administration

← Older revision		Revision as of 19:54, 8 April 2026
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	*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>		*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>
	**''Continue CPR for at least 15 minutes after lytic administration''		**''Continue CPR for at least 15 minutes after lytic administration''
	**[[Tenecteplase]] (TNK~~-tPA~~): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg),<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref> ~~'''OR'''~~		**[[Alteplase]]: 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg) ('''first line''')
	**[[Alteplase]]: 50 mg IV Push over ~60 seconds		**[[Tenecteplase]] (TNK): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg),<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>

	===Related Instructions===		===Related Instructions===

Rossdonaldson1: /* Administration */

2026-04-08T19:46:13Z

Administration

← Older revision		Revision as of 19:46, 8 April 2026
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	*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>		*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>
	**''Continue CPR for at least 15 minutes after lytic administration''		**''Continue CPR for at least 15 minutes after lytic administration''
	**[[Tenecteplase]] (TNK-tPA): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg)<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref> '''OR'''		**[[Tenecteplase]] (TNK-tPA): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg),<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref> '''OR'''
	**[[Alteplase]]: 50 mg IV Push over ~60 seconds		**[[Alteplase]]: 50 mg IV Push over ~60 seconds

Rossdonaldson1: /* Administration */

2026-04-08T19:44:33Z

Administration

← Older revision		Revision as of 19:44, 8 April 2026
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	*Systemic therapy is recommended over catheter-directed therapy		*Systemic therapy is recommended over catheter-directed therapy
	*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>		*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>
	**[[Tenecteplase]] (~~not FDA approved for PE~~) - 50 mg ~~bolus or~~ 0.5 mg/kg ~~bolus has been used for PEA arrest~~		**''Continue CPR for at least 15 minutes after lytic administration''
	<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>'''OR'''		**[[Tenecteplase]] (TNK-tPA): 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg)<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref> '''OR'''
	**[[Alteplase]] - 50 mg ~~of by~~ IV Push over ~60 seconds		**[[Alteplase]]: 50 mg IV Push over ~60 seconds
	**Continue CPR for 30-60 minutes after lytic administration.

	===Related Instructions===		===Related Instructions===

Rossdonaldson1: Reverted edits by Danbot (talk) to last revision by Rossdonaldson1

2026-04-08T19:37:33Z

Reverted edits by Danbot (talk) to last revision by Rossdonaldson1

Danbot: Strip excess bold

2026-03-22T09:15:31Z

Strip excess bold

Rossdonaldson1: /* See Also */

2023-10-18T22:00:53Z

Cmb23: /* Administration */

2023-10-16T01:27:31Z

Administration

← Older revision		Revision as of 01:27, 16 October 2023
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	==Administration==		==Administration==
	*Standard dose: [[Alteplase]] 100mg over 2 hours <ref>Martin C et al. Systemic thrombolysis for pulmonary embolism: a review. P T. 2016 Dec; 41(12):770-775.</ref><ref>Kearon C et al. Antithrombotic therapy for VTE disease. Chest. 2016;149(2):315-352. doi: 10.1016/j.chest.2015.11026</ref>		*Standard dose: [[Alteplase]] 100mg over 2 hours <ref>Martin C et al. Systemic thrombolysis for pulmonary embolism: a review. P T. 2016 Dec; 41(12):770-775.</ref><ref>Kearon C et al. Antithrombotic therapy for VTE disease. Chest. 2016;149(2):315-352. doi: 10.1016/j.chest.2015.11026</ref>
	*Alternative dose: [[Alteplase]] 50mg over 2 hours		*Alternative dose (preferred): [[Alteplase]] 50mg over 2 hours (efficacy equal with fewer complications than 100mg) <ref> Wang C, Zhai Z, Yang Y, Wu Q, Cheng Z, Liang L, Dai H, Huang K, Lu W, Zhang Z, Cheng X, Shen YH; China Venous Thromboembolism (VTE) Study Group. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010 Feb;137(2):254-62. doi: 10.1378/chest.09-0765. Epub 2009 Sep 9. PMID: 19741062; PMCID: PMC7126994. </ref> or alternatively for crashing patients, 20mg IV bolus followed by infusion over two hours for the remaining medication <ref> https://emcrit.org/ibcc/pe/ </ref>
	**Half-dose regimen can be considered in patients >65yo, higher bleeding risk, or submassive PE (see [[EBQ:MOPETT_Trial\| MOPETT trial]])		**Half-dose regimen can be considered in patients >65yo, higher bleeding risk, or submassive PE (see [[EBQ:MOPETT_Trial\| MOPETT trial]])
	*Systemic therapy is recommended over catheter-directed therapy		*Systemic therapy is recommended over catheter-directed therapy

Hoxbox: /* External Links */

2020-11-03T22:41:59Z

External Links

← Older revision		Revision as of 22:41, 3 November 2020
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	==External Links==		==External Links==
			*Example of decision making guide factoring in size of PE and lytics contraindications: https://emcrit.org/ibcc/pe/#algorithm
	*http://emcrit.org/emcrit/aha-pulmonary-embolism-guidelines-2011/		*http://emcrit.org/emcrit/aha-pulmonary-embolism-guidelines-2011/

← Older revision		Revision as of 22:00, 18 October 2023
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	==See Also==		==See Also==
	*[[Thrombolytics]]
	*[[Pulmonary embolism]] (main)		*[[Pulmonary embolism]] (main)
	{{Thrombolysis Submassive PE Trials}}		{{Thrombolysis Submassive PE Trials}}

← Older revision		Revision as of 19:37, 8 April 2026
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	==Overview==		==Overview==
	*For most hemodynamically stable patients, thrombolytic therapy is NOT indicated		*'''For most hemodynamically stable patients, thrombolytic therapy is NOT indicated'''
	*Major controversy exists regarding thrombolytic therapy in submassive PE. <ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> The mortality benefit may be greatest in patients with right ventricular dysfunction. <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref>		*Major controversy exists regarding thrombolytic therapy in submassive PE. <ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> The mortality benefit may be greatest in patients with right ventricular dysfunction. <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref>

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	*There is no evidence suggesting administering thrombolytics within a certain window of time improves outcomes <ref>Daniels L et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol. 1997 Jul 15;80(2):184-8</ref>		*There is no evidence suggesting administering thrombolytics within a certain window of time improves outcomes <ref>Daniels L et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol. 1997 Jul 15;80(2):184-8</ref>

	*There is no evidence suggesting administering thrombolytics empirically during cardiac arrest improves outcomes		*There is no evidence suggesting administering thrombolytics '''empirically''' during cardiac arrest improves outcomes
	**In patients with PEA secondary to confirmed PE, administration of thrombolytics may be indicated<ref>15. Sharifi M et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016 Oct;34(10):1963-1967. doi: 10.1016/j.ajem.2016.06.094</ref>		**In patients with PEA secondary to '''confirmed''' PE, administration of thrombolytics may be indicated<ref>15. Sharifi M et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016 Oct;34(10):1963-1967. doi: 10.1016/j.ajem.2016.06.094</ref>

	==Indications==		==Indications==
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	===Evaluation===		===Evaluation===
	*See [[Pulmonary Embolism (PE)]]		*See [[Pulmonary Embolism (PE)]]
	*Massive PE<ref>Circulation 2011;123:1788</ref>		*'''Massive PE'''<ref>Circulation 2011;123:1788</ref>
	**Acute with		**Acute with
	***Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016		***Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016
	***Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)		***Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)
	*Submassive PE<ref>Circulation 2011;123:1788</ref>		*'''Submassive PE'''<ref>Circulation 2011;123:1788</ref>
	**Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis		**Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis
	***RV dysfunction means the presence of at least 1 of the following:		***RV dysfunction means the presence of at least 1 of the following:
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	*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>		*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>
	**[[Tenecteplase]] (not FDA approved for PE) - 50 mg bolus or 0.5 mg/kg bolus has been used for PEA arrest		**[[Tenecteplase]] (not FDA approved for PE) - 50 mg bolus or 0.5 mg/kg bolus has been used for PEA arrest
	<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>OR		<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>'''OR'''
	**[[Alteplase]] - 50 mg of by IV Push over ~60 seconds		**[[Alteplase]] - 50 mg of by IV Push over ~60 seconds
	**Continue CPR for 30-60 minutes after lytic administration.		**Continue CPR for 30-60 minutes after lytic administration.
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	**Major bleeding OR 2.73 (9.24% vs 3.42%) compared to anticoagulant alone		**Major bleeding OR 2.73 (9.24% vs 3.42%) compared to anticoagulant alone
	**[[Intracranial hemorrhage]] OR 4.63 (1.46% vs 0.19%)		**[[Intracranial hemorrhage]] OR 4.63 (1.46% vs 0.19%)
	**There was no statistically significant increase in major bleeding risk in patients 65yo or younger		**'''There was no statistically significant increase in major bleeding risk in patients 65yo or younger'''
	*No standard or evidence-based reversal regimen exists but general guidelines include: <ref> Yaghi S, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplace in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the AHA/ASA. Stroke. 2017;48:e343–e361</ref>		*No standard or evidence-based reversal regimen exists but general guidelines include: <ref> Yaghi S, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplace in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the AHA/ASA. Stroke. 2017;48:e343–e361</ref>
	**Supportive care (e.g. [[transfusion]])		**Supportive care (e.g. [[transfusion]])

← Older revision		Revision as of 09:15, 22 March 2026
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	==Overview==		==Overview==
	*~~'''~~For most hemodynamically stable patients, thrombolytic therapy is NOT indicated~~'''~~		*For most hemodynamically stable patients, thrombolytic therapy is NOT indicated
	*Major controversy exists regarding thrombolytic therapy in submassive PE. <ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> The mortality benefit may be greatest in patients with right ventricular dysfunction. <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref>		*Major controversy exists regarding thrombolytic therapy in submassive PE. <ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> The mortality benefit may be greatest in patients with right ventricular dysfunction. <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref>

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	*There is no evidence suggesting administering thrombolytics within a certain window of time improves outcomes <ref>Daniels L et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol. 1997 Jul 15;80(2):184-8</ref>		*There is no evidence suggesting administering thrombolytics within a certain window of time improves outcomes <ref>Daniels L et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol. 1997 Jul 15;80(2):184-8</ref>

	*There is no evidence suggesting administering thrombolytics ~~'''~~empirically~~'''~~ during cardiac arrest improves outcomes		*There is no evidence suggesting administering thrombolytics empirically during cardiac arrest improves outcomes
	**In patients with PEA secondary to ~~'''~~confirmed~~'''~~ PE, administration of thrombolytics may be indicated<ref>15. Sharifi M et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016 Oct;34(10):1963-1967. doi: 10.1016/j.ajem.2016.06.094</ref>		**In patients with PEA secondary to confirmed PE, administration of thrombolytics may be indicated<ref>15. Sharifi M et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016 Oct;34(10):1963-1967. doi: 10.1016/j.ajem.2016.06.094</ref>

	==Indications==		==Indications==
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	===Evaluation===		===Evaluation===
	*See [[Pulmonary Embolism (PE)]]		*See [[Pulmonary Embolism (PE)]]
	*~~'''~~Massive PE~~'''~~<ref>Circulation 2011;123:1788</ref>		*Massive PE<ref>Circulation 2011;123:1788</ref>
	**Acute with		**Acute with
	***Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016		***Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction) - ACCP 2016
	***Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)		***Other definitions include pulselessness or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock)
	*~~'''~~Submassive PE~~'''~~<ref>Circulation 2011;123:1788</ref>		*Submassive PE<ref>Circulation 2011;123:1788</ref>
	**Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis		**Acute without systemic hypotension (see above) but with either RV dysfunction or myocardial necrosis
	***RV dysfunction means the presence of at least 1 of the following:		***RV dysfunction means the presence of at least 1 of the following:
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	*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>		*Cardiac arrest dose:<ref>Scott Weingart. EMCrit 261 – Thrombolysis during Cardiac Arrest. EMCrit Blog. Published on December 12, 2019. Accessed on December 13th 2019. Available at https://emcrit.org/emcrit/thrombolysis-cardiac-arrest/ </ref>
	**[[Tenecteplase]] (not FDA approved for PE) - 50 mg bolus or 0.5 mg/kg bolus has been used for PEA arrest		**[[Tenecteplase]] (not FDA approved for PE) - 50 mg bolus or 0.5 mg/kg bolus has been used for PEA arrest
	<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>~~'''~~OR~~'''~~		<ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>OR
	**[[Alteplase]] - 50 mg of by IV Push over ~60 seconds		**[[Alteplase]] - 50 mg of by IV Push over ~60 seconds
	**Continue CPR for 30-60 minutes after lytic administration.		**Continue CPR for 30-60 minutes after lytic administration.
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	**Major bleeding OR 2.73 (9.24% vs 3.42%) compared to anticoagulant alone		**Major bleeding OR 2.73 (9.24% vs 3.42%) compared to anticoagulant alone
	**[[Intracranial hemorrhage]] OR 4.63 (1.46% vs 0.19%)		**[[Intracranial hemorrhage]] OR 4.63 (1.46% vs 0.19%)
	**~~'''~~There was no statistically significant increase in major bleeding risk in patients 65yo or younger~~'''~~		**There was no statistically significant increase in major bleeding risk in patients 65yo or younger
	*No standard or evidence-based reversal regimen exists but general guidelines include: <ref> Yaghi S, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplace in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the AHA/ASA. Stroke. 2017;48:e343–e361</ref>		*No standard or evidence-based reversal regimen exists but general guidelines include: <ref> Yaghi S, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplace in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the AHA/ASA. Stroke. 2017;48:e343–e361</ref>
	**Supportive care (e.g. [[transfusion]])		**Supportive care (e.g. [[transfusion]])