RESUMO
BACKGROUND: Tissue plasminogen activator (tPA) is used emergently to dissolve thrombi in the treatment of fulminant pulmonary embolism. Currently, there is a relative contraindication to tPA in the setting of traumatic or prolonged cardiopulmonary resuscitation > 10 minutes because of the risk of massive hemorrhage. METHODS: Our single-center, retrospective study investigated patients experiencing cardiac arrest (CA) secondary to pulmonary embolus. We compared the effectiveness of advanced cardiac life support with the administration of tPA vs. the standard of care consisting of advanced cardiac life support without thrombolysis. The primary endpoint was survival to discharge. Secondary endpoints were return of spontaneous circulation (ROSC), major bleeding, and minor bleeding. RESULTS: We analyzed 42 patients, of whom 19 received tPA during CA. Patients who received tPA were not associated with a statistically significant increase in survival to discharge (10.5% vs. 8.7%, P = 1.00) or ROSC (47.4% vs. 47.8%, P = 0.98) compared to the control group. We observed no statistically significant difference between the groups in major bleeding events (5.3% in the tPA group vs. 4.3% in the control group, P = 1.00) and minor bleeding events (10.5% in the tPA group vs. 0.0% in the control group, P = 0.11). CONCLUSION: This study did not find a statistically significant difference in survival to discharge or in ROSC in patients treated with tPA during CA compared to patients treated with standard therapy. However, because no significant difference was found in major or minor bleeding, we suggest that the potential therapeutic benefits of this medication should not be limited by the potential for massive hemorrhage. Larger prospective studies are warranted to define the efficacy and safety profile of thrombolytic use in this population.
RESUMO
BACKGROUND: Chest pain (CP) is a frequent cause of emergency room visits in United States and adds a huge financial burden to our healthcare cost. With the addition of observation units, standard CP protocols have shown to decrease length of stay (LOS) and cost per discharge (CPD). We report our experience with the development and implementation of "CP protocol for intermediate cardiac risk patients" and its impact on healthcare resource utilization at our medical center. METHODS AND RESULTS: We retrospectively analyzed 30 patients who presented to Advocate Christ Medical Center (ACMC) with CP and were considered to be at intermediate risk for acute coronary syndrome after obtaining IRB approval. Patients were treated with our standardized CP protocol and labeled as "protocol patients". Our control group consisted of patients with similar demographics and diagnosis but not treated with our CP protocol admitted in the same time period and under our own faculty. This helped remove the bias of different treating attending. Our protocol algorithm consisted of medications, an electrocardiogram (EKG), cardiac troponin I level, and a stress test if indicated. Primary clinical endpoints for this study were LOS in hours and CPD for patients in our protocol group compared to control group. LOS in the protocol group was lower compared to the control but the difference was not statistically significant (P = 0.74). The average CPD in the control group (mean = $13,446) was almost $830 more than the protocol group (mean = $14,276, P = 0.827). CONCLUSION: Implementation of standardized protocols for patients with CP has proven to be a cost effective strategy at several institutions across the country. Our study showed a reduction in CPD although not statistically significant. LOS was also reduced but did not meet statistical significance mainly due to our small sample size. Previous studies had demonstrated much larger savings between a protocol-driven group and a non-protocol-driven group. On further analysis of our data, our protocol group contained five patients who underwent invasive diagnostic tests including computed tomography for pulmonary embolism scans which were not present in the control group. This accounted for the small reduction in costs for the protocol group.
