TPA in pulmonary embolism

[kimber3ks, ASN, BSN, RN, EMT-B]

I am a relatively new nurse, having graduated in 5/07 and going directly to a community hospital ED. Now orienting in a bigger teaching community hospital and had a medication test today that I think I bombed.

I humbly consider still learning when it comes to the more acute situations. A question I got wrong was what is the loading dose for TPA in pulmonary embolism?

I put 20 mg IV push over 30 seconds, which is wrong. Not sure if I was thinking more stroke protocol. Nevertheless, having a hard time finding a definitive answer.

Also, with pt with arrhythmia with V-fib: initial dose of amiodarone should be what? I put 340 mg and got it wrong? For some reason my memory was saying bigger loading dose, then titrate down? to 150?

TIA

[hypocaffeinemia, BSN, RN]

From emedicine:

100 mg IV infusion over 2 h (FDA-approved regimen for PE)

Accelerated 90-min regimen is used widely, and most authors believe it is both safer and more effective than 2-h infusion; for accelerated regimen, recommended total dose based upon patient weight, not to exceed 100 mg

>67 kg: 100 mg given as 15-mg IV bolus followed by 50 mg infused over next 30 min and then 35 mg infused over next 60 min

Heparin therapy should be instituted or reinstituted near end of or immediately following alteplase infusion, when aPTT or thrombin time returns to twice normal or less

Pediatric

Use weight-adjusted accelerated regimen as in adults

[Lunah, MSN, RN]

Also, with pt with arrhythmia with V-fib: initial dose of amiodarone should be what? I put 340 mg and got it wrong? For some reason my memory was saying bigger loading dose, then titrate down? to 150?

Per ACLS, the initial dose of amiodarone is 300 mg, and you can repeat it at 150 mg.

[MikeyBSN]

We don't use TPA much in our ED, and I'm very thankful of that. I've never seen it used with PE. Every time I'm seen it used the patient bleeds out and dies. From what I remember when we do use it, there is an initial loading dose that is weight dependent (for strokes). That is a slow bolus over several minutes (I think 10, but not sure). Then it is an hourly infusion. You need to put 3 large-bore IV's in the person prior to administration. Amio is an intial dose of 300 and can be followed by 150.

[hypocaffeinemia, BSN, RN]

We don't use TPA much in our ED, and I'm very thankful of that. I've never seen it used with PE. Every time I'm seen it used the patient bleeds out and dies. From what I remember when we do use it, there is an initial loading dose that is weight dependent (for strokes). That is a slow bolus over several minutes (I think 10, but not sure). Then it is an hourly infusion. You need to put 3 large-bore IV's in the person prior to administration. Amio is an intial dose of 300 and can be followed by 150.

We just became certified as a primary stroke center last year, and I've seen it given to about five or six acute ischemic patients who recovered within 24 hours, no residual effects. Our tPA screening is insanely thorough though, so I'm sure this helps make a difference.

It isn't routinely used for PE here, but we did use it recently on a guy with massive saddle embolus. I mean, in that case your choices are to die due to hypoxia or risk bleeding and attempt to reperfuse.