So you pick up this acute CVA and drive like crazy to the emergency department — and the #@1! ED doctor doesn’t use thrombolytics! What gives?
As a practicing ED physician in a busy Level 2 trauma center, I get to see all types of patients being brought to the ED via EMS. I am sure you have all been called out on a 911 call only to find out the patient really just wanted a ride to the ED to get a prescription refill. I know how frustrating it can be to take care of that sort of patient and I can just imagine how frustrating it must be to be called out in crappy weather to do so.
But every now and then, both in the ED and in the field, we get a patient with a real disease. I find this sort of patient can make the rest of my shift go pretty quickly, and I feel good when I go home, thinking that maybe I made a difference. I am referring to patients like the bad asthmatic, an acute myocardial infarction, or severe CHF. These patients are fun!
Now don’t get me wrong; I’m not wishing for bad things to happen to people. It is just that I entered emergency medicine wanting to make a difference, just like you did. So here you have an acute CVA — one of those cases where you can really make a difference — and the ED doc isn’t cooperating with your vision! Why not?
As you know, there is a lot of pressure to do stroke evaluations in the field and then to transport the patient to an appropriate stroke center. All this has to be done quickly because the clock is ticking. But ticking for what exactly?
Well, certain subsets of patients who are experiencing an acute ischemic stroke seem to benefit from the early administration of TPA. The devil is in the details, of course. In the first few minutes after you deliver the patient to the ED doorstep, a well orchestrated cascade of events must occur before a go/no-go decision about thrombolytics can be made. Rapidly, the patient’s blood chemistries and platelets need to be measured, and their blood pressure needs to get controlled. In addition, a brain CT needs to be obtained and interpreted by a radiologist.
All this has to happen within three hours of the onset of symptoms. We have to be very precise about the time of onset since it’s been shown there can be lots of bad consequences if thrombolytics are given outside that time. Just noticing a stroke when Grandma wakes up doesn’t count. When was the last time Grandma was normal? If she was normal five hours ago when she went to bed, then we must assume the worst-case scenario: that we are beyond the window of treatment to use thrombolytics.
We have to go back to the basics and take a good history. If the patient had recent surgery, or had a seizure associated with a stroke, or suffered a severe headache at the same time, all of these would be reasons not to give thrombolytics. The reason is that the patient’s symptoms may not be due to an ischemic stroke, but due to another disease process.
The real kicker for me, as the ED physician, has to do with the potential side effects of thrombolytics given for an acute ischemic stroke. Across many studies, there seems to be about the same complication rate. Approximately 6 percent of the people who receive thrombolytics for stroke will begin bleeding in the brain.
But wait, it gets worse.
Half of the people who bleed into the brain from thrombolytics will die (that’s 3 percent). It’s very scary to have a syringe in your hands that can potentially do great good, but will kill three out of a 100 people that you give it to. You might correctly guess that this may cause some sleepless nights, if the patient you gave thrombolytics to ended up dying.
In our ED, we have seen great results, as well as the tragic ones; so it is hard to be sure that your decision is “right” every time. But at least it is the very best “right” decision you can give.
If you are looking for a good summary that you can use for (or give to) your patients, check out http://www.aaem.org/education/tpaedtool-AAEM.pdf. The article shows the risks and benefits of thrombolytics, and also lists several additional references.
Authors’s Note: The next time you find yourself frustrated because the ED doc didn’t give thrombolytics to the patient, for whom you busted your butt getting to the ED quickly, let’s talk about it. Got any other gripes, comments or questions about a patient you have dropped off at your local ED? If so, please send me an e-mail. I will take the interesting and/or challenging ones and I’ll discuss it my future columns. Don’t spare me any punches; I can take it! — Robert Donovan, FACEP |
