Intravenous Thrombolytic Therapy

CRITERIA FOR THROMBOLYSIS:

  1. Ischemic chest pain of at least 15 minutes duration, and unrelieved with sublingual nitroglycerine (2 times).
  2. ECG evidence of Acute Myocardial Infarction (1- 2 mm ST segment elevation in two contiguous leads or new onset of complete left bundle branch block.
  3. Thrombolytic therapy should be given within 12 hours (preferably < 4 hours) of onset of chest pain that is consistent with myocardial infarction .In case of recurrence or persistence  of chest pain the period can be extended to 24 hours.

ABSOLUTE CONTRAINDICATIONS:

  • Any prior intra — cranial hemorrhage.
  • Known structural cerebral vascular lesion (e.g. arterio-venous malformation).
  • Known malignant intra — cranial neoplasm (primary or metastatic).
  • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours.
  • Suspected aortic dissection.
  • Active bleeding or bleeding diathesis (excluding menses).
  • Significant closed head or facial trauma within 3 months.
  • Acute pericarditis.
  • Esophageal varices.
  • Recent major surgery (within < 3 weeks).

RELATIVE CONTRAINDICATIONS:

  • History of chronic severe poorly controlled hypertension.
  • Severe uncontrolled hypertension on presentation (SBP > 180; DBP > 110 Hg).
  • 3 History of prior ischemic stroke > 3 months, dementia or known intra cranial pathology not covered in contraindications.
  • Traumatic or prolonged (> 10 minutes) cardio — pulmonary resuscitation (CPR) or major surgery (> 3 weeks).
  • Recent (within 2-4 weeks) internal bleeding.
  • Non – compressible vascular punctures.
  • For Streptokinase / Anistreplase; prior exposure (more than 5 days ago) or prior allergic reaction to these agents.
  • Pregnancy
  • Active peptic ulcer.
  • Active peptic ulcer.
  • Current use of anticoagulants; the higher the INR, the risk of bleeding.
  • Potent hemorrhagic focus:
    • Within 6 months of GI hemorrhage or CVA (Stroke).
    • Within 2-4 weeks of
      • Organ biopsy
      • Major trauma
      • Minor head trauma
    • Proliferative diabetic retinopathy.
    • History of bleeding diathesis, hepatic dysfunction and / or malignancy.
#Responsible PartyWhat should be done 
1Medical residentWhile administering thrombolytic therapy attention to control chest pain is most important.
1)       IV nitroglycerine — start at 5 mcg / minute and titrate for control of pain;
2)       Avoid hypotension (systolic pressure less than 90 mmHg.) and sinus tachycardia if more than 110 bpm.
3)       Morphine sulphate — give 2-4 mg IV and repeat every 5 -15 minutes until pain relieved
4)       Beta-blockers should be given if there are no contraindications.
5)       e) Follow ACLS algorhythms for the management of dysrhythmias.
Also;
·          Complete the pre thrombolytic check list.
·          Evaluate any case of chest pain / equivalent referred to him.
·          Establish whether the patient fulfills the criteria of STEMI.
·          Initiate Clinical Pathway for uncomplicated STEMI/ NSTEMI
·          Decide if it is a case of acute STEMI, whether the patient is a candidate for thrombolytic therapy.
·          Explain the risks and benefits of the therapy to the patient / patient representative and may obtain consent verbally and document in the medical record. The patient's signature on a consent form is not required.
·          Fill the Intravenous "Thrombolytic Therapy Reperfusion Check List" and sign, date, time and stamp it.
2consultant cardiologist ConsultationConsultant Cardiologist will be consulted when:
·          The case is not typical
·          Any contraindications are present.
·          All the classic criteria are not met.
·          When there is any doubt.
·          For the choice of thrombolytic agent, follow the Thrombolytic Therapy Standing Order.
·          Initiate and sign the appropriate adapted orders.
3Assigned Nurse·          Assigned nurse will start Pre therapy management:
·          Assess and record baseline data i.e. vital signs, skin color and temperature; CNS: orientation, reflexes; CVS: peripheral perfusion.
·          Review medical history for existing or previous conditions that -
·          Require cautious use of thrombolytic agents.
·          Contraindicate use of thrombolytic agents.
·          Ensure the establishment of Clinical Pathway for uncomplicated STEMI/ NSTEMI.
·          Ensure that one- nurse remains at patient's bed side observing the patient during the administration of thrombolytic agent.
·          Establish minimum two peripheral venous lines, with # 18 or # 20 gauge cannula prior the administration of thrombolytic agent.
·          Ensure emergency trolley is at bedside and ready for use.
·          Medication administration: follow thrombolytic therapy standing order.
·          Follow thrombolytic therapy standing order once it is filled, signed, stamped and timed by the Medical resident on duty.
·          Monitor patient for vital signs every 15 minutes during the therapy and then hourly.
·          Monitor patient for any potential internal or external bleeding.
·          Monitor patient for any signs of allergic reactions and inform doctor promptly.
·          Avoid arterial invasive procedures and IM injections before and during the therapy.
·          Maintain patient on bed rest during entire course of therapy and avoid handling patient unnecessarily because bruising occurs readily.
·          Document appropriately.
4Consultant in- charge / on call·          Respond promptly to the call of Medical resident.
·          Refer the patient to Consultant Cardiology.

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