All Aboard the tPA Hype Bus

Indiscriminate use of tPA in those with undifferentiated stroke is a low-value proposition – even if you find the evidence reliable. The utility of tPA for stroke depends on anatomy, time, and tissue status – information the traditional non-contrast head CT does not usually provide. Unfortunately, one of the latest “innovations” in stroke care is simply to do this useless test faster – in a bus, down by the river.

This is the PHAST project out of Cleveland, which, like similar efforts in Berlin, Chattanooga, and Houston, puts a CT scan machine in an oversized ambulance. Many of the initial phases of these projects included a stroke physician physically in the vehicle – but this, as you would expect, takes advantage of telemedicine technology to provide consultation from afar.

The stated hypothesis of this project is “that the MSTU will allow significant reductions in time to evaluation and treatment of patients when compared to a traditional ambulance model in an American urban environment”, which is just mind-numbingly infantile. Of course, pre-hospital administration will be faster than in-house thrombolysis – the interesting data would be with regard to safety and misdiagnosis.

This report is of the first 100 patients evaluated – generated by 317 system alerts. Of these, 33 were given a preliminary diagnosis of probable stroke, 30 possible stroke, 4 transient ischemic attacks, 5 intracerebral hemorrhages, and 28 non-cerebrovascular. Of the 33 probable strokes, 16 received thrombolysis – and, by most of their various metrics, care was accelerated by 20-40 minutes. And, then, no outcomes, safety, or follow-up data is presented – apparently we are simply supposed to operate under the assumption this resource outlay and rush to provide the substrate for potential tPA administration is obviously prudent and effective care.

Probably the only interesting tidbit from this paper was with regard to one of the cases of ICH diagnosed by CT in the prehospital setting. One patient was identified as taking anticoagulation, and prothrombin concentrate complexes were initiated in the pre-hospital setting. The timeliness of anticoagulation reversal is almost certainly beneficial, although the magnitude of effect for the few minutes saved is uncertain.

“Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis”

http://www.neurology.org/content/early/2017/03/08/WNL.0000000000003786.abstract

1 thought on “All Aboard the tPA Hype Bus”

  1. We have put in a budget request for a bedside ultrasound machine for the ED, and for a new ambulance carrying a 3 Tesla MRI, a neurologist, and a pharmaceutical rep. I am told only one will be approved.
    I can only hope …..

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