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• What is the best way to start investing?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What are the tax implications of investing in the stock market?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• What is the difference between a traditional IRA and a Roth IRA?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What is the best way to start investing?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What are the tax implications of investing in the stock market?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• What is the difference between a traditional IRA and a Roth IRA?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What is the best way to start investing?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What are the tax implications of investing in the stock market?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• What is the difference between a traditional IRA and a Roth IRA?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What is the best way to start investing?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What are the tax implications of investing in the stock market?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• What is the difference between a traditional IRA and a Roth IRA?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What is the best way to start investing?

  In the U.S., the terms lawyer and attorney are often used interchangeably. A lawyer provides legal services such as giving legal advice, writing legal documents and providing policy counsel to governments. An attorney, on top of these things also holds a state or regional license to represent clients in a law court.

• What are the tax implications of investing in the stock market?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I improve my credit score?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• What is the difference between a traditional IRA and a Roth IRA?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

• How can I reduce my tax liability as a self-employed individual?

  Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sit convallis nunc neque, bibendum pulvinar vitae commodo velit. Proin diam tortor sed malesuada nunc, habitant. Dignissim ipsum porta enim, magna urna, quam.

Acute Ischemic Stroke - LYTICS

Thrombolytic Treatment

• TNK Eligibility
  • Patients of any age with suspected ischemic stroke within 4.5 hours of last known well.
  • Selected patients beyond 4.5 hours from last known well, with unwitnessed time of onset.
  • See more details regarding eligibility criteria below (GWTG Goal Times).
• TNK Criteria (2018 AHA/ASA Guidelines)
  Within 4.5 hrs:

  • No upper age limit
  • SBP <185 or DBP <110 (see pretreatment recommendations below)

  Exclusions:

  • CT brain imaging exhibits extensive regions of clear hypoattenuation
  • Ischemic stroke within 3 months
  • Severe head trauma within 3 months
  • Intracranial/intraspinal surgery within 3 months
  • History of intracranial hemorrhage
  • Suspected subarachnoid hemorrhage
  • GI malignancy or recent GI bleed
  • Platelets <100 000/mm3, INR >1.7, aPTT >40 s, or PT >15 s
  • LMWH within 24 hours
  • DOAC within 48 hours
  • High suspicion of infectious endocarditis
  • Suspected aortic dissection
  • Suspected intra-axial intracranial neoplasm

  Beyond 4.5 hours from last known well (based on published WAKE UP trial: https://www.nejm.org/doi/full/10.1056/NEJMoa1804355)

  • Unwitnessed event (recognized symptoms upon awakening or unable to report timing of onset due to, for example, confusion or aphasia)
  • MRI suggestive of more recent onset of event (Based on MRI-DWI positivity and FLAIR negativity
  • Note that acute MRI may be challenging to obtain in some practice environments and this may limit eligibility by this criteria.
  • Age up to 80 years and functionally independent
  • No LVO; LVO patients are prioritized for EVT
  • Not severe stroke (NIHSS <=25)
  • Meets other standard IV thrombolytic eligibility other than time from last known well
• Goal Times (GWTG)
  • Determine “Last Known Well” time. WITHIN 5 MIN OF ED ARRIVAL
  • Activate Stroke Team (513-584-8282) WITHIN 10 MIN OF ED ARRIVAL
  • Perform non-contrast CT scan and CTA (head/neck). WITHIN 20 MIN OF ED ARRIVAL
  • Draw bloods for lab tests (CBC, renal, coags, pregnancy, fingerstick glucose).
  • Obtain fingerstick glucose promptly to determine IV thrombolytic eligibility.
  • Do not delay thrombolytic for other lab results unless clinical suspicion of abnormality.
  • Establish two IV lines.
  • Record blood pressure.
  • Gently treat (usually labetalol 10 mg to start, assuming no clinical contraindications) if ≥185 systolic or ≥110 diastolic if potential IV thrombolytic candidate (details below).
  • Review eligibility criteria for IV thrombolytic (details below)
  • Interpret CT scan -- rule out bleed or subacute ischemia. WITHIN 35 MIN OF ARRIVAL
  • Start IV thrombolytic bolus if eligible. WITHIN 45 MIN OF ARRIVAL 
• TNK Dosing
  • Mix IV thrombolytic (rt-PA)
  • Recommended Dosage for Acute Ischemic Stroke (AIS)
    • Initiate treatment as soon as possible and within 3 hours after the onset of stroke symptoms.
    • TNKase is for IV administration only, administered as a single bolus over 5 seconds.
    • Maximum recommended dose is 25 mg (5 mL). Increased Risk of Heart Failure and Recurrent Ischemia when used with recommended dose is 25 mg (5 mL).
    • Administer as bolus over 5 seconds, followed by a 10mL bolus of 0.9% sodium chloride (NS).
    • Individualize dosage based on the patient’s weight (see Table 1 below).
• Adjunctive / Additional therapies
  • Potential IV thrombolytic candidates should not receive antiplatelets (aspirin, clopidogrel) or anticoagulants (heparin, warfarin, or DOACs) upon arrival to ED.
  • However, patients who have taken antiplatelets prior to arrival in the Emergency Department are still considered IV thrombolytic candidates and those taking anticoagulant medications may still be candidates as well.
  • At 24 +/- 6 hours, a non-contrast CT scan or MRI should be performed (to rule out any intracranial hemorrhage) before starting an antiplatelet or anticoagulant medication.
• Consider NICU Transfer
  Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:

  • Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
  • Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
  • Fluctuating neurological symptoms requiring specialized blood pressure management.
    Hold infusion and repeat head CT stat
  • Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.
• Post-IV thrombolytic stroke monitoring
  Admit patient to ICU and follow post-IV thrombolytic order set, including:

  • Monitor BP and neuro status:
    Q15 min X 2 hours, q30 min X 6 hours, then q1 hour X 16 hours
  • Treat SBP≥180 or DBP ≥105 (details below)
  • Call stroke physician at 513-584-8282 if there is a decline in neuro status, new headache, nausea, or vomiting.
    Hold infusion and repeat head CT stat
  • NPO until swallowing assessed
  • DVT prophylaxis with intermittent stocking compression devices (SCDs) but no anticoagulants

  Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:

  • Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
  • Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
  • Fluctuating neurological symptoms requiring specialized blood pressure management.
    Hold infusion and repeat head CT stat
  • Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.
• BP management considerations: PRE-TREATMENT
  For IV thrombolytic candidates: BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.

  • BP MANAGEMENT PRIOR TO IV THROMBOLYTIC ADMINISTRATION
  • Up to two of the following agents may be used for nonaggressive treatment:
    • Labetalol 10 to 20 mg IV over 1-2 minutes, may repeat X 1 (max dose 40 mg)
    • Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5-15-minute intervals (up to max dose 15 mg/h; when desired BP attained, reduce to 3 mg/h)
    • Enalaprilat 0.625 to 1.25 mg IV (up to max dose of 1.25 mg)
    • Hydralazine 10 mg IV over 1-2 minutes, may repeat X1 (max dose 20 mg)
    • Nitropaste 1 to 2 inches (up to max dose of 2 inches)
  • If IV thrombolytic not planned, then permissive HTN up to 220/120 may be reasonable
• BP management considerations: POST-TREATMENT
  During/after treatment with thrombolytic or other acute reperfusion intervention, BP must be aggressively maintained at SBP <180 or DBP <105 BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.

  • Monitor BP every 15 minutes for first 2 hours, then every 30 minutes for next 6 hours, then every hour for the next 16 hours.
  • Monitor blood pressure every 15 minutes during the antihypertensive therapy. Observe for hypotension.
    
    BLOOD PRESSURE MANAGEMENT DURING/AFTER ADMINISTERING IV thrombolytic
    If systolic BP ≥180–230 mm Hg or diastolic BP ≥105–120 mm Hg:
    
    • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
    • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h
    If BP not controlled or diastolic BP >140 mm Hg:
    
    • Consider IV sodium nitroprusside
• Management of sICH after thrombolysis
  • If an sICH is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
  • Suspect sICH if there is any acute neurological deterioration (new headache, acute hypertension, seizure, or nausea and vomiting) or acute increase in BP.
  • If hemorrhage is suspected, then do the following:
    
    
    
    Management of sICH after thrombolysis is the same with tenecteplase as it is with alteplase.
• Management of angioedema after thrombolysis
  • If angioedema is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
  •  
  • 

Acute Ischemic Stroke (2023)

Thrombolytic Treatment - AIS

• TNK Eligibility
  • Patients of any age with suspected ischemic stroke within 4.5 hours of last known well.
  • Selected patients beyond 4.5 hours from last known well, with unwitnessed time of onset.
  • See more details regarding eligibility criteria below (GWTG Goal Times).
• TNK Criteria (2018 AHA/ASA Guidelines)
  Within 4.5 hrs:

  • No upper age limit
  • SBP <185 or DBP <110 (see pretreatment recommendations below)

  Exclusions:

  • CT brain imaging exhibits extensive regions of clear hypoattenuation
  • Ischemic stroke within 3 months
  • Severe head trauma within 3 months
  • Intracranial/intraspinal surgery within 3 months
  • History of intracranial hemorrhage
  • Suspected subarachnoid hemorrhage
  • GI malignancy or recent GI bleed
  • Platelets <100 000/mm3, INR >1.7, aPTT >40 s, or PT >15 s
  • LMWH within 24 hours
  • DOAC within 48 hours
  • High suspicion of infectious endocarditis
  • Suspected aortic dissection
  • Suspected intra-axial intracranial neoplasm

  Beyond 4.5 hours from last known well (based on published WAKE UP trial: https://www.nejm.org/doi/full/10.1056/NEJMoa1804355)

  • Unwitnessed event (recognized symptoms upon awakening or unable to report timing of onset due to, for example, confusion or aphasia)
  • MRI suggestive of more recent onset of event (Based on MRI-DWI positivity and FLAIR negativity
  • Note that acute MRI may be challenging to obtain in some practice environments and this may limit eligibility by this criteria.
  • Age up to 80 years and functionally independent
  • No LVO; LVO patients are prioritized for EVT
  • Not severe stroke (NIHSS <=25)
  • Meets other standard IV thrombolytic eligibility other than time from last known well
• Goal Times (GWTG)
  • Determine “Last Known Well” time. WITHIN 5 MIN OF ED ARRIVAL
  • Activate Stroke Team (513-584-8282) WITHIN 10 MIN OF ED ARRIVAL
  • Perform non-contrast CT scan and CTA (head/neck). WITHIN 20 MIN OF ED ARRIVAL
  • Draw bloods for lab tests (CBC, renal, coags, pregnancy, fingerstick glucose).
  • Obtain fingerstick glucose promptly to determine IV thrombolytic eligibility.
  • Do not delay thrombolytic for other lab results unless clinical suspicion of abnormality.
  • Establish two IV lines.
  • Record blood pressure.
  • Gently treat (usually labetalol 10 mg to start, assuming no clinical contraindications) if ≥185 systolic or ≥110 diastolic if potential IV thrombolytic candidate (details below).
  • Review eligibility criteria for IV thrombolytic (details below)
  • Interpret CT scan -- rule out bleed or subacute ischemia. WITHIN 35 MIN OF ARRIVAL
  • Start IV thrombolytic bolus if eligible. WITHIN 45 MIN OF ARRIVAL 
• TNK Dosing
  • Tenecteplase (TNKase) - 0.25mg/kg (maximum 25mg). Administer as a bolus over 5 seconds, followed by a 10mL bolus of 0.9% sodium chloride (NS).
  • OR, if tenecteplase is not available, use alteplase (Activase) - 0.9 mg/kg dose (maximum 90 mg). Administer 10% as bolus over 1-2 minutes and the remainder as an infusion over 60 minutes.
  • Do not use the cardiac dose.
  • Do not exceed the maximum dose.
  • Use rt-PA = tenecteplase = TNKase. Do not use other thrombolytic agents. Use alteplase (Activase) only if tenecteplase is unavailable in the adult population. Note that the dose is different for each IV thrombolytic (see above).
  • Do not give aspirin, clopidogrel, heparin, warfarin or other oral anticoagulants for the first 24 hours after IV rt-PA.
• Adjunctive / Additional therapies
  • Potential IV thrombolytic candidates should not receive antiplatelets (aspirin, clopidogrel) or anticoagulants (heparin, warfarin, or DOACs) upon arrival to ED.
  • However, patients who have taken antiplatelets prior to arrival in the Emergency Department are still considered IV thrombolytic candidates and those taking anticoagulant medications may still be candidates as well.
  • At 24 +/- 6 hours, a non-contrast CT scan or MRI should be performed (to rule out any intracranial hemorrhage) before starting an antiplatelet or anticoagulant medication.
• Consider NICU Transfer
  Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:

  • Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
  • Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
  • Fluctuating neurological symptoms requiring specialized blood pressure management.
    Hold infusion and repeat head CT stat
  • Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.
• Post-IV thrombolytic stroke monitoring
  Admit patient to ICU and follow post-IV thrombolytic order set, including:

  • Monitor BP and neuro status:
    Q15 min X 2 hours, q30 min X 6 hours, then q1 hour X 16 hours
  • Treat SBP≥180 or DBP ≥105 (details below)
  • Call stroke physician at 513-584-8282 if there is a decline in neuro status, new headache, nausea, or vomiting.
    Hold infusion and repeat head CT stat
  • NPO until swallowing assessed
  • DVT prophylaxis with intermittent stocking compression devices (SCDs) but no anticoagulants

  Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:

  • Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
  • Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
  • Fluctuating neurological symptoms requiring specialized blood pressure management.
    Hold infusion and repeat head CT stat
  • Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.
• BP management considerations: PRE-TREATMENT
  For IV thrombolytic candidates: BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.

  • BP MANAGEMENT PRIOR TO IV THROMBOLYTIC ADMINISTRATION
  • Up to two of the following agents may be used for nonaggressive treatment:
    • Labetalol 10 to 20 mg IV over 1-2 minutes, may repeat X 1 (max dose 40 mg)
    • Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5-15-minute intervals (up to max dose 15 mg/h; when desired BP attained, reduce to 3 mg/h)
    • Enalaprilat 0.625 to 1.25 mg IV (up to max dose of 1.25 mg)
    • Hydralazine 10 mg IV over 1-2 minutes, may repeat X1 (max dose 20 mg)
    • Nitropaste 1 to 2 inches (up to max dose of 2 inches)
  • If IV thrombolytic not planned, then permissive HTN up to 220/120 may be reasonable
• BP management considerations: POST-TREATMENT
  During/after treatment with thrombolytic or other acute reperfusion intervention, BP must be aggressively maintained at SBP <180 or DBP <105 BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.

  • Monitor BP every 15 minutes for first 2 hours, then every 30 minutes for next 6 hours, then every hour for the next 16 hours.
  • Monitor blood pressure every 15 minutes during the antihypertensive therapy. Observe for hypotension.
    
    BLOOD PRESSURE MANAGEMENT DURING/AFTER ADMINISTERING IV thrombolytic
    If systolic BP ≥180–230 mm Hg or diastolic BP ≥105–120 mm Hg:
    
    • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
    • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h
    If BP not controlled or diastolic BP >140 mm Hg:
    
    • Consider IV sodium nitroprusside
• Management of sICH after thrombolysis
  • If an sICH is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
  • Suspect sICH if there is any acute neurological deterioration (new headache, acute hypertension, seizure, or nausea and vomiting) or acute increase in BP.
  • If hemorrhage is suspected, then do the following:
    
    
    
    Management of sICH after thrombolysis is the same with tenecteplase as it is with alteplase.
• Management of angioedema after thrombolysis
  • If angioedema is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
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