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Emergency management of complications of thrombolysis C. Roffe

Emergency management of complications of thrombolysis C. Roffe. The recommendations in this presentation are for guidance only. Guidance based on ASA recommendations 2007, EUSI recommendations 3003, Lancet Feb 2007 and IST-3 training folder (as indicated). Suspicion of Intracranial Haemorrhage

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Emergency management of complications of thrombolysis C. Roffe

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  1. Emergency management of complications of thrombolysisC. Roffe The recommendations in this presentation are for guidance only. Guidance based on ASA recommendations 2007, EUSI recommendations 3003, Lancet Feb 2007 and IST-3 training folder (as indicated).

  2. Suspicion of Intracranial Haemorrhage (headache, neurological deterioration, reduced consciousness, seizure, N&V) Stop alteplase infusion Immediate non contrast CT head Immediate PT, APTT, fibrinogen FBC Group and save Prepare 6 units platelets Prepare 6 units cryoprecipitate Haemorrhage on CT? NO YES Check lab results Give cryoprecipitate and platelets Notify Neurosurgeons Resume alteplase infusion Khaja, Lancet 2007; 396:319-330.

  3. Extracranial bleeding (drop in blood pressure, shock, evidence of blood loss e.g. melaena, haematuria) Stop alteplase infusion Use mechanical compression, if possible, to control bleeding form puncture sites Immediate PT, APTT, fibrinogen, FBC, group and save Support circulation with fluids and blood transfusion, as appropriate For severe life threatening bleeding tranexamic acid 1 g i.v. over 15 min, repeated at 8 h if needed Consider transfusion of FFP and/or cryoprecipitate depending on the results of the coagulation screen IST-3 thrombolysis training manual.

  4. Orololingual Angiooedema (swollen lips or tongue, dyspnoea) Stop alteplase infusion Antihistamines (clorpheniramine 10 mg i.v.) Hydrocortisone 200 mg i.v. Observe vital for signs of progression, dyspnoea, anaphylactic shock If sx are mild and non-progressive, alteplase can be restarted under close observation Khaja, Lancet 2007; 396:319-330.

  5. Anaphylaxis (rash, urticaria, dyspnoea, bronchospasm, angiooedema, hypotension, shock) Stop alteplase infusion Urgent medical assessment: Airway, Breathing, Circulation Adrenaline 0.5 -1 ml 1:1000 im or sc (not iv) Clorpheniramine 10 mg i.v. Hydrocortisone 200 mg i.v. Salbutamol nebulizer 5 mg If shocked i.v. saline and consider repeat doses of adrenaline IST-3 thrombolysis training manual.

  6. Hypertension within 24 hours of thrombolysis (BP > 185/110) Labetalol 10-20 mg over 1-2 min (onset of action 5-10 min, duration 3-5h) repeat PRN q10-20 min Followed, if necessary, by an infusion at 0.5-2 mg/min, max dose 200 mg/24 h (1, 2) or GTN infusion start with 5 mcg/min titrate as necessary Or GTN patch 5 mg (1, 2) or Captopril 6.25 mg po/sc (sc effective in 15-30 min, duration 4-6h) (1, 2) If nothing helps Nitroprusside 0.25-10 mcg/kg/min (onset of action: 1-5 min) (1, 2) • Aim to reduce BP slowly (not more than 10-20 mm Hg in the first hour, not more than 50 mm Hg in 24 h • Ensure appropriate continuation of treatment to avoid resurgence hypertension 1. AHA/ASA Stroke 2007;38:1655-1711. 2. ESC recommendations. Cerebrovasc Dis 2003; 16:311-337.

  7. Reperfusion cerebral oedema (agitation, clouding of consciousness, seizures, neurological deterioration within 24-48 h of alteplase infusion and no haemorrhage on CT head scan) Elevate the head to 30 degrees Correct hyperthermia, hypoxia, hyperglycaemia, hypotension Mannitol 0.25-0.5 g/kg over 20 min i.v. (e.g. 100-200ml 20%mannitol for 80 kg), repeat q 4-8 h, if necessary Dexamethasone 4 mg iv qds* Frusemide 20-40 mg iv* Avoid antihypertensives, especially vasodilators Consider decompressive hemicraniectomy (once clotting correct/corrected) If symptoms improve with mannitol reduce dose/frequency gradually AHA/ASA Stroke 2007;38:1655-1711. *as used by C. Roffe in Stoke, not in AHA/ASA guidance (See also Bardutsky Stroke 2007;38;3084-94 for a review of antioedema strategies in cerebral oedema)

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