Doc Holiday wrote:
>
> Sorry, people -
>
> STUPID QUESTION OF THE WEEK #6:
>
> Please help solve an argument. In comparing various sources/texts for lists
> of standard absolute & relative contr-indications to thrombolysis, we found
> many sources state "prolonged CPR" as one. Not all do. Some actually state
> that this means over 10 minutes. Now, I'm not too concerned at the mo' about
> who's correct and whether this should be a contra-indication.
>
> But, as irrelevant as it might seem, the question we have been tasked with
> answering is: Why? i.e. if one does accept that this IS a contra-indication,
> what is the reason? The immediate reply initially was "broken ribs" risk,
> but then we decided that even if we had KNOWN broken ribs we sould still
> thrombolyse. So is there another pathology, recognised as a risk from
> PROLONGED CPR, which makes it too risky to thrombolyse? Anyone with the
> right pathology texts or post-mortem analyses to answer this please do...
>

Dear Doc,

Our LAPS Committee is presently discussing thrombolysis DURING CPR. 3
abstracts follow that you may find of interest, particularly the first.
We are just struggling the issue of consent thanks to a DoH document on
consent that effectively has strangled prehospital research.

Anton

Lancet 2001 May 19;357(9268):1583-5

Efficacy and safety of thrombolytic therapy after initially unsuccessful
cardiopulmonary resuscitation: a prospective clinical trial.

Bottiger BW, Bode C, Kern S, Gries A, Gust R, Glatzer R, Bauer H, Motsch
J, Martin E.

Departments of Anaesthesiology, University of Heidelberg, D-69120,
Heidelberg, Germany. [log in to unmask]

BACKGROUND: During cardiopulmonary resuscitation (CPR), thrombolysis can
help to stabilise patients with pulmonary embolism and myocardial
infarction. Moreover, thrombolysis during CPR has beneficial effects on
cerebral reperfusion after cardiac arrest. We investigated this new
therapeutic approach in patients in whom conventional CPR had been
unsuccessful. METHODS: We assessed, in a prospective study, patients
undergoing CPR after out-of-hospital cardiac arrest for cardiological
reasons in whom return of spontaneous circulation was not achieved
within 15 min. According to the Ustein criteria, our control group
consisted of patients who were assessed during 1 year. After this year
patients were treated with a bolus of 5000 U of heparin and 50mg, over 2
min, of tissue-type plasminogen activator (rt-PA treated group). This
intervention was repeated if return of spontaneous circulation was not
achieved within the following 30 min. For controls only CPR was given.
FINDINGS: Overall, 90 patients were included; heparin and rt-PA were
given to 40 patients. There were no bleeding complications related to
the CPR procedures. Of the rt-PA group, 68% (27) had return of
spontaneous circulation and 58% (23) were admitted to a cardiac
intensive care unit, compared with 44% (22; p=0.026) and 30% (15;
p=0.009) of the controls, respectively. At 24 h after cardiac arrest a
larger proportion of the rt-PA group than of the controls was alive (35%
[14] vs 22% [11], p=0.171), and 15% (six) of rt-PA-treated patients and
8% (four) of controls could be discharged from hospital. INTERPRETATION:
After initially unsuccessful out-of-hospital CPR, thrombolytic therapy
combined with heparin is safe and might improve patient outcome. On the
basis of our data a randomised controlled trial might be regarded as
ethical.


Anasthesiol Intensivmed Notfallmed Schmerzther 2001 May;36(5):306-8

[Successful cardiopulmonary resuscitation with a high-dosage bolus
injection of rt-PA after fulminant pulmonary embolism].

[Article in German]

Grabner C, Wahl U, Reineke H.

Abteilung fur Anasthesiologie und Operative Intensivmedizin
Karl-Olga-Krankenhaus Stuttgart. [log in to unmask]

The fulminant pulmonary embolism is one of the most feared complications
of hospitalized patients. A high percentage of those patients need
resuscitation within a short period of time. In such cases, the
thrombolysis is a quickly attained therapeutical alternative to
pulmonary embolectomy. A 77-year-old man with a surgically managed
femoral fracture who suffered a massive pulmonary embolism, had to be
resuscitated on the 11th postoperative day. Because of the fast
confirmation of the diagnosis with the ECG and transthoracical
echocardiography, it was possible to initiate thrombolysis with a bolus
of 100 mg rt-PA immediately after the beginning of cardiac arrest and
resuscitation. After 20 min of cardiopulmonary resuscitation (CPR), the
patient could be stabilized under high dosage of catecholamines. The
patient survived after prolonged intensive care treatment without severe
bleeding complications, neither did he present any neurological deficit.
We conclude that in the case of massive pulmonary embolism with small
chance of resuscitation, the high-dose bolus injection of rt-PA could
enrich the therapeutical possibilities.


Curr Opin Crit Care 2001 Jun;7(3):176-83

Thrombolytic therapy during cardiopulmonary resuscitation and the role
of coagulation activation after cardiac arrest.

Bottiger BW, Martin E.

Department of Anesthesiology, University of Heidelberg, Im Neuenheimer
Feld 110, D-69120 Heidelberg, Germany.
[log in to unmask]

Thrombolysis is an effective causal therapy for patients suffering from
massive pulmonary embolism or acute myocardial infarction. In more than
70% of patients with cardiac arrest, one of these two diseases is the
underlying cause of deterioration. Nevertheless, because of the fear of
severe bleeding complications, thrombolytic therapy during
cardiopulmonary resuscitation (CPR) has been contraindicated. Increasing
clinical experience and data from open studies now suggest that
thrombolysis during CPR can contribute to hemodynamic stabilization and
survival in patients with massive pulmonary embolism and acute
myocardial infarction, after conventional CPR procedures have been
performed unsuccessfully. After administration of thrombolytic agents,
some patients have been stabilized even after more than 90 minutes of
CPR. Besides the specific causal action of thrombolytic agents at the
site of pulmonary emboli and coronary thrombosis, experimental data
indicate that thrombolysis during CPR can improve microcirculatory
reperfusion, which may be most important in the brain. In accordance
with these data, marked activation of blood coagulation without adequate
activation of endogenous fibrinolysis has been demonstrated during
reperfusion after cardiac arrest. Massive coagulation activation with
subsequent fibrin formation is responsible for microcirculatory
reperfusion disorders, and thrombolytic therapy may be indicated.
However, no controlled studies are available on this therapeutic
concept. Because the risk of bleeding complications is potentially
associated with the administration of thrombolytic agents, although this
occurs far less than anticipated, thrombolysis during CPR is presently a
treatment strategy that can be performed on an individual basis. Whether
thrombolysis during CPR can improve survival rates and neurologic
outcomes should be addressed in randomized, controlled trials.