Difference between revisions of "Thrombolytics for acute ischemic stroke"

(Created page with "==Inclusion Criteria== 1) Clinical diagnosis of stroke 2) Clear onset (last witnessed well) <3 hours 3) Age >18 yrs ==Exclusion Criteria== (ABSOLUTE) 1) BP Systolic...")
 
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==Inclusion Criteria==
 
==Inclusion Criteria==
 
+
# Clinical diagnosis of stroke
 
+
# Clear onset (last witnessed well) <3 hours
1) Clinical diagnosis of stroke
+
# Age >18 yrs
 
 
2) Clear onset (last witnessed well) <3 hours
 
 
 
3) Age >18 yrs
 
 
 
 
  
 
==Exclusion Criteria==
 
==Exclusion Criteria==
 +
===(ABSOLUTE)===
 +
# BP Systolic >185, diastolic >110 (can receive 1-3 doses anti-hypertensive)
 +
# PTT >34, PT >15, or INR >1.7
 +
# Platelet count <100,000
 +
# Blood Glucose <50 or >400 mg/dl
 +
# Minor stroke or rapidly resolving stroke
 +
# Hemorrhage or edema on non-con head CT
 +
# Suspected SAH
 +
# Seizure at onset of stroke
 +
# Heparin treatment during the past 48 hours with an elevated PTT
 +
# Evidence of acute myocardial infarction
  
 +
===(RELATIVE)===
 +
# History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm
 +
# Major surgery/trauma within <14 days
 +
# Stroke or serious head injury within 3 months
 +
# GI/GU bleeding within <21 days
 +
# Lactation or pregnancy within <30 days
  
+
===(ADDITONAL PER HARBOR NEURO)===
 
+
# AMI or pericarditis (ECG)
(ABSOLUTE)
+
# Aggressive treatment needed to control BP
 
+
# Lumbar puncture within <7 days
1) BP Systolic >185, diastolic >110 (can receive 1-3 doses anti-hypertensive)
+
# Occult blood in urine or stool (UA + Guiac)
  
2) PTT >34, PT >15, or INR >1.7
+
===ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)===
 
+
#Age > 80
3) Platelet count <100,000
+
#Baseline NIHSS > 25
 
+
#Any oral anticoagulant use
4) Blood Glucose <50 or >400 mg/dl
+
#History of prior stroke and DM
 
 
5) Minor stroke or rapidly resolving stroke
 
 
 
6) Hemorrhage or edema on non-con head CT
 
 
 
7) Suspected SAH
 
 
 
6) Seizure at onset of stroke
 
 
 
7) Heparin treatment during the past 48 hours with an elevated PTT
 
 
 
8) Evidence of acute myocardial infarction
 
 
 
 
 
 
(RELATIVE)
 
 
 
5) History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm
 
 
 
6) Major surgery/trauma within <14 days
 
 
 
7) Stroke or serious head injury within 3 months
 
 
 
8) GI/GU bleeding within <21 days
 
 
 
9) Lactation or pregnancy within <30 days
 
 
 
(ADDITONAL PER HARBOR NEURO)
 
 
 
10) AMI or pericarditis (ECG)
 
 
 
11) Aggressive treatment needed to control BP
 
 
 
12) Lumbar puncture within <7 days
 
 
 
13) Occult blood in urine or stool (UA + Guiac)
 
 
 
 
 
 
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==
 
==Studies Needed==
 
+
# Head CT
 
+
# CBC
1) Head CT
+
# PT/PTT
 
+
# Glu check
2) CBC
+
# ECG
 
+
# Icon
3) PT/PTT
 
 
 
4) Glu check
 
 
 
5) ECG
 
 
 
6) Icon
 
 
 
 
  
 
==Giving tPA==
 
==Giving tPA==
 
+
# Alteplase (Activase/tPA): 0.9mg/kg (max 90mg total) IV; Give 10% as bolus over 1 min, remainder by continous infusion over 60min
 
+
# Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
1) Alteplase (Activase/tPA): 0.9mg/kg (max 90mg total) IV; Give 10% as bolus over 1 min, remainder by continous infusion over 60min
+
# Keep BP <185/95 (labetalol/nipride gtt if nec)
 
+
# NO anticoatulation/antiplatelet agents x24hrs
2) Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
+
# Stop tPA if worsening neuro exam --> STAT head-CT
 
 
3) Keep BP <185/95 (labetalol/nipride gtt if nec)
 
 
 
4) NO anticoatulation/antiplatelet agents x24hrs
 
 
 
5) Stop tPA if worsening neuro exam --> STAT head-CT
 
 
 
 
  
 
==See Also==
 
==See Also==
 
 
 
Neuro: post-tPA Hemmorhage
 
Neuro: post-tPA Hemmorhage
 
 
  
 
==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)
 
 
 
  
 
[[Category:Neuro]]
 
[[Category:Neuro]]

Revision as of 06:28, 28 March 2011

Inclusion Criteria

  1. Clinical diagnosis of stroke
  2. Clear onset (last witnessed well) <3 hours
  3. Age >18 yrs

Exclusion Criteria

(ABSOLUTE)

  1. BP Systolic >185, diastolic >110 (can receive 1-3 doses anti-hypertensive)
  2. PTT >34, PT >15, or INR >1.7
  3. Platelet count <100,000
  4. Blood Glucose <50 or >400 mg/dl
  5. Minor stroke or rapidly resolving stroke
  6. Hemorrhage or edema on non-con head CT
  7. Suspected SAH
  8. Seizure at onset of stroke
  9. Heparin treatment during the past 48 hours with an elevated PTT
  10. Evidence of acute myocardial infarction

(RELATIVE)

  1. History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm
  2. Major surgery/trauma within <14 days
  3. Stroke or serious head injury within 3 months
  4. GI/GU bleeding within <21 days
  5. Lactation or pregnancy within <30 days

(ADDITONAL PER HARBOR NEURO)

  1. AMI or pericarditis (ECG)
  2. Aggressive treatment needed to control BP
  3. Lumbar puncture within <7 days
  4. Occult blood in urine or stool (UA + Guiac)

ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)

  1. Age > 80
  2. Baseline NIHSS > 25
  3. Any oral anticoagulant use
  4. History of prior stroke and DM

Studies Needed

  1. Head CT
  2. CBC
  3. PT/PTT
  4. Glu check
  5. ECG
  6. Icon

Giving tPA

  1. Alteplase (Activase/tPA): 0.9mg/kg (max 90mg total) IV; Give 10% as bolus over 1 min, remainder by continous infusion over 60min
  2. Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
  3. Keep BP <185/95 (labetalol/nipride gtt if nec)
  4. NO anticoatulation/antiplatelet agents x24hrs
  5. Stop tPA if worsening neuro exam --> STAT head-CT

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)