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Fresh frozen plasma
16%
15/94
Vitamin K
6%
6/94
Protamine sulfate
3%
3/94
Aminocaproic acid
65%
61/94
Argenine vasopressin
2%
2/94
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This patient has become suddenly hypotensive and tachycardic in the setting of initiation of thrombolytic agents. The antidote for thrombolytics include aminocaproic acid or tranexamic Acid. tPA induced hemorrhage results from thrombolysis of hemostatic clots. Aminocaproic acid inhibits both the activation of plasminogen and the action of fibrinolysin (plasmin). Tranexamic acid, another antifibrinolytic, has also been used for hemorrhage secondary to tPA use. The use of thrombolytics in the management of acute stroke requires careful patient selection. Initial rule out of a hemorrhagic stroke is done through non-contrast CT scan of the head. Patients that fall within the first 4.5 hours since symptom onset are candidates. Rozen et al. stress that conditions that contraindicate the use of thrombolytics include: Hypertension of >185/110 refractory to management, seizure onset at time of stroke, abnormal lab values (such as thrombocytopenia), and recent surgery. Lin et al. discuss the mechanism of action of aminocaproic acid in the reversal in the inhibition of tPA. Through their study, they were able to demonstrate that aminocaproic acid blocks the activation of plasminogen through two mechanisms (as described above). This provides the theoretical basis for therapy with aminocaproic acid in tPA induced hemorrhage. The American College of Emergency Medicine Physicians recommends the use of tPA for the acute management of stroke when the time to treatment is within 3hrs of symptom onset. In the 3-4.5 hour window, the committee suggests careful inclusion of patients for therapy based on European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria. Figure A shows a non-contrast head CT with no hemorrhagic foci. Incorrect Answers: Answer 1 and 2: Fresh frozen plasma and vitamin K are appropriate therapies for warfarin induced hemorrhage due to factor depletion. Answer 3: Protamine sulfate is an appropriate reversal agent for heparins. Answer 5: Arginine vasopressin (DDAVP) is at times used to treat Von Willebrand's disease by increasing expression of vWF by endothelial cells.
3.0
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