Pulmonary embolism treatment thrombolysis

Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org]

Overview
Thrombolysis is the breakdown (lysis) of blood clots by pharmacological means. It is colloquially referred to as clot busting for this reason. It works by stimulating fibrinolysis by plasmin, through infusion of analogs of tissue plasminogen activator, the protein that normally activates plasmin.

Dosage
Loading dose:250 000 IU over 30 min. Maintenance dose:100 000 IU/h over 12–24 hr. Accelerated regimen: 1.5 million IU over 2 hr. Loading dose:4400 IU/kg over 10 min. Maintenance dose:4400 IU/kg/h over 12–24 hr. Accelerated regimen: 3 million IU over 2 hr. 100 mg over 2 hr or 0.6 mg/kg over 15 min (maximum dose 50 mg).
 * Streptokinase
 * Urokinase
 * Recombinant tissue plasminogen activator (rtPA)

Absolute contraindications

 * Haemorrhagic stroke or stroke of unknown origin at any time.
 * Ischaemic stroke in preceding 6 months.
 * Central nervous system damage or neoplasms.
 * Recent major trauma/surgery/head injury (within preceding 3 weeks).
 * Gastrointestinal bleeding within the last month.
 * Known bleeding.

Relative contraindications

 * Transient ischaemic attack in preceding 6 months.
 * Oral anticoagulant therapy.
 * Pregnancy or within 1 week post partum.
 * Non-compressible punctures.
 * Traumatic resuscitation.
 * Refractory hypertension (systolic blood pressure 180 mm Hg).
 * Advanced liver disease.
 * Infective endocarditis.
 * Active peptic ulcer.

ACC/AHA Guidelines- Recommendations for Fibrinolysis for Acute PE (DO NOT EDIT)
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Class IIa
1. Fibrinolysis is reasonable for patients with massive acute PE and acceptable risk of bleeding complications. (Level of Evidence: B)

Class IIb
2. Fibrinolysis may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory insufficiency, severe RV dysfunction, or major myocardial necrosis) and low risk of bleeding complications(Level of Evidence: C).

Class III
3. Fibrinolysis is not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening(Level of Evidence: B).

4. Fibrinolysis is not recommended for undifferentiated cardiac arrest(Level of Evidence: B).}}

Guidelines Resources

 * Guidelines on the management of Pulmonary embolism: Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension