why no tPA if glucose is low/high?

[lazlohollyfeld]

Hi guys,

I'm an RN studying for ACLS. I can't intuit why tPA is contraindicated if blood glucose is <50 or >400 mg/dl, and can't find the info online either.

Thanks very much to anyone willing to share their expertise.

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[WilcoWorld]

Hypoglycemia can cause focal neurologic deficits and thereby masquerade as a true ischemic stroke. It would be a shame to subject someone to the risk of intracranial hemorrhage from tPA if all they needed was dextrose.

hope that helps

 

[lazlohollyfeld]

Thanks, WilcoWorld!
Your response makes total sense and also clarified that the "real" issue is that I don't understand how ischemic stroke is diagnosed--I was assuming that the premise was that the patient DID have an ischemic stroke, and yet there was still a contraindication to tPA use with abnormal blood glucose. (Does the CT scan then only rule-out hemorraghic stroke, not confirm an ischemic one?)

Simple questions to you all, I know.
Lots to learn...thanks again.

 

[dchristismi]

Bingo. CT will only show hemorragic stroke acutely. Ischemia may become apparent after several hours, but not initially.

 

[EMCC]

Actually there are four early signs of an ischemic cva on a CT scan that ED docs can look out for--but most radiologists will miss:

1) Hyperdense MCA--usually due to large clot burden sitting in the affected side's MCA

The next three can be seen on the one slice of a CT

2) Loss of the Sylvian Fissure--again on the affected side
3) Grey-white differentiation
4) Loss of the Globus Pallidus and Putamen on the affected side

I don't remember the exact order of the 4, but they will be there on a stroke alert CT even within 1/2 hour if the patient is truly having a CVA

 

[kungfufishing]

hyperdense MCA does seem to be one that I almost never notice a rads comment on. Of course, the patients I've seen who have a hyperdense MCA on CT also clinically often have a dense MCA stroke.

 

[bulgethetwine]

Actually there are four early signs of an ischemic cva on a CT scan that ED docs can look out for--but most radiologists will miss:

1) Hyperdense MCA--usually due to large clot burden sitting in the affected side's MCA

The next three can be seen on the one slice of a CT

2) Loss of the Sylvian Fissure--again on the affected side
3) Grey-white differentiation
4) Loss of the Globus Pallidus and Putamen on the affected side

I don't remember the exact order of the 4, but they will be there on a stroke alert CT even within 1/2 hour if the patient is truly having a CVA

Don't know too many radiologists who would miss a dense MCA sign in these times (were these 4 things in an article in one of the throw-aways a few years back?).

Don't forget that although any one of these 4 things *might* be on a stroke within 1/2 hour of someone having a true CVA, the most consistent finding on head CT in ACUTE STROKE is "NO FINDING AT ALL" i.e. a normal head CT.

So if you believe in and are going to give thrombolytics (another thread ENTIRELY) don't be dissuaded by a normal head CT.

After you check the glucose of course (Bulge puts thread back on railway tracks)

 

[roja]

In honor of Bulge, I will refrain from commenting on the general idea that most people shouldn't be getting tPA

 

[bulgethetwine]

In honor of Bulge, I will refrain from commenting on the general idea that most people shouldn't be getting tPA

Bulge is honored, winks at Roja, and agrees with the general idea that most people shouldn't be getting tPA

By the way, if I come into your ED with a serious stroke - give me a double. Bring me recovery or death!