Monday, January 25, 2021

tPA in PE - when to stop

 Q: 52 years old male is admitted to ICU with acute pulmonary embolism (PE) and started on fibrinolytic therapy. Patient started to bleed from femoral site where a central venous catheter (CVC) was placed. No other clinical signs or symptoms witnessed. Bleeding is mostly around the insertion site. Your next line of management? (select one)

A) Stop fibrinolysis infusion

B) Check hemoglobin level

C) Check Fibrinogen level

D) Apply pressure dressing

E) CT scan of the head

Answer: D

The objective of this question is to highlight the fact that minor bleeding is usually expected during fibrinolysis infusion and should be continued as pulmonary embolism can be more fatal. Minor bleeding from venipuncture, arterial puncture sites, in the skin and gums, is usually tolerable - and should be taking care of with local measures (choice D). Minor epistaxis can also be managed with nasal packing. Bleeding from the gastrointestinal or genitourinary tract should also be OK. Infusion of fibrinolysis should be stopped only if there is a sign of hemodynamic instability, neuro signs, a significant drop in hemoglobin with a need for transfusion, or apparent massive bleed. 

Hemoglobin level (choice B) should be checked if there is a concern for massive bleed. Fibrinogen level (choice C) is expected to be low with fibrinolysis therapy, and there is no need to check it.

CT scan of the head (choice E) should be checked only if there is a neuro sign or a concern for neuro-bleed.




1. Meyer G, Gisselbrecht M, Diehl JL, et al. Incidence and predictors of major hemorrhagic complications from thrombolytic therapy in patients with massive pulmonary embolism. Am J Med 1998; 105:472. 

2. Sadiq I, Goldhaber SZ, Liu PY, et al. Risk factors for major bleeding in the SEATTLE II trial. Vasc Med 2017; 22:44.

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