tPA Question

Wise Woman RN · Nov 28, 2007

signs of stroke would be pretty much the same, but there is a time frame in which a CT scan is done to determine if the stroke is caused by a bleed or a clot. I think it's a two hour window...

Altra, BSN, RN · Nov 28, 2007

signs of stroke would be pretty much the same, but there is a time frame in which a CT scan is done to determine if the stroke is caused by a bleed or a clot. I think it's a two hour window...

The 3-hour window from time of onset of symptoms is the time frame in which administration of tPa or another thrombolytic can be effective. The frequent difficulty in nailing down the exact time that patient was last seen "normal" is a primary reason that thrombolytics, frequently presented to the public as a wonder drug to reverse the effects of a CVA, are not given nearly as often as one might think.

OP: it's important to remember that tPa is not a "blood thinner" (like Coumadin) but a thrombolytic.

ERRNTraveler, RN · Nov 28, 2007

MLOS is right- the window is 3 hours, and TPA is not a blood thinner, but a "clot buster".

The signs of stroke can be the same whether it is hemorrhagic or ischemic. That is why a stat CT is needed to determine what type of stroke it is, then, if it is ischemic, TPA can only be given if the family/caregivers are ABSOLUTELY SURE the onset has been within 3 hours. BUT, never ask family members "has it been less than 3 hours?" because they might just say yes, even if it's been longer. I always ask, "What time did you first notice these symptoms?" If they're not sure, ask "when did you last see him/her acting normally?". These questions will usually give you a more accurate answer, and, like MLOS said, usually the time of onset is either greater than 3 hours, or can't be determined- which is why most of the time, TPA isn't an option.

EDValerieRN, ASN, RN · Nov 28, 2007

So being that I'm in a neuro-focused ER, we give lotsa the tPA. Here are a few points.

~ Our window is six hours from time of onset. However, I have never seen it given more than four hours out.

~tPA can only be given for an ischemic stroke. The patient will have a stat CT-Head (we strive for a door to CT time of 20 minutes)

~IF the CT is negative, but the patient is experiencing symptoms, we will screen the pt for eligibility, get permission, and give the juice. If you see an ischemic stroke on the scan, then it's too late to give tPA. Reason being that if you see the stroke, the stroke has been there too long to benefit from clot-busters.

~tPA has a six percent mortality rate due to head bleeds.

~Often, you'll see marked improvement in only a few minutes after giving it. Truly is a miracle drug. However, a large scale study just came out that shows tPA to be no more effective than an aspirin. More research really needs to be done, and other studies have shown it to be tremendously effective if used correctly.

~ You'll need to do more neuro checks in the next few hours than you've probably done in your life... unless you give tPA a lot. It is REALLY important to get a great baseline assessment of your patients neuro status. Without it, you won't have anything to go on.

~The very first sign that there may be a bleed is a subtle change in LOC. The patient will seem tired.... will stutter, or not recall certain things... may get agitated, combative, or just sit up in bed and have a wild look. Pupillary changes are a late sign of a bleed. While helpful to assess, it won't be the first thing you see. You may also see bleeding at IV sites, tachycardia (early) and bradycardia (late), blood pressure changes, etc. None of this is good. When you see it STOP THE TPA and do a stat head CT. tPA patients can herniate fast.

~When we give tPA I'll often sit in the room and just visit with the patient/family for about 30 minutes. I can do that because I don't have a patient assignment as charge, but a lot of nurses don't have that luxury. tPA pts should be 1:1, due to the high risk for bleed/death. I've caught a bleeds before, and it's scary. I've also seen a lot of fab outcomes from it as well.

Lemme know if you need anything else.

WonderRN · Jun 1, 2010

EDValerieRN,

I just gave TPA for the first time the other night. I was really scared, because I know the risk of hemorrhage..... The patient had improvement after the bolus and halfway through the infusion-could move his left side of his body better, less facial drooping, dizziness and headache went away. And, its the first time I felt like a real nurse (being a new grad) because I noticed he was having the stroke when he came in- he was brought in by EMS as a chest pain/dizziness! (given asa and ntg en route)

I was wondering.... at what point are we out of the woods with the risk of hemorrhage? The patient went to sleep after the infusion (it was the middle of the night), I was getting ready to take him to the unit- and I checked his LOC before getting him upstairs. This was about 1.5 hours after the completion of the infusion. He was tired, arousable to verbal stimulation, and could recall the night's events easily...... but it made me a bit scared because he was groggy. Once I got him to the unit, everything seemed okay...... but at what point can I be less hypervigilant that he isn't bleeding?

Great advice,by the way. Wish I could give you 20 kudos for it!!!!:bowingpur

crissrn27, RN · Jun 1, 2010

So being that I'm in a neuro-focused ER, we give lotsa the tPA. Here are a few points.
~IF the CT is negative, but the patient is experiencing symptoms, we will screen the pt for eligibility, get permission, and give the juice. If you see an ischemic stroke on the scan, then it's too late to give tPA. Reason being that if you see the stroke, the stroke has been there too long to benefit from clot-busters.

I don't understand this. Why wouldn't you see the clot on CT regardless of how long it has been there?

Editorial Team / Moderator · Jun 2, 2010

I don't understand this. Why wouldn't you see the clot on CT regardless of how long it has been there?

You won't see a clot on CT, but you will eventually see an area of ischemia after a few hours.

Amnesiac70 · Jun 3, 2010

New onset ischemic CVA will usually have a negative CT. I believe that the CT is to rule out Hemorrhagic CVA. And you should be doing NIH score pretty regularly on these patients and notice differences one way or another.

I've had only bad outcomes with tPA. (6 and counting).

Oh, one more thing. In trying to determine the onset of symptoms. I typically ask "When did you last see him normal?". This usually helps pinpoint the latest onset of symptoms.

murphyle, BSN, RN · Jun 3, 2010

On the topic of tPA administration timing: our window is four hours. Some docs will push it if they feel that there might be some issue with how long the patient's actually been symptomatic or if they think the patient has enough collateral circulation to avoid ischemia.

We had a case not too long ago where a patient came in with strokelike symptoms, where the family got into a big debate in the resus room over when the symptoms had started. One child said six hours, one said the patient had been acting squirrelly all week, one said two hours, and the spouse said three hours. CT was negative for bleeds and ischemic damage. We got permission from the spouse and gave the juice (much to the dismay of two of the kids, but that was another fight). Patient improved immediately.

We don't do a lot of it, but I agree with EDValerie: it's a miracle under appropriate conditions.

Editorial Team / Moderator · Jun 3, 2010

I did a paper on tPA administration windows for one of my BSN classes, and there are some studies in which they're giving tPA to people who wake up with stroke symptoms (so totally unknown onset), as long as the patients don't have any contraindications to receiving tPA in the first place. Interesting.

crissrn27, RN · Jun 3, 2010

That is interesting. I get them after all the damage is done (SNF), so didn't know initial a CVA wouldn't show on a CT unless hemm. I guess I assumed that a clot or such would show at that time.