Massive pulmonary embolism (PE) frequently leads to cardiac arrest (CA) which carries an extremely highmortality rate. Although\navailable, randomized trials have not shown survival benefits from thrombolytic use. Thrombolytics however have been used\nsuccessfully during resuscitation in clinical practice in multiple case reports and in retrospective studies. Recent resuscitation\nguidelines recommend using alteplase for PE related CA; however they do not offer a standardized treatment regimen. The most\nconsistently applied approach is an intravenous bolus of 50mg tissue plasminogen activator (t-PA) early during cardiopulmonary\nresuscitation (CPR). There is no consensus on the subsequent dosing. We present a case in which two 50mg boluses of t-PA\nwere administered 20 minutes apart during CPR due to persistent hemodynamic compromise guided by bedside echocardiogram.\nThe patient had an excellent outcome with normalization of cardiac function and no neurologic sequela. This case demonstrates\nthe benefit of utilizing bedside echocardiography to guide administration of a second bolus of alteplase when there is persistent\nhemodynamic compromise despite achieving return of spontaneous circulation after the initial bolus, and there is evidence of\npersistent right ventricle dysfunction. Future trials are warranted to help establish guidelines for thrombolytic use in cardiac arrest\nto maximize safety and efficacy.
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