Indication:

·         New ischemic stroke with clearly defined onset.

·         Period from first symptoms to t-PA <3 hours.

·         Patient evaluated by in-house neurologist and t-PA approved by stroke attending.

Contraindications:

1.        CT scan showing evidence of intracranial hemorrhage.*

2.        Minor neurological deficit or rapidly improving symptoms.

3.        Ischemic stroke or head trauma <3 months.

4.        Any history of intracranial hemorrhage.

5.        Cocaine-induced stroke.

6.        Known intracranial neoplasm, arteriovenous malformation or aneurysm.

7.        Symptoms suggestive of subarachnoid hemorrhage.

8.        Seizure at stroke-onset.

9.        Major surgery <2 weeks.

10.     Known bleeding diathesis.

11.     Internal hemorrhage (GI hemorrhage, urinary tract hemorrhage) <3 weeks.

12.     Pretreatment systolic BP >185 mm Hg or diastolic BP >110 mm Hg.

13.     Blood sugar <50 or >400 mg/dl.

14.     Platelets <100,000.

15.     Current use of anticoagulants, or a PT>15 sec. or INR> 1.7

16.     Use of heparin in the previous 48 hours and a prolonged PTT i.e., 35 seconds or greater.

17.     Pregnancy.

18.     Age >80 or <18.

19.     Arterial puncture at non-compressible site <1 week.

Warnings:

1.        Ischemic lesion on CT scan showing evidence of >1/3 of MCA territory infarction.*

2.        Severe neurological deficit (NIH stroke scale score >22).

3.        Age >75.

4.        History of IVDA and/or suspicion for endocarditis.

5.        Tox-screen positive for ETOH, cocaine, opiates, or amphetamines (if available).

6.        History of hemorrhagic diabetic retinopathy.

Not a contraindication:

1. Current aspirin, NSAID, Ticlopidine or Clopidogrel use.

2. History of PUD (not active).

3. Recent myocardial infarction.

*Stroke attending/neuroradiologist verifies that:

·         CT shows no hemorrhage and,

·         CT shows either no evidence of early infarction or early infarction in area smaller than 1/3 OF MCA territory.

Sequence of events:

1. EMT/Triage: alert EM-MD if patient with stroke symptoms <3 hrs.

2. Patient is transferred/assigned to the Trauma Room or Acute Side

3. EM/MD: ORDER STAT HEAD-CT (non-contrast enhanced) AND STAT NEURO-CONSULT.

4. In-house neurologist alerts stroke fellow/stroke attending after brief evaluation of patient (638-5795 pager 1620).

5. t-PA is approved by stroke attending.

6. RN/MD:

·         Establish 2 IV sites, start 0.9% NS at KVO.

·         Cardiac monitor, pulse oximeter, continuous vital signs.

·         Clinical evaluation for active illicit drug use or ETOH intoxication.

7. STAT Labs: PTT, INR, CBC (without diff.), electrolytes, BUN, creatinine, glucose, type & hold.

Avoid (when clinically feasible):

·         ABGs, central lines, IM injections, and nasogastric tubes (anticoagulation precautions) until 24 hours after the infusion.

·         Indwelling bladder catheters until 30 minutes after the infusion.

·         Heparin, aspirin, warfarin, ticlopidine, clopidogrel or NSAIDS x 24 hrs.

Administration of t-PA (Alteplase):

·         Administer t-PA in monitored setting (unit bed or emergency room).

·         Mix two 50 mg t-PA vials with 50 ml normal saline each --> one ml solution contains one mg t-PA.

·         Estimate total body weight.

·         Calculate TOTAL t-PA DOSE: 0.9 mg per kg (not to exceed 90 mg total dose)
-->Give 10% as IV bolus
-->Give other 90% as IV infusion over 60 minutes.

·         Vital signs at least every 15 min.

·         Treat systolic BP if it rises to >180 mm Hg and diastolic BP >105 mm Hg for more than 15 minutes. (See appendix attached, for management of hypertension.)

·         Avoid BP decrease <140/85 mm Hg.

After t-PA is given:

·         Monitor patient in MICU for a minimum of 24 hours, and on a regular hospital ward for 72 hours. A longer period of monitoring may be indicated.

·         Maintain BP 140-180/85-105 mm Hg (see appendix attached for management of hypertension).

·         Use 0.9% NS only, as needed (avoid hypotonic solutions).

·         Admit to MICU.

·         Maintain anticoagulation precautions. Avoid heparin, warfarin, aspirin, ticlopidine, or NSAIDS, for 24 hours.

·         Further work-up/interventions as per neurology-consult.

Appendix to t-PA protocol in Acute Ischemic Stroke

Treatment of hypertension:

1. Monitor arterial blood pressure during the first 24 hours after starting treatment.

·         Every 15 minutes for 2 hours after starting the infusion, then

·         Every 30 minutes for 6 hours, then

·         Every 60 minutes until 24 hours after starting treatment.

2. If systolic blood pressure is 180-230 mmHg or if diastolic blood pressure is 105-120 mmHg for 2 or more readings 5 to 10 minutes apart, the following is recommended:

·         Give intravenous labetalol 10 mg over 1 to 2 minutes. The dose may be repeated or doubled every 10 to 20 minutes up to a total dose of 150 mg.

·         Monitor blood pressure every 15 minutes during treatment and observe for development of hypotension.

3. If systolic blood pressure is greater than 230 mmHg or if diastolic pressure is in the range of 121 -140 mmHg for 2 or more readings 5 to 10 minutes apart, the following is recommended:

·         Give intravenous labetalol 10 mg over 1 to 2 minutes. The dose may be repeated or doubled every 10 minutes up to a total dose of 150 mg.

·         Monitor blood pressure every 15 minutes during use of labetalol treatment and observe for hypotension.

·         If no satisfactory response, infuse sodium nitroprusside (0.5 to 10 mcg/kg/min).*

·         Continue to monitor blood pressure.

4. If the diastolic blood pressure is greater than 140 mmHg for 2 or more readings 5 to 10 minutes apart, the following is recommended:

·         Infuse sodium nitroprusside (0.5 to 10 mcg/kg/min).*

·         Monitor blood pressure every 15 minutes during the infusion of sodium nitroprusside and observe for development of hypotension.

* Use of continuous arterial monitoring is advised if sodium nitroprusside is used. The risk of bleeding secondary to arterial puncture should be weighed against the possibility of missing significant changes in pressure during the infusion.