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Rapid Algorithm Review Fibrinolytics

Hi, I’m Mark for ACLS Certification Institute and welcome to another Rapid Algorithm Review. Today we’re reviewing the checklist for Fibrinolytic Therapy for acute coronary syndrome. Now, all things being equal, most practitioners during an acute coronary event would probably prefer to take their patient to the cath lab rather than giving thrombolytics. I remember 20 years ago before we had cath labs popping up like daisies, we were given TPA in the ER. One of the big risks in using a clot busting drug is ICH or intra-cranial hemorrhage and this occurs in about 3 out of every  100 patients. Regardless of contraindications and do the best job you can, 3 in 100 will develop an intra-cranial bleed.

Now, when would we give fibrinolytic therapy rather than taking the patient to the cath lab? We can’t get them to the cath lab, either the cath lab’s down, the patient has to be transferred somewhere for PCI, percutaneous cardiac intervention, the cath lab, and we can’t get them there. I live in the Chicago area and general rule of thumb out here is if you don’t like the weather, wait 10 minutes. I got two feet of snow outside right now. We’re not going anywhere, so this may be a case when we can’t get the patient to a cath lab so we have to administer fibrinolytic therapy.

Let’s take a look at this checklist and see is this patient a candidate to receive TPA, to receive fibrinolytic therapy. One of the first things that the literature points out is that this checklist is not all inclusive, is not all definitive, it’s used as a guide to help the doctors, the nurses, the medics to see if we’re going to be able to give this patient fibrinolytic therapy without causing more damage, more harm to the patient. Now that’s the first rule of medicine is first do no harm, so we have to make sure that we’re not going to make these worse by administering this medication.

One, patient presents with signs of acute coronary syndrome. Next, get a 12-lead EKG; take a closer look at that heart. Are they having an ST segment elevation MI or a new or presumably left bundle branch block? We need to get them to the cath lab. Can’t get them to the cath lab? We got to look at fibrinolytic therapy. Let’s go through our inclusion list. First, assess their blood pressure and the literature says the systolic between 180 and 200 and diastolic of 100 to 110, I just remember 200/110, those are the upper limits for both. If the patient is currently hypertensive, we need to treat that. Now we can, we could treat that. It doesn’t exclude the use of it. We can give them Lopressor or some drug and we could bring their pressure down, so first assess their blood pressure.

Next, we want to assess for a blood pressure change greater than 15 millimeters of Mercury between the right arm and the left arm. Now, a normal variance between the right arm and the left arm is probably fine; if the numbers are off a little bit, that’s probably okay. In the elderly, this could be maybe peripheral vascular disease and a small difference is okay. Once we get passed 15 millimeters of Mercury, around in that range, what we’re really looking for is an aortic dissection. That’s what why we want to know the difference between the blood pressure in one arm and in the other arm.

It’s important because an aortic dissection can present a lot like a heart attack. The symptoms are the same, only more severe. They’re definitely going to have chest pain. They can be pale, diaphoretic, trouble breathing, an impending sense of doom, these patients think they’re going to die because they are if we don’t get this thing fixed or aorta is dissecting.

Now, let’s first look at the aortic vessel itself. The aortic vessel has layers to it and what’s happened in a dissection is that intima, the inside layer of the aorta has torn and blood is starting to pump in and literally tear the aorta open. It’s creating a false lumen and blood is going into that lumen, pushes the vessel outward a little bit and restricts blood flow around it. Looking at the anatomy, we come off the aortic valve, come around the aortic arch, the first vessel we’re going to hit is the right brachiocephalic artery. That branches off to the right subclavian and the right carotid artery.

Now, if I have a dissection there, have created a false lumen, I could have decreased blood flow to the right subclavian vessel which is going to drop the blood pressure in my right arm. That’s why we have that difference in the blood pressure and that’s really what we need to rule out. When you have this great blood pressure difference between one arm and the other arm, is the patient currently having an aortic dissection? Those patients definitely will not receive fibrinolytic therapy.

Next, does the patient have a history of structural defect in the central nervous system? Did they have a previous bleed, a tumor or aneurysm? These patients are definitely not a candidate for fibrinolytic therapy. Has the patient had a significant closed head injury in the last three weeks, significant? What’s significant? This is subjective and this is where the clinician at the bedside really has to get into the story and see is this a significant injury or is this just a bonk in the head? Does the risk outweigh the benefit in giving this fibrinolytic therapy? Has the patient had a recent stroke say greater than three hours but less than three months? That patient may not be a candidate for fibrinolytic therapy.

Any major trauma, GI bleed, laser surgery within the last month would probably exclude them from receiving fibrinolytic therapy. Again, major, subjective, get into that patient history, does the risk outweigh the benefit. Any history of intra-cranial hemorrhage anytime in their life excludes them from fibrinolytic therapy, any history of intra-cranial hemorrhage. Does this patient have a history of bleeding disorders? Are they currently taking blood thinners? They may not be a candidate for TPA. Is the patient currently pregnant? Again, the literature goes back and forth on this. We need to save mom. To save baby, we need to save mom. Again, it’s a relative contraindication, dive into that patient, get more of a history. Does this patient have an advanced cancer, advanced liver, kidney failure? All of these again could exclude them from receiving fibrinolytic therapy.

Okay, next moving down, let’s see if this patient’s at high risk. Now, if any of these questions are answered yes, we really want to try to get this patient to a cath lab. First, are they tachycardic and hypotensive? We need to fix that. Next, does the patient have signs of pulmonary edema? Is this patient shocky? Are they showing signs and symptoms of being in a shocked state? Lastly, go back up to your contraindication list. Did the patient have any of these exclusion criteria checked? Again, they may not be receiving fibrinolytic therapy. Lastly, if it’s been determined that this patient cannot receive fibrinolytic therapy, we need to get that patient to a cath lab.

I’m Mark for ACLS Certification Institute. This has been Rapid Algorithm Review for Fibrinolytic checklist for acute coronary syndrome. Remember, like us on Facebook and please become a subscriber to our YouTube channel. Thanks. I’ll see you in the next video.