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EMS POST-ALTEPLASE/ACTIVASE RECOMMENDATIONS FOR ACUTE ISCHEMIC STROKE

These recommendations should be sent with EMS 1. Alteplase Treatment Dosing Recommendations (To be completed by transferring facility): • Calculated total dose = mg (0.9 mg/kg, not to exceed 90 mg) Bolus dose (10% of total) = mg over 1 minute. Time Administered: Infusion dose (90% of total) = mg over 60 minutes. Time infusion started: Time Infusion expected to be completed = Time Infusion completed = • When bag empty, inject 20 mL of NS into Alteplase IV bag and continue infusion at same rate until bag empty.

2. During and Post-Alteplase infusion recommendations: • Obtain and Record vital signs and neurological assessment q 15 minutes for 2 hours, then q ½ hour for 6 hours, then q 1 hour for 16 hours. • If O2 Sat below 94% start O2 at 2L to maintain oxygenation greater than 94% Strict NPO • If BP greater than 180/105, increase frequency of vital signs and administrator antihypertensive. See medication recommendation in section 4 below. • Limit venous or arterial puncture for 24 hours following completion of Alteplase infusion. Apply direct pressure or pressure dressing to any compressible sites. • Bedrest • HOB 30 degrees • Do not give anticoagulant modifiers or antiplatelets such as: Aspirin, Heparin, Low Molecular Weight Heparin, Warfarin, Dabigatran, Rivaroxaban, Apixaban, Edoxaban, Ticagrelor, Prasrugrel or clopidogrel for 24 hours. • Monitor for signs of angioedema. If present, see medication recommendation in section 4 below. • If clinical suspicion of ICH (neurologic deterioration, severe headache, acute hypertension, or nausea and vomiting) do the following: a. Discontinue Alteplase if still infusing. b. Notify receiving facility of change in status to obtain further recommendations.

3. Medication recommendations: • BP management: • Labetalol IV 10-40 mg q 15 minutes prn to maintain BP within target (start with 10 mg, if not effective may double dose up to 40 mg (max 300 mg per day) • Nicardipine IV continuous infusion start at 5 mg per hr, increase the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum to 15 mg/hr to maintain BP within target • Angioedema management: • Diphenhydramine (Benadryl) 25 mg IV q 6 hrs prn

4. Transfer Preparation: • Obtain Emergency contact number for family or caregiver to obtain further information Send copies of all patient records (include a copy of this completed form). • Send copy of CT scan on disk • Provide a copy of these recommendations to the transport team. • Review with transport team the IV bolus given, total IV infusion and expected time infusion should be completed. • Transport team to continue to obtain and document vital signs and Neurological assessment q15 min. Continue to monitor for complications and follow recommendations above.

NOT IN EPIC Department of Neurosurgery Revised: 12/29/2016