‘‘Sugar for the Heart’’, a bitter pill for tenecteplase: the crystallisation trap of pre-hospital fibrinolysis

Recent evidence suggests that empiric prehospital administration of tenecteplase in out-of-hospital cardiac arrest is associated with decreased survival and lower rates of return of spontaneous circulation. While diagnostic uncertainty is a primary factor, operational hazards in austere environments must also be examined. This comment explores an underappreciated and potentially lethal operational hazard: the immediate chemical incompatibility between tenecteplase and dextrose-containing solutions. In chaotic pre-hospital settings, clinicians often rely on the cognitive heuristic of using dextrose lines to limit sodium intake, especially during cardiac emergencies. However, mixing tenecteplase with dextrose triggers instant crystallization and line occlusion. This effectively denies the patient the fibrinolytic agent while simultaneously compromising a critical intravenous access. To mitigate this risk, we propose three clinical safety barriers: physical segregation of dextrose from acute coronary syndrome kits, the mandatory implementation of a 20-mL normal saline flush before and after administration, and the use of point-of-care cognitive aids on drug packaging. Addressing the complex outcomes of prehospital thrombolysis requires mitigating simple, yet catastrophic, chemical errors. Environmental design and strict operational protocols are essential to ensure the safe delivery of tenecteplase in the field.