Thrombolysis (Mercy Hosptial of Pittsburgh protocols 4/1/90)
with revision of TPA into more "front loaded" protocol per ED clinical
protocol.

Eligibility
===========

Mercy Hospital:
--------------
  - Suggestive chest pain for more than 30' despite SL NTG
  - ST elevation >= 1.0 mm in 2 contiguous leads
    (or appropriate chest pain and LBBB per Vanderbilt ED)
  - less than 75 years old
  - TPA can be given within 6 hours.

per ACEP "Foresight" #33, January 1995
--------------------------------------
"Candidates for thrombolytic therapy are those patients with typical symptoms
of MI accompanied by ECG findings of St segment elevation greater than 2 mm in
two or more contiguous precordial leads, greater than 1 mm in two or more
contiguous limb leads, or a new bundle branch block. Thrombolytic therapy also
should be strongly considered in patients with a clinical history and
presentation highly suggestive of AMI accompanied by left bundle branch block,
2nd or 3rd degree A-V block, Q waves greater than 2 mm, T wave inversion, or
any arrhythmia.  Following these criteria will prevent the administration of
thrombolytics to patients with conditions that would deteriorate following
thrombolysis." [cites: The GUSTO investigators. An international randomized
trial comparing four stretegies for acute myocardial infarction. N Engl J Med
1993;329(10):573-582.]

Note:  some patients may have MI secondary to aortic dissection reaching the
coronary ostia.

Consider PTCA if excluded from thrombolytics.

PDR warnings from SK, t-PA, APSAC inserts:
------------------------------------------
 "In the following conditions, the risks of thrombolytic therapy may be
 increased and should be weighed against the anticipated benefits:
 - recent (within 10 days) major surgery
 - cerebravasular disease
 - recent (within 10 days) GI or GU bleeding
 - recent (within 10 days) trauma, including CPR
 - hypertension:  systolic > 180 and/or diastolic > 110
 - high likelihood of left heart thrombus (e.g., mitral stenosis with atrial
   fibrillation)
 - subacute bacterial endocarditis
 - acute pericarditis
 - hemostatic defects, including those secondary to severe hepatic or renal
   disease
 - pregnancy
 - age > 75
 - diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions
 - patients currently receiving oral anticoagulants
 - any other condition in which bleeding constitutes a a significan hazard or
   would be particularly difficult to manae because of it location."}

Treatment:
==========
  - Baseline CBC+platelets, PT/PTT, BUN/Cr/lytes, and cardiac enzymes
  - Two large-vein peripheral IV's
  - TPA:  if over 65 kg. give 100 mg:  15 mg over 2 min, then 50 mg over 30
    minutes, then 35 mg for 1 hour.
  - If less than 65 kg. give 15 mg over 2 minutes, then 0.75 mg/kg over 30
    minutes (max 50 mg) then 0.5 mg/kg (max 35 mg) over 60 minutes.  (This is
    also the new dosage regimen recommended by the PDR insert.)
  - Check BP Q 15'
  - Aspirin 160-325 mg daily
  - Heparin 5000 u bolus and 1000 units/hr, to keep PTT 1-1/2 to 2 times
    control.  Draw PTT NO SOONER than 1/2 hr. after completion of TPA infusion.
    Heparin must be in separate line from TPA, but may be given with Lido.
    Start at 1200 mg/hour if over 80 kg.
  - (Prophylactic lidocaine originally part of protocol but now dropped).
Contraindications:
  - Unclear dx.
  - Possible aortic dissection or pericarditis
  - Recent GI bleed or suspected active ulcer disease.
  - Surgery, biopsy, trauma, obstetric delivery, or CPR within past 2 weeks
  - Intracranial neoplasm, AVM, or aneurysm.
  - Intracranial or intraspinal surgery within past 2 months.
  - History of a CVA.
  - Severe uncontrolled HTN (SBP > 180 or DBP > 110)
  - Pregnancy.
  - Hemorrhagic diabetic retinopathy.
  - Known hemostatic defects, including secondary to severe renal or liver
    disease, or oral anticoagulants (e.g., warfarin, coumadin)
More suggested contraindications from Vanderbilt ED:
  (- CPR for more than 10 minutes)
  (- history of a TIA)
  (- central vein or artery puncture within last 4 days)

  - Atenolol 5 mg IV over 5 minutes, repeat in 10 minutes if HR over 60,
    then 50 mg orally if HR more than 60.

  - MgSO4 2 grams IV over 1st hour, then 0.65g/hour for 24 hours (unless
    creatinine > 3.0, or SBP < 100, moderate to severe CHF, or worse than 1st
    degree AV block.

Follow-up care
  - Blood draws via 22ga needle, then pressure for 10', then pressure dressing
  - Avoid CVP lines, arterial lines, and ABG's.
  - Routine CCU protocols and H/H and PT/PTT Q8H x 24H then QD x 2D.
Management of complications (Annals of Internal Medicine 111:1010-1022,
    12/15/89)
  - Bleeding from punctures:  pressure for 30' then pressure dressing
  - Uncontrolled or internal bleeding, stop TPA and heparin, and reverse
    heparin with protamine.<Protamin.TXT>
  - For massive or life-threatening bleeding, give cryoprecipitate 10 units to
    replete fibrinogen and Factor VIII.  If bleeding persists, check fibrinogen
    level; if less than 100, give 10 units more cryo, then give 2 units FFP
    (fresh frozen plasma) to replete Factor V.
  - For bleeding unresponsive to cryo and FFP, give 10 units of platelets.
  - As a last resort, give Amicar (epsilon amino caproic acid) 5 grams in 250 NS
    over 30-60 minutes, followed by 0.5-1.0 grams per hour.