Intravenous Thrombolytic Therapy
CRITERIA FOR THROMBOLYSIS:
- Ischemic chest pain of at least 15 minutes duration, and unrelieved with sublingual nitroglycerine (2 times).
- 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.
- 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.
- 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).
- 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.
- 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 Party||What should be done|
|1||Medical resident||While 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.|
|· 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.|
|2||consultant cardiologist Consultation||Consultant 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.|
|3||Assigned 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.|
|4||Consultant in- charge / on call||· Respond promptly to the call of Medical resident.|
|· Refer the patient to Consultant Cardiology.|