We present the case of a successful CPR of a 55 y.o. patient with a massive pulmonary embolism on the second day after an elective right total knee replacement. CPR team was dispatched by ward nurses. On assessment patient was soporous, cyanotic, RR 30/min, HR 100-120/min. During the assessment respiratory arrest and asystole occurred. CPR was started immediately. Without interrupting chest compressions patient was intubated and ventilated. On the next rhythm check ventricular fibrillation was detected and sinus rhythm was restored by a single 200J shock. Hemodynamics in the postresuscitation period was supported by norepinephrine infusion. Massive pulmonary embolism was suspected as a cause of cardiac arrest – confirmed by CT, CT obstruction index was 45% (massive PE) Fig. 1,2.
Twenty mins later the second episode of asystole developed. After 10 minutes of CPR, sinus rhythm was restored. Heparin was administered 5000 U bolus, infusion 1000 U/h. Hemodynamics was maintained by norepinephrine infusion.
Considering the extremely severe condition a decision to perform thrombolysis was made: according to the guidelines, all absolute contraindications become relative in case of a threat to the patient’s life. An arterial tourniquet was applied to the right thigh under the palpatory and ultrasound control. A total dose of Alteplase administered was 100 mg (10 mg within one minute with and infusion of 90 mg for 2 hours). After completion of the procedure arterial tourniquet was removed, blood circulation in the limb was restored, there were no signs of bleeding from the postoperative wound or any other hemorrhagic complications. An hour later doses of sedation were reduced and the appearance of consciousness was noted; infusion of norepinephrine was stopped; acid-base and lactate were normal. On the following day, the patient was extubated and transferred to the ward without any neurological deficit. Resolution of pulmonary embolism was detected on a CT (Fig 3,4).

8 - Case report of a successful thrombolysis after cardiac arrest in early postoperative period