Moderator EMEDPA Posted December 9, 2018 Moderator Share Posted December 9, 2018 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. Quote Link to comment Share on other sites More sharing options...
Boatswain2PA Posted December 16, 2018 Share Posted December 16, 2018 ENLS course says cryoprecipitate. Doubt that's around most places I work, so might start thawing plasma. I think the key is to get them OUT of my Ed before the bleed. Quote Link to comment Share on other sites More sharing options...
telemedic Posted December 16, 2018 Share Posted December 16, 2018 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 Quote Link to comment Share on other sites More sharing options...
narcan Posted February 16, 2019 Share Posted February 16, 2019 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". 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 16, 2019 Author Moderator Share Posted February 16, 2019 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? Quote Link to comment Share on other sites More sharing options...
narcan Posted February 17, 2019 Share Posted February 17, 2019 I just followed up. Family transitioned to comfort care given fairly devastating neuro prognosis and underlying comorbidities. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 17, 2019 Author Moderator Share Posted February 17, 2019 10 hours ago, narcan said: I just followed up. Family transitioned to comfort care given fairly devastating neuro prognosis and underlying comorbidities. thanks for f/u. most big intracranial bleed stories end that way... Quote Link to comment Share on other sites More sharing options...
narcan Posted February 27, 2019 Share Posted February 27, 2019 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/ 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 28, 2019 Author Moderator Share Posted February 28, 2019 Thanks. Nice reference document. Quote Link to comment Share on other sites More sharing options...
lightbearer06 Posted March 19, 2019 Share Posted March 19, 2019 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... Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 19, 2019 Author Moderator Share Posted March 19, 2019 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. 1 Quote Link to comment Share on other sites More sharing options...
kargiver Posted April 4, 2019 Share Posted April 4, 2019 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 Quote Link to comment Share on other sites More sharing options...
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