Tenecteplase in Patients With COVID-19

Inclusion Criteria * Patient/legally authorized representative has completed the Informed Consent Form * Age ≥18 years * Ability to comply with the study protocol, in the investigator's judgment * Respiratory failure secondary to COVID-19 requiring mechanical ventilation for no greater than 24 hours, or high-flow nasal cannula (HFNC),non-rebreather (NRB) mask or non-invasive positive pressure ventilation (NIPPV) for no greater than 48 hours * Confirmed infection with SARS-CoV-2 virus (PCR positive within 14 days) * Elevated D-dimer (\>6 times upper limit of normal within past 72 hours) * For patient who are intubated \>12 hours prior to randomization or with any evidence of neurologic deficit a head CT within 12 hours demonstrating no evidence of acute or subacute infarct or hemorrhage Exclusion Criteria * Current participation in another investigational drug study within the prior 7 days * Known hypersensitivity or allergy to any ingredients of tenecteplase * Active internal bleeding * Known bleeding diathesis * Use of one of the new oral anticoagulants within the last 48 hours (dabigatran, rivaroxaban, apixaban, edoxaban) * Treatment with a thrombolytic within the last 3 months prior to randomization (exception for the use of Cathflo alteplase for occlusions of central venous catheters) * Baseline platelet count \<80,000/L (results must be available prior to treatment) * Baseline blood glucose \>400 mg/dL (22.20 mmol/L) * Baseline blood glucose \<50 mg/dL needs to be normalized prior to randomization * Intracranial or intraspinal surgery or trauma within 2 months * Other, non-COVID-19 related, serious, advanced, or terminal illness (investigator judgment) or life expectancy is less than 6 months * History of acute ischemic stroke in the last 90 days * History of intracranial bleeding, including hemorrhagic stroke * Presumed septic embolus; suspicion of bacterial endocarditis * Mechanical ventilation \> 24 hours, HFNC, NRB, NIPPV, or any combination, for greater than 48 hours * Mechanical ventilation, HFNC, NRB, or NIPVV (for reasons other than obstructive sleep apnea) within the prior 30 days (excluding 48 hours prior to randomization) * Moribund status suggesting imminent vascular collapse and inability to survive \> 72 hours (investigator determination) * Uncontrolled hypertension defined as systolic BP \> 180 mm Hg and/or diastolic BP \> 110 mm Hgb * Age \> 75 years * History of traumatic brain injury within 2 months * Recent head trauma with fracture or brain injury * History of Heparin Induced Thrombocytopenia (HIT) and/or other hereditary or acquired hemorrhagic diathesis or coagulation factor deficiency * INR \> 2 or recent oral anticoagulant therapy with INR \>1.7 * Pregnancy or lactation within the prior 30 days; women of childbearing age (\<55 years old) should have documentation of a negative pregnancy test * Chronic liver disease defined as \> Childs-Pugh Class B * Atrial fibrillation, mitral stenosis, or known left heart thrombosis * Any other condition that, in the opinion of the investigator, precludes administration of tenecteplase or poses a significant hazard to the patient receives tenecteplase