1. Start second large bore IV cannula with normal saline at KVO rate.
2.TPA (Activase Alteplase)is given
according to body weight. Patient's actual or

estimated body weight in kilograms: 89.0 kg

(max dose is 90 mg)
Patient's dose of TPA is 0.9 mg/kg: 80.1 ml (80.1 mg)
3. Administer 10% of total TPA dose over

1-2 minutes -- 80.1 ml (80.1 mg) dose x 0.1:
8.0 ml (8.0 mg) over 1-2 minutes
4. Administer remainder of TPA dose over

60 minutes -- 80.1 ml (80.1 mg) dose x 0.9:
72.1 ml (72.1 mg) over 60 minutes
5. Continue to monitor patient and record data every 15 minutes.

SBP less than or equal to 185 and DBP less than or equal to 110 required for tPA dosing

THEN:

SBP less than or equal to 180 and DBP less than or equal to 105 MUST be maintained for 24

hours after tPA dosing.
6.DO NOT administer antplatelet agents (Aspirin, Plavix, aggrenox) or anticoagulants (heparin, Low molecular weight heparins or coumadin) for 24 hours after tPA dosing.
7. Blood pressure management options:
a. Pre tPA:
Goal BP: Systolic less than or equal to 185 mm Hg and diastolic less than or equal to 110 mm Hg

Labetalol 10 to 20 mg IV over 1 to 2 minutes, If no effect repeat escalating doses every 5-10 mins of 40mg then 80mg, then 80mg, then 80mg until BP goal achieved or 300 mg maximum is reached

or

Nitropaste 1 to 2 inches;

or

Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5-to 15-minute intervals, maximum dose 15 mg/h; when desired blood pressure attained, reduce to 3 mg/h Do not give tPA if BP uncontrolled and remains above 185/110
b. Post tPA:
Goal BP: Systolic less than or equal to 180 mm Hg or diastolic less than or equal to 105 mm Hg

Labetalol 10 to 20 mg IV over 1 to 2 minutes, If no effect repeat escalating doses every 5-10 mins of 40mg then 80mg, then 80mg, then 80mg until BP goal achieved or 300 mg maximum is reached

or

Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min

or

Nicardipine infusion, 5 mg/h, titrate up to desired effect by increasing 2.5 mg/h every 5-15 minutes to maximum of 15 mg/h

or (reserved for cases when lesser measures fail)

Nitroprusside infusion, dosing range: 0.3 - 10 mcg/kg/min. Start low and titrate q 3-5 mins to required BP target.BP checks q 3-5 mins when this therapy is required.