NAPLEX Question of the Week: To t-PA or not to t-PA...that is the question

Under Pressure! Should our patient receive t-PA?

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Ms. CV is wheeled into the emergency department 90 minutes after coworkers found her to be speaking nonsense while at lunch. They also state the left side of her face appeared to be drooping. Initial workup is consistent with high likelihood of ischemic stroke. Other workup as follows:

 BP: 175/90 mmHg

HR: 85 bpm

Glucose: 85 mg/dL

Her physicians want to start alteplase (t-PA) at 0.9mg/kg. Is this an appropriate treatment? 

A. Yes, patient is experiencing an acute ischemic stroke and should be treated

B. Yes, but after lowering her blood pressure to less than 160/80mmHg

C. No, the patient is outside the 60 minute window of symptom onset

D. No, the patient is hypoglycemic, a common stroke mimic

E. No, the initial loading dose should be 9mg/kg

 

Rationale:

 

Correct answer: A

 

The symptoms strongly suggest the patient is having an acute ischemic stroke. Answer B is incorrect; our goal blood pressure for t-PA is less than 185/110 mmHg initially, then maintain less than 180/105 mmHg while infusing. Answer C is incorrect; while our goal door-to-needle window is 60 minutes, t-PA can be administered up to 3 to 4.5 hours after symptom onset. Answer D is incorrect; hypoglycemia can mimic a stroke, but she is normoglycemic. Lastly, answer E is incorrect as 0.9mg/kg is the correct overall dose. The patient should receive 0.09mg/kg (10%) as an IV bolus over 1 minute followed by 0.81mg/kg (90%) as a continuous infusion over 60 minutes.

 

Other things we want to keep in mind prior to administering t-PA for ischemic stroke: any active internal bleeding; neurosurgery, head trauma, or stroke in past 3 months; or, history of hemorrhagic stroke.  These patient factors would eliminate patients from receiving t-PA as they are absolute contraindications. 

Next week we will "hear" about ear infections!

Dr. B

Christopher M. Bland

Clinical Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.