Thrombolytics for acute ischemic stroke: Difference between revisions
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===Relative=== | ===Relative=== | ||
# Minor stroke or rapidly improving stroke symptoms | |||
# Seizure at onset with postictal residual neuro impairments | |||
# Major surgery or serious trauma within previous 14 days | |||
# Acute GI or GU hemorrhage (within previous 21 days) | |||
# Acute MI (within previous 3 months) | |||
===ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)=== | ===ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)=== |
Revision as of 06:43, 28 March 2011
Background
- Pros:
- 30% greater chance of good neurologic outcome at 3 months
- Comparable 3-month mortality rate
- Cons
- Intracranial hemorrhage occurs in ~5% of pts
- Coag results prior to tx is only required for pts on anticoagulants
- ...but if history unable to be obtained must wait for coag results prior to starting tx
Inclusion Criteria
- Clinical diagnosis of stroke
- Clear onset (last witnessed well) <3 hours
- Age >18 yrs
Exclusion Criteria
Absolute
- Head trauma or prior stroke in previous 3 months
- Symptoms suggestive of SAH
- Arterial puncture at noncompressible site in previous 7 days
- History of previous ICH
- Elevated BP (sys > 185 or dia > 110
- Active bleeding on exam
- Acute bleeding diathesis:
- Plt count < 100K
- PTT > upper limit of normal
- INR >1.7
- Blood Glucose <50
- CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere)
Relative
- Minor stroke or rapidly improving stroke symptoms
- Seizure at onset with postictal residual neuro impairments
- Major surgery or serious trauma within previous 14 days
- Acute GI or GU hemorrhage (within previous 21 days)
- Acute MI (within previous 3 months)
ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)
- Age > 80
- Baseline NIHSS > 25
- Any oral anticoagulant use
- History of prior stroke and DM
Studies Needed
- Head CT
- CBC
- PT/PTT
- Glu check
- ECG
- Icon
tPA Administration
- Alteplase 0.9mg/kg IV (max 90mg total)
- Load with .09mg/kg (10% of dose) as IV bolus over 1min, followed by 0.81mg/kg (90% of dose) as cont. infusion over 60min
- Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
- Keep BP <180/105
- Labetalol 10mg IV followed by continous IV infusion 2-8mg/min OR
- Nicardipine IV 5mg/h, titrate up to desired effect by 2.5mg/hr q 5-15min, maximum 15mg/h
- If BP not controlled or dia > 140 consider nitroprusside
- No anticoatulation/antiplatelets x 24hrs
- Stop tPA and consider head CT if pt develops:
- Neuro changes
- Acute hypertension
- Nausea/vomiting
See Also
Neuro: post-tPA Hemmorhage
Source
1/26/06 DONALDSON (adapted from Lampe, Tintinali)
2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations)