Alteplase (trade names Activase, Actilyse) is a protease (enzyme)-the conversion of plasminogen to plasmin for breakdown blood clots.

1. ACUTE ISCHEMIC
STROKE
ON ALTEPLASE THERAPY
(THROMBOLYSIS)
Nursing Management
By WONG PEI YIN (Charissa)
BSN, SRN

2. Definitions – What is STROKE?
• A stroke is a sudden impairment in brain function.
• It occurs when blood flow to an area of brain cut off.
• Brain cells are deprived of oxygen and begin to die.
• Abilities controlled by that area of the brain such as memory,
sensation and muscle control are lost.

3. STROKE
Ischemic
stroke
Thrombotic Embolic
Hemorrhagic
stroke
Aneurysm
Arteriovenous
malformation
HTN
Stroke 85% - Blockage Stroke 15% - Bleed

5. Thrombolytic Drug: Recombinant tissue
plasminogen activator (rt-PA)
• Alteplase (trade names
Activase, Actilyse)
• is a protease (enzyme)-the
conversion of plasminogen to
plasmin for breakdown blood
clots.

7. Brain cells DIE every MIINUTE, increasing the risk of permanent
brain damage, disability or death

8. Side effects
• Bleeding (ICH, GIB, incision, catheter, or needle injection)
• Allergic reaction: Urticaria; SOB; Orolingual angioedema
(swelling of face, lips, tongue, or throat)

9. Indications for IV r-tPA
• Acute ischemic stroke
• Less than 4.5 hours from onset of stroke
• Age 18 - 80 years old
• National Institute of Health Stroke Scale (NIHSS)
between 6 to 20

10. Contraindications for IV rt-PA
• Time of onset unknown
• GCS with fixed eye deviation and ≤ 8
• Seizure have occurred at onset of stroke
• Stroke or serious head injury or surgery within the past 3 months
• CT brain show MCA infarction greater than 1/3 of MCA territory
• Uncontrolled hypertension with ≥ 180/110 mmHg.
• Mild or rapidly improving symptoms
• Taking an oral anticoagulant (ex: warfarin) regardless of INR
• Received heparin within the last 48 hours and Platelet count < 100,000
• INR > 1.7
• Glucose levels < 2.8 mmol/L or 22.0 mmol/L

11. Acute stroke in ED flow chart
Step 1: Is it a stroke? Perform FAST assessment:
• Face – smile, facial asymmetry?
• Arms – raise both arms, is one side weak?
• Speech – unable to? Slurred?
• Time – Act fast could be candidate for Alteplase
Consider non-stroke
diagnosis and proceed with
routine management
Routine stroke care
Symptom onset within 4.5
hours?
Possible candidate for
Alteplase
NO
YES
YES
NO

12. Step 2: Immediately management for
potential thrombolysis patient
• Vital signs every 15 minutes
• Obtain urgent blood ix (FBC, RP, PT/APTT/INR, DXT, GSH)
• Insert two large venofix (eg: 18 G)
• Perform ECG
• Perform NIHSS
• Provide O2 therapy if needed
• Keep patient NBM
• Withhold anticoagulants and anti-platelets
• Keep family members with patient
• Get patient’s estimated weight
• Prepare to escort patient for urgent CT brain

13. Step 3: After CT brain, has stroke consultant instructed Alteplase to be given and has
the medication prescription been charted by a doctor? If YES, proceed
• Consent for r-tpa
• Cardiac monitoring
• Recommended dose is 0.9 mg/kg (not to
exceed 90 mg total dose),
• 10% of the total dose administered as an
initial intravenous bolus over 1 minute
and the remainder infused over 60
minutes.

17. Step 5: During & Post Alteplase management NURSING
INTERVENTIONS
Neurological observations for signs of increase intracranial pressure or bleeding
• Vital sign & GCS every 15 minutes for 2 hours
• Then every 30 minutes for the next 4 hours
• Then hourly
Reportable observations
• Hypertension (if SBP ≥ 180/110 mmHg )
• Hypotension (SBP ≤ 110 mmHg)
• Temp ≥ 38 °C
• Signs of bleeding (e.g. from IV site, gum bleed)
• Deteriorate GCS, worsening stroke symptoms, headache)
• Allergic reaction (including peri-oral angioedema)

18. RISK FACTORS for symptomatic
intracranial hemorrhage
• Older age
• Greater stroke severity
• Higher baseline glucose
• Hypertension
• Congestion heart failure
• Renal impairment
• Ischemic heart disease
• Baseline antiplatelet use
• Symptomatic intracranial hemorrhage
(sICH) after IV tPA for ischemic
stroke occurs in 2%-7% of patients.
• Approximately half of sICH occur by
10hours after treatment IV tPA, with
the rest occuring by 36 hours.
• ICH occur after 36 hours is not likely
due to tPA.
• Patients with ICH have mortality rates
up to 83%
References: Andrew N. Wilner, MD (2018). Risk of Intracranial Hemorrhage After tPA: 5 Important Facts. Stroke

19. Reminder
• Minimize delays between bolus and infusion
• Alteplase infused through one IV line and IV fluids or IV co-medication
administer through another IV line
• Do not use a razor blade for shaving for 24 hours
• Avoid NG tube insertion for 24 hours if possible
• Safety precautions to prevent falls
• Minimise invasive procedures
• CRIB for 24 hours
• NBM with hydration support (IV drip)
• If baseline DXT is high, DXT 4 hourly (otherwise avoid needle sticks)

20. THANK YOU!