Tenecteplase Dosing for Pulseless Electrical Activity (PEA) in Suspected or Confirmed Pulmonary Embolism

Guideline-Based Recommendations

The American Heart Association recommends thrombolysis as a reasonable emergency treatment option (Class IIa) for patients with confirmed pulmonary embolism as the precipitant of cardiac arrest 1
The 2015 AHA Guidelines state that thrombolysis can be beneficial even when chest compressions have been provided (Class IIa, LOE C-LD) 1
Standard contraindications to thrombolysis may be superseded by the need for potentially lifesaving intervention in fulminant pulmonary embolism, given the poor outcomes without clot-directed therapy 1
Thrombolysis may be considered when cardiac arrest is suspected to be caused by pulmonary embolism (Class IIb) 1

The American College of Cardiology recommends a standard weight-based dosing regimen for tenecteplase: 30 mg for <60 kg, 35 mg for 60-69 kg, 40 mg for 70-79 kg, 45 mg for 80-89 kg, and 50 mg for ≥90 kg 1, 2, 3

The American Heart Association recommends administering tenecteplase as a single IV bolus over 5-10 seconds during ongoing cardiopulmonary resuscitation 1
Early administration of systemic thrombolysis is associated with improved resuscitation outcomes compared with use after failure of conventional ACLS 1
Thrombolytics should be administered with or followed by systemic anticoagulation 1

The European Society of Cardiology notes that PEA is the presenting rhythm in 36-53% of pulmonary embolism-related cardiac arrests, while primary shockable rhythms are uncommon 1
Clinical markers suggesting pulmonary embolism include conventional thromboembolism risk factors, prodromal dyspnea or respiratory distress, and witnessed arrest 1
The European Heart Journal recommends not delaying thrombolysis waiting for absolute diagnostic confirmation if clinical suspicion is high and the patient is in cardiac arrest—the mortality benefit outweighs bleeding risk in this scenario 1
The European Heart Journal also recommends not withholding thrombolysis solely because chest compressions are being performed; this is explicitly supported by guidelines 1
The European Heart Journal advises not using reduced doses in elderly patients for pulmonary embolism-related cardiac arrest (the 50% dose reduction applies only to STEMI in patients >75 years, not to pulmonary embolism) 4, 5