Emergency physician treatment of acute stroke with recombinant tissue plasminogen activator: a retrospective analysis.
Stroke teams are advocated for the rapid treatment of patients who have acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rt-PA). An alternate model uses existing ED resources with specialist consultation as needed.


OBJECTIVE
To evaluate the treatment of AIS with rt-PA in this alternate ED model.


METHODS
A retrospective observational review was performed of consecutive patients with AIS treated with rt-PA at four hospitals affiliated with an emergency medicine residency. Emergency physicians (EPs) were directly responsible for the treatment of all patients according to predefined guidelines. Records were evaluated from the implementation of the guidelines through December 15, 1997.


RESULTS
37 patients with AIS received rt-PA. Mean age+/-SD was 63+/-16 years (range 22-87), with 25 (68%) male. Patients presented 67+/-29 minutes after stroke onset. After ED arrival, they were seen by the EP in 14+/-13 minutes, had CT in 46+/-22 minutes, and were treated in 97+/-35 minutes. Neurologist consultation occurred in the department for nine patients (24.3%), and by telephone for 14 (37.8%). Symptomatic intracerebral hemorrhage (ICH) occurred in four (10.8%, 95% CI = 0.8% to 20.8%). There were two deaths, neither associated with ICH. Neurologic outcome at discharge compared with presentation in survivors was normal for four patients (11.4%), improved for 16 (45.7%), unchanged for ten (28.6%), and worse for five (14.3%).


CONCLUSIONS
In this analysis, EPs, with specialty consultation as required, successfully identified patients with AIS and delivered rt-PA with satisfactory outcomes. Important elements of this model include early patient identification, preestablished protocols, and rapid access to CT scanning and interpretation.
Smith
R W
RW
St. Joseph Mercy Hospital, University of Michigan, Section of Emergency Medicine, Ann Arbor 48106, USA. rosmith@msms.org
Scott
P A
PA
Grant
R J
RJ
Chudnofsky
C R
CR
Frederiksen
S M
SM
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002561:Cerebrovascular Disorders / Q000145:classification / Q000188:drug therapy* / Q000401:mortality; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008824:Michigan; D008875:Middle Aged; D011994:Recombinant Proteins / Q000627:therapeutic use; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator