7/29/12

Thrombolytic Therapy in Emergency Medicine

Medscape Reference Reference

News Reference Education MEDLINE

Thrombolytic Therapy in Emergency Medicine

Author: Wanda L Rivera-Bou, MD, FAAEM, FACEP; Chief Editor: David FM Brown, MD more... Updated: May 3, 2012

Thrombolytic Therapy for Acute Ischemic Stroke

Stroke is the leading cause of long-term disability and the third leading cause of death in the United States. Each year, about 795,000 people experience a new or recurrent stroke. Of these, 610,000 are first attacks and 185,000 recurrent attacks. Of all strokes, 87% are ischemic strokes, 10% are intracerebral hemorrhage strokes , and 3% are subarachnoid hemorrhage strokes. Among patients with ischemic strokes, 8-12% die within 30 days.[13] Intravenous (IV) thrombolytic therapy for acute ischemic stroke (AIS) is now generally accepted. The US Food and Drug Administration (FDA) approved the use of IV tissue plasminogen activator (tPA) in 1996, partly on the basis of the results of the National Institute of Neurological Disorders and Stroke (NINDS) trial of IV recombinant tPA (rtPA). Favorable outcomes were achieved in 31-50% of patients treated with rtPA and 20-38% of patients given placebo; the major risk of treatment was symptomatic intracranial hemorrhage, which occurred in 6.4% of patients treated with rtPA and in 0.6% of patients given placebo.[40] Since the publication of the NINDS trial of IV tPA for AIS, the benefit and frequency of use of IV tPA in the elderly have remained uncertain.[41] Ongoing clinical trials may provide more direct evidence about the utility of thrombolytics in elderly patients with AIS.[42, 43] Other IV thrombolytic agents have been considered for treatment of patients with AIS. Clinical trials of streptokinase were halted prematurely because of high rates of hemorrhage; therefore, this agent should not be used.[44] Tenecteplase appears promising as an effective thrombolytic agent, apparently causing fewer bleeding complications. A pilot dose-escalation study of tenecteplase in human stroke showed that clinical outcomes with the lowest dose (0.1 mg/kg) were equivalent to those with higher doses.[45] A prospective, nonrandomized, pilot study evaluated imaging-guided tenecteplase therapy with 0.1 mg/kg IV given 3-6 hours after ischemic stroke onset; control subjects were treated within 3 hours with 0.9 mg/kg IV alteplase according to standard selection criteria. The study demonstrated that the former approach may have significant biologic efficacy, but in view of the imaging selection differences, it could not determine whether this approach has an enhanced therapeutic margin compared with the latter approach.[46] Desmoteplase, a fibrin-specific plasminogen activator, is a genetically engineered version of a clot-dissolving
emedicine.medscape.com/article/811234-overview#aw2aab6b8 1/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

protein from vampire bats. Previous studies suggested that desmoteplase has clinical benefits when given within 39 hours of symptom onset, with magnetic resonance imaging (MRI) criteria used to identify those eligible for the trials on the basis of diffusion-perfusion mismatch.[47, 48] The completed phase III Desmoteplase in Acute Stroke Trial-2 (DIAS-2) did not confirm this suggested benefit.[49]

Alteplase
Alteplase is the only drug approved by the FDA for use in AIS with a well-established time of symptom onset (< 3 hours). Patient delays in seeking treatment and the narrow therapeutic time window (0-3 hours) have been major limiting factors in IV alteplase usage. The European Cooperative Acute Stroke Study (ECASS III) tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of stroke symptoms and documented a favorable outcome at 90 days in 52.4% of treated patients and in 45.2% in controls.[50] Symptomatic intracranial hemorrhage was reported in 2.4% of the IV tPA-treated group and 0.2% of the control group. The inclusion and exclusion criteria for ECASS III were comparable to those of the original NINDS study, except that those with a National Institutes of Health (NIH) stroke scale score higher than 25, those taking oral anticoagulants (regardless of international normalized ratio [INR]), those with both diabetes mellitus and a previous stroke, and those older than 80 years were excluded.[50] The FDA has not yet approved IV alteplase for use beyond 3 hours. The American Heart Association and the American Stroke Association have published a scientific advisory statement recommending its use 3 to 4.5 hours from AIS symptom onset for eligible patients without contraindications.[51] Ideally, patients arrive at an institution with a stroke center. The time of symptom onset must be well established (< 4.5 hours), and the patient must be presenting with a measurable neurologic deficit. Stroke severity must be assessed with the NIH stroke scale (maximum score, 42). Patients with an NIH stroke scale score higher than 22 are considered to be at high risk for hemorrhagic conversion because of the probability of a large infarcted area. Patients with a score lower than 4 have only minor neurologic deficits, for which thrombolytic therapy is not indicated. On computed tomography (CT), high-risk patients often have early changes showing a large area of edema or mass effect. For hospitals with limited access to neurologists or without a stroke center, some small studies indicate that the drip-and-ship approach is efficacious and safe. With the help of video technology or phone consultation with a neurologist at the stroke center, emergency physicians can initiate IV alteplase therapy within the critical therapeutic window, and then transfer patients to another facility for continuation of care. Larger studies comparing drip-and-ship management to routine care are needed to validate the safety of this approach.[52] Despite the increased risk of hemorrhage in patients with a massive stroke, fibrinolysis remains indicated whenever other exclusion criteria are absent. The potential benefit is tremendous in this population of patients, who almost always will have a dismal outcome if therapy is withheld. Inclusion and exclusion criteria must be reviewed before administration of a thrombolytic agent. Be aware of subarachnoid hemorrhages that present early without CT findings. Absolute contraindications for alteplase therapy for AIS include the following: History or evidence of intracranial hemorrhage Clinical presentation suggestive of subarachnoid hemorrhage Known arteriovenous malformation Systolic blood pressure exceeding 185 mm Hg or diastolic blood pressure exceeding 110 mm Hg despite repeated measurements and treatment Seizure with postictal residual neurologic impairment Platelet count below 100,000/L Prothrombin time (PT) above 15 or INR above 1.7 Active internal bleeding or acute trauma (fracture) Head trauma or stroke in the previous 3 months
emedicine.medscape.com/article/811234-overview#aw2aab6b8 2/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

Arterial puncture at a noncompressible site within 1 week Relative contraindications for alteplase therapy for AIS include the following: Suspected acute pericarditis Rapidly improving stroke symptoms Myocardial infarction (MI) in the previous 3 months Glucose level lower than 50 mg/dL or higher than 400 mg/dL The eligibility criteria in the extended time period of 3 to 4.5 hours are similar to those for patients treated at earlier time periods. In addition, the following exclusion criteria must be considered: patients older than 80 years, those taking oral anticoagulants regardless of their INR, those with an NIH stroke scale score higher than 25, and those with both a history of stroke and diabetes.

Alteplase regimen
If there are no contraindications, start 2 peripheral IV lines, one for alteplase infusion and the other to manage any complications that may occur. The recommended dose of alteplase for AIS is 0.9 mg/kg (maximum, 90 mg) infused over 60 minutes, with 10% of the total dose administered as an initial IV bolus over 1 minute.[4, 53] The patient must be admitted to a critical care area so that frequent neurologic assessments and blood pressure and cardiovascular monitoring can be carried out. The clinician must be ready to recognize and manage possible complications. The effectiveness of thrombolytic therapy in stroke is strongly correlated with strict patient selection within the inclusion and exclusion criteria. No adjunctive therapies should be given along with alteplase for the management of AIS. Anticoagulants and antiplatelet agents may increase the risk of bleeding complications and are not recommended within 24 hours of alteplase administration. Alteplase is a safe and effective treatment for carefully selected stroke patients presenting within 3 hours of symptom onset,[40, 53, 54] and current evidence shows that it is safe if administered within 4.5 hours of the onset of AIS symptoms.[50, 51] The benefit is higher if alteplase is given earlier; this enhanced benefit is attributed to rescuing the area of ischemic penumbra. Although risks are associated with its use, these risks, in appropriate patients, do not outweigh the benefits. Early treatment remains essential. To maximize the benefit, patients should be treated with alteplase as soon as possible, ideally within 60 minutes of arrival in the emergency department (ED). An alternative to systemic thrombolysis is local intra-arterial thrombolysis using a lower dose. Endovascular techniques have been used for achieving acute revascularization after ischemic stroke within a longer therapeutic window from symptom onset. At present, no drugs are approved by the FDA for intra-arterial treatment of AIS, and such therapy is not standard. Intra-arterial thrombolysis is an option for treatment of selected patients who can be treated within 3-6 hours after the onset of symptoms due to occlusion of the middle cerebral artery and who are not otherwise candidates for IV tPA.[53, 54, 55]

Contributor Information and Disclosures

Author Wanda L Rivera-Bou, MD, FAAEM, FACEP Assistant Professor and ACLS Training Center Director, Department of Emergency Medicine, University of Puerto Rico School of Medicine Wanda L Rivera-Bou, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose.
emedicine.medscape.com/article/811234-overview#aw2aab6b8 3/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

Coauthor(s) Jos G Cabaas, MD, FACEP Deputy Medical Director, Office of the Medical Director, Austin/Travis County EMS System Jos G Cabaas, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Salvador E Villanueva, MD, FACEP Assistant Professor, Department of Emergency Medicine, Ponce School of Medicine, Puerto Rico Salvador E Villanueva, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Puerto Rico Medical Association Disclosure: Nothing to disclose. Chief Editor David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Additional Contributors Craig F Feied, MD, FACEP, FAAEM, FACPh Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group Disclosure: Nothing to disclose. William G Gossman, MD Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine Disclosure: Nothing to disclose. Jonathan A Handler, MD HSG Chief Deployment Architect, Microsoft Corporation, Adjunct Associate Professor, Department of Emergency Medicine, Northwestern University, Feinberg School of Medine Disclosure: Nothing to disclose. Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment

emedicine.medscape.com/article/811234-overview#aw2aab6b8

4/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

References
1. Ouriel K. A history of thrombolytic therapy. J Endovasc Ther. Dec 2004;11 Suppl 2:II128-133. [Medline]. 2. Sikri N, Bardia A. A history of streptokinase use in acute myocardial infarction. Tex Heart Inst J . 2007;34(3):318-27. [Medline]. 3. Hoffman R, Benz EJ, Shattil SJ, et al. Antithrombotic Drugs. In: Hematology: Basic Principles and Practice. 5th ed. Philadelphia, PA: Churchill Livingston Elsevier; 2008:chap 137. [Full Text]. 4. Alteplase (Activase) [package insert]. South San Francisco, CA: Genentech, Inc; 2005. [Full Text]. 5. Cathflo Activase (Alteplase) [package insert]. South San Francisco, CA: Genentech, Inc; 2001. [Full Text]. 6. Reteplase [package insert]. Fremont, CA: PDL BioPharma, Inc; 2006. [Full Text]. 7. Tenecteplase [package insert]. South San Francisco, CA: Genentech, Inc; 2000. [Full Text]. 8. Sinnaeve P, Alexander J, Belmans A, et al. One-year follow-up of the ASSENT-2 trial: a double-blind, randomized comparison of single-bolus tenecteplase and front-loaded alteplase in 16,949 patients with ST-elevation acute myocardial infarction. Am Heart J . July 2003;146(1):27-32. [Medline]. 9. Van De Werf F, Adgey J, Ardissino D, et al. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Lancet. August 1999;354(9180):716-22. [Medline]. 10. Urokinase (Abbokinase, Kinlytic) [package insert]. Tucson, Arizona: ImaRx Therapeutics, Inc; 2007. [Full Text]. 11. Gurewich V, Pannell R, Simmons-Byrd A, et al. Thrombolysis vs bleeding from hemostatic sites by a prourokinase mutant compared with tissue plasminogen activator. J Thromb Haemost. July 2006;4(7):1559-65. [Medline]. 12. Streptokinase (Streptase) [package insert]. Ottawa, Ontario: CSL Behring Canada, Inc; 2007. [Full Text]. 13. Writing Group Members, et al. Heart Disease and Stroke Statistics 2010 Update: A Report From the America Heart Association. Circulation. 2010;121:e46-e215. [Full Text]. 14. [Guideline] 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 8: Stabilization of the Patient with Acute Coronary Syndromes. Circulation. Dec 13 2005;112(Suppl IV):IV-89-IV-110. [Full Text]. 15. Jacobs AK. Regionalized care for patients with ST-elevation myocardial infarction: it's closer than you think. Circulation. March 2006;113(9):1159-61. [Medline]. [Full Text]. 16. Chakrabarti A, Krumholz HM, Wang Y, et al. Time-to-reperfusion in patients undergoing interhospital transfer for primary percutaneous coronary intervention in the U.S: an analysis of 2005 and 2006 data from the National Cardiovascular Data Registry. J Am Coll Cardiol. June 2008;51(25):2442-3. [Medline]. 17. [Guideline] Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society Endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. Jan 2008;117(2):296-329. [Medline]. [Full Text]. 18. [Guideline] Kushner FG, Hand M, Smith S, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the
emedicine.medscape.com/article/811234-overview#aw2aab6b8 5/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. Nov 2009;120(22):2271-2306. [Medline]. [Full Text]. 19. Di Mario C, Dudek D, Piscione F, et al. Immediate angioplasty versus standard therapy with rescue after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet. Feb 2008;371(9612):55968. [Medline]. 20. Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. Jun 2009;360(26):2705-18. [Medline]. 21. [Best Evidence] COMMIT collaborative group. Addition of Clopidrogel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. Nov 2005;366(9497):1607-21. [Medline]. 22. [Best Evidence] Sabatine MS, Cannon CP, Gibson CM, et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. Mar 2005;352(12):1179-89. [Medline]. 23. Antman EM, Morrow DA, McCabe CH, et al. Enoxaparin versus unfractionated heparin as antithrombin therapy in patients receiving fibrinolysis for ST-elevation myocardial infarction. Design and rationale for the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction study 25 (ExTRACT-TIMI 25). Am Heart J . Feb 2005;149(2):217-26. [Medline]. 24. Fengler BT, Brady WJ. Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm. Am J Emerg Med. Jan 2009;27(1):84-95. [Medline]. 25. Konstantinides SV. Massive pulmonary embolism: what level of aggression?. Semin Respir Crit Care Med. Feb 2008;29(1):47-55. [Medline]. 26. Todd JL, Tapson VF. Thrombolytic therapy for acute pulmonary embolism: a critical appraisal. Chest. May 2009;135(5):1321-9. [Medline]. 27. Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation. July 12 2005;112(2):e28-32. [Medline]. [Full Text]. 28. Kline JA, Hernandez-Nino J, Jones AE. Tenecteplase to treat pulmonary embolism in the emergency department. J Thromb Thrombolysis . Apr 2007;23(2):101-5. [Medline]. 29. [Guideline] Hirsh J, Guyatt G, Albers GW, et al. Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):71S109S. [Medline]. 30. Wicky ST. Acute deep vein thrombosis and thrombolysis. Tech Vasc Interv Radiol. Jun 2009;12(2):14853. [Medline]. 31. Enden T, Sandvik L, Hafsahl G, et al. Catheter-directed Venous Thrombolysis in acute iliofemoral vein thrombosis--the CaVent study: rationale and design of a multicenter, randomized, controlled, clinical trial. Am Heart J . Nov 2007;154(5):808-14. [Medline]. 32. Vik A, Holme PA, Singh K, et al. Catheter-directed thrombolysis for the treatment of deep venous thrombosis in upper extremities. Cardiovasc Intervent Radiol. Sep 2009;32(5):980-7. [Medline]. 33. Chang R, Chen CC, Kam A, et al. Deep vein thrombosis of lower extremity: direct intraclot injection of alteplase once daily with systemic anticoagulation--results of pilot study. Radiology. Feb 2008;246(2):61929. [Medline]. 34. Grunwald MR, Hofmann LV. Comparison of urokinase, alteplase and reteplase for catheter-directed thrombolysis of deep venous thrombosis. J Vasc Interv Radiol. Apr 2004;15(4):347-52. [Medline].
emedicine.medscape.com/article/811234-overview#aw2aab6b8 6/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

35. Razavi MK, Wong H, Kee ST, et al. Initial clinical results of tenecteplase (TNK) in catheter-directed thrombolytic therapy. J Endovasc Ther. Oct 2002;9(5):593-8. [Medline]. 36. Parikh S, Motarjeme A, McNamara T, et al. Ultrasound-accelerated thrombolysis for the treatment of deep vein thrombosis: initial clinical experience. J Vasc Interv Radiol. Apr 2008;19(4):521-8. [Medline]. 37. Kuter DJ. Thrombotic complications of central venous catheters in cancer patients. Oncologist. Jan 2004;9(2):207-16. [Medline]. 38. Baskin JL, Pui CH, Reiss U, et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet. Jul 2009;374(9684):159-69. [Medline]. 39. Deitcher SR, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. Jan 2002;20(1):317-24. [Medline]. 40. [Best Evidence] Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 333(24);Dec 1995:1581-7. [Medline]. 41. Longstreth WT, Katz R, Tirschwell DL, et al. Intravenous tissue plasminogen activator and stroke in the elderly. Am J Emerg Med. Mar 2010;28(3):359-63. [Medline]. 42. De Keyser J, Gdovinova Z, Uyttenboogaart M, et al. Intravenous alteplase for stroke: beyond the guidelines and in particular clinical situations. Strok e. Sep 2007;38(9):2612-8. [Medline]. [Full Text]. 43. Engelter ST, Bonati LH, Lyrer PA. Intravenous thrombolysis in stroke patients of > or = 80 years of age--a systematic review across cohort studies. Age Ageing. Nov 2006;35(6):572-80. [Medline]. 44. Thrombolytic Therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial-Europe Study group. N Engl J Med. Jul 1996;335(3):145-50. [Medline]. 45. Haley EC Jr, Lyden PD, Johnston KC, et al. A pilot dose-escalation safety study of tenecteplase in acute ischemic stroke. Strok e. Mar 2005;36(3):607-12. [Medline]. [Full Text]. 46. Parsons MW, Miteff F, Bateman GA, et al. Acute ischemic stroke: imaging-guided tenecteplase treatment in an extended time window. Neurology. Mar 2009;72(10):915-21. [Medline]. 47. Hacke W, Albers G, Al-Rawi Y, et al. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9 hour window acute stroke thrombolysis trial with intravenous desmoteplase. Strok e. Jan 2005;36(1):66-73. [Medline]. [Full Text]. 48. Furlan AJ, Eyding D, Albers GW, et al. Dose Escalation of Desmoteplase for Acute Ischemic Stroke (DEDAS): Evidence of Safety and Efficacy 3 to 9 Hours After Stroke Onset. Strok e. May 2006;37(5):1227-31. [Medline]. [Full Text]. 49. Hacke W, Furlan AJ, Al-Rawi Y, et al. Intravenous desmoteplase in patients with acute ischemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurol. Feb 2009;8(2):141-50. [Medline]. 50. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. Sep 2008;359(13):1317-29. [Medline]. 51. del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Strok e. Aug 2009;40(8):2945-8. [Medline]. [Full Text]. 52. Martin-Schild S, Morales MM, Khaja AM, Barreto AD, Hallevi H, Abraham A, et al. Is the Drip-and-Ship Approach to Delivering Thrombolysis for Acute Ischemic Stroke Safe?. J Emerg Med. Aug 2011;41(2):135-41. [Medline]. [Full Text].
emedicine.medscape.com/article/811234-overview#aw2aab6b8 7/8

7/29/12

Thrombolytic Therapy in Emergency Medicine

53. [Guideline] Adams HP Jr, del Zoppo G, Albers MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council , Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologist. Strok e. May 2007;38(5):1655-711. [Medline]. [Full Text]. 54. Finley Caulfield A, Wijman CA. Management of acute ischemic stroke. Neuro Clin. May 2008;26(2):34571. [Medline]. 55. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. JAMA. Dec 1999;282(21):2003-11. [Medline]. 56. Lipsitz EC, Kim S. Antithrombotic therapy in peripheral arterial disease. Cardiol Clin. May 2008;26(2):28998, vii. [Medline]. 57. [Guideline] Sobel M, Verhaeghe R. Antithrombotic therapy for peripheral artery occlusive disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):815S-843S. [Medline]. 58. Gray BH, Conte MS, Dake MD, et al. Atherosclerotic Peripheral Vascular Disease Symposium II: LowerExtremity Revascularization: State of the Art. Circulation. Dec 2008;118(25):2864-2872. [Full Text]. 59. Han SM, Weaver FA, Comerota AJ, et al. Efficacy and safety of alfimeprase in patients with acute peripheral arterial occlusion (PAO). J Vasc Surg. Mar 2010;51(3):600-9. [Medline]. 60. Summers D, Leonard A, Wentworth D, et al. Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement From the American Heart Association. Strok e. Aug 2009;40(8):2911-44. [Medline]. [Full Text]. 61. Aminocaproic acid [package insert]. Shirley, NY: American Regent, Inc; 2007. [Full Text]. 62. Bozeman WP, Kleiner DM, Ferguson KL. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. Jun 2006;69(3):399-406. [Medline]. 63. Arntz HR, Wenzel V, Dissmann R. Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction. Resuscitation. Feb 2008;76(2):180-4. [Medline]. 64. Archan S, Prause G, Kgler B, et al. Successful prolonged resuscitation involving the use of tenecteplase without neurological sequelae. Am J Emerg Med. Nov 2008;26(9):1068.e5-7. [Medline]. 65. Stadlbauer KH, Krismer AC, Arntz HR, et al. Effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation. Am J Cardiol. Feb 2006;97(3):305-8. [Medline]. 66. Garvey JL, MacLeod BA, Sopko G, et al. Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support--National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health. J Am Coll Cardiol. Feb 2006;47(3):485-91. [Medline]. 67. Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options. J Am Coll Cardiol. Sep 2007;50(10):917-29. [Medline]. 68. Millin MG, Brooks SC, Travers A. Emergency medical services management of ST-elevation myocardial infarction. Prehosp Emerg Care. Jul 2008;12(3):395-403. [Medline]. Medscape Reference 2011 WebMD, LLC

emedicine.medscape.com/article/811234-overview#aw2aab6b8

8/8