Stroke hemorrhagic conversion

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?

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

I am responding to both comments here.

Journal of Cerebral Blood Flow & Metabolism - Hemorrhagic transformation after ischemic stroke in animals and humans

And here.

Aspirin, anticoagulants, and hemorrhagic conversion of ischemic infarction: hypothesis and implications. - PubMed - NCBI

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.

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.

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?

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

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.

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?

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.

Yes. As I said my training indicates that anticoagulation is never given after a stroke until the CT and MRI are read and the patient cleared by Neuro.

The doctor that ordered the anticoagulation was a hospitalist. At our center (recently listed as a best hospital) some touted magazine....any way in rounds new nurses are grilled about why to hold the aspirin, the lovenox and the heparin and are faulted if they plan to give it. Seems silly why it was ever ordered but the intensivists are hot on this one. Never give anticoagulation.

While there is variability by region clearly I did the correct thing. By the end of my shift the patient was asymptomatic. I will really never know if my actions were the "best" but in this case no harm was caused. Nursing is like that no? We try our best given the circumstances damned if we do and damned if we don't. All said, I have to live with myself and I feel very comfortable with the decisions I made. I am truly surprised however that there is so much debate on something so crucial. The studies clearly reveal the conversion is a real risk when anticoagulation is given. The patient did not get worse while I was his nurse and I can live with that.