Let's talk about thrombolytic therapy. Okay.
This is an amazing thing.
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.
I mean, it was a horrible looking like
it was going to be an outcome.
They got her in quickly. They gave
her thrombolytic therapy,
and she walked out of the hospital
with barely any residual.
So when it works, it is a beautiful thing.
The problem is, this therapy
has a very high risk, too.
It can cause bleeding, rampant
anywhere in the body, including your head.
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.
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.
So when it works, it's a beautiful
thing, but don't ever get
too comfortable with giving a thrombolytic.
Watch your patient really closely
and do your screening carefully.
Because this is called alteplase.
It's an example of one.
It's a recombinant tissue
That's why we call it tPA - tissue
It rapidly, and I cannot underscore
that word, rapidly, like,
boom, like a bomb goes off, it
dissolves all the blood clots.
Not just the ones like that you
specifically want to dissolve,
it dissolves every blood clot.
So, that increases your risk
of bleeding which
that knocks some people out who
are at a high risk for hemorrhage.
So we're going to look for risk factors
that would identify patients
who are at high risk for hemorrhage.
Here's some examples.
If Mr. Johnson had current active
internal bleeding, he's out.
This would not be a safe option for him.
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.
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.
They'd had recent surgery, they have
GI bleeding, same thing.
If they have a low platelet count.
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.
We drew a lot of lab that let us
know about his clotting.
If we found out from the CVC that
he had a low platelet count,
platelets' job is to clump and to
clog and to form plugs.
So if we know already he has a low
platelet count, he's a bleeder.
It's not a really professional term,
but you get the concept.
So we don't want to give somebody who already
has low platelet count a thrombolytic.
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.
Now, if he had untreated high blood pressure,
so a persistent blood pressure > 185/110.
Someone who maybe he didn't know
he had high blood pressure
or sometimes people are hesitant to
take their blood pressure medication.
They know they should,
or maybe they don't have the resources
to pay for their medication.
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.
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.
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.
It's not as easy as it sounds,
most people in the emergency room
are in crisis and they're stressed.
So you're really going to have to practice
being calm and remaining calm
when family members and patients get
extremely agitated from anxiety.
Okay. So let's put this in
a checklist for you.
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.
So, if the patient has, we're thinking
does he have a clinical diagnosis
of acute ischemic stroke,
and some definite neurological deficit?
Well, think about Mr. Johnson.
We knew from the CAT scan that
he has ischemic stroke,
and he definitely has the definite
Remember, his speech is
difficult and it's slow,
and he has weakness, one-sided weakness.
We went through the checklist. He doesn't
have any bleeding risk contraindications.
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.
See, that's why it matters.
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.
Now think back in your notes of report.
What time did his symptoms start?
So, we've got to get this into
him before 12:15, right?
That's what we're looking for.
The reason is, this is such
a high-risk medication.
We have about a 4-hour window where
if we restore perfusion to the brain,
that tissue will come back.
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.
It's not coming back.
So it wouldn't be worth the risk
of giving a thrombolytic.
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.
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.
Now, the patient needs to be
older than 18 years of age,
they cannot be pregnant.
We make sure that we've ruled
So we know that the cause
of this neuro change
is not because they have low blood sugar.
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.
And then the CAT scan or MRI
showed no signs of hemorrhage.
Okay. Pause the video. I know you've
heard me use a lot of words.
Pause the video.
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.
Okay. Welcome back.
This is what you will do mentally, also,
when you're taking care of these types of
patients and before you hang the alteplase.
See, here's the deal. We're on the same team.
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.