Checklist: Bleed post TPA

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Half life of TPA is ~5 minutes and only 20% is present and active 10 mins after completion of infusion, but PT and PTT prolongation and fibrinogen levels are decreased x 24 hours or more.

Checklist:

  • STOP alteplase
  • VS q15h, GCS, pupil response, treat BP, increased ICP
  • Neurosurgery consult
  • DIAGNOSTICS: STAT CT head, PT/PTT, platelets, fibrinogen, type and cross 2-4 unit pRBC
  • THERAPEUTICS:
  1. Transfuse cryoprecipitate 6-8 units IV
    1. If fibrinogen 50-100mg/dL transfuse 10 bags
    1. If fibrinogen <50 mg/dL transfuse 20 bags
  2. Check fibrinogen level 30-60 mins post transfusion, goal fibrinogen level >100 mg/dL
  3. ALTERNATIVE: transfuse single donor platelets or 6-8 bags of random donor platelets

*each bag of cryoprecipitate contains 200-250 mg of fibrinogen, increases fibrinogen levels by 6-8 mg/dL (in a 70 Kg adult)

*half life of fibrinogen is 3-5 days

Reference:

Gross, H. and Grose, N. (2017). Emergency Neurological Life Support: Acute Ischemic Stroke. Neurocritical Care, 27(S1), pp.102-115.

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