stroke

[basementbeast]

any community attendings out there working at designated stroke centers? do your neurologist come to the bedside to examine potential tPA candidates? how long do they have to arrive? do you start tPA with a phone consult only? do you start tPA without neurology consult?

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[ERMudPhud]

any community attendings out there working at designated stroke centers? do your neurologist come to the bedside to examine potential tPA candidates? how long do they have to arrive? do you start tPA with a phone consult only? do you start tPA without neurology consult?

I was at a designated community stroke center. The neurologist didn't like it but they had to examine and consent the patient before TPA. We initiated the workup and did everything up to mixing the lytic but they had to be there before the drug was hung. No exceptions. Part of that was due to previous behaivior on their part. We had more than one case of patient who were thought not be candidates for lytics being told days later by neuro that they would have given them the miracle drug. Conversely on a few cases that bled they documented after the bleed why they wouldn't have lysed that particular stroke: too big, too old too whatever. In the end it was easier to put the burden in their laps. If you want to have a stroke center you need to step up to the plate and start acting like the cardiologists

 

[basementbeast]

mudphud: was there an expected time of arrival to the bedside?

 

[ERMudPhud]

mudphud: was there an expected time of arrival to the bedside?

The only expectation was that they had to be there before the three hour window was up for thrombolytics and at least by the time the workup (CT, labs) was complete. We could do the entire workup but if they didn't make it in time to review the scan, examine the patient, and fill out the consent the drugs didn't get pushed. We also were careful to document the time they were called. Most responded in under an hour. The consent was an issue because their interpretation of risks and benefits of lytics was somewhat more rosy than ours. For whatever reason our relationship with neuro at that hospital was bit more contentious then our relationship with the other nonsurgical specialties.

 

[southerndoc]

The ED physicians starts the tPA at our community hospital. The neurologist usually comes in as the tPA is being administered.

 

[EMCC]

I am at a community hospital, as a designated stroke center, that has an ED residency, but no neurology residency/fellows. So, for every possible CVA, we quickly do the NIH scale, get stat labs, get the patient over to CT, and call the neurologist. While the patient is at CT, we go over the case over the phone. The expectation is that the neurologist will be at the bedside within 20 minutes. That way, the CT has been read and dictated, the labs are all back, and a more thorough history has been taken. Then, with the blessing of the neurologist, the ED nurse pushes the tPA and the patient is then wisked away to the ICU to spend the night.

So far, we have not had any problems with regards to getting the neurologist to see the patients. Every so often they will not come the hospital, and give us the go ahead to push the tPA, assuming the patient meets criteria.

Interestingly, Canadian EM group (forget the name) requires a neurologist, radiologist and an ED doc be on board prior to the admin of tPA. SAEM leaves it up to each individual hospital to decide whether they want to give tPA. ACEP leaves it up to the individual EM doc. So, there is no consensus on tPA administration...

You get sued if you gave it and the patient bleeds, you get sued if you withheld the tPA... no win.