Help me understand

surferbettycrocker · Feb 18, 2011

did you ask the doc to help you understand? seems like the ER doc would be the perfect person to ask why no tpa for this patient

alabamaparamedic · Feb 18, 2011

From what I understand, there's a fairly significant rate of brain bleeds, even when TPA is given within the time frame. TPA can help...I've watched a patient with significant defects improve greatly during my one hour transport, but by the time I arrived at the receiving hospital, the patient was bleeding from every single scratch and scrape and IV puncture site on his body.

Could he have been on any blood thinners that might've caused TPA to be contraindicated?

If the patient is still recovering significantly, maybe the TPA just wasn't worth the risk? Any chance this could have been a TIA instead?

BrnEyedGirl, BSN, MSN, RN, APRN · Feb 18, 2011

I will talk to the ER doc. I am looking for info to help me have a more educated conversation. The patient was not on any anticoagulants, and it was a stroke. The Sx even 8 hours later are enough to prevent ambulation, reading, watching TV, etc.

Editorial Team / Moderator · Feb 18, 2011

Two stents and no Plavix? Really? Geez, I thought every stented human was on Plavix these days! :)

Our ED docs and neurologists hesitate to give tPA if the patients' symptoms are resolving -- sometimes it's a TIA vs. a CVA. The potentially catastrophic side effects of tPA can be devastating and awful to see.

Esme12, ASN, BSN, RN · Feb 18, 2011

It makes me think that there is another problem as they aren't giving Plavix for the stents and the patient is still not on any anticoagulants. TPA while can be a miracle worker can be devestating when it causes bleeds and death. I remeber one case.......profound paralysis on presentation facial droop the whole nine yards. We gave TPA the patient had a miracle recovery but complained of a headache :eek: full neuro exam later I went to get him a percocet....when I came back he was comatose 2 hours later he died. They may have decided against it because the patient was already resolving symptoms and the risk was greater than the benefit. Ask the ED MD they love to teach! here are some helpful links

http://www.theuniversityhospital.com/stroke/ischemic.htm

http://www.acep.org/content.aspx?id=29936

http://www.stroke-site.org/guidelines/tpa_guidelines.html

**canoehead, BSN, RN** · Feb 19, 2011

In our ER we don't give clotbusters if the patient's symptoms are improving.

casi, ASN, RN · Feb 20, 2011

Two stents and no Plavix? Really? Geez, I thought every stented human was on Plavix these days! :)

Cardiologists around here are d/cing Plavix after a year and placing patients on ASA. I guess there has been a study that shows that plavix doesn't continue to be a benefit after a year?

Guy could have also been prescribed Plavix, but not taking it because it's flipping expensive.

86toronado, BSN, RN · Feb 21, 2011

i worked neuro icu, and saw several patients come in with relatively minor ischemic strokes, given t-pa, developed bleeds, and are now brain dead. which is why once i'm 60 i will have [color=darkslategray]dnr/i, no t-pa tattoo'd on my chest.

Fribblet · Feb 21, 2011

If the symptoms are resolving, blood flow is returning to the affected area of the brain. There is no long an occlusion.

At that point the risks of t-PA out weighs the benefits.

EmilyCCRN · Apr 5, 2011

Cardiologists around here are d/cing Plavix after a year and placing patients on ASA. I guess there has been a study that shows that plavix doesn't continue to be a benefit after a year?
Guy could have also been prescribed Plavix, but not taking it because it's flipping expensive.

Anti-platelet therapy depends on several things, such as whether the patient received a bare metal or drug-eluting stent. Generally speaking, all stented patients should take ASA "indefinitely" and Plavix/Effient for at least 30 days (bare metal) or 6-12 months (DES). But dual anti-platelet therapy (DAPT) is the standard recommendation. They should be on ASA and a thienopyridine together, not one or the other (unless they have an allergy, etc.).

steelydanfan · Apr 7, 2011

Here's the scenario:
59 M
c/o rapid onset of L sided weakness, slurred speech, double vision, onset at 0800
EMS arrival at 0830, pt with L facial droop, slurred speech, L arm et leg numbness et weakness reporting double vision
Hx CAD with 2 stents, HTN, Hyperlipidemia, Renal Ca with nephrectomy 6 yrs ago and normal renal function.
Arrival at ER 0845 Sx unchanged, CT scan neg for bleed
1015 Sx significantly improved, but still obvious deficits
ER physician states pt isn't a "good candidate for TPA,..I hate the stuff and I think the risks will out way the benefits since you seem to be improving",..pt still with facial droop, slurred speech, weakness and numbness of L arm et leg and double vision.
Neurologists sees pt at 1300 in ER and explains the time frame for meds and assures pt he will cont to recover.
Why wasn't this pt a good candidate for TPA? It sounded to me like the ER doc just didn't like giving it, and this pt has disabling deficits that for instance will not allow him to drive a car. Maybe over the next few days he will improve??

You stated that "sx. significantly improved", but at 1015, he seemed to have the same symptoms he came in with.

I guess there was no INL that could have done localized therapy?