0 Rtpa for Acute Ischemic Stroke

From Harrison's Principles of Internal Medicine, 18th Edition

Table 370-1 Administration of Intravenous Recombinant Tissue Plasminogen Activator (Rtpa) for Acute Ischemic Stroke (Ais)a
Indication Contraindication

Clinical diagnosis of stroke

Onset of symptoms to time of drug administration 3 h

CT scan showing no hemorrhage or edema of >1/3 of the MCA territory

Age 18 years

Consent by patient or surrogate

Sustained BP >185/110 mm Hg despite treatment

Platelets <100,000; HCT <25%; glucose <50 or >400 mg/dL

Use of heparin within 48 h and prolonged PTT, or elevated INR

Rapidly improving symptoms

Prior stroke or head injury within 3 months; prior intracranial hemorrhage

Major surgery in preceding 14 days

Minor stroke symptoms

Gastrointestinal bleeding in preceding 21 days

Recent myocardial infarction

Coma or stupor
Administration of rtPA 

Intravenous access with two peripheral IV lines (avoid arterial or central line placement)

Review eligibility for rtPA

Administer 0.9 mg/kg IV (maximum 90 mg) IV as 10% of total dose by bolus, followed by remainder of total dose over 1 h

Frequent cuff blood pressure monitoring

No other antithrombotic treatment for 24 h

For decline in neurologic status or uncontrolled blood pressure, stop infusion, give cryoprecipitate, and reimage brain emergently

Avoid urethral catheterization for 2 h

aSee Activase (tissue plasminogen activator) package insert for complete list of contraindications and dosing. Abbreviations: BP, blood pressure; HCT, hematocrit; INR, international normalized ratio; MCA, middle cerebral artery; PTT, partial thromboplastin time.

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