Thrombolytic Therapy (Alteplase) – Stroke Nursing Care in ER

00:01 Let's talk about thrombolytic therapy. Okay. This is an amazing thing.

00:06 One time when I was in California working with the hospital there, there was a young mother of 3, a single mother of 3, who came in with the left side of her body paralyzed.

00:17 I mean, it was a horrible looking like it was going to be an outcome.

00:21 They got her in quickly. They gave her thrombolytic therapy, and she walked out of the hospital with barely any residual.

00:28 So when it works, it is a beautiful thing.

00:32 The problem is, this therapy has a very high risk, too.

00:37 It can cause bleeding, rampant hemorrhaging anywhere in the body, including your head.

00:45 So, we do everything we can to minimize the risk of that happening, because I have another memory of a cardiac patient who received thrombolytic therapy, and he was the sole provider for multiple generations in his family; for his mother, for his wife, and for his daughter.

01:05 He had -- we went through all the risk factors with him, came up like it was a good decision to give the medication, and yet he ended up having a massive head bleed, and unfortunately died.

01:16 So when it works, it's a beautiful thing, but don't ever get too comfortable with giving a thrombolytic.

01:23 Watch your patient really closely and do your screening carefully.

01:28 Because this is called alteplase. It's an example of one.

01:31 It's a recombinant tissue plasminogen activator.

01:34 That's why we call it tPA - tissue plasminogen activator.

01:41 It rapidly, and I cannot underscore that word, rapidly, like, boom, like a bomb goes off, it dissolves all the blood clots.

01:50 Not just the ones like that you specifically want to dissolve, it dissolves every blood clot.

01:56 So, that increases your risk of bleeding which that knocks some people out who are at a high risk for hemorrhage.

02:03 So we're going to look for risk factors that would identify patients who are at high risk for hemorrhage. Here's some examples.

02:10 If Mr. Johnson had current active internal bleeding, he's out.

02:15 This would not be a safe option for him.

02:18 If he had recently had a head trauma, he's out, because if he recently had a head trauma, he might have had some bleeding in his head, and then we would have clots in there that could be broken open.

02:29 So, he's been to CAT scan, we know he doesn't have active bleeding now, but if he'd had a recent head trauma, that would also knock him out.

02:37 They'd had recent surgery, they have GI bleeding, same thing.

02:41 If they have a low platelet count. Aha! Remember? We did that lab work, initially, when you came in like an octopus and took care of all these things for Mr. Johnson all at the same time, where you're getting vitals and lab and getting him to CAT scan.

02:56 We drew a lot of lab that let us know about his clotting.

02:59 If we found out from the CBC that he had a low platelet count, platelets' job is to clump and to clog and to form plugs.

03:08 So if we know already he has a low platelet count, he's a bleeder.

03:13 It's not a really professional term, but you get the concept.

03:16 So we don't want to give somebody who already has low platelet count a thrombolytic.

03:20 If we knew he had intracranial bleeding that would knock him out, but that's why we did the CAT scan. So we knew if it was a hemorrhagic stroke, and we also knew if he had any bleeding going on anywhere else.

03:31 Now, if he had untreated high blood pressure, so a persistent blood pressure > 185/110.

03:39 Someone who maybe he didn't know he had high blood pressure or sometimes people are hesitant to take their blood pressure medication.

03:46 They know they should, or maybe they don't have the resources to pay for their medication.

03:51 Whatever the case, if we knew that Mr. Johnson's blood pressure was consistently and persistently elevated, that would rule him out for thrombolytics because he would be at an increased risk to experience severe bleeding.

04:04 Now, the last one. If Mr. Johnson had been on anticoagulant therapy, if he had an elevated PT or INR, remember, we drew those labs, then he would also be knocked out.

04:15 So you can see how critical it is in a very fast-paced environment that nurses get as complete a history as they possibly can.

04:23 It's not as easy as it sounds, especially when most people in the emergency room are in crisis and they're stressed.

04:30 So you're really going to have to practice being calm and remaining calm when family members and patients get extremely agitated from anxiety.

04:40 Okay. So let's put this in a checklist for you.

04:42 Call this an Alteplase Checklist. Now, each hospital probably has a set standard policy, and maybe they even have a special form or own electronic health record, but you'll have to think through these questions.

04:54 So, if the patient has, we're thinking about alteplase, does he have a clinical diagnosis of acute ischemic stroke, and some definite neurological deficit? Well, think about Mr. Johnson.

05:05 We knew from the CAT scan that he has ischemic stroke, and he definitely has the definite neurologic deficit.

05:12 Remember, his speech is difficult and it's slow, and he has weakness, one-sided weakness.

05:18 We went through the checklist. He doesn't have any bleeding risk contraindications.

05:24 We know that it's been less than 4 hours from the start of his symptoms, so we have to hurry, but it's okay to start alteplase.

05:31 See, that's why it matters.

05:33 That's why we need to get him to CT quick and get the results quick, and meet with the family quickly because we have 4 hours from the time that his symptoms started.

05:44 Now think back in your notes of report.

05:46 What time did his symptoms start? Right. 8:15.

05:52 So, we've got to get this into him before 12:15, right? That's what we're looking for.

05:58 The reason is, this is such a high-risk medication.

06:03 We have about a 4-hour window where if we restore perfusion to the brain, that tissue will come back.

06:09 If it's longer than 4 hours, if Mr. Johnson had been experiencing this for 8, 10, 12 hours, there'd be no reason to risk a thrombolytic because that tissue is gone, dead.

06:22 It's not coming back.

06:24 So it wouldn't be worth the risk of giving a thrombolytic.

06:27 Now, if you don't know when the symptoms started, that's a little more shady, right? We're not sure what to do. There's some gray there.

06:36 You just work with the family or people that are with the patient, try and figure out the last time the patient was known to be their normal neuro baseline, and that's the time that you go with.

06:47 Now, the patient needs to be older than 18 years of age, they cannot be pregnant.

06:52 We make sure that we've ruled out hypoglycemia.

06:55 So we know that the cause of this neuro change is not because they have low blood sugar.

07:00 Remember, in the beginning when we did a finger stick blood sugar at the bedside plus we drew lab? That helped us rule that out. That's why we did it.

07:08 And then the CAT scan or MRI showed no signs of hemorrhage.

07:12 Okay. Pause the video. I know you've heard me use a lot of words.

07:17 Pause the video.

07:18 And for every one of these checklists, I want you to repeat what you know about Mr. Johnson's progress through the health care system.

07:29 Okay. Welcome back.

07:32 This is what you will do mentally, also, when you're taking care of these types of patients and before you hang the alteplase.

07:38 See, here's the deal. We're on the same team.

07:42 But as a nurse, if you're the one that gives the alteplase, you need to be very clear that you've thought through all these areas because yes, physicians write the orders, but we are professionally responsible and ethically responsible that we give medications safely.