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I read with interest the case report by MacCarthy et al1 describing the use of transthoracic echocardiography during cardiac arrest due to massive pulmonary embolism (PE). Such cases raise the question of whether thrombolysis could be used routinely during all non-traumatic cardiac arrests, not just those known to be caused by PE.
Up to 70% of cardiac arrests have thrombosis (PE or myocardial infarction) as their underlying cause.2 Thrombolysis is of verified therapeutic benefit in both these conditions. Bottiger has prospectively studied administration of recombinant tissue plasminogen activator (r-tPA) in patients suffering out of hospital cardiac arrest.2 Compared with controls, patients who received thrombolysis were significantly more likely to have return of spontaneous circulation and survive to admission to a coronary intensive care. There was no significant difference in survival to discharge, although numbers were very small. Several retrospective studies of out of hospital arrests of all causes have shown similar results.
Administration of thrombolysis not only treats the direct cause of the cardiac arrest, but it has also been shown to improve blood flow in the microvascular circulation of the brain during the post-arrest period.3 This may account for the excellent neurological status of the survivors in several of the studies.
With the introduction of single bolus thrombolytic agents, administration of thrombolysis during cardiac arrest would be a rapid, simple procedure. On the basis of the current evidence however, thrombolysis could not be recommended as a routine treatment in all cardiac arrests, but it should be considered on a case by case basis by the arrest team leader. Large randomised controlled trials are needed to provide a definitive answer to this important clinical question. Such a study, led by Bottiger, is due to start in Germany later this year (2002) (personal communication) and its results are eagerly awaited.