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anyone given TPA and TXA to same pt?


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So I had a pt recently with a significant  cva who received tpa on recommendation of the on call stroke neurologist via telestroke robot. shortly after completion of the tpa infusion they developed a significant h/a without neuro deficits. I repeated a noncontrast head CT and fortunately they had no visible bleed at that time. I know how to deal with anticoagulated head bleeds, but have not specifically had to deal with a post TPA head bleed. I imagine I would try FFP, platelets, K-centra and TXA +/- hypertonic saline and mannitol and transfer to a facility with neurosurg availability.. has anyone had to deal with this before?  any pointers. I am in the process of doing some research.

just found this: https://www.emra.org/emresident/article/management-of-post-tpa-intracerebral-hemorrhage/

they recommend cryoprecipitate as well.

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Thrombolytic Reversal

We recommend discontinuing thrombolytic agents when intracranial hemorrhage is present or suspected (Good Practice statement).

We suggest using cryoprecipitate (10 units initial dose) in patients with thrombolytic agent-related symptomatic intracranial hemorrhage who have received a thrombolytic agent in the previous 24 hours (Conditional recommendation, low quality evidence).

In cases where cryoprecipitate is contraindicated or not available in a timely manner, we suggest using an antifibrinolytic agent (tranexamic acid 10–15mg/kg IV over 20min or ε-aminocaproic acid 4–5 g IV) as an alternative to cryoprecipitate (Conditional recommendation, very low quality evidence).

We suggest checking fibrinogen levels after administration of reversal agents. If the fibrinogen is less than 150mg/dL, we suggest administration of additional cryoprecipitate (Conditional recommendation, very low quality evidence).

It is unclear if platelet transfusion is useful and we cannot offer a recommendation at this time.

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage- Executive Summary. A Statement for Healthcare Professionals From the Neurocritical Care Society and the Society of Critical Care Medicine. .pdf

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  • 1 month later...

I just had this patient last week. Patient had a massive embolic stroke followed by life-threatening bleeding after tPA.

We transfused a 10-pack of cryo and a loading dose of Amicar (aminocaproic acid) prior to going to the OR (long story), but I think TXA would have worked just as well. Decided against FFP as the patient was not warfarin anticoagulated and the INR of FFP is only 1.6. I think adding PCC/Kcentra or Factor VII would have been reasonable things as well if you need to "throw the kitchen sink at it".

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8 hours ago, narcan said:

I just had this patient last week. Patient had a massive embolic stroke followed by life-threatening bleeding after tPA.

We transfused a 10-pack of cryo and a loading dose of Amicar (aminocaproic acid) prior to going to the OR (long story), but I think TXA would have worked just as well. Decided against FFP as the patient was not warfarin anticoagulated and the INR of FFP is only 1.6. I think adding PCC/Kcentra or Factor VII would have been reasonable things as well if you need to "throw the kitchen sink at it".

did they survive in a meaningful way?

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  • 2 weeks later...

Had another tPA gone bad case this week. 82 yof, relatively healthy, with NIHSS of 5 and given tPA. 3 hours later when she gets to my ICU, she acutely developed right hemiplegia. Massive left hemispheric ICH. Discussed with the neurointensivist at our referral hospital who recommended against TXA, so we just gave a 10-pack of cryo. 

I did find this review by EMRA that at least talks about all of the options while admitting there is no data for any of it: https://www.emra.org/emresident/article/management-of-post-tpa-intracerebral-hemorrhage/

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  • 3 weeks later...

I think you "can." The bigger question is whether there is anything you can do that will actually help. I doubt it. To me, TPA is pulling the trigger...once the bullet is out of the barrel, you can't get it back. That is why it is so alarming how neurologists give it like asking a nurse to give a glass of water. I have heard of patients with completely resolved symptoms getting TPA ordered by the neurologists in my shop...

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1 hour ago, lightbearer06 said:

I think you "can." The bigger question is whether there is anything you can do that will actually help. I doubt it. To me, TPA is pulling the trigger...once the bullet is out of the barrel, you can't get it back. That is why it is so alarming how neurologists give it like asking a nurse to give a glass of water. I have heard of patients with completely resolved symptoms getting TPA ordered by the neurologists in my shop...

yup, I wonder how many of these tpa "saves" are actually TIAs that would have resolved anyway.

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  • 3 weeks later...
On 2/16/2019 at 5:46 AM, narcan said:

I just had this patient last week. Patient had a massive embolic stroke followed by life-threatening bleeding after tPA.

We transfused a 10-pack of cryo and a loading dose of Amicar (aminocaproic acid) prior to going to the OR (long story), but I think TXA would have worked just as well. Decided against FFP as the patient was not warfarin anticoagulated and the INR of FFP is only 1.6. I think adding PCC/Kcentra or Factor VII would have been reasonable things as well if you need to "throw the kitchen sink at it".

If you don't mind my asking - why the tPA in a massive embolic stroke? These are known to cause significant vasogenic edema, are prime setups for hemorrhagic conversion, and lytics are generally not recommended in these patients... was it a stroke that evolved?

Just curious,

G

 

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