Fibrinolytic Checklist - inclusion and exclusion criteria

Fibrinolytic Checklist:

Step One:

• • Has Pt. experienced chest discomfort for greater than 15 minutes and less than 12 hours?

    • No: stop

    • Yes:

      • Does the ECG show STEMI or new or presumably new LBBB?

        • No: stop

        • Yes:

Step Two:

• • Are there C/I due to fibrinolysis?

  • If ANY of the following is checked YES, fibrinolysis MAY be contraindicated.

    • SBP >180 mm Hg

    • DBP >110 mm Hg

    • Right vs Left arm SBP difference >15 mm Hg

    • History of structural CNS disease

    • Significant closed head/facial trauma within the previous 3 months

    • Recent (<6 wks) major trauma, surgery (including laser eye surgery), GI/GU bleed

    • Bleeding or clotting problems or on blood thinners

    • CPR greater than 10 minutes

    • Pregnant female

    • Serious systemic disease (eg. advanced/terminal cancer, severe liver or kidney disease)

Step Three:

• • Is patient at high risk?

  • If ANY of the following is checked YES, CONSIDER transport/transfer to PCI facility

    • HR greater than or equal to 100 bpm AND SPB <100 mm Hg

    • Pulmonary edema (rales)

    • Signs of shock (cool, clammy)

    • C/I to fibrinolytics therapy

Indications:

• • ST-segment elev >0.5 mm (>0.15 mV in 2 or more anatomically contiguous leads (eg, leads III, aVF; leads V3, V4; leads I, aVL) without contraindications.

  • Consider the use of fibrinolytic therapy in the following:

    • In the absence of CI, and in presence of favorable risk-benefit ratio, fibrinolytic therapy is one option for reperfusion in patients with STEMI and onset of sx within 12 hours of presentation and qualifying ECG findings.

    • In the absence of CI, it is also reasonable to give fibrinolytics to patients with onset of sx within the prior 12 hours and ECG findings consistent with true posterior MI, characterized by ST segment depression in early precordial leads in equivalent to ST segment elevation in others. When these changes are associated with other ECG findings, it is suggestive of "STEMI" on the posterior wall of the heart.

    • Fibrinolytics are generally not recommended for patients presenting more than 12 hours after onset of sx. But may be considered if ischemic CP continues with persistent ST-segment elevation of more than 1 mm in 2 or more contiguous chest or limb leads.

    • Do not give fibrinolytics to patients who present >24 hours after the onset of symptoms or patients with ST segment depression unless a true posterior MI is suspected.

CI - absolute:

• • Trauma or major surgery <2 wks

  • Head trauma <past mo

  • CVA/TIA in <6 mo or h/o H'gic CVA

  • Intracranial or intra-spinal neoplasm, aneurysm, or AVM

  • Known bleeding d/o or active bleeding

  • Persistent severe HTN: systolic pressure 200 mm Hg, diastolic pressure 120 mm Hg

  • Suspected aortic dissection or pericarditis

CI - relative

• • Active PUD

  • Traumatic CPR or CPR >10 min

  • Ischemic or embolic CVA >6 mo

  • Use of warfarin (INR >2 - 3)

  • Significant trauma or major surgery >2 wks and <2 mo ago

  • Uncontrolled HTN: DPB >100 mm Hg

  • Subclavian or internal jugular cannulation

  • H'gic ophthalmic conditions

  • Pregnancy

Streptokinase is highly immunogenic and cannot be used in the same patient twice within a 6 month period.

• • Fibrin-specific agents: tPA, reteplase, and tenecteplase. Streptokinase was the first fibrinolytic used widely, but is not fibrin specific; still used widely worlwide for acute STEMI reperfusion therapy.