Reviving the Standstill Heart: Multimodal Management of Refractory Cardiac Arrest due to Massive Pulmonary Embolism.

INTRODUCTION: Massive pulmonary embolism (PE) is a life-threatening condition frequently associated with right ventricular (RV) strain, hypotension, and cardiac arrest. Recommended management includes IV alteplase for high-risk PE. However, evidence guiding higher thrombolytic doses during cardiac arrest remains limited and is rarely reported. We present a case of massive PE requiring an atypically high cumulative tPA dose administered during CPR, resulting in return of spontaneous circulation (ROSC). CASE DESCRIPTION: A 38-year-old female with prior DVT and PE presented with syncope and left lower extremity edema. Imaging confirmed bilateral PE and DVT. She was found to be hemodynamically unstable and was treated with 100 mg IV tPA. This resulted in transient improvement, but she subsequently suffered a prolonged PEA arrest. During ACLS, there was confirmation of cardiac standstill on POCUS. A second bolus of 50 mg tPA was administered 29 min into the code, which led to sustained ROSC within 2 min. Despite maximal vasopressor and inotropic support, persistent shock and hypoxemia necessitated pulmonary angiography and attempted thrombectomy, which was aborted due to recurrent arrest. Catheter-directed thrombolysis with bilateral EKOS catheters was initiated, and by ICU Day 3, echocardiography revealed normalized RV function. DISCUSSION: Massive PE causes acute RV failure and impaired pulmonary perfusion, which may limit thrombolytic delivery. Repeat tPA dosing during CPR may enhance clot penetration and improve outcomes. When systemic thrombolysis is insufficient, catheter-directed therapies can provide additional hemodynamic benefit. Adjunctive strategies including ventilatory optimization, pulmonary vasodilation, and neuroprotection were critical for the patient to achieving full recovery. CONCLUSION: Aggressive, multidisciplinary management, including repeat thrombolysis during arrest, can overcome traditionally poor prognostic indicators in massive PE and result in favorable neurologic outcomes.