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.

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