Unique Plan Description: tPA Complications
Plan Selection Display: tPA Complications
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2023-07-25 14:29:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-07-25 14:29:00
Available at all facilities: No

tPA Complications
Patient Care

Post tPA Angio edema Treatment
Vital Signs
	Vital Signs
		T;N, Q15MIN, then if stable q1h. SBP goal <160mmHg
Medications
	methylPREDNISolone
		125 mg, Injection, IV Push, Once, STAT
	diphenhydrAMINE
		50 mg, Injection, IV Push, Once, STAT
	famotidine
		20 mg, Injection, IV Push, Once, STAT
	EPINEPHrine 1 mg/mL injectable solution
		0.3 mg, Injection, SUBCUTANEOUS, Once, STAT
			Comment: MD discretion, risk of increased BP and hemorrhage
Patient Care
	Discontinue Medication
		T;N, Discontinue tPA if drip still going.
	No ACE (angiotensin converting enzyme) inhibitors
		
	Notify MD
		T;N, Notify ED or ICU MD of signs of angioedema or airway compromise
	Obtain supplies/equipment
		T;N, Assemble airway supplies/Crash cart
	Neurological Assessment-Focused
		T;N, Q15MIN, 4, Dose(s)/Time(s)
			Comment: then if stable q1h
Consults/Follow-up
	Consult Neurologist
		Reason for Referral: ICH on CT
	Consult Tele Neurology (JEFH)
		Reason for Referral: ICH on CT

Post tPA Hemorrhage Treatment
Vital Signs
	Vital Signs
		T;N, Q15MIN, 4, Dose(s)/Time(s), then if stable q1h. SBP goal <160mmHg
Laboratory
	CBC with Diff
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
		T;N+240, Routine, spec type = Blood
	Type and Crossmatch (Product Available)
		T;N, Stat, Need by STAT, # to HOLD 2, To be Transfused
			Comment: For Possible Transfusion
	Fibrinogen Level - MH/WH/JE
		T;N, Stat, spec type = Blood
	Fibrinogen Level - FH
		T;N, Stat, spec type = Blood
	Fibrinogen Level - MH/WH/JE
		T;N+90, Timed, spec type = Blood
			Comment: To be drawn 30 minutes after Cryoprecipitate infusion complete
	Fibrinogen Level - FH
		T;N+90, Timed, spec type = Blood
			Comment: To be drawn 30 minutes after Cryoprecipitate infusion complete
Cryopreciptate
	Cryoprecipitate
		T;N, Stat, # to GIVE 2, # to HOLD 0 (Zero), Need by STAT, No Requirements, To be Transfused
			Comment: MUST Call blood bank to notify of need for cryoprecipitate. 10 of single cryo u= 2 pre-pooled units
Platelet Pheresis
	Platelet Pheresis
		T;N, Stat, # to GIVE 1, # to HOLD 0 (Zero), Need by STAT, No Requirements, To be Transfused
			Comment: To be given if platelet count < 100,000.  MUST Call blood bank to notify of need for platelets
Diagnostic Tests

	CT Head w/o Contrast
		T+1;0400, Routine, Hemorrhage
	CT Head w & w/o Contrast
		T+1;0400, Routine
IV Solutions
	niCARdipine 20mg/NS 200mL
		200 mL, IV, STAT, Start: T;N, Duration: 1 Dose(s)/Time(s), Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter with SBP < 160mmHG. Discontinue order after 12hr if patient does not require IV re-initiation.
		20 mg, EVERY BAG, 5 mg/hr
	niCARdipine 25 mg/NS 250 mL
		250 mL, IV, Routine, Start: T;N+240, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter SBP < 160 mmHG. Discontinue order after 12hr if patient does not require IV re-initiation.
		25 mg, EVERY BAG, 5 mg/hr
	nicardipine 20mg/NS 200mL premix
		20 mg, EVERY BAG, 5 mg/hr
		200 mL, IV, STAT, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter with SBP < 160mmHG. Discontinue order after 12hr if patient does not require IV re-initiation.
Medications
	labetalol  injection
		10 mg 2 mL, Injection, IV Push, Q10MIN, PRN, see comment, T;N, Duration: 2 Dose(s)/Time(s)
			Comment: systolic bp > 160 mmHG. Give over 2 minutes. Notify MD if labetalol 10mg, IV q 10 min PRN x2 doses is not effective
	tranexamic acid IVPB
		15 mg/kg, INT, IVPB, Once, STAT, T;N, Infuse Over 20 min(s)
			Comment: infuse over 20 min. Pharmacy to round to nearest 1gm dose
	aminocaproic acid
		5,000 mg, INT, IVPB, Once, STAT, infuse over 1 hr
			Comment: Follow 5gm bolus with 1gm/hr infusion x8hr
		8,000 mg, INT, IVPB, Once, infuse over 8 hr, T;N+60
			Comment: To infuse over 8hr following 5gm bolus
Patient Care
	Order Lab
		T;N, Fibrinogen Level To be drawn 30 minutes after Cryoprecipitate infusion complete
		T;N, Order 2 units of Cryo if Fibrinogen < 150 after first cryo transfusion
	Discontinue Medication
		T;N, Discontinue tPA if drip still going.
	Neurological Assessment-Focused
		T;N, Q15MIN, 4, Dose(s)/Time(s)
			Comment: then if stable q1h
	Notify MD
		T;N, Notify MD of neurological decline, SBP > 160mmHG, or signs of bleeding.
Consults/Follow-up
	Consult Neurologist
		Reason for Referral: ICH on CT
	Consult Tele Neurology (JEFH)
		Reason for Referral: ICH on CT

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase