Thrombolytics

(Redirected from Thrombolysis)

Thrombolysis contraindications

Absolute contraindication

  • Any prior ICH
  • Known structural cerebral vascular lesion (AVM)
  • Known intracranial neoplasm
  • Ischemic stroke within 3 mo
  • Active internal bleeding (excluding menses)
  • Suspected aortic dissection or pericarditis

Relative contraindications

  • Severe uncontrolled BP (>180/110)
  • History of chronic severe poorly controlled hypertension
  • History of prior ischemic stroke >3 mo
  • Known intracranial pathology not covered in absolute contraindications
  • Current use of anticoagulants with known INR >2–3
  • Known bleeding diathesis
  • Recent trauma (past 2 wk)
  • Prolonged CPR (>10 min)
  • Major surgery (<3 wk)
  • Noncompressible vascular punctures (e.g. IJ, subclavian)
  • Recent internal bleeding (within 2–4 wk)
  • Patients treated previously with streptokinase should not receive streptokinase a 2nd time
  • Pregnancy
  • Active peptic ulcer disease
  • Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)

Thrombolysis in Acute Ischemic Stroke (tPA)

Alteplase

Dosing:

  • 0.9mg/kg IV (max 90mg total)
    • 10% of dose is administered as bolus; rest is given over 60min
  • Neuro check Q15min x 2hr
  • No anticoagulation/antiplatelets x 24hr
  • Blood pressure (keep SBP <180, DBP <105)

If SBP is >180-230 or DBP is >120:

  • Nicardipine 5 mg/hr by slow infusion (50 mL/hr) initially; may be increased by 2.5 mg/hr every 15 minutes; not to exceed 15 mg/hr OR
  • Labetalol 10mg IV over 1–2 min; repeat dose q10–20min up to 300mg max OR
  • Labetalol 10mg IV followed by infusion at 2–8 mg/min

If BP not controlled by above measures:

  • Nitroprusside 0.5–10mcg/kg/min
  • Continuous arterial monitoring advised
  • Use with caution in patients with hepatic or renal insufficiency

Thrombolysis in Pulmonary Embolism

Thrombolytics in STEMI

Alteplase (TPA)

Dosing based on patient weight:

  • 67kg: Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr)
  • ≤67kg: Infuse 15mg IV over 1-2min; then 0.75 mg/kg (max 50mg) over 30 min; then 0.5 mg/kg over 60min (max 35 mg)

Tenecteplase-TNKase

  • Reconstitute 50 mg vial in 10 mL sterile water (5 mg/mL)
  • < 60 kg = 30 mg IV push over 5 seconds
  • 60-69 kg = 35 mg IV push over 5 seconds
  • 70-79 kg = 40 mg IV push over 5 seconds
  • 80-89 kg = 45 mg IV push over 5 seconds
  • > 90 kg = 50 mg IV push over 5 seconds

See Also

References