Fibrinolytic Therapy Checklist

hi I'm mark for ACLS certification

Institute and welcome to another rapid

algorithm review today we're reviewing

the checklist for fibrinolytic therapy

for acute coronary syndrome now all

things being equal most practitioners

during an acute coronary event would

probably prefer to take their patient to

the cath lab rather than giving


I remember 20 years ago before we had

cath labs popping up like daisies we

were given TPA in the ER one of the big

risks in using a clot busting drug is I

see H or intracranial hemorrhage and

this occurs in about 3 out of every 100

patients regarding it regardless of

contraindications and you do the best

job you can 3 and 100 will develop an

inner cranial bleed now what would we

give fibrinolytic therapy rather than

taking the patient to the cath lab we

can't get into the cath lab either the

cath labs down the patient has to be

transferred somewhere for PCI

percutaneous cardiac intervention the

cath lab and we can't get them there I

live in the Chicago area and general

rule of thumb out here is if you don't

like the weather wait 10 minutes we got

two feet of snow outside right now we're

not going anywhere so this may be a case

where we can't get the patient to a cath

lab so we have to administer

fibrinolytic therapy so let's take a

look at this checklist and see is this

patient a candidate to receive TPA to

receive fibrinolytic therapy

one of the first things that the

literature points out is that this

checklist is not all-inclusive is not

all definitive it's used as a guide to

help the doctors the nurses the medics

to see if we're going to be able to give

this patient fibrinolytic therapy

without causing more damage more harm to

the patient that's the first rule of

medicine is first do no harm so we have

to make sure that we're not going to

make things worse by administering this

medication one patient presents with

signs of acute coronary syndrome next

get a 12-lead EKG take a closer look at

that heart

are they having an ST segment elevation

MI or a 'new or presumably left bundle

branch block we need to get them to the

cath lab can't get him to the cath lab

we got a look at fibrinolytic therapy so

let's go through our exclusion list

first assess their blood pressure and

the literature says the systolic between

180 and 200 and a diastolic of 100 to

110 I just remember 200 over 110 those

are the upper limits for both so if the

patient is currently hyper tense so we

need to treat that and we can we can

treat that doesn't exclude the use of it

we can give them a lopressor or some

drug we can bring their pressure down so

first assess their blood pressure next

we want to assess for a blood pressure

change greater than 15 millimeters of

mercury between the right arm and the

left arm now a normal variance between

the right arm and the left arm is

probably fine the numbers are off a

little bit that's probably okay in the

elderly this could be maybe peripheral

vascular disease and a small difference

is okay but once we get past 15

millimeters of mercury around in that

range what we're really looking for is

an aortic dissection that's why we want

to know the difference between the blood

pressure in one arm and in the other arm

it's important because an aortic

dissection can present a lot like a

heart attack the symptoms are the same

only more severe they're definitely

going to have chest pain they can be

pale diaphoretic trouble breathing an

impending sense of Doom these patients

think they're gonna die because they are

if we don't get this thing fixed or a

word is dissecting now let's first look

at the aortic vessel itself the aortic

vessel has layers to it and what's

happened in a dice

section is that intima the inside layer

of the aorta has torn and blood is

starting to pump in and literally tear

the aorta open it's creating a false

lumen and Bloods going into that lumen

pushes the vessel outward a little bit

and restricts blood flow around it

looking at the anatomy we come off the

aortic valve come around the aortic arch

the first vessel we're going to hit is

the right brachiocephalic artery that

branches off to the right subclavian and

the right carotid artery now if I have a

dissection there I've created a false

lumen I could have decreased blood flow

to the right subclavian vessel which is

going to drop the blood pressure in my

right arm that's why we have that

difference in the blood pressure and

that's really what we need to rule out

so when you have this great blood

pressure difference between one arm and

the other arm is a patient currently

having an aortic dissection those

patients definitely will not receive

fibrinolytic therapy next does the

patient have a history of structural

defect in the central nervous system did

they have a previous bleed a tumor

aneurysm these patients are definitely

not a candidate for fibrinolytic therapy

has a patient had a significant closed

head injury in the last three weeks

significant significant what's

significant this is subjective and this

is where the clinician at the bedside

really has to get into the story and see

is this a significant injury or was this

just a bonk in the head does the risk

outweigh the benefit in giving this

fibrinolytic therapy as a patient had a

recent stroke say greater than three

hours but less than three months that

patient may not be candidate for

fibrinolytic therapy any major trauma GI

bleed laser surgery within the last

month would probably exclude them from

receiving fibrinolytic therapy again

major subjective

get into that patient history does the

risk outweigh the benefit any history of

intracranial hemorrhage any time in

their life excludes them from

fibrinolytic therapy any history of

inter-cranial hemorrhage does this

patient have the history of bleeding

disorders are they currently taking

blood thinners they may not be a

candidate for TPA is the patient

currently pregnant again the literature

kind of goes back and forth on this we

need to save mom to save baby we need to

save mom again it's a relative

contraindication dive into that patient

get more of a history Knossos patient

have an advanced cancer advanced liver

kidney failure all of these again could

exclude them from receiving fibrinolytic



okay next moving down let's see if this

patients at high risk now if any of

these questions are answered yes we

really want to try to get this patient

to a cath lab first are they tachycardic

and hypotensive we need to fix that next

does the patient of science of pulmonary

oedema is this patient shocky are they

showing signs and symptoms of being in a

shock state lastly go back up to your

contraindication list did the patient

have any of these explosion criteria

checked again they may not be receiving

fibrinolytic therapy lastly it's been

determined that this patient cannot

receive fibrinolytic therapy we need to

get that patient to a cath lab period

I'm mark for ACLS certification

Institute this has been rapid algorithm

review for fiber linic checklist for

acute coronary syndrome remember like us

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I'll see you in the next video