Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke
First Things First (assess for & treat the following):
Myocardial infarction (MI)
- Appropriately used thrombolytics will:
- Limit infarct size
- Improve left ventricular function
- Reduce mortality
- Once MI confirmed, other medical diagnostics and treatment should not delay implementation of reperfusion strategy
- Most benefit (ST-elevation MI, if percutaneous coronary intervention [PCI] not available within 90 minutes of first medical contact) if < 3 hrs from symptom onset
- Shorter time to reperfusion leads to better outcome
- Proven value up to 12 hrs from symptom onset
- 12-24 hrs from symptom, fibrinlysis may be indicated if signs of continuing ischemia are present
- Primary PCI
- Most rapid & reliable for restoring coronary flow
- Use instead of thrombolytics if available within 90 minutes of symptom debut
Pulmonary embolism (PE)
- Thrombolytics appropriate for confirmed massive PE only (PE with systolic blood pressure < 90 mmHg)
- Hemodynamic instability: hypotension with right ventricular strain
- Modest, careful volume resuscitation: ~1 L, cautious vasoactive/inotropic support if progressive deterioration
- Respiratory insufficiency: hypoxemia or respiratory distress
- Oxygen therapy
- Intubate for refractory hypoxemia or frank respiratory distress.
- Diagnostic testing in unstable patients
- CT angiogram to confirm massive PE
- Consider supporting tests available in ICU/ER for decision to anticoagulate if CT not available.
- Echocardiography
- Lower extremity duplex ultrasound
- CXR
- EKG
- D-dimer; PaO2
Stroke (acute ischemic stroke)
- Time is critical (for patients eligible for tPA)
- < 3 hrs from clearly defined symptom onset to IV thrombolytic administration
- Decreased risk of death
- Improved neuro outcome
- 3-4.5 hrs from symptom onset, no indication for IV thrombolytics
- >4.5 hours, strong recommendation against use of thrombolytics for ischemic stroke
- No thrombolytics for patients with extensive stroke (>1/3 MCA territory) or clear hypodensity on CT
- Streptokinase associated with bleeding complications in ischemic stroke, contraindicated
- Intra-arterial thrombolytics suggested if available for middle cerebral artery occlusion, (within 6 hrs from symptom onset)
- For confirmed acute basilar artery occlusion, IV or intra-arterial thrombolysis may be useful if available
- Streptokinase associated with bleeding complications in ischemic stroke, contraindicated
- < 3 hrs from clearly defined symptom onset to IV thrombolytic administration
- Consideration for thrombolytics must begin in ER.
- Critical pathways streamline process.
There's more to see -- the rest of this topic is available only to subscribers.
Last updated: May 5, 2010
Citation
"Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke." Pocket ICU Management, PocketMedicine.com, Inc, 2010. Anesthesia Central, anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534210/4/Thrombolysis_Anticoagulation_Recommendations_for_MI_PE_Stroke.
Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke. Pocket ICU Management. PocketMedicine.com, Inc; 2010. https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534210/4/Thrombolysis_Anticoagulation_Recommendations_for_MI_PE_Stroke. Accessed October 4, 2024.
Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke. (2010). In Pocket ICU Management. PocketMedicine.com, Inc. https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534210/4/Thrombolysis_Anticoagulation_Recommendations_for_MI_PE_Stroke
Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke [Internet]. In: Pocket ICU Management. PocketMedicine.com, Inc; 2010. [cited 2024 October 04]. Available from: https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534210/4/Thrombolysis_Anticoagulation_Recommendations_for_MI_PE_Stroke.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC
T1 - Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke
ID - 534210
Y1 - 2010/05/05/
BT - Pocket ICU Management
UR - https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534210/4/Thrombolysis_Anticoagulation_Recommendations_for_MI_PE_Stroke
PB - PocketMedicine.com, Inc
DB - Anesthesia Central
DP - Unbound Medicine
ER -