How do you treat patients with symptoms of acute ischemic stroke who have an allergic reaction to alteplase?

For patients with an allergic reaction (i.e. perioral or lingual edema, difficulty breathing, or other serious reactions), our protocol is to stop tPA (and not resume), discuss with the ED attending whether there is a need for epinephrine 0.3 mg (1:1000 dilution) or intubation, monitor respiratory status closely, and administer

- Famotidine 40 mg IV once

- Diphenhydramine 50 mg IV once

- Methylprednisolone 125 mg IV once, repeated every 6 hours for 4 doses for continued swelling

Finally, tPA should be added as an allergy to the patient's med list. Admission to an ICU can be considered as well.