TPA when drunk

ParalyticAgent · Oct 19, 2015

This is actually a really interesting question.

I did a little bit of research, and I can't come up with anything definitive. It isn't a contraindication, but most protocols and research have something along the lines of "symptoms cannot be explained by other etiology- migraine, intoxication."

There was a study that showed slightly poorer outcomes for cocaine intoxicated patients who were treated with t-PA, but a cursory search did not result in any discussions about ETOH intoxication.

TiggerBelly · Oct 19, 2015

Was there a blood alcohol level done?

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bear14 · Oct 19, 2015

There was but my shift was over and those labs did not result yet.

emtb2rn, BSN, RN, EMT-B · Oct 19, 2015

How would consent work with an intoxicated pt? And did the etoh have an impact on the assessment?

MunoRN, RN · Oct 19, 2015

Confirmation that a patient is actually having a stroke to give TPA is done solely by symptoms, so it is often difficult to differentiate stroke symptoms from ETOH intoxication unless it's really distinct unilateral paralysis or something like that. A CT scan is done prior to TPA but not to find a stroke, it's only to rule out a hemhorragic stroke so that isn't of much use in differentiating stroke vs intoxication. It may also be difficult to establish a clear time of onset, if the patient is a long standing alcoholic with liver disfunction and a resulting coagulation abnormality then that may also rule them out. It's not impossible but there are a number of things that might rule such a patient out.

bear14 · Oct 20, 2015

The patient's speech was clearly affected and he had right sided weakness. It was not just drunken babble it was word salad. We could not smell any etoh on him. We all thought he was intoxicated at first but the ruling was stroke. I was curious though had he been drinking could it have been given if he was drunk and had a stroke? I wish I could have seen his all of his labs.

nurse lala, BSN, RN · Oct 21, 2015

I would like to see GLU level.

bear14 · Oct 21, 2015

It was 157 or something like that. That was checked quickly.

Guest219794 · Oct 21, 2015

When I read the title, my first thought was that it is tricky to mix, and you should probably sober up first, or find a designated pharmacist.

Roy Fokker, BSN, RN · Oct 24, 2015

Disregard the "distracting injury" (i.e. patient may be drunk) - you said patient had clear right sided weakness and 'word salad' (not just slurred speech). No hypoglycemia. No clear trauma.

(assuming rest of contraindications were not present) The key is the measurable right sided weakness. What makes this tricky is "time of onset of symptoms" - if the time of onset was known and was 'within the window'; I don't think tPA wound be contraindicated.

tPA isn't just given for strokes. I had a case where a pregnant mamma got it following a massive PE!

How would consent work with an intoxicated pt? And did the etoh have an impact on the assessment?

Patients with 'altered mental status' (drunk/high/demented etc.) cannot give consent. Consent is implied (i.e. cannot refuse treatment) - baring an advanced directive/living will etc.

- Roy

irishstormy · Nov 15, 2015

I just recently had a patient who came in for intoxication and began having stroke s/s in the squad in route. We consulted with neurology and they recommended tpa. After administration he had improvement of his symptoms and weakness began to reverse.