Emergency and stroke physician combined consensus statement on thrombolysis for acute stroke

The latest NZMJ contained a consensus statement from the NZ faculty of ACEM which differs slightly from the ACEM statement. It is longer than the ACEM statement and fills out some of the brief statements. As with many of these documents many of the statements are fairly obvious.

Small difference is noted in the section regarding the informed consent for thrombolysis. Suggesting that it should be discussed by someone with sound knowledge of the benefits and harms. This doesn’t mention or require patients are informed of the disagreement amongst medical professionals of the risks and benefits of the intervention.” A minor but possibly significant difference.   

Another interesting statement is around the timing of thrombolysis with the group unable to come to a consensus around the utility of thrombolysis in the 3-4.5 hour group.

So here is their statement:

Consensus Statement:

  • Stroke thrombolysis with intravenous alteplase is applicable only to a minority of stroke patients and should be seen as a treatment option indicated in carefully selected stroke patients.
  • Patients should be selected in accordance with agreed protocols with explicit inclusion and exclusion criteria. These protocols should be aligned with the published literature and established collaboratively between emergency physicians, neurologists, stroke physicians, and other relevant stakeholders. Treatment outside of agreed criteria might increase the risk of adverse outcomes.
  • The strongest evidence for benefit of stroke thrombolysis is for patients treated within 3 hours of stroke onset. Emergency physicians, neurologists, and stroke physicians should work collaboratively to minimise treatment delays.
  • This group was unable to reach a consensus about the utility of stroke thrombolysis between 3–4.5 hours of symptom onset.
  • Inpatient stroke team pre-notification of a potential thrombolysis patient’s arrival is encouraged to facilitate rapid patient assessment and to assist with potential resource constraints in emergency departments.
  • Appropriate infrastructure should be present including timely access to neuro-imaging (CT scanning) and timely interpretation of these scans prior to thrombolysis by consultant radiologists, neurologists, or stroke physicians/delegated radiology registrars with appropriate expertise and training.
  • Informed consent for thrombolysis should be discussed and obtained by a medical specialist or delegated registrar with appropriate expertise and training in stroke assessment/management and with a sound knowledge of the benefits and harms of stroke thrombolysis.
  • There should be appropriate care and documentation of progress after thrombolysis including recording of vital signs and neurological observations according to agreed protocols.
  • Patients should be expeditiously transferred to a designated intensive monitoring ward area or Stroke Unit (ideally immediately following neuro-imaging prior to or immediately after administration of thrombolysis).
  • Services who provide thrombolysis should audit their service regularly to monitor safety and measure outcomes. Audit results should be reported routinely to local clinicians and regional stroke networks. Ideally a national database should be established to audit all stroke patients, including individuals treated with thrombolysis, to measure outcomes, with the results made available to all clinicians involved in the care of stroke patients.
  • The ongoing appropriate use of thrombolysis in stroke should be reconsidered as the results of audits, or further research, become available.

 Ref: NZ faculty statement:  http://journal.nzma.org.nz/journal/127-1392/6096/

 ACEM statement: https://www.acem.org.au/getattachment/1636cfd5-3829-4fc6-9eb2-91742f3d250b/Statement-on-Intravenous-Thrombolysis-for-Ischaemi.aspx

Biting off more than you can chew.

After being very keen and kicking off with the #FOAMed question of the day I’ve realised that it takes more effort and time that I want to invest at the moment. So I’ll be moving back to more old style posts of cases, discussion of papers and publications.

Thanks to everyone who has been involved in the QOTD project.

 

 

FOAMed question of the day 66 #FOAMedQOTD

A drunk patient is admitted to your ED to “sober up”

His nurse suggests some IV fluids to help him.

How effective is fluid therapy for alcohol intoxication?

drunk

Answer

FOAMed question of the day 65 #FOAMedQOTD

What volume of fluid from thoracocentesis is associated with an increased risk of re-expansion pulmonary oedema?

 

Answer

FOAMed question of the day 64 #FOAMedQOTD

 Kernigs and Brudzinskis sign are both used to identify patients with meningeal irritation.

How sensitive are these signs for the diagnosis of meningitis?

Kernig