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tPA-Delay


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Not surprised.

I have taken care of elderly stroke patients whom would not make a decision till their kids gave input.

I also had a case where pt had a dense stroke, 50 y/o female, aphasic with severe unilateral neglect. Divorced. All children minors.

Parents deceased. Sister, only sibling, available by long distance who lost her composure when I spoke with her about risks and benefits and hung up on me and would not take return call.

Discussed at length with on call neurologist and we made decision to use implied consent given her clinical condition and inability to participate. We both agreed that a younger pt with a bad stroke would want everything done possible.

So we gave tPA. All of that got us right to the brink of the 3 hr window (this was several years ago).

Her sister called back an hour later and told me she thought giving the tPA would be a good idea as long as I and the neurologist thought it may help her.

Unfortunately she died 3 days later, had hemorrhage when she reperfused, not uncommon, she had a stroke scale over 20. Discussed with stroke neurologist who cared for her till end, agreed with our course of action and told extended family and children he would have done the exact same thing given her condition and hopes for recovery.

But that window can quickly go by.

GB PA-C

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the window is potentially getting bigger. they are starting to talk about TPA for folks who wake up with sx.

The whole issue of tpa for stroke is a slippery slope. many er docs think it is almost always a bad idea as chance of improvement is about equal to chance of no change or worsening. some folks also are likely having a tia which will resolve on its own. many folks also are not candidates now with the new anticoagulants gaining popularity (dabigitran, etc) , because they are a contraindication for use of tpa because there is no way to measure the effect of their use (such as an INR for those on Coumadin).

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I think that there will be a lot of wake up strokes that with a good history will reveal grandpa who lives alone was found fully clothed in the recliner monday am after drop off from sunday dinner. That is not a wake up stroke.

On the other hand, spouse and pt go to bed, spouse finds pt in the am trying to get out of bed usual time except has right sided weakness and aphasic. There is your wake up stroke.

It really comes down to consent. Having a good handle on the harm and the good that tPA can do to a patient and conveying that to decisionmakers.

Some of what we do is going to be determined by case law, both the suits stating should have gotten tPA but didnt or got it and harm resulted. 

The answer is to have a well thought out protocol in place, clear means of consultation and a sole focus on the patient.

GB PA-C

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I think that there will be a lot of wake up strokes that with a good history will reveal grandpa who lives alone was found fully clothed in the recliner monday am after drop off from sunday dinner. That is not a wake up stroke.

On the other hand, spouse and pt go to bed, spouse finds pt in the am trying to get out of bed usual time except has right sided weakness and aphasic. There is your wake up stroke.

It really comes down to consent. Having a good handle on the harm and the good that tPA can do to a patient and conveying that to decisionmakers.

Some of what we do is going to be determined by case law, both the suits stating should have gotten tPA but didnt or got it and harm resulted. 

The answer is to have a well thought out protocol in place, clear means of consultation and a sole focus on the patient.

GB PA-C

agree. I have had several folks inside the tpa window with disabling sx and nl cts who I have offered tpa to after explaining the pros and cons. I have yet to have anyone accept the tpa based on a very real possibility that they might get worse and/or die.

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That's funny, the CME I was at last weekend, the stroke update doc was talking about the ethics of even talking to the family about consent for tPA. That is, waiting around to talk to family members about a time-sensitive intervention that has a great, safe track record when administered *right* *away* to appropriate patients is against the patient's best interests.

 

Even more interesting, clot retrieval post-tPA administration seems to be pretty compelling, but we have a paucity of stroke centers that can actually do this...

 

http://www.wsj.com/articles/a-fast-track-to-treatment-for-stroke-patients-1425338329

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That's funny, the CME I was at last weekend, the stroke update doc was talking about the ethics of even talking to the family about consent for tPA. That is, waiting around to talk to family members about a time-sensitive intervention that has a great, safe track record when administered *right* *away* to appropriate patients is against the patient's best interests.

 

Even more interesting, clot retrieval post-tPA administration seems to be pretty compelling, but we have a paucity of stroke centers that can actually do this...

 

http://www.wsj.com/articles/a-fast-track-to-treatment-for-stroke-patients-1425338329

it does not have a great track record...lots of bleeds and bad outcomes. at least as many as "miracle saves". some folks get better but no way of knowing if that is because they would have anyway or because the drug worked. most er docs are against giving it. the big push to give it comes from the folks who make it (genentech) and surprisingly enough they funded all the studies showing great outcomes...

see this for example. one of my favorite tpa rants:

http://www.emrap.tv/index.php?option=com_content&view=article&id=2232&catid=34:emrap&Itemid=60

another stat from one lecture I remember a few years ago (from an anti tpa for stroke er doc to be sure, but he had the study to back it up):

what % of  very subtle head bleeds can an er doc see on noncontrast CT? 40%

what % can a general radiologist see? 50%

what about a fellowship trained neuroradiologist? 60%

that leaves a lot of room to giving tpa to folks who actually have a bleed at the time of their ct scan...

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That's funny, the CME I was at last weekend, the stroke update doc was talking about the ethics of even talking to the family about consent for tPA. That is, waiting around to talk to family members about a time-sensitive intervention that has a great, safe track record when administered *right* *away* to appropriate patients is against the patient's best interests.

 

Even more interesting, clot retrieval post-tPA administration seems to be pretty compelling, but we have a paucity of stroke centers that can actually do this...

 

http://www.wsj.com/articles/a-fast-track-to-treatment-for-stroke-patients-1425338329

tPA can be safe at the major medical center that is designated a stroke center, with stroke neurologists and neuroradiologists available. But at a community hospital you dont have that.

Push tPA studies out into the community and I think you will see much different data.

Likely your stroke up date speaker is someone whom believes it works. When you are a true believer, everyone else is wrong including the individuals with bad outcomes. 

 

I would and am wary of this kind of advice. If the speaker is a community hospital EM physician using tPA several times a year over a decade with success, I will listen to what he/she says with interest. If the speaker is other, my first question is how does my environment compare to theirs. If it is apples to oranges, they are entitled to their opinion but not to the facts.

 

WSJ article is interesting. Robots and mobile CT are a great concept. Where the money comes to support all of that endeavor though? Quite an investment. Plus, the decision making is not in the ED but with the neurologists using the robot. Would be interesting to see a retrospective evaluation of this prospective process done outside of the institution rather than a one page gee whiz article in a financial publication.

Interesting to read the comments after the article also. 

GB PA-C

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tPA can be safe at the major medical center that is designated a stroke center, with stroke neurologists and neuroradiologists available. But at a community hospital you dont have that.

Push tPA studies out into the community and I think you will see much different data.

Likely your stroke up date speaker is someone whom believes it works. When you are a true believer, everyone else is wrong including the individuals with bad outcomes. 

 

This is where a telestroke program is so valuable; it helps to bring the resources of a major medical center out to the community hospitals that don't typically have those resources.

 

We have been running a successful telestroke program for several years, covering 8 different hospitals around the state.  Our stroke neurologists can remotely evaluate patients and imaging studies from the outside facility, and in conjunction with the ED team make the call on tPA.  I believe we saw a 90% increase in tPA administration at the first hospital we partnered with after beginning the program.

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