1. Initial Assessment
   1. Determine from the history the duration since stroke onset.
   2. Briefly assess the patient to confirm the diagnosis of probable ischemic stroke.
   
   
2. Preliminary Management for strokes less that 2 1/2hours
   1. Simultaneously page the Neurology resident and the stroke team member on call (See Stroke Team call schedule).
   2. Discuss the case with the member of the Stroke Team on call who should come to bedside.
   3. Request a CT scan STAT
   4. Send PT/PTT ultrastat, contact lab directly and do stool quiac.
   
   
3. Protocol for tPA administration:
   1. Inclusion criteria:
      1. ischemic stroke age > 18 years (pediatric exceptions may be considered) onset within 3 hours of drug initiation
   2. Exclusion criteria:
      1. Absolute:
         1. CT evidence of intracranial hemorrhage or hypodensity in over 1/3 of the MCA territory
         2. systolic BP > 185 or diastolic > 110 Hg despite aggressive management
         3. headache or stiff neck suggestive of SAH
         4. intracranial tumor, AVM or aneurysm
         5. evidence of active GI bleeding
      2. Relative:
         1. NIHSS < 4 (see Assessment Scales)
         2. rapidly improving deficits
         3. female that is pregnant or lactating
         4. platelet count < 100,00, PT>15
         5. treatment with warfarin or heparin
         6. major surgery or trauma within 14 days, or head trauma within 3 months
         7. GI or GU bleeding in the last 3 weeks
         8. arterial puncture at a non-compressible site or LP within 1 week
         9. systolic BP > 185 or diastolic > 110 Hg
         10. prior intracranial hemorrhage
         11. recent previous stroke
         12. presentation consistent with acute MI or Post MI pericarditis
         13. seizure associated with stroke onset
      3. Dosage:
         1. Administer 0.9 mg/kg (90mg max.), as 10% bolus over 1 minute followed by continuous infusion of the remaining 90% over 1 hour.


4. Management Guidelines:
   1. Vital signs:
      1. (temperature every hour), B/P and pulse immediately before bolus B/P and pulse immediately following bolus during infusion:
      2. B/P and pulse every 15 minutes for hypertensive patients every 10 minutes, if treating with labetelol prefer every 5 minutes after infusion complete check temperature again and every two hours for four hours and
         1. B/P and pulse every 15 minutes for two hours then
         2. B/P and pulse every 30 minutes for four hours then
         3. B/P and pulse every 1 hour for four hours
         4. Target B/P is 180/90. See Medical Management of Acute Ischemic Stroke for details.
   2. Transfer patient to Stroke Unit or ICU as soon as possible.
      1. No antiplatelet or anticoagulant medication unless required for management of associated medical problems in consultation with a member of the Stroke Team.
      2. Avoid arterial, central venous or lumbar punctures for 60 minutes after tPA
      3. Avoid urinary catheterization for 30 minutes after tPA
      4. If suspected ICH notify Stroke Neurologist caring for patient
      5. STAT fibrinogen
      6. CT scan STAT

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