Thrombolytics for acute ischemic stroke: Difference between revisions
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== Background == | == Background == | ||
#Pros: | #Pros: | ||
##30% greater chance of good neurologic outcome at 3 months | ##30% greater chance of good neurologic outcome at 3 months | ||
##Comparable 3-month mortality rate | ##Comparable 3-month mortality rate | ||
#Cons | #Cons | ||
##Intracranial hemorrhage occurs in ~5% of pts | ##Intracranial hemorrhage occurs in ~5% of pts | ||
<br> | |||
*Coag results prior to tx is only required for pts on anticoagulants | |||
*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 | *...but if history unable to be obtained must wait for coag results prior to starting tx | ||
== Inclusion Criteria == | == Inclusion Criteria == | ||
#Diagnosis of ischemic stroke causing measurable neuro deficit | #Diagnosis of ischemic stroke causing measurable neuro deficit | ||
#Clear onset (last witnessed well) | #Clear onset (last witnessed well) <3 hours (see below for extension to <4.5 hours) | ||
#Age >18 yrs | #Age <u>></u>18 yrs | ||
== Exclusion Criteria == | == Exclusion Criteria == | ||
=== Absolute === | === Absolute === | ||
#Head trauma or prior stroke in previous 3 months | #Head trauma or prior stroke in previous 3 months | ||
#Symptoms suggestive of SAH | #Symptoms suggestive of SAH | ||
#Arterial puncture at noncompressible site in previous 7 days | #Arterial puncture at noncompressible site in previous 7 days | ||
#History of previous ICH | #History of previous ICH | ||
#Elevated BP (sys | #Elevated BP (sys > 185 or dia > 110) | ||
#Active bleeding on exam | #Active bleeding on exam | ||
#Acute bleeding diathesis: | #Acute bleeding diathesis: | ||
##Plt count | ##Plt count < 100K | ||
##PTT | ##PTT > upper limit of normal | ||
##INR | ##INR >1.7 or PT>15 sec | ||
#Blood Glucose | #Blood Glucose <50 | ||
#CT demonstrates multilobar infarction (hypodensity | #CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere) | ||
=== Relative === | === Relative === | ||
#Minor stroke or rapidly improving stroke symptoms | #Minor stroke or rapidly improving stroke symptoms | ||
#Seizure at onset with postictal residual neuro impairments | #Seizure at onset with postictal residual neuro impairments | ||
#Major surgery or serious trauma within previous 14 days | #Major surgery or serious trauma within previous 14 days | ||
#Acute GI or GU hemorrhage (within previous 21 days) | #Acute GI or GU hemorrhage (within previous 21 days) | ||
#Acute MI (within previous 3 months) | #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) === | ||
#Age | All the above absolute exclusion criteria apply, but now with the additional exclusion criteria below | ||
#Baseline NIHSS | |||
#Any oral anticoagulant use | #Age > 80 | ||
#Baseline NIHSS > 25 | |||
#Any oral anticoagulant use regardless of INR | |||
#History of prior stroke and DM | #History of prior stroke and DM | ||
== Studies Needed == | == Studies Needed == | ||
#Head CT | #Head CT | ||
#CBC | #CBC | ||
#PT/PTT | #PT/PTT | ||
#Glu check | #Glu check | ||
#ECG | #ECG | ||
#Icon | #Icon | ||
== tPA Administration == | == tPA Administration == | ||
#Alteplase 0.9mg/kg IV (max 90mg total) | #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 | ##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 | #Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs | ||
#Keep BP | #Keep BP <180/105 | ||
##Labetalol 10mg IV followed by continous IV infusion 2-8mg/min OR | ##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 | ##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 | ##If BP not controlled or dia > 140 consider nitroprusside | ||
#No anticoatulation/antiplatelets x 24hrs | #No anticoatulation/antiplatelets x 24hrs | ||
#Stop tPA and consider head CT if pt develops: | #Stop tPA and consider head CT if pt develops: | ||
##Neuro changes | ##Neuro changes | ||
##Acute hypertension | ##Acute hypertension | ||
##Nausea/vomiting | ##Nausea/vomiting | ||
==Complications== | == Complications == | ||
== See Also == | [[Post-tPA Hemorrhage]] | ||
*[[CVA (Main)]] | |||
== See Also == | |||
*[[CVA (Main)]] | |||
*[[Post-tPA Hemorrhage]] | *[[Post-tPA Hemorrhage]] | ||
== Source == | == Source == | ||
1/26/06 DONALDSON (adapted from Lampe, Tintinali) | |||
1/26/06 DONALDSON (adapted from Lampe, Tintinali) | |||
2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations) | 2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations) | ||
AHA/ASA Guidelines | AHA/ASA Guidelines | ||
[[Category:Neuro]] | [[Category:Neuro]] [[Category:Procedures]] | ||
[[Category:Procedures]] |
Revision as of 05:22, 4 August 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
- Diagnosis of ischemic stroke causing measurable neuro deficit
- Clear onset (last witnessed well) <3 hours (see below for extension to <4.5 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 or PT>15 sec
- 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)
All the above absolute exclusion criteria apply, but now with the additional exclusion criteria below
- Age > 80
- Baseline NIHSS > 25
- Any oral anticoagulant use regardless of INR
- 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
Complications
See Also
Source
1/26/06 DONALDSON (adapted from Lampe, Tintinali)
2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations)
AHA/ASA Guidelines