Stroke hemorrhagic conversion

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Specializes in Critical Care.

I am helping out at a hospital some miles from my home while the staff goes through EMR training. There was a patient admitted for CVA was told the CT was negative and he was also going for MRI which is pretty standard. The MD ordered Plavic, Aspirin and Lovenox which I held. When the night shift nurse was taking report she insisted that I should have given the anticoagulants. I talked with her briefly about how terribly incorrect she was and she was defiant stating that hemp goes to one floor and ischemic goes to this floor. I asked her if she even knew about strokes converting to a bleed and she would not answer.

As an experienced nurse I wonder what my responsibility would be to this hospital. I am there only 4 weeks more. There are other issues as well but this is really dangerous for them to be doing.

Your thoughts appreciated.

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Specializes in Emergency & Trauma/Adult ICU.

I work at a JC-accredited comprehensive stroke center. If initial CT is negative for a bleed, we give ASA and sub q heparin.

Did you communicate with the ordering physician?

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Specializes in Neuroscience.

If the stroke is a thrombolytic/ischemic and not hemorrhagic, why wouldn't you give anticoagulants? I'm just curious.

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Specializes in Critical Care.

To answer your question no...we routinely hold the anticoagulation until the MRI is completed. My "day" job is in a stroke center as well. We apply SCD for anticoagulation effect make the patient NPO and do checks every hour following a CVA. If given TPA we do the checks every 15 minutes for 2 hours. I did not receive a call back from the ordering MD. That unfortunately is quite typical for the hospital in question.

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Specializes in Emergency & Trauma/Adult ICU.

I would suggest that for further discussion we eliminate patients who receive tPA ...

I assumed we were talking about suspected ischemic stroke patients with no evidence of bleed on initial head CT.

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Specializes in Critical Care.

That is correct. Negative head CT and whether to give or not give anticoagulation.

Here is a specific article to that population I believe.

Anticoagulation After Cardioembolic Stroke: To Bridge or Not to Bridge?

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Specializes in Critical Care.

This is what I was looking for. Regional differences apply it would appear and the use of anticoagulation after stroke is controversial. It does seem to me that since this patients stroke was not progression and I could neither see the CT or the MRI or the reports it was prudent to hold the anticoagulation. That is my practice where I work regularly and I can't really conceive why anticoagulation would be a priority in a negative CT if there are other methods to keep blood flow. I am somewhat stunned that this would not have been established by the NIH given all the training we do.

Anticoagulant therapy for ischemic stroke: A review of literature

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Specializes in Emergency, Telemetry, Transplant.

I also worked for a Joint Commission certified stroke center. Pretty much every person with stroke symptoms and a negative CT (i.e., no bleed) got ASA. Many were also started on a heparin gtt or Lovenox (again, excluding the patients who got tPA)--this was all before MRI was done. That does not definitely prove that we always did the right thing, but to say the other nurse was "terrible incorrect" seems a bit harsh.

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Specializes in Critical Care.

Yes and thanks. These articles which I saw for the first time show that yes anticoagulation may hurt and lovenox and heparin may be the worst. That said differences clearly exist and I am left wondering why the stroke folks who make rules don't establish which is safest?

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Specializes in Neuroscience.
That is correct. Negative head CT and whether to give or not give anticoagulation.

Here is a specific article to that population I believe.

Anticoagulation After Cardioembolic Stroke: To Bridge or Not to Bridge?

I've read two articles so far, and I'm finding them fascinating. Thank you for posting them. However, this jumped out at me while reading:

"Our work has several limitations. First, this is a retrospective study comparing various treatments assigned in a nonrandomized manner. Therefore, differences are present between the treatment groups that might not be completely accounted for by our multivariate analysis. The results should be viewed as hypothesis generating, and further prospective validation may be required. Until such validation occurs, our conclusions should be interpreted with caution"

I have no idea why you were unable to get a hold of the doctor, that is ridiculous. However, it is not up to us (at least in my state) to interpret a CT scan. If there were concerns that the anticoagulants should not be given, you should've been calling the doctor until he answered.

My Granny died of a bleed after being given TPA. The family understood the risk associated with TPA, we understood that she could die, and we would've made the same decision regardless of what literature was presented to us. She didn't want to be trapped in a body that didn't work properly, and the benefit outweighed the eventual outcome.

Knowing what a stroke is capable of, as a stroke nurse, what decision would you make for your body if you had a debilitating stroke? Would you take the chance that you might die in order to gain function on the side affected?

I understand now why you didn't give the anticoagulants. I wonder if not giving the anticoagulants was truly in the best interest of the patient.

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