Hi. I’m Mark for ACLS Certification Institute. Welcome to another Rapid Algorithm Review. Today we’re reviewing the checklist for fibrinolytic therapy for acute coronary syndrome.
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 giving tPA in the ER. Once of the big risks in using a clot-busting drug is ICH (intracranial hemorrhage). This occurs in about three out of every 100 patients. Regardless of contraindications and doing the best job you can, three in 100 will develop an intracranial bleed. Why would we give fibrinolytic therapy rather than taking the patient to the cath lab? We can’t get into the cath lab—either the cath lab is down or the patient has to be transferred somewhere for PCI (percutaneous cardiac intervention) in the cath lab and we can’t get them there. I live in the Chicago area. General rule of thumb out here is if you don’t like the weather, wait 10 minutes. I’ve got 2 feet of snow outside right now. We’re not going anywhere. This may be a case where 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 the literature points out is that this checklist is not all-inclusive. It’s 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. That’s the first rule of medicine, first do no harm. We have to make sure we’re not going to make things worse by administering this medication.
One, patient presents with signs of acute coronary syndrome. Next, get a 12-lead EKG and take a closer look at that heart. Are they having an ST-segment elevation MI or a new, presumably, left bundle branch block? We need to get them to the cath lab. If we can’t get them to the cath lab, we have to look at fibrinolytic therapy. Let’s go through our exclusion list.
First, assess their blood pressure. The literature says a systolic between 180 and 200 and a 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 and we can. We can treat that. It doesn’t exclude the use of it. We can give them Lopressor or some drug, and we can bring their pressure down. So first, assess their blood pressure. Next, we want to assess for a blood pressure change >15 mmHg between the right arm and the left arm. 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 maybe be peripheral vascular disease and a small difference is okay, but once we get past 15 mmHg, around in that range, what we’re really looking for is an aortic dissection. That’s 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, have trouble breathing and an impending sense of doom. These patients think they’re going to die, because they are if we don’t get this thing fixed. Their aorta is dissecting.
Let’s first look at the aortic vessel itself. The aortic vessel has layers to it. 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. It pushes the vessel outward a little bit and restricts blood flow around it. Looking at the anatomy, when 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. If I have a dissection there and I’ve 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. That’s really what we need to rule out. When you have a 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, tumor, aneurysm? These patients are definitely not candidates for fibrinolytic therapy. Has the patient had a significant closed-head injury in the last three weeks? Significant, significant. What’s significant? This is subjective. 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 on 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 ago? 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 intracranial hemorrhage, anytime in their life, excludes them from fibrinolytic therapy—any history of intracranial 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 kind of 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 or kidney failure? All of these, again, could exclude them from receiving fibrinolytic therapy.
Next, moving down, let’s see if this patient’s at high risk. 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, period.
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.