Alteplase

INTRODUCTION

Indications

Acute myocardial infarction (MI). Acute ischemic stroke. Pulmonary embolism (PE). Occluded central venous access devices. Unlabeled Use: Deep venous thrombosis (DVT). Acute peripheral arterial thrombosis.

Action

Directly converts plasminogen to plasmin, which then degrades clot-bound fibrin. Therapeutic Effects: Lysis of thrombi in coronary arteries, with improvement of ventricular function, and reduced risk of heart failure or death. Lysis of pulmonary emboli. Lysis of thrombi causing ischemic stroke, reducing risk of neurologic sequelae. Restoration of cannula or catheter function.

Adverse Reactions/Side Effects

CNS: INTRACRANIAL HEMORRHAGE. EENT: epistaxis, gingival bleeding. Resp: bronchospasm, hemoptysis. CV: reperfusion arrhythmias, hypotension, RECURRENT ISCHEMIA/THROMBOEMBOLISM. GI: GI BLEEDING, nausea, RETROPERITONEAL BLEEDING, vomiting. GU: GU TRACT BLEEDING. Derm: ecchymoses, flushing, urticaria. Hemat: BLEEDING. Local: hemorrhage at injection site, phlebitis at injection site. MS: musculoskeletal pain. Misc: ALLERGIC REACTIONS, INCLUDING ANAPHYLAXIS, fever.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; coughing up blood; black, tarry stools; hematuria; fall in hematocrit or blood pressure). Be especially alert for signs of intracranial bleeds, including sudden severe headache, confusion, nausea, vomiting, paralysis, numbness, speech problems, visual disturbances. Notify physician or nursing staff immediately if these signs occur.

• Be alert for signs of recurrent cardiac ischemia (chest pain, pain radiating into the arm or jaw, shortness of breath, dizziness, sweating, anxiety) or recurrent cerebral ischemia (sudden dizziness, vertigo, slurred speech, incoordination, numbness). Notify physician or nursing staff immediately if these signs occur.

• Monitor signs of recurrent thromboembolism and PE (shortness of breath, chest pain, cough, bloody sputum). Notify physician immediately, and request objective tests (Doppler ultrasound, lung scan, others) if PE is suspected.

• Monitor signs of allergic reactions or anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.

• Assess heart rate, ECG, and heart sounds when cardiac perfusion is restored (see Appendices G, H). Report any rhythm disturbances or symptoms of increased arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess blood pressure, especially for the first few days after infusion. Report low blood pressure (hypotension), especially if patient experiences dizziness or syncope.

• Assess any muscle of joint pain to rule out musculoskeletal pathology or hemorrhage; that is, try to determine if pain is drug induced rather than caused by anatomic or biomechanical problems. Be especially concerned about back pain that could indicate retroperitoneal bleeding.

• Assess injection site during and after IV administration, and report signs of bleeding or phlebitis (local pain, swelling, inflammation).