The TPA time limit for acute stroke causes mass chaos in the ER

I hate acute strokes. There are several reasons for it. Most of them are logistical. First, everyone gets into a tizzy because of the 3 (or 4.5) hour time limit after the onset of symptoms that which TPA can be given and hopefully improve the patient’s outcome. Unfortunately, this time limit (and the data for TPA’s efficacy is only OK at best) causes mass chaos and annoyance.

First, one has to establish 100% what the exact time of onset was. This is not easy most of the time. I would say about 80% of “acute” strokes brought in by EMS turn out to not be within that window. It takes more than just saying “when did the symptoms start?”

Often the patient is elderly and demented. Often they live alone. Often there were milder symptoms before that were ignored or unrealized. Occasionally the person has hemi-neglect and can’t really say when things started. Sometimes there is alcohol on board. Sometimes the symptoms are on top of pre-existing stroke damage and it is hard to tell if it is really new or worse. Sometimes patients probably had a seizure at onset and that prevents them from getting TPA.

All these things make history taking a royal pain in the ass. And remember, it must be done quick! The exam can be hard too. Sometimes the patient can’t reliably follow commands or there is a language barrier. Sometimes the patient’s preexisting abnormal findings make it hard to tell if something is old or not. Sometimes the person is so out of it the whole thing is a waste of time.

Second, once you are sure it is a stroke, you have to hustle. If the person came in within one hour, no prob. But if 2 have passed (or 3.5 in a younger patient eligible for the 4.5 hour window), it is tough. The bloods have to be sent off.  Blood pressure  may have to be corrected. You have to zoom the patient over to CT and get it read. You have to get consent (often from a family member who is on the telephone), as well as the worst  part of all. That would be calling the neurologist.

Many hospitals (like mine) require that the giving of TPA is a two-doctor job – and one is the neurologist. I think mostly because neurologists are the best at making sure it really is a stoke. In many cases it is pretty obvious, but in the borderline, more challenging cases, they are much more astute than me at teasing out the minutiae from the history and subtle exam findings. This is important because TPA has a big risk; bleeding like stink. Turn a ischemic stoke into a hemorrhagic one and you’ve screwed the patient royally. Cause a bleed in someone who really was not having a stoke? You are so screwed it is not even funny.

Anyway, calling the neurologist sucks. Why? The same reason it sucks for everyone else. They have to drop whatever it is they are doing and come flying in. As you can guess, strokes that happen at 2am are truly unwelcome. They hate to get awoken, and I hate to wake them. Even if it is during the day, they have to abandon their rounds or their patients in the office to come in. Of course I know it sucks (it wrecks my rhythm too) but part of me is just like, “You guys did the research for this stuff and published the papers and made it standard of care.”

Regardless, one cannot explain how grumpy and unpleasant to deal with the neurologist is at 4am. If anything is out of place, if the flow of things is not perfectly smooth, or if the nurses don’t have everything ready for them, it’s freak-out time. God forbid if the diagnosis is wrong. Or if they feel the symptoms started earlier and the patient is out of the window. Or if it turns out the patient has some contraindication to getting the drug. Lets just say the discussion between the doctors is not pleasant.

All this is bad enough but what really takes the cake is that the treatment is not very good. The data in the big studies is sub-par (certainly compared to many other treatments for things we do). Even under the best of circumstances (which seem to almost never occur) the improvement the patient gets is only moderate (and even worse during the 3-4.5 hour window). Of course, that may be significant in the long run for the patient’s functioning but a good part of the time, they don’t improve at all.

Add that in with the people who bleed and you have a treatment that few people are enthusiastic about. Of course this leads to another part, the giving or not giving of TPA in acute stroke is a huge lawsuit waiting to happen. If you give it and the person does poorly, you get sued. If you don’t give it and the person does worse, you get sued. So, I say please invent something better for strokes.

Finally, of course, I hate it for what it does to patients. It can be truly devastating and the costs to the patient, family, and society is staggering.

ER Stories is an emergency physician who blogs at his self-titled site, ER Stories.

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