Alteplase (tPA)
Acute ischemic stroke, Massive PE with hemodynamic instability, STEMI (if no PCI available)
Indications
- Acute ischemic stroke
- Massive PE with hemodynamic instability
- STEMI (if no PCI available)
Adult dosing
- stroke: dose: 0.9; unit: mg/kg (max 90mg) — 10% bolus, rest over 60 min; route: IV; weightBased: true; maxDose: 90; maxDoseAbsolute: true; pe: dose: 100; unit: mg IV over 2 hours; route: IV; fixed: true; pe cardiac arrest: dose: 50; unit: mg IV bolus; route: IV; fixed: true
Pediatric dosing
- stroke: dose: 0.9; unit: mg/kg; maxDose: 90; maxDoseAbsolute: true; route: IV (10% bolus, rest over 60 min); weightBased: true; pedNote: Off-label in children >2 years; specialist guidance required
Contraindications
- Active internal bleeding
- Recent (3 months) intracranial surgery, stroke, or head trauma
- Known intracranial neoplasm or AVM
- Severe uncontrolled hypertension
Clinical pearls
- Stroke: must give within 4.5 hours of symptom onset (ECASS-III)
- PE: consider in massive PE with hemodynamic instability — survival benefit
- Half-dose (50mg) PE protocol increasingly used with similar efficacy (MOPETT)
- In cardiac arrest suspected from PE: 50mg bolus through existing line, continue CPR 15+ min
Source and review
- AHA/ASA Stroke Guidelines 2019; ACEP PE Clinical Policy. Last reviewed: 2024-11-01