Use of tpa in strokes – emergency nausea in the morning male physicians monthly

It is unlikely that reasonable emergency physicians will ever universally nausea in the morning male agree that thrombolytics are the standard of care in acute nausea in the morning male ischemic strokes. A 2005 survey by brown et al. Showed that 40% of emergency physicians are unwilling to use tpa in an nausea in the morning male acute stroke (note that this case took place in 2004). While the NINDS study showed a relative benefit of tpa nausea in the morning male use in acute strokes, subsequent studies such as ECASS and ATLANTIS showed little benefit, and ATLANTIS demonstrated an increase in symptomatic intracerebral hemorrhage with nausea in the morning male tpa use. AAEM’s policy statement on tpa use in stroke specifically states nausea in the morning male that available data are insufficient to deem thrombolytics as a nausea in the morning male standard of care. ACEP’s thrombolytic policy states that further studies are needed to nausea in the morning male define the patients most likely to benefit from tpa use nausea in the morning male in acute strokes, noting that there is insufficient evidence to endorse tpa use nausea in the morning male when NINDS guidelines cannot be followed. Both organizations note that no subsequent randomized double-blinded study has been able to replicate the NINDS findings. Regardless of which position an expert takes, ethical testimony should acknowledge that there is much conflicting data nausea in the morning male regarding the efficacy of tpa in acute stroke. While tpa may improve outcomes in certain patient populations under nausea in the morning male certain conditions, as the answers to this scenario demonstrate, it is likely that there is no universal “standard of care” for use of tpa in acute strokes.

Further, if the patient was suspected of having a posterior circulation nausea in the morning male CVA, the failure to contact a neurologist (I’m not sure a neurosurgeon is the right person) is below the standard of care. Failing to consult the neurologist or neurosurgeon within three hours nausea in the morning male of the patient’s symptoms to discuss whether tpa should have been given. The EP should have expedited the CT, certainly ahead of non-emergent patients. Specifically, the expert believed that other patients needing CT scans should nausea in the morning male have been made to wait and stated that “all things being equal,” a 42-year-old should receive preferential treatment over a 77-year-old when both need CT scans of the head. For my opinion, it depends on the nature of the clinical picture of nausea in the morning male the 77-year-old’s problem. Having said all this, I don’t think that the current knowledge of thrombolysis in CVA nausea in the morning male would allow us to say that the expeditious administration of nausea in the morning male tpa would have resulted in a wonderful and remarkable recovery nausea in the morning male and complete resolution of the patient’s symptoms. However, since there is some evidence (regardless of how weak) that the administration of tpa may help, the patient has the right to know about that therapy nausea in the morning male and make an informed decision on whether to accept the nausea in the morning male therapy or not. If I were in this poor man’s position and was told the risks, I think I would opt for the tpa. However, that is my opinion and not what all patients would nausea in the morning male do, although all eps should discuss the pros and cons of nausea in the morning male this therapy with their patients and consult with an expert nausea in the morning male (neurologist) in these cases.

1. Evidence for TPA has never been good. Personally I would never order it for stroke. I keep a couple of emergency medicine abstracts in my nausea in the morning male desk that show TPA intracranial hemorrhagic complications and mortality are nausea in the morning male much higher than for stroke treatment without TPA. Bukata and hoffman have been strong opponents of TPA for nausea in the morning male stroke from the beginning and they have a wide audience nausea in the morning male in the emergency medicine community.

2. Stroke symptoms accompanied by vomiting point quite often to the nausea in the morning male stroke being hemorrhagic which would exclude TPA but may require nausea in the morning male neurosurgical intervention, so the quicker the CT can be done the better. We should do all we can to expedite the CT. However, we all know that though we want things to be nausea in the morning male done quickly we can’t always make it happen. I would try to get them to scan this patient nausea in the morning male before less emergent problems.

3. The scenario doesn’t say if any findings are already visible on CT nausea in the morning male scan. That would make hemorrhage due to TPA even more likely nausea in the morning male and be an exclusion criterion. With such a severe cerebellar stroke that it caused death nausea in the morning male so quickly, TPA would have a low probability for success. The original articles show a small percent were improved a nausea in the morning male small amount at 3 months. I am skeptical of the anecdotal cases of rapid improvement nausea in the morning male with TPA. These are likely to be the same ones that would nausea in the morning male rapidly improve without TPA.

9. If the ED doc is correct that there was no nausea in the morning male focal extremity weakness, it is likely that the stroke score would not be nausea in the morning male high enough for the patient to meet criteria to be nausea in the morning male a TPA candidate. If he had focal weakness initially and that had resolved nausea in the morning male by the time of the ED physician exam, that would exclude TPA. Rapid improvement is an exclusion criterion.

10. I believe the ED doc met the standard of care nausea in the morning male in not giving the TPA. If I see a patient that actually does meet TPA nausea in the morning male criteria, I would pull out the EMA articles showing about double nausea in the morning male the brain bleeds and mortality and give it to patient nausea in the morning male and family and say that personally I could not advocate nausea in the morning male with a clear conscience a medicine that I know is nausea in the morning male twice as likely to make them worse or kill them. If after that informed consent they still want it, then I’d let the neurologist order it.

2) consultation with radiology and neurology is the standard at stroke nausea in the morning male centers. Having said that, there is a difficult choice to make. The choice of thrombolytics is in part driven by the nausea in the morning male bed availability in the ICU for a stroke code patient nausea in the morning male and also by the availability of neurology and an intensivist. These may not be available in many smaller hospitals. Smaller hospital would benefit from a transfer plan to a nausea in the morning male stoke center. These protocols did not exist in 2001.

3) the statement that the symptom complex is specific for a nausea in the morning male cerebellar CVA is a bit of stretch. The history does not clearly state ataxia in the ED nausea in the morning male exam. More concerning for CVA is the history of the unilateral nausea in the morning male focal deficits. These did improve or were improving however. No statement of normal blood glucose either. Assume this to be the case given the outcome.

3) this statement is on the edge of being offensive. We do not have enough information about the condition of nausea in the morning male the 77 year old to make a triage decision. The MDM should have documented that the triage decision was nausea in the morning male made based on medical condition. The “experts” apparent age bias is offensive and not the standard of nausea in the morning male care. It is not his place to see a 39 year nausea in the morning male old as having more value than 77 year old. The 77 yr old could have had a neurosurgical emergency nausea in the morning male (bleed with or without blowing pupil, a CVA more clear cut than this patient and needing nausea in the morning male TPA). Having said that the time of 1 hour 17 minutes nausea in the morning male for CT is a bit long given only one other nausea in the morning male patient. That should be tempered by the technology of that year nausea in the morning male and not judged by our new scanners. The fault in my mind is not showing the necessary nausea in the morning male urgency and due diligence and documenting it.

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