1055 N. Curtis Rd.

• Boise, ID 83706 • (208) 367-2121

THROMBOLYTIC CHECKLIST FOR STROKE

Yes No ABSOLUTE EXCLUSION CRITERIA
Hemorrhagic stroke, mass effect or edema on baseline CT, or history of intracranial hemorrhage
Suspicion of subarachnoid hemorrhage
Intracranial neoplasm, arteriovenous malformation or aneurysm
Previous cerebral infarction or head trauma within past three months
Sustained or uncontrolled hypertension (Systolic greater than 185 or Diastolic greater than 110 after attempt to treat HTN)
Onset of symptoms is more than three hours prior to the beginning of treatment (unless utilizing 3-4.5 hr. extended window)
Major surgery within 14 days prior
Platelet count below 100,000
INR greater than 1.7
Blood glucose below 50 mg/dL
Patient received warfarin (Coumadin®), heparin, or lovenox within 48 hours preceding onset of symptoms and PTT not in normal range
Direct thrombin inhibitors or direct factor Xa inhibitors within the last 48 hrs
Severe neurological deficits at discretion of neurologist
Arterial puncture at non-compressible site within previous 7 days
Severe complicated condition, such as AIDS or cancer, that would confound treatment
Age < 18 years of age
Yes No Cautions/Warnings
Known bleeding disorder or associated condition with high risk of bleeding, GI or GU bleeding within the past 21 days.
Recent acute myocardial infarction within one month
Major surgery within 14 days prior
Seizure at onset of stroke symptoms or pretreatment
Rapidly Improving neurologic deficit
Sensory loss, ataxia, dysarthria alone or minimal weakness
Preexisting neurologic, psychiatric or other illness that would confound treatment
If female, patient has positive blood or urine pregnancy test on record
Lumbar Puncture within 7 days Yes No Expanded Treatment (3-4.5 hrs) Criteria
Serious trauma in the previous 14 days All of the above EXCEPT ABSOLUTE CONTRAINDICATIONS:
Pericarditis or subacute bacterial endocarditis Age > 80 years
Significant liver or kidney dysfunction Taking oral anticoagulants regardless of INR
Diabetic hemorrhagic retinopathy NIHSS >25
Combination of previous stroke and diabetes mellitus

REASONS FOR NON-TREATMENT WITH THROMBOLYTICS

Time Patient/Family Refused
Uncontrolled Hypertension No IV access
CT finding Platelet count (less than 100,000)
Stroke severity Abnormal aPTT, PT/INR
Blood Glucose less than 50 Active internal bleeding (previous 21 days)
Recent IC surgery (3 mo.) Head trauma/Stroke

Additional considerations may apply, and these are guidelines to be used at the discretion of the attending physician.

Rev. 8/13 BO-1581

*BO-1581*

Rev. 8/13 BO-1581