anyone using tPA for acute ischemic stroke in the ED?

[dewp_63]

We've been discussing the use of tPA in the ED for acute non-hemorrhagic stroke patients. I know that ACLS teaches this algorithm, but our MD's are hesitant to institute. Some of their hesitancy in the fact that the local neuro docs don't like it. I know this is happening in some of the "stroke centers" in the nation, but I haven't found a nurse in our area who has participated in this... I practice in a large urban area, with a medical center/med school/nursing school etc. in the same city. Just needed to know if this is just something the very elite do, or if it is something I should expect to see soon.

[CEN35]

I've given it twice. The ER doc will NEVER be the one to institute it. First with malpractice and lawsuites, if they end up bleeding, the first thing the attorney will say is, "are you certified in neurology?". It's a risk they will pass off to neuro surgey and neurology.

At our hospital, you have to have parameters.

1. CT that has absolutely NO abnormalitys. That means, no densitys, no tumors, no bleed, no anythig. Perfect.

2. Neurology has to order it.

3. The pt has to meet a certain criteria, which I don't remember exactly what it's called? Something like the NNIS score? It's basically a 0-10 score. 2 or 4 extrimity movement = 1 or 2. Cognitive ability = 1 or 2. Coordination, etc etc. it has to be less than a 7, to be worth the risk according to standards.

4. Must have a SBP

5. All must be established within 3 hours. (even though the national standard is less than 6 hours). This is very tough to do. It has to be identified almost immediately to get all this done in 3 hours. Most strokes are caught, and by the time anyone realizes it and gets them to the hospital its too late.

My experience in two patients which I followed up on.

1st - 45 yo male, walking through the park with his wife a nurse. Dragging his left foot, sluured speech and weakness with nystagmus. She brought him to the ER immediately. CT perfect. NIH? scale 6. Vasotec 1.25 mg IVP. 2 hrs 50min, B/P down to 175/80. gave the TPA.

Result: Complete function return within 30 days. (which is quick, even with TPA use)

#2 - 64 yo male questionable time of onset. Estimated to be 2 hours? CT good, B/P good, NIH 4. Pt received the TPA.

Result: No function restored ever.

It's an questionable issue how well it works, and weather it's worth possible hemmorhaging or death? In our society too many people view death as the worst possible thing. Too many people view living for 8 years as a gomer (so to speak) with no activity or real life as better than death. So most physicians are extremely hesitant.

CYA! :-)

[geekgolightly, BSN, RN]

question for those using tPA for ischemic BA: has MRI been used for diagnostics, or strictly CT and symptoms?

MRI here, but if CT shows, then we go ahead with that.

[CEN35]

MRI here, but if CT shows, then we go ahead with that.

For us, it takes to long to get MRI techs and stuff in here. CT is always here. Only a neuro guy can order an MRI here also.