anyone using tPA for acute ischemic stroke in the ED?

NYCRN16 · Jan 4, 2005

We are starting to use it as we have just become a stroke center, but of all the stroke cases that I have seen, I have only had to use it once. They provide us with a box that includes the drugs and the instructions on how to use it. I dont think any hospital that is not a stroke center would use it, but then again maybe things are changing?

Dixielee, BSN, RN · Jan 4, 2005

I have used it several times but have not seen any improvement in outcome because of it. I have not seen any complications either, but did know of one patient who died of a big bleed afterward. I think the main reason it is not used often is the time limitation. There most be an exact moment of onset that is noted, and then they have to have CT scan and be ready for the med within 4 hours I believe. That is often hard to do. Most CVA's don't have an exact moment that can be documented, and most people don't seek help immediately. There must be CT available instantly and a neurologist or gutsy ER doc to order it. There is of course the side effect of bleeding, and I think lots of docs are afraid to try it. From what I understand, the initial control study for use of it was a very small group and a lot of docs just don't believe the outcomes are worth the risks.

Trauma Columnist · Jan 4, 2005

We are a stroke center also and have used it several times over the past couple of years with amazing results. One lady (in her 50's) had complete left-sided neglect and within a half hour was able to move her left side and improved back to baseline within an hour! Her family was just amazed too.

Tweety, BSN, RN · Jan 4, 2005

We're not very elite here and we use it. The ER docs aren't the one's to make the decision to give the tpa, it's the neurologists. They give it very sparingly. In our facility the charge nurse of the neuro unit comes down to help with the protocol. I've done tpa a couple of times when I was the working that unit. One patient did fabulously, recovering 100% from one-sided flacidness (sp?). Another patient, who was more elderly had a cerebral bleed and died a few days later. More often than not, I've seen the patient not get very much better.

I don't see without the local neurologists support how it will work.

dewp_63 · Jan 4, 2005

Thanks for all your feedback. I don't doubt that the therapy can be advantageous for some patient groups, but we don't have a neurology floor in our hospital, and neuro coverage can be scanty. We have problems getting neuro docs to come to the ER to evaluate our documented ICB's, let alone a stroke patient. My experience with CVA patients when I worked ICU was that we pretty much just watched for any progression...hourly neuro checks, etc. Anyone doing q15 min neuro check outside of a stroke center? Anyone having the nurses do the NIH stroke scale??? It seems to me that it is a good idea to know what's on the scale, but that is the MD's responsibility.

erjulie · Jan 6, 2005

We use tPa consistently for ischemic stroke, and we're not a "stroke center". The onset has to be within 3 hrs, and they have severalcriteria to meet. I have seen wonderful turn-arounds, and some that had some improvement but not alot. However, if I have a stroke, you can believe I'd want a chance at some improvemtn, if not full recovery instead of bedridden and diapered. So, use it. It's no harder than treating acute MI. We use the NIH stroke scale, and nurses do it. You can hone it down pretty quickly. Lately we have not been using it at all, just history, CT, Labs and then tPa. The neurologists were the catalyst here.

Good luck, it really is a wonderful drug for a potentially awful disease.

candyndel · Jan 7, 2005

We've been using it for at least 8 years (when i came here). It isnt used that frequently because it is hard to pipoint the exact time at which the symptoms began (3 hour window of safety. Why do they always wake up with a change in MS?)

We have seen dramatic changes in the ED from resolution of symptoms to no change at all. We have a BAT (Brain Attack Team) also in our facilities that are paged with any possible tPA candidate. Time is muscle and tissue!

UM Review RN, ASN, RN · Jan 7, 2005

Thanks for all your feedback. I don't doubt that the therapy can be advantageous for some patient groups, but we don't have a neurology floor in our hospital, and neuro coverage can be scanty. We have problems getting neuro docs to come to the ER to evaluate our documented ICB's, let alone a stroke patient. My experience with CVA patients when I worked ICU was that we pretty much just watched for any progression...hourly neuro checks, etc. Anyone doing q15 min neuro check outside of a stroke center? Anyone having the nurses do the NIH stroke scale??? It seems to me that it is a good idea to know what's on the scale, but that is the MD's responsibility.

Save the Penumbra!

You CAN learn to do the NIHSS online, and yes, nurses need to know how to do it. It's not that hard, once you get the hang of it. Here's the website. Plus, I think you get a lot of examples. The teachings are in video format, so you'd do better with a fast computer.

http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

needsmore$ · Jan 8, 2005

We use TPA as well- seen some good outcomes and some not so good- it seems to be the way of the future--now we just have to educate the public and some docs to send their patients in, instead of saying- "well, it sounds like a stroke-nothing we can do-take an aspirin..."Anne

rjflyn, ASN, RN · Jan 9, 2005

I am at a level one teaching hospital in the midwest. Last I checked- only working in the ED PRN currently- there were 2 or 3 different stroke studies ongoing. Even here it is an infrequent to occasional ie maybe2-3 times a month that TPA gets given. Typically its because the patient's symptom onset is outside the 3 hr window. Most often its the senario of he woke up this way this morning or he went to take a nap at 1PM and woke at supper time like this. I'd be willing to say 75-90% of the patients are like this. The other 10-25% most of them end up having improving symptoms that exclude its use. So it ends up maybe 5 to 10 out of 100 patients get the TPA.

DOnt quote these numbers as this is based on my experence and may not be the actual numbers.

Rj:rolleyes:

zambezi, BSN, RN · Jan 9, 2005

We use tPA on all possbile canidates that meet the strict criteria...we have an ED flowsheet/alogorithim...ER doc calls neuro with possible stroke canidate (while in the mean time labs, CT, etc are being done)...Neuro comes in, looks at the patient, labs, ct, if patient is a candiate, consent is reviewed with pt/family and it is started in the ER. The patient then goes to ICU for blood pressure monitoring, q15 min neuro checks x1, the Q30, etc...you get the idea. We have also just instituted a big stoke clinical pathway that we are implementing hospital wide. We also participate in a clinical trial for actue stroke that has shown some good results (at least in our small pt. population)...