• Start IV Normal Saline and send Stat CBC, PT/INR, PTT, Glucose, General Screen.
• Stat EKG
• Notify CT Technician and Attending Stroke Neurologist.
• Obtain patient's Weight (from patient, helicopter or nursing staff, or estimate)
• Do a rapid History and Physical, including: (Response to ALL should be YES)
  • NIH Stroke Scale Score < 22
  • Age >18
  • Time of known and <=3 hours
  • Systolic BP <=185, Diastolic BP <=110
  • Not a minor stroke or rapidly resolving
  • No prior intracranial hemorrhage, neooplasm, AVM or aneurysm
  • Not taking warfarin (within 48 hours)
  • Not receiving heparin during hte past 48 hours with elevated PTT
  • Platelet count <=100,000
  • No acute myocardial infarction
  • Blood sugar >=50 and <= 400 mg/dl
  • No major surgical procedures within 14 days
  • No prior stroke or serious head injury within 3 months
  • PT <=15 seconds or INR <=1.7
  • No seizure at onset of stroke
  • No gastrointestinal or urinary bleeding within preceding 21 days
  • No Lactation or Parturition within 30 days and Not Pregnant
  • Patient and/or Family aware of risk of hemorrhage (1 in 16) and potential benefit (30% greater chance of improvement to No or Minimal Disability) and have obtained consent
• If all the above are TRUE:
  • Call Nursing Supervisor to arrange bed in Stroke Unit
  • Take 2 vials of rtPA (50 mg each) and 2 vials of sterile non-bacteriostatic water for dilution syringes and needles to Radiology - CT Scan
• If CT demonstrates NO Hemorrhage or early changes of Recent Infarction (sulcal effacement, mass effect, or edema), then initiate therapy:
  • A. Calculate Dose: Weight in Kg * 0.90 mg/kg or 90 mg (whichever is less)

    B. Give 10% of dose as Bolus, then infuse remainder over 60 minutes as a constant infusion.

• Transfer to the Stroke Unit with the following orders:
  • Cardiac Monitoring for 24 hours
  • NPO for 24 hours
  • BP and Neuro checks: q15 minutes x 2 hours, q30 minutes x 6 hours, q60 minutes x 16 hours
  • Notify stat if [180<SBP<120] or [105<DBP<70]
  • Notify stat if change in neurologic status or bleeding
  • Bedrest x 24 hours
  • No arterial punctures or central lines unless sodium nitroprusside required
  • No NG tube x 24 hours
  • No bladder catheter x 30 minutes
  • No ASA, Heparin, Ticlopidine, Warfarin, NSAID x 24 hours
  • CBC, PT, PTT, CT scan without at 24 hours.

If Called by Nursing Staff:

• For Suspected Major Bleeding or Intracranial Hemorrhage:
  • Stop infusion if still in progress
  • Stat Fibrinogen, CBC w/ platelets, PT, PTT, FDP
  • Type and Cross 4 units PRBCs, 6 units Cryoprecipitate, 2 units FFP, 1 unit Platelets
  • Stat CT scan without contrast of head if Intracranial Hemorrhage suspected
• If Elevated BP:
  • If [180<SBP<120] OR if is [105<DBP<120] for two or more readings 5-10 minutes apart:
    • Give IV labetalol 10 mg over 1-2 minutes. The dose may be repeated or doubled every 10-20 minutes up to a total dose of 150 mg.
    • Monitor blood pressure every 15 minutes during labetalol treatment and observe for development of hypotension.
  • If [SBP>230] or if [121<DBP<140] for two or more readings 5-10 minutes apart:
    • Give IV labetalol 10 mg over 1-2 minutes. The dose may be repeated or doubled every 10 minutes up to a total dose of 150 mg.
    • Monitor blood pressure every 15 minutes during labetalol treatment and observe for development of hypertension.
    • If no satisfactory response, infuse Sodium Nitroprusside (0.5-10 ug/kg per minute)*
    • Continue monitoring blood pressure
  • If [DBP>140] for two or more readings 5-10 minutes apart:
    • Infuse Sodium Nitroprusside (0.5-10 ug/kg per minute)*.
    • Monitor blood pressure every 15 minutes during infusion of Sodium Nitroprusside and observe for development of hypotension.

*Continuous arterial monitoring is advised if sodium nitroprusside is used. The risk of bleeding secondary to an arterial puncture should be weighed against the possibility of missing dramatic changes in pressure. 

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