Stroke drugs?

[jenac]

Once again- I need your help. To make a long story short- my early-fiftyish father had what they believe to be a stroke early this morning. My mom found him in the kitchen around 8:30 a.m. , fumbling around, shuffling and leaning heavily to the right (marked right-sided weakness), with very garbled word "salad". She rushed him to the ER-where they started the "stroke clock", did a CT and phoned for a life-flight to a larger hosital with a great neuro team. Now- I know it doesn't matter, but they have no insurence-none at all, so this was a very expensive trip. Well worth it- and never in doubt- but very expensive nonetheless. He was recieved at this other hospital at noon-and wasn't seen untill after 2:30-when it was outside the window of opportunity to give the "stroke drugs" (I know- I have so many issues here....)

My question to all of you is this- can you please fill me in on these drugs that would be commenly given in a situation like this? I don't even know names...but I do remember learning about the six hour window. Being after 2:30 when he was seen- it was outside that theraeutic time frame. I am VERY upset with his care to this point- but understand that I know nothing of these drugs. So, I'm asking for your input here before I fly off the handle. It has been a tough weekend-I'm emotionally and physically exhausted. Hence the request for input here. Thank you.

[Erin RN]

The drug we used was TPA (Tissue Plasminogin Activator)..there is a 3 hour window (I think they can exten it to 6 but it works best in the first 3)..one thing to note, there are two types of CVA..ischemic where there is a clot blocking the bloodflow to the brain and hemorrhagic where there is active bleeding in the brain. TPA is given ONLY for the ischemic, where it can break up the clot and minimize damage by restoring bloodflow. It is not given in hemorrhagic stroke because it will only increase the bleeding and potentially casue more damage.. A CT will dx which type of stroke a person is having. If the pt is having a hemorrhagic stroke then there really is no magic pill..surgery (sometimes) or admit to the ICU and monitor and control ICP. Erin

[jenac]

I know that they tried to help him- but it's so frustrating that they couldn't give him anything more than an ASA at the first hosital- and waited to long to give him anything else at the second. He is so young. They did comfirm the clot with the CT- which is why I'm so surprised that they didn't give him something. My mom did everything she was suppose to-recognized the signs and got to the ER fast. The whole point of the life-flight was to get him to the other hospital as fast as possible-twenty minutes by air-so that he could get the clot-buster. To find out that he didn't recieve it because they didn't get to him in time just makes me want to cry. We did everything we could- and somewhere the system in place still broke down. It just makes me furious.

Right now he's in ICU on a Heparin drip. VS are stable. I guess all we can do know is pray- and be there for them.

[RNCENCCRNNREMTP]

If....

He really had an ischemic (clot induced) stroke

and...

He really was in the THREE hour window from onset of symptoms to time when drug could be available

and....

He was not improving and had no significant bleeding risk factors (quite a few for stroke TPA)

Then I feel he should have received the TPA at the first hospital, not flown away to sit and wait.

IF TPA is going to work for CVA then it must be given within 3 hours of onset symptoms. No later! A study done a few years ago (ATLANTIS I think) showed far increased mortalty/morbidity if TPA was given for CVA after 3 hours.

[Erin RN]

Jenac

When your dad was flown to the other hospital wasn't he put through the ER? I was just wondering since whenever lifeflight brought someone to our hospital they went through ER (except OB)..I was just wondering if there were some legitimate reason for them not administering the TPA?? Did the first hospital not have TPA? It seems strange they wouldn't since it is an "emergency" drug...I am sorry for you and your family, I hope your dad recovers. I will be thinking of you....Erin

[rstewart]

The true window of opportunity for TPA is three hours, not 6; That time frame is what the FDA approved the drug for and with good reason in my opinion.

TPA is approved for ischemic strokes because it appeared to improve outcomes in one large randomized study if given within 3 hours. Sounds pretty clear cut, I know.......find out quickly what type of stroke it is and if it's ischemic, start the TPA. But the problem is the TPA itself carries some known and very significant risks so a risk/benefit analysis is always crucial, not just because the drug is not likely to help but also because its use can cause a good deal of major damage.

Various "checklists" beyond just determining what type a stroke a patient is having are in use in an attempt to better quantify whether or not the benefits exceed the risks. In addition to these lists there is professional judgement of the neuro docs which basically amounts to "Is the stroke bad enough to warrant using something that could make things worse but not so bad that it likely won't make any positive difference what you do to treat at that point?"

While much has been made of TPA administration even in the lay press, its use is not a standard of care at this point------at least it has not been endorsed as such by the major emergency organizations in the US. Aspirin has been shown in at least one study to offer great benefit with far least risk (than TPA) to many stroke patients. Of course, ASA doesn't carry near the price tag that Altaplase does.

Of course I have no way of knowing, however, after reviewing all the relevant information the second hospital may have decided TPA would potentially do more harm than good (as opposed to oversight or delay). For example, it was mentioned that the patient was found at 8:30 and arrived at the second hospital at noon; that would be outside the usual "window" even assuming that he was discovered exactly when the event began. That alone may have ruled out administration. Factors in his health history, his blood pressure, professional judgement that there may in fact be a bleed, "size" of the stroke, etc etc may have influenced their decision as well.

My point is TPA obviously WAS considered. For whatever reason its use was deferred. I would suggest that you ask what the reasons were for doing so, keeping in mind that valid reasons may exist.

[Erin RN]

Good Post RStewart..I attended an inservice on TPA a long time ago..and your post spells it out great. I, too, would talk to the attending and find out why it was not given. One of my friends recently had a stroke and she did not get it..she said it was something to do with they thought she was too high of a bleeding risk..she actually recovered without any deficits. When she went to the ER she could not speak and she had double vision..the double vision persisted for several days and she was also unable to walk. It is Jenacs dad though and we both know that all the rules change when it is a family member..we just want them better as soon as possible..Jenac, speak with the attending and find out why..so you will feel better...:) Erin

[jenac]

I will definately look into the reasoning here. My understanding is that the whole point of the lifeflight transfer was for the TpA. The first hosital had already confirmed that it was a clot-not a hemorrage-and had administered the ASA. (Which I am VERY grateful for, of course.) I am aware of the benefits of getting the ASA fast. He has no history of HTN-has been a heavy smoker for years. No h/o MI or any arrythmias. He is a young, active man-so we still don't know why the clot developed in the first place.

It is definately possible that the second hospital choose not to give the TpA for a reason- I just don't know what that reason may be. From what my mom is saying- the Dr. told her they had another lifeflight come in at the same time, which is why he wasn't seen immediately. The nurse told my brother last night that he wasn't as bad as they said at first. Something to look into, that's for sure. Thanks to all your posts- I will keep in mind that there may have been a very legitamite reason for not giving it. Your guidence is invaluable.

Sometimes-it really does suck to be a nurse.I'm just trying to do my best not to upset my mom anymore than I have to. I hate the red flags that go up in your head....