STROKE CODELytics · Contraindications
Thrombolytics LKW ≤ 4.5 h · disabling deficit
- TNK
- 0.25 mg/kg IV bolus over 5 s, max 25 mg (preferred). Do NOT use 0.4 mg/kg.
| Wt kg | <60 | 60–69 | 70–79 | 80–89 | ≥90 |
|---|---|---|---|---|---|
| TNK mg | 15 | 17.5 | 20 | 22.5 | 25 |
| mL @5 mg/mL | 3 | 3.5 | 4 | 4.5 | 5 |
- tPA
- 0.9 mg/kg, max 90 mg: 10% bolus over 1 min, remaining 90% over 60 min.
| Wt kg | 50 | 60 | 70 | 80 | 90 | ≥100 |
|---|---|---|---|---|---|---|
| Total mg | 45 | 54 | 63 | 72 | 81 | 90 |
| Bolus mg | 4.5 | 5.4 | 6.3 | 7.2 | 8.1 | 9 |
Before lytic: BP <185/110. Glucose is the only lab required unless coagulopathy is suspected.
Absolute contraindications
- ICH on CT, or prior ICH
- BP can't be lowered to <185/110
- Glucose <50 and deficit resolves with correction
- Plt <100k · INR >1.7 · PT >15 s · elevated aPTT (heparin <48 h)
- DOAC / thrombin or Xa inhibitor <48 h, unless labs confirm clear
- Ischemic stroke, serious head trauma, intracranial or spinal surgery <3 mo
- Bleeding diathesis · active internal bleeding · GI malignancy or bleed <21 d
- Infective endocarditis · aortic dissection · intra-axial neoplasm
Scan for tracker
+ NIHSS calculator
+ NIHSS calculator
Timestamps, door-to-needle clock, NIHSS and lytic dosing.
timetotreat.org/stroke/tracker
BP & AGENTSIschemic · ICH
BP targets
Ischemic
Pre-lytic / EVT
<185/110
During & 24 h after lytic
<180/105
No reperfusion: treat only if >220/120, lower ~15% over 24 h.
After EVT, reperfused: keep <180/105; don't push SBP below 140.
Hemorrhage (ICH)
Target SBP
~140 (range 130–150)
Start within 2 h, reach target within 1 h. Avoid SBP <130 and large swings.
SBP >220: lower cautiously toward 160–180.
Reverse any anticoagulant now.
IV antihypertensives
- Labetalol
- 10–20 mg IV over 1–2 min (≈0.15–0.3 mg/kg, max 20 mg/dose), repeat q10 min. Infusion 2–8 mg/min. Max 300 mg/24 h. Avoid: asthma/COPD, HR <60, 2°/3° block, decompensated HF.
- Nicardipine
- 5 mg/h, +2.5 mg/h q5–15 min, max 15 mg/h. Drop to 3 mg/h at goal.
- Clevidipine
- 1–2 mg/h, double q2–5 min, max 21 mg/h. Avoid: soy or egg allergy.
- Hydralazine
- 10–20 mg IV q4–6 h. Second line.
- Nitroprusside
- Only for refractory DBP >140 when nothing else works.
Early antithrombotics
- Aspirin 160–325 mg within 24–48 h. After a lytic, wait 24 h and confirm no ICH on repeat imaging.
- Minor stroke (NIHSS ≤3) or high-risk TIA (ABCD² ≥4): aspirin + clopidogrel 300–600 mg load, then 75 mg daily × 21 d, then one agent. Start within 24 h. Not after a lytic.
- AF / cardioembolic: start anticoagulation after the acute phase. Early DOAC (≤4 d) is reasonable if bleed risk is low.
Verify doses against institutional protocol.Lincoln EM · Oct 2026