29.11 Thrombolytics

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Welcome back and today we are going to discuss thrombolytics.

Unlike anticoagulants which prevent future clots, thrombolytics dissolve current clots with a goal to re-establish blood flow. Thrombolytics work by activating the conversion of plasminogen to plasmin. What does that mean? Plasmin causes fibrinolysis aka dissolution of clots. Don’t let the fancy works confuse you, it all comes down to clot existing breakdown. It’s all about the clot dissolution to get the blood flow back on track and all organs perfused. Now if blood flow is a concern, so is timing - these drugs must be given promptly so permanently damage doesn’t take place.

Thrombolytics come in many forms, with a trend being that most end in -PLASE. The most common you will see is alteplase. I’ve had many patients with ischemic strokes receive this drug and it’s pretty miraculous to see someone being with severe neurological deficits and within hours, they begin to be able to move their arms. It’s a complete 180, these drugs are really amazing!

Now if thrombolytics dissolve clots, indications would then be based on processes that include clots such as MI, arterial thrombosis, DVT/PE, occlusion of shunts or catheters and acute ischemic stroke. All of these involve an occlusion in some sort of the body. Don’t get caught up in memorization just think CLOTS. The most common indications being stroke, acute MI and PE. While, occlusions involve localized application and site dwelling.

Alright, so thrombolytics dissolve clots, we are deactivating the body’s regular clotting cascade therefore causing an increased risk of bleeding. The goal is the dissolve the clot but we don't want to cause harm, so thrombolytics are contraindicated in individuals who are already at an increased chance of bleeding. Don’t let the list overwhelm you here, focus on what patient populations are at high risk of bleeding. I had a patient with uncontrolled HTN who was given TPA (without BP treatment) and the patient subsequently had a massive brain bleed. CT Heads are usually completed with patient with prior history of hemorrhagic stroke before the patient can be given this medication. These drugs are great but the patient has to have the proper vital signs and background in order to see the therapeutic results and lower the risk of complications.

Interactions are all related to drugs that further increase your patient’s chances of bleeding. Anticoagulants, antiplatelets and other medications that affect PLT function will be of concern. One OTC medications, aspirin, is one many tend of forget about. If a patient gets TPA and ASA, there bleeding risk if drastically increased.

So as stated before, we’ve increased the chances of bleeding - so side effects will follow that same concept. Hypotension is new one but if you have active bleeding, you will eventually have a low blood pressure and anemia. Ventricular arrhythmias are also new and due to hypoperfusion issues related to hypotension. I had a patient receive tpa due to a stroke and soon after the patient subsequently has an intracranial bleed. Again, you use these drug bleeding is a big component. Please keep that in mind.

Priority nursing concepts for a patient receiving thrombolytics include: clotting, perfusion and pharmacology.

Let’s do a review, thrombolytics are used to re-establish blood flow within the body by dissolving clots. Types of drugs in this class end in -PLASE, with indications related to clot occlusion through the body. Contraindications are related to processes that cause increase chances of bleeding. And side effects include bleeding, hypotension and dysrhythmias. Remember, these drugs can save and improve lives but they have serious side effects that must be monitored.

Now you know all your need to know about thrombolytics. Now go out and be your best self and happy nursing!

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