Successful Return of Spontaneous Circulation and Good Neurologic Recovery Following Full Dose Tissue Plasminogen Activator (tPA) Administration for Pulmonary Embolism-Induced Cardiac Arrest: A Case Report

Massive pulmonary embolism (PE) during cardiac arrest presents considerable risks, especially in patients with traumatic injuries. Timely diagnosis and effective coordination among interdisciplinary teams are vital for managing this critical condition, especially amid the tumult of resuscitation efforts. Alteplase (tPA) is often used off-label for massive PE in cardiac arrest situations, typically administered as a 50 mg intravenous (IV) bolus, followed by 15 minutes of continuous cardiopulmonary resuscitation (CPR). Decisions regarding further dosing depend on the return of spontaneous circulation (ROSC), with recent guidelines suggesting that a single reduced dose of 50 mg may provide comparable efficacy while lowering the risk of bleeding. This case report discusses a 23-year-old male who experienced witnessed in-hospital cardiac arrest on the second day after sustaining a lumbar spine fracture from a motor vehicle accident. Given the high suspicion of PE, a 50 mg IV bolus of alteplase was administered, followed by 15 minutes of continuous CPR, which successfully restored spontaneous circulation. An additional 50 mg of alteplase was given after ROSC. Neurological outcomes were evaluated using standardized scales, showing no significant deficits at discharge. The patient returned home 60 days after the incident, demonstrating effective management of PE-related cardiac arrest and positive long-term outcomes.