Elsevier

Resuscitation

Volume 50, Issue 1, July 2001, Pages 71-76
Resuscitation

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest

https://doi.org/10.1016/S0300-9572(01)00317-3Get rights and content

Abstract

Background: Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. Methods and Results: A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. Conclusions: Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.

Sumàrio

Contexto: A utilização de terapêutica trombolı́tica durante a Reanimação cardiorespiratória (RCR) é controversa. O objectivo deste estudo foi determinar se a administração de activador tecidular do plasminogeneo recombinante (rt-PA) em vı́timas de paragem cardiorespiratória (PCR) extra-hospitalar de etiologia não traumática, melhora a evolução. Métodos e resultados: Foi efectuada uma avaliação retrospectiva a partir da revisão dos registos de 401 doentes vı́timas de PCR extra-hospitalar reanimados pelos serviços médicos de emergência (SEM) no decorrer de 6 anos de actividade. A rt-PA foi usada num total de 108 doentes durante a RCR, sendo comparada com um grupo controlo de 216 doentes, com situações genericamente comparáveis em termos situação á entrada e achados no ECG. A utilização de rt-PA foi opcional. A recuperação da circulação espontânea (ROSC) ocorreu em 76 doentes submetidos a rt-PA (70.4 vs. 51% no grupo controlo; P=0.001). Cinqüenta e dois doentes do grupo submetido a tombolı́ticos sobreviveram nas 24 horas iniciais (48.1 vs. 32.9% no grupo controlo; P=0.003) enquanto 27 (25.9%) tiveram alta hospitalar. Os estudos necrópsicos revelaram complicações hemorrágicas significativas em 6 doentes do grupo submetido a rt-PA. Hemorragia intracerebral fulminante foi documentada num doente do grupo submetido a rt-PA e em 2 casos do grupo controlo. Conclusões: A terapêutica trombolı́tica pode aumentar significativamente a percentagem de recuperações de circulação espontânea e de sobrevivência primária em vı́timas de PCR não traumática. Complicações hemorrágicas graves não são freqüentes em doentes submetidos a rt-PA

Introduction

In Western countries, cardiac arrest due to cardiovascular disease is the leading cause of death in adults with an incidence of up to 128 per 100 000 people [1], [2]. Thrombolytic therapy was reported to improve survival in patients with acute myocardial infarction (MI) and massive pulmonary embolism (PE) [3], [4]. In MI, in particular, early administration of thrombolytic agents may diminish the extent of damage to the heart muscle by reducing the duration of ischaemia and consequently improve the quality of outcome. The question arises why thrombolytic therapy is rarely considered in patients with cardiac arrest of cardiovascular aetiology [5]. Anticipated profound haemorrhage is a prime reason why little is reported about the efficacy of thrombolytic therapy during cardiopulmonary resuscitation in out-of-hospital cardiac arrest [5], [6], [7].

There is evidence that ischaemia/hypoxia triggers marked activation of blood coagulation and massive fibrin generation [8]. Endogenous thrombolysis may not be sufficient to counteract blood coagulation [9]. Formation of microthrombi impairs microcirculation and contributes to reperfusion disorders. Consequently, it determines the degree of derangement of vital organ function and outcome [10], [11], [12].

Our hypothesis was that successful recanalization of obstructed vessels following thrombolysis produces better results in patients resuscitated with cardiac arrest of non-traumatic aetiology. Irrespective of the benefit for patients with MI or PE, thrombolysis may improve the overall circulatory function in CPR. This study was designed to evaluate the impact of thrombolytic therapy on ROSC, hospitalization and outcome in patients with out-of-hospital resuscitation.

Section snippets

Study background

Innsbruck, a city in the alpine part of Austria, has a population of 129 800 (1998 census), 16.8% of whom are more than 65 years old. Another 20 000 people live in semi-rural areas in the close vicinity. During the entire period of data collection, the EMS was two-tiered. In emergency cases, the dispatcher immediately sent an ambulance with rescue personnel able to provide basic life support including chest compression and bag mask ventilation with 100% oxygen. Simultaneously, the advanced

Baseline data

From 1 January 1993 to 31 December 1998, a total of 712 out-of-hospital cardiac arrests received an attempt of resuscitation by the EMS in Innsbruck. There were 401 patients (56.6% of all cases), whose primary cardiac arrest was attributed to non-traumatic aetiology according to our inclusion criteria; of these, 108 received rt-PA. In 25.9% of them, 500 mg of acetyl salicylic acid, and in 18.5% heparin, was given in addition to rt-PA. Of the 293 controls, 216 were closely matched at a 1:2

Discussion

The results of a single city 6 year observational experience attempting to assess whether or not thrombolytic therapy may be beneficial in patients suspected of acute myocardial infarction or pulmonary embolus with out-of-hospital cardiac arrest embolism are presented. In this study, ROSC and primary survival were observed more commonly with rt-PA treatment. We are aware that survival rates for out-of-hospital cardiac arrest depend on many factors and vary widely between communities.

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