Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke

Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke is a topic covered in the Pocket ICU Management.

To view the entire topic, please or purchase a subscription.

Anesthesia Central is an all-in-one web and mobile solution for treating patients before, during, and after surgery. This collection of drug, procedures and test information is derived from Davis’s Drug, MGH Clinical Anesthesia Procedures, Pocket Guide to Diagnostic Tests, and MEDLINE Journals. Explore these free sample topics:

Anesthesia Central

-- The first section of this topic is shown below --

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
  • Consideration for thrombolytics must begin in ER.
    • Critical pathways streamline process.

-- To view the remaining sections of this topic, please or purchase a subscription --

Last updated: May 5, 2010