What is the management for a patient experiencing a TNK (Tenecteplase) bleed?

Management of Tenecteplase-Related Bleeding

Immediate cessation of tenecteplase infusion is the first step in managing tenecteplase-related bleeding, followed by rapid assessment and targeted interventions to control hemorrhage and restore hemostasis. 1

Initial Assessment and Stabilization

• Secure airway, breathing, and circulation
• Establish large-bore IV access (at least two lines)
• Administer oxygen as needed
• Position patient appropriately (head elevation for suspected intracranial hemorrhage)
• Assess vital signs every 15 minutes initially
• Perform laboratory tests:
  • Complete blood count
  • Coagulation studies (PT/INR, aPTT, fibrinogen)
  • Type and cross-match for blood products

Reversal of Anticoagulation

• If concurrent heparin was administered:
  • Administer protamine sulfate (1 mg per 100 units of heparin given in previous 2-3 hours)
  • Maximum single dose: 50 mg
  • Monitor aPTT
• If enoxaparin was administered:
  • Protamine partially neutralizes enoxaparin (1 mg protamine per 1 mg enoxaparin) 1

Blood Product Administration

1. Cryoprecipitate: 10 units to replenish fibrinogen (target level: 1 g/L) 1, 2
2. Fresh frozen plasma: 15-20 mL/kg to replace coagulation factors 1
3. Platelet transfusion: If platelet count <100,000/μL or if patient is on antiplatelet therapy 1
4. Packed red blood cells: For hemodynamic instability or significant drop in hemoglobin 1

Antifibrinolytic Therapy

• Consider tranexamic acid: 1 g IV over 10 minutes, followed by 1 g over 8 hours 1

Site-Specific Interventions

Intracranial Hemorrhage

• Urgent neurosurgical consultation
• Control blood pressure (SBP <140-160 mmHg)
• Urgent CT scan 1

Gastrointestinal Bleeding

• Endoscopic evaluation and intervention 1

Access Site Bleeding

• Direct pressure
• Compression devices
• Surgical repair if needed 1

Retroperitoneal Bleeding

• Interventional radiology consultation for possible embolization 1

Monitoring and Follow-Up

• Serial hemoglobin/hematocrit measurements every 4-6 hours until stable
• Coagulation studies every 6 hours until normalized
• Repeat imaging as clinically indicated to assess bleeding resolution 1

Risk Factors and Prevention

• Higher risk in elderly patients (>75 years) 1
• Increased risk with concurrent antiplatelet therapy (aspirin, clopidogrel) 1
• Renal impairment may prolong half-life of tenecteplase and associated anticoagulants 1

Pitfalls to Avoid

1. Delaying reversal of anticoagulation when active bleeding is present
2. Unnecessary arterial or venous punctures during and immediately after treatment
3. Overlooking subtle signs of intracranial hemorrhage (headache, altered mental status)
4. Failing to monitor fibrinogen levels during replacement therapy
5. Excessive fluid resuscitation without blood product support in severe hemorrhage

The European Society of Cardiology emphasizes that more than 70% of bleeding episodes occur at vascular puncture sites, highlighting the importance of careful patient selection and avoidance of unnecessary invasive procedures 3, 2.