ivTPA in acute stroke

 

Indication

contraindications

Dose

F/up

HTN management

 

 

Indication:

3 hr from the onset

 

contraindications :

 

  1. ICH
  2. h/o ICH
  3. SAH
  4. Recent intracranial surgery, head trauma, stroke
  5. Intracranial neoplasm, AVM, aneurysm
  6. active internal bleeding
  7. hemorrhagic diathesis:
    1. coumadin – PT > 15 sec
    2. heparin within 48 hrs and PTT prolonged
    3. PLT < 100
  8. Seizure @ onset of stroke
  9. HTN – uncontrolled (see below) with SBP > 185 or DBP >110

 

Relative contraindications

  1. NIHSS > 22
  2. Early major infarct signs on head CT (edema, mass effect, midline shift)

 

 

Dose

0.9 mg/kg; max dose = 90mg

10% of the total dose adm as iv bolus over 1 minute

90% of the total dose adm in infusion over 60 min.

 

F/up

Neurochecks q1h

BP < 185/110 mmHg

No anticoag or antiplats for 24 hrs

24 hr post TPA head CT

 

HTN management

Pretx

-          BP < 185/110; monitor q15min

-          If BP > 185/110 , give 1-2 doses of Labetalol 10-20mg iv within 1 hr; if BP is not < 185/110 after labetalol , pt should not receive TPA

 

During and posttx

First 24 hrs :

Q 15 min x 2 hr

Q 30 min x 6 hrs

Q 1 hr x 18 hrs

 

-          If DBP > 140mmHg – start Nitroprusside (0.5-10micro g / kg/min)

-          If SBP > 230 and DBP is 120-140 mmHg – start Labetalol 20mg iv over 1-2 min ; can repeat q10min up to 150 mg; if no good response, use nitroprusside

-          If SBP is 180-230 mmHg and DBP is 105-120 mmHg ; use 2 readings 5 min apart; give labetalol 10mg q10min up to max dose 150mg

-          Monitor BP q15 min during antiHTN tx