Medication 7-910 - tPA (Tissue Plasminogen Activator)

CMH EMS & MIH Protocols

Scope of Practice:

• Registered Nurse
• Paramedic
• Community Paramedic

Route(s):

• IO, IV,

Pharmacodynamics (class and mechanism of action):

• tPA attaches to the fibrin on the clot surface and activates the fibrin-bound plasminogen. Plasmin is subsequenty cleaved from the plasminogen affiliated with the fibrin. The plasmin breaks up the molecules of fibrin, and the clot dissolves.

Pharmacokinetics:

• Half-life: 5-10 min.
• Onset time: 30 min.
• Peak action time: 60 min.
• Duration of action: Unknown.

• Peak	7	14	21	28	35	42	49	56	63	70	77	minutes
  Duration	7	14	21	28	35	42	49	56	63	70	77	minutes

Dosing:

• Refer to specific protocol(s) below for dose(s).

Indications:

• Protocol 2-880 - Suspected Stroke.

Contraindications:

• If the risk of bleeding and serious complications are greater than the potential benefit of tPA therapy. These include patients with current intracranial hemorrhage (ICH), subarachnoid hemorrhage, and those who have active internal bleeding.
• If the patient underwent recent (less than three months ago) intracranial or intraspinal surgery or suffered a serious head trauma.
• Evidence of intracranial conditions that may increase the risk of bleeding.
• Bleeding diathesis (hemorrhagic diathesis).
• Patients with severe uncontrolled hypertension.
• Do not administer tPA in any patient who had a hypersensitivity reaction to a previous dose of tPA (urticarial or anaphylactic reactions).

Pregnancy Risk Factor:

• Category C
• Risk not ruled out: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. FDA requires a relatively large amount of high-quality data on a pharmaceutical for it to be defined as Pregnancy Category A. As a result of this, many drugs that would be considered Pregnancy Category A in other countries are allocated to Category C by the FDA.

Potential Incompatibilities:

• Monitor closely with any drug that causes anticoagulation as there is an increased risk of bleeding.
• Defibrotide: Through pharmacodynamic synergism, defibrotide increases the effects of tPA drugs and is thus contraindicated.
• Prothrombin complex concentrate, human: This can cause pharmacodynamic antagonism of the tPA drugs.
• Apixaban: Apixaban and tPA drugs increase anticoagulation and can lead to an increased bleeding risk.
• Nitroglycerin: This could decrease the serum concentration of tPA drugs.
• Salicylates: These could enhance the toxic effects of thrombolytic drugs. Monitor therapy, as there is an increased risk of bleeding.

Precautions and Adverse Effects:

• The most common adverse effect is bleeding, and the most serious is a stroke. Other side effects include bruising, pulmonary edema, arterial embolism, deep vein thrombosis, orolingual angioedema, intracranial hemorrhage, shock, hypersensitivity, nausea/vomiting, seizure, ischemic stroke, thromboembolism, and sepsis.
• Perform a regular neurologic assessment on the patient.
• Check thoroughly for major or minor bleeding.
• Continuously monitor the blood pressure of the patient.
• Check for the signs and symptoms of ICH.
• Check for the signs of orolingual angioedema.
• Discontinue tPA infusion and order an emergency CT scan if the patient develops a severe headache, severe hypertension, nausea/vomiting, or a worsening neurologic examination.
• If a hypersensitivity reaction occurs in the patient, stop the tPA administration and immediately initiate supportive therapy with antihistamines and corticosteroids.

Antidote:

• Aminocaproic Acid (Amicar)

Controlled Substance Information:

• Not a scheduled drug
• The DEA and FDA have not identified this drug with a schedule classification.
• DEA number: NA.
• Narcotic: No.
• Street names: NA.

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Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.