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Episode 899: Thrombolytic Contraindications

Emergency Medical Minute

Release Date: 04/15/2024

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Contributor: Travis Barlock MD

Educational Pearls:

  • Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes

  • Use of anticoagulants with INR > 1.7 or  PT >15

    • Warfarin will reliably increase the INR

  • Current use of Direct thrombin inhibitor or Factor Xa inhibitor 

    • aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto) 

  • Intracranial or intraspinal surgery in the last 3 months

    • Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding

  • Current intracranial or subarachnoid hemorrhage

    • History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK

  • Recent (within 21 days) or active gastrointestinal bleed

  • Hypertension

    • BP >185 systolic or >110 diastolic

    • Administer labetalol before thrombolytics to lower blood pressure

  • Timing of symptoms

    • Onset > 4.5 hours contraindicates tPA

  • Platelet count < 100,000

  • BGL < 50

    • Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics

References

1. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532

2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit