Treatment with systemic thrombolytics is only a class I recommendation for hypotension.
May consider thrombolysis in acute pulmonary embolism with
- shock index > 1
- altered mental status
- SaO2 < 95% and Borg score > 8 *†
- RV hypokinesis *
- estimated RV systolic pressure > 40mmHg *
- elevated troponin *
- BNP > 100pg/mL or pro-BNP > 900pg/mL *
- obstructing flow to one lobe or multiple lung segments‡
* Per the 2011 AHA guidelines for treatment of acute PE. These are disputed as indications for thrombolytics amongst many emergency physicians. The 2016 ACCP guidelines recommend thrombolysis ONLY for hypotensive patients.
† Borg score is severity of dyspnea from 0 to 10 (0 = no dyspnea, 10 = sensation of choking to death)
‡ Per alteplase manufacturer guidelines
Absolute Contraindications:
- Any prior intracranial hemorrhage (ICH)
- Known structural cerebral vascular lesion (ex: AVM)
- Known malignant intracranial neoplasm (primary or metastatic)
- Active bleeding or bleeding diathesis
- Severe uncontrolled hypertension (unresponsive to emergency therapy)
- Within the past 3 months:
- Ischemic stroke (except acute ischemic stroke w/in 4.5h)
- Significant closed-head or facial trauma
- Intracranial or intraspinal surgery
- For streptokinase, prior treatment within the prior 6 months
Relative Contraindications:
- History of chronic, severe, poorly controlled hypertension
- BP > 180/110 on presentation
- History of prior ischemic stroke > 3 months ago
- Dementia
- Known intracranial pathology not excluded by absolute contraindications
- Traumatic or prolonged (> 10min) CPR
- Major surgery within 3 weeks
- Internal bleeding within 2-4 weeks
- Noncompressible vascular punctures
- Pregnancy
- Active peptic ulcer
- Oral anticoagulant therapy
Dosing of tPA (Alteplase, Activase®)
Additional medication dosing:
- Aspirin 162-325mg PO
- Prasugrel (Plavix®) 300mg PO x1
- Nitroglycerin:
- 0.4mg SL x3 q5min prn chest pain
- 0.5-2 inch topical to chest for chest pain
Class I evidence for aspirin, plavix, and an anticoagulant after receiving fibrinolytic therapy.
Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. Circulation. 2011; 123: 1788-1830.
Activase.com