Clinical Practice and Cases in Emergency Medicine

We present the case of an 88-year-old female who presented to the emergency department (ED) with suspected massive pulmonary embolism (PE) causing respiratory failure, right heart strain, and shock, who despite early and aggressive resuscitation with vasopressors and continuous peripheral infusion of tissue plasminogen activator (tPA), suffered a cardiac arrest in the ED. We describe the approach of a tPA bolus directed through a central venous catheter, resulting in return of spontaneous circulation and immediate improvement in physiologic parameters prior to confirmation of PE with computed tomography angiogram. We further hypothesize that in patients deemed too unstable to be transferred for embolectomy or catheter-directed thrombolysis, central venous catheter-directed bolus tPA may be more effective than peripheral infusion alone.