- Consider bleeding the likely cause of neurologic worsening after use of a thrombolytic drug until a brain scan confirms or refutes hemorrhage
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- Immediately discontinue ongoing infusion of thrombolytic drug
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- Obtain stat noncontrast head CT or MRI
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- Obtain blood samples for type and cross match, complete blood count, platelet count, PT, INR, aPTT, and fibrinogen
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- If symptomatic intracerebral hemorrhage is confirmed by imaging:
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- Give cryoprecipitate 10 units infused over 10 to 30 minutes and more as needed to achieve a serum fibrinogen level of 150 to 200 mg/dL
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- Consider aminocaproic acid 4 to 5 g IV over one hour followed by 1 g/hour for 8 hours until bleeding is controlled, or tranexamic acid 10 to 15 mg/kg IV over 10 to 20 minutes
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- For patients on warfarin therapy prior to alteplase treatment, consider vitamin K and PCC as adjunctive therapy to cryoprecipitate, or FFP if PCC is not available
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- For patients with thrombocytopenia (platelet count <100,000/microL), give 6 to 8 units of platelets
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- For patients receiving unfractionated heparin for any reason, give 1 mg of protamine for every 100 units of UFH received in the preceding four hours
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- Obtain neurosurgery and hematology consultations; consider evacuation of the hematoma
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