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    Ventura County Medical Center: Mi Thrombolysis, Management of

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    Ventura County Medical Center: Mi Thrombolysis, Management of

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    blackcat657
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    Thrombolysis.pdf

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    Ventura County Medical Center: Mi Thrombolysis, Management of

    Uploaded by

    blackcat657

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3
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    The key takeaways are the criteria for candidates and contraindications for thrombolysis in acute myocardial infarction (MI) as well as the typical post-thrombolysis medications and their purposes.

    Definite candidates are patients under 75 years old presenting with chest pain consistent with acute ST segment elevation MI and at least 0.1 mV of ST elevation in at least two contiguous EKG leads within 12 hours of treatment, as well as those presenting with a bundle branch block obscuring ST analysis within 12 hours.

    Absolute contraindications include previous hemorrhagic stroke, ischemic or embolic stroke within 1 year, known intracranial neoplasm, active internal bleeding, and suspected aortic dissection.

    VENTURA COUNTY MEDICAL CENTER

    CLINICAL PRACTICE GUIDELINES / PROTOCOLS

    MI THROMBOLYSIS, MANAGEMENT OF
    The contents of this clinical practice guideline are to be used as a guide. Healthcare professionals should use
    sound clinical judgment and individualize patient care. This CPG is not meant to be a replacement for
    training, experience, CME or studying the latest literature and drug information.

    I. CANDIDATE FOR THROMBOLYSIS IN ACUTE MI.

    A. DEFINITE:

    1. Patients who present with chest pain consistent with a diagnosis of acute ST segment
    elevation MI and at least 0.1 mV of ST segment elevation in at least 2 contiguous EKG leads
    with time to treatment 12 hours or less, age less than 75 years.
    2. Patients who present with chest pain consistent with a diagnosis of acute MI and a Bundle
    Branch Block (obscuring ST- segment analysis) with time to treatment 12 hours or less, age
    less than 75 years.

    B. PROBABLE:
    1. Patients 75 years or older who present with chest pain consistent with a diagnosis of acute ST
    segment elevation MI and at least 0.1 mV of ST elevation in at least two contiguous EKG
    leads with time to treatment 12 hours or less.

    II. CONTRAINDICATIONS:

    A. ABSOLUTE
    1. Previous hemorrhagic stroke at any time
    2. Ischemic or embolic stroke within 1 year
    3. Known intracranial neoplasm
    4. Active internal bleeding (does not include menses)
    5. Suspected aortic dissection

    B. RELATIVE
    1. Uncontrolled HTN>180/110 mmHg
    1. HX of prior CVA or known intracerebral pathology not covered in absolute
    contraindications.
    2. Use of anticoagulants in therapeutic doses (INR> 2)
    3. Coagulopathy
    4. Recent trauma (within 2-4 weeks), including head trauma, major surgery (<3 weeks) or
    prolonged CPR>10 minutes.
    5. Non compressible vascular puncture.
    6. Recent (within 2-4 weeks) internal bleeding
    7. Pregnancy
    8. Active peptic ulcer
    9. Chronic severe hypertension

    III. PROCEDURE:

    A. The Cardiologist or the Staff ER Attending in consultation with the cardiologist or intensivist
    will initiate thrombolytic therapy in the ER. The cardiologist will be notified as soon as possible.
    The Attending Staff Physician will be present during the procedure until the patient's condition is
    stable.

    B. GENERAL CARE:

    1. Start two IVs, one IV for drug access, one IV with large bore (16-18 gauge) Jelco in large
    stable vein of forearm opposite first IV site along with 3-way stopcock and heparin lock
    to be used for drawing lab work.
    2. 02 via nasal cannula at 2 liters/min-to keep 02 sat>90%
    3. Check vital signs-notify MD immediately if BP>160/90 or <100 systolic
    VCMC CPG
    Page 2 of 3
    MI Thrombolysis, Mgmt of

    4. Continuous EKG monitoring looking for arrhythmias or ST changes


    5. NPO except for meds and sips of water
    6. Have infusion pump with guardrails available.
    7. Monitor BP with automatic BP device-

    C. LAB

    1. STAT LAB
    A. EKG, CXR
    B. CBC, lytes, creatinine, glucose, serial cardiac enzymes, INR, aPTT, and stool
    guaiac
    2. REPEAT LAB
    A. EKG
    EKG repeated after first dose of RETAPLASE and after second dose. Repeat
    EKG at 4 hours, 12 hours post admission and daily for 3 days.
    B. CXR-on admission
    C. CARDIAC ENZYMES
    Repeat at 4,8,12 hours after admission, then twice daily for 48 hours.
    D. aPTT
    See THROMBOLYTIC AGENTS

    D. MEDS:

    1. ASPIRIN - 325 mg stat -chew and swallow, then ASA 81 mg daily.


    If NPO, ASA 325 mg per rectum

    2. THROMBOLYTIC AGENT- Door-to-needle time < 30 minutes


    Reteplase (Retavase )
    HEPARIN 60 units/kg (max5000units) is given followed by a constant infusion of
    heparin @ 12 micrograms per hour (max 1000 units/hr) for 24 hours.

    RETAPLASE-After heparin bolus, 10 units Reteplase is given over 2 minutes via a


    dedicated IV line in which no other medication is being infused.

    Repeat 10 units of Reteplase 30 minutes after initiation of the first bolus. If Reteplase is
    given through the heparin line, flush with normal saline before starting the RETAPLASE
    bolus.

    Check aPTT at 6 hours (target 1.5 to 2 X control or 50-75 seconds,


    (See attached arterial heparin protocol.)

    3. BETA BLOCKER: Consult Attending prior to starting. Start within 12 hours.


    MYOCARDIAL SALVAGE, RECURRENT ISCHEMIA, RAPID A FIB) – Metoprolol
    (Lopressor ®) 5 mg IV q 5 minutes X 3 doses, followed in 15 minutes by 50 mg orally
    every 6 hours for 48 hours, then 100 mg orally twice daily.

    CONTRAINDICATIONS TO BETA BLOCKER:


    Heart rate < 60 bpm
    SBP < 100 mmHg
    Acute CHF
    PR interval > 0.24 seconds, 2' or 3' AV BLOCK
    Asthma
    Concurrent use of Verapamil, diltiazem
    Severe peripheral vascular disease

    4. ATORVASTATIN (Lipitor): 80 mg is given orally stat, then 80 mg daily.

    5. CLOPIDOGREL (Plavix): 300 mg is given orally stat, the 75 mg daily


    VCMC CPG
    Page 3 of 3
    MI Thrombolysis, Mgmt of

    6. ACE INHIBITIOR:
    start low dosage (CAPTROPRIL 6.25 mg once or twice daily)
    INDICATIONS: within 24 hours of acute MI---IF: BP after thrombolysis and
    beta blocker still elevated >160 mmHg otherwise start on day 2.

    CONTRAINDICATIONS:
    SBP < 100 mmHg
    Renal failure- (creatinine > 2.5 mg/ml)
    HX bilateral renal artery stenosis
    Allergy to ACEI

    7. NITROGLYCERIN: IV FOR 24-48 hrs


    INDICATIONS:
    Acute MI & Recurrent Ischemia
    Acute MI & persistence of CHF
    Acute MI & HTN
    IV-10-20 micrograms/minute increase by 5 micrograms/minute until clinical
    response or SBP< 110 mm Hg
    SL-NTG 0.4 mg SL as needed for anginal pain

    8. LIDOCAINE:
    If significant ventricular arrhythmias are present: 1-1.5mg/Kg via IV bolus,
    may repeat 0.5 mg/Kg dose every 10 minutes up to total dose of 3mg/Kg,
    then begin drip at a rate of 1-4 mg/minute.

    9. MORPHINE:
    2-4 mg every 5 minutes slowly titrate to control pain.

    10. DOPAMINE / LEVOPHED: (per protocol)


    To keep SBP>90 mmHg
    Dopamine/ Levophed must be administered by a central line access.

    IV. CLINICAL EVIDENCE OF REPERFUSION:

    A. Prompt relief of pain after thrombolysis


    B. Decrease in ST elevation
    C. “Reperfusion arrhythmias” -late PVC's or slow VT

    V. COMPLICATIONS:

    A. If central venous access is required perform cutdown on median basilic vein.


    If arterial line required use radial artery-avoid noncompressible vessels.
    B. Serious bleeding-
    1. Stop thrombolytic and heparin
    2. Reverse heparin with protamine sulfate 25 mg IV slowly
    3. Recheck PTT
    4. Repeat protamine sulfate until PTT is less than 50 seconds
    5. Check serum fibrinogen level and replace with cryoprecipitate until greater than
    100 mg/dl.
    6. Administer 2-3 units fresh frozen plasma
    7. Transfuse with packed red blood cells as need to keep Hemoglobin>10.

    Prepared by: Dan Clark, MD


    Review / approval:
    Medicine Cmte: 3/2006
    Exec Cmte: 4/2006

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