Acs Thrombolytic Therapy Protocol 002

ADDRESSOGRAPH
GREY BRUCE HEALTH NETWORK

Page 1 of 4 SITE: __________________
Allergies: □ NKA or: __________________________
Weight (kg) _______________
ACS Thrombolytic Therapy Protocol
Inclusion Criteria (For Thrombolysis, patient must have all four)

Yes No Characteristic chest pain lasting more than 30 min
Yes No ST elevation greater than 1 mm in two or more contiguous limb leads, new complete left bundle
branch block, or ST elevation greater than 2 mm in more than 2 contiguous precordial leads
Yes No Onset of chest pain 12 hours or less before expected start of infusion
Yes No No contraindications to thrombolytic therapy (see Exclusion Criteria below)
Exclusion Criteria
1a Yes No Is there evidence of aortic dissection? Tearing mid scapular pain, radiating to lower back, BP
difference R-L arm greater than 15 mmHg, pulse deficits, mediastinal widening
1b Yes No Is there evidence of pericarditis? Chest pain with pleuritic component, worse in recumbent position,
pericardial rub, typical ECG appearance
1c Yes No Is there evidence of active bleeding? Current Hemoptysis, Hematemesis, rectal bleeding, melena
stool, current trauma with blood loss, obvious bleeding
If answer to any #1 questions is yes – DO NOT ADMINISTER thrombolytic therapy
2a Yes No Has there ever been a proven/suspected cerebral hemorrhage?

2b Yes No Is there a proven/suspected intracerebral malignancy?
2c Yes No Is there a proven/suspected intracerebral A-V malformation?
2d Yes No Has there been a proven non-hemorrhagic CVA in the past 6 months?
2e Yes No Has there been a GI bleed in the past 6 months? Hematemesis, melena, rectal bleed, positive stool
for occult blood?
2f Yes No Has there been major surgery, organ biopsy or puncture of a non compressible vessel in past 2 – 4
weeks?
2g Yes No Has there been prolonged CPR with chest trauma in past 2 – 4 weeks?
2h Yes No Has there been multiple trauma in the past 2 – 4 weeks?
2i Yes No Has there been any head trauma in the past 2 – 4 weeks?
2j Yes No Is there diabetic proliferative retinopathy?
2k Yes No Is there severe uncontrolled hypertension? Systolic greater than 200 or Diastolic greater than 120?
2l Yes No Is there a history of bleeding diathesis, unexplained or prolonged bleeding, hemophilia or factor
deficiencies, platelet disorders?
2m Yes No Is there a history of significant liver dysfunction or kidney disease?
2n Yes No Is there a current diagnosis of cancer?
2o Yes No Is the patient, or could the patient be pregnant?
2p Yes No Is the duration of this infarct pain greater than 12 hours?
If the answer to any #2 question is yes, the relative risks and benefits should be considered prior to initiating
thrombolytic therapy
N/2/GBHN/CS/-/ACS_Thrombo/MD/10-07/V1/- Copyright © 2007 Grey Bruce Health Network
NOTE: this is a CONTROLLED document as are all management system files on this server. Any documents appearing in paper form are not controlled
and should ALWAYS be checked against the server file versions (electronic version) prior to use.
ADDRESSOGRAPH

Page 2 of 4 SITE: __________________
Allergies: □ NKA or: __________________________
Weight (kg) _______________
COMPLETE
Children’s ASA (80-81 mg) 2 chewable tabs STAT
ECG STAT
Start 2 Saline Locks #18 Gauge
Reviewed Physician’s checklist for ineligibility
Discussed complications and actions with patient
Ensure blood drawn before thrombolytics given
(CBC, Electrolytes, Creatinine, Glucose random, APTT, INR, CK, Troponin, Group & Screen)
IV Puncture sites identified and “dead-ended”
Apply pressure dressings to vena puncture sites
Note: Check with physician for catheter order prior to thrombolytics
Baseline Neurovitals then Q2H X 24 hours
ECG 60min post thrombolytic infusion
Follow Thrombolytic Orders
Thrombolytic Therapy Tenecteplase (TNKase)

1. Reconstitute as per directions – dilute TNKase 50 mg with 10 mL sterile water for injection provided to give a
concentration of 5 mg/mL, using the dual cannula device included in the package. Inject sterile water into the TNKase vial
directing diluent down the side of the vial and into the powder.
2. Do NOT Shake – roll vial gently until powder is dissolved. Allow the vial to stand to settle foam.
3. Give weight adjusted ________ TNKase IV over 5 seconds (given by physician at SBGHC and HDH)
4. Flush line with 10 mL Sodium Chloride
Anticoagulants
under 75 years (HDH and SBGHC only):
1. Enoxaparin 30 mg IV bolus by Dr. _______________________
2. Flush line with 10 mL Sodium Chloride
3. Immediately follow with Enoxaparin Subcutaneous, according to weight 1mg/kg________ Subcutaneous (max 100
mg for 1st two Subcutaneous doses)
4. Continue Enoxaparin 1 mg/kg ________ Subcutaneous Q12H until discharge or revascularization - max of 7 days
Note: If Creatinine clearance is less than 30 mL/min (see chart on back), discontinue Q12H Enoxaparin. Start Heparin infusion
12 hours after last Subcutaneous Enoxaparin (no Heparin bolus). Heparin 25,000 units/500 cc saline at ______________cc/h
(12 units/kg, max 1000 units or 20 cc/h). PTT 6 hours post then follow nomogram.
OR
under 75 years
1. Immediately follow with Enoxaparin Subcutaneous, according to weight 1mg/kg________ Subcutaneous (max 100
mg for 1st two Subcutaneous doses)
OR
ADDRESSOGRAPH

Page 3 of 4 SITE: __________________
Allergies: □ NKA or: __________________________
Weight (kg) _______________

over 75 years
1. Immediately follow with Enoxaparin Subcutaneous, according to weight 1 mg/kg________ Subcutaneous (max 75 mg for
1st two Subcutaneous doses)
(max 75 mg for 1st two Subcutaneous doses)
OR
patients with renal impairment

1. Immediately follow with Enoxaparin Subcutaneous, according to weight 1 mg/kg________ Subcutaneous
OR
Unfractionated Heparin
Less than 68 kg give IV Heparin bolus 60 units/kg ________ (max 4000 units)
Follow with Heparin drip 25,000 units in 500 mL D5W at an initial infusion rate of 12 units/kg (max 1000 units/h)
PTT 6 hours after initiation of therapy then follow Thrombolytic Heparin Nomogram
Greater than 68 kg give IV heparin bolus 5000 units
Follow with Heparin drip 25,000 units in 500 mL D5W to start at 1000 units/hr (20 ml/hr)
PTT 6 hours after initiation of therapy then follow Thrombolytic Heparin Nomogram
ADDRESSOGRAPH

Page 4 of 4 SITE: __________________
Allergies: □ NKA or: __________________________
Weight (kg) _______________
Serum Creatinine at which the estimated Creatinine

Clearance is less than 30 mL/min
Age Male Female
21-25 Greater than 345 Greater than 295
TNKase weight chart

PATIENT WT (kg) TNKase (mg) VOLUME OF TNKase (mL)
Less than 60 30 6
60 – 69 35 7
70 – 79 40 8
80 – 89 45 9
Greater than 90 50 10

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ADDRESSOGRAPH

GREY BRUCE HEALTH NETWORK