Protocol for patients arriving in ER for Possible TPA

• Start IV Normal Saline at 60 ml/hour
• Saline lock in opposite arm
• Stat CBC, SMA7, PT/INR, PTT
• Stat EKG and Chest X ray
• Notify CT Technician and Neurologist on call
• Obtain patient's weight (from patient, family or estimate)

Patient is a candidate for TPA

• Call nursing supervisor to arrange for Critical care bed
• Take 2 vials of TPA (50 mg each) and 2 vials of sterile nonbacteriostatic water for dilution syringes and needles to CT Suite
• If CT demonstrate NO hemorrhage, no sign of early changes on CT scan of acute stroke
  then initiate therapy
  • Calculate dose:
    • Weight _____ Kg x 0.9 mg/kg = ______ mg
    • or 90 mg (whichever is less)
  • Give 10% dose as bolus
  • Infuse remaining dose over 60 minutes.

Sample Admission orders

• Admit to Critical care bed, notify Neurologist of Room #
• Telemetry
• Diagnosis: Acute stroke, received TPA treatment
• NPO for 24 hours
• BP and Neuro check: q 15 minutes x 2 hours q 30 minutes x 6 hours q 60 minutes x 16 hours
• If Systolic BP > 180 or diastolic BP > 105, initiate elevated BP protocol
• Notify Neurologist if change in neurological status or bleeding
• Bedrest for 24 hours, bed rail up
• No arterial puncture or central lines for 8 hours
• No NG tube for 24 hours
• No bladder catheter for 30 minutes
• No ASA, Heparin, Ticlopidine, Warfarin, NSAID for 24 hours
• CBC, PT, PTT, CT scan without contrast at 24 hours after TPA

Protocol for elevated Blood Pressure
for patient on TPA

• If diastolic BP > 140
  • Start IV Nitroprusside (0.5 to 1 mcg/kg/min starting dose) and titrate untilil diastolic decreases by 20%
• For BP systolic > 230 or diastolic 121-140 
  • Give IV Labetalol 20 mg over 1- 2 minutes
  • May double or repeat dose every 10 min up to a total of 150 mg
  • Alternatively, after the first dose, start IV infusion of 2-8 mg/min
  • If no satisfactory response, start Nitroprusside (0.5-1 mcg/kg/min)
  • Continue monitoring blood pressure every 15 minutes.
• For BP systolic 180-230  or diastolic 105-120 with 2 readings 5 minutes apart
  • Give IV Labetalol 10 mg over 1- 2 minutes
  • Dose may be repeated or doubled every 10-20 min up to a total of 150 mg
  • Alternatively, after the first dose, start IV infusion of 2 mg/min
  • monitor BP every 15 minutes during treatment

Protocol for suspected Major bleeding or intracranial hemorrhage

• Stop TPA infusion if still in progress
• Stat CT scan without contrast of head if Intracranial Hemorrhage suspected.
• Obtain blood samples for coagulation tests (hematocrit, hemoglobin, PT, PTT, platelet count, fibrinogen, D-dimer). Repeat q2h until bleeding is controlled.

For major hemorrhage or intracranial hemorrhage

• Give fresh frozen plasma 2 units every 6 hours for 24 hours.
• Give cryoprecipitate 5 units. If fibrinogen level < 200mg/dl at 1 hour, repeat cryoprecipitate dose.
• Give platelets 4 units.
• May give aminocaproic acid (Amicar) 5g IV in 250ml of normal saline over 1 hour as a last resort.
• Obtain neurosurgical consultation.