AISpostTpa

First 24 hr post TPA

  • Get CTA of head and neck if not contraindicated, creatine normal.
  • No antiplatelet (including aspirin), no anticoagulant for 24 hours
  • Bed rest
  • Keep BP <185/105
  • Acetaminophen if temperature over 38 degree C
  • Treat hyperglycemia to achieve a range of 140-180
  • Avoid arterial puncture, Foley, NG if possible
  • VTE prophylaxis with SCD
  • Swallow eval, ST, PT, OT
  • Order CT or MRI AT 24 hour post tpa, to check for bleed
  • Document stroke type, more information.

Angioedema

  • Occurs in 1-8 percent of patients
  • Usually mild and transient.
  • Discontinue tpa if still infusing and hold ACEI
  • If only lips and anterior tongue involve, monitor closely
    • If palate or pharynx are involved, may need intubation
  • Medications:
    • Methylprednisolone iv 125 mg
    • Diphenhydramine 50 mg iv
    • Ranitidine 50 mg or Famotidine 20 mg iv
  • If further increase in angioedema: epinephrine 0.1% 0.3 ml sq or by nebulizer 0.5 ml
  • Icatibant, a selective bradykinin B2 receptor antagonist, 3 mL (30 mg) sq in abdominal area. Additional injection of 30 mg may be given at intervals of 6 h not to exceed total of 3 injections in 24 h.
  • Plasma-derived C1 esterase inhibitor (20 IU/kg) has been successfully used in hereditary angioedema and ACEI-related angioedema

CTA results:

  • high grade stenosis or thrombosis at
    • Carotid or Middle cerebral artery
    • or other large artery