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 acu te ischemic stroke (AIS) with recombinant tissue plasminogen activator (rt- PA). An alternate model uses existing ED resources with specialist consulta tion as needed.. Objectives: 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 hosp itals affiliated with an emergency medicine residency. Emergency physicians (EPs) were. directly responsible for the treatment of all patients accordi ng 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 consultati on occurred in the department for nine patients (24.3%), and by telephone f or 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 sur vivors was normal for four patients (11.4%), improved for 16 (45.7%), uncha nged for ten (28.6%), and worse for five (14.3%). Conclusions: In this anal ysis, EPs, with specialty consultation as required, successfully identified patients with AIS and delivered rt-PA with satisfactory outcomes. Importan t elements of this model include early patient identification, preestablish ed protocols, and rapid access to CT scanning and interpretation.