Emergency Medicine Literature of Note
Musings on Emergency Medicine, Clinical Informatics, & High-Value Care.
It isn’t news to anyone in the Emergency Medicine community that tPA isn’t as effective as its efficacy trials suggested, and its overuse is driven by “quality” measures and medicolegal concerns more than any true belief in its usefulness. However, it remains rare in the Neurology literature to challenge the primacy of tPA – it … Continue reading “The tPA Pushback Begins”
When you think you’ve seen it all – a call to administer tPA to acute stroke patients without a prior non-contrast CT. Indeed, in this “Views & Reviews” article, the authors ask explicitly the question: “Is the administration of alteplase to patients with primary ICH that harmful?” After much stimulating confabulation, the authors bafflingly conclude: … Continue reading “You Can’t Spell “Insanity” Without tPA”
It is well-established many patients with minor or rapidly improving stroke fail to thrive. The NIHSS is a crude tool, and its correlation with infarct size and ultimate disability is limited. It is not inconceivable some patients with minor stroke could be candidates for intervention. However, these patients would need to fit our critical requirements: … Continue reading “tPA – For Minor Strokes, With Many Caveats”
Coming to us from the Department of Common Sense: don’t give tPA to stroke patients who already have intracranial hemorrhage. There’s a little more subtlety here, of course, because in this instance, we’re dealing with cerebral microbleeds – tiny foci of angiographic damage visualized only on MRI. These authors performed a pooled and individual-patient meta-analysis … Continue reading “Try to Avoid tPA When Already Bleeding”
There’s been another scientific update from Genentech-by-proxy, this time lamenting the low utilization for tPA in ischemic stroke patients. This guideline panel from the AHA notes administering tPA in a safe and timely fashion to stroke patients is a non-trivial organizational exercise, but, what really gets their goat are the various exclusion criteria. These criteria … Continue reading “Give More tPA, Pretty Please?”
The first hints of a rollback in tPA use are starting to emerge – not unexpectedly, from those working to improve the outcomes of their endovascular programs. This is a retrospective evaluation of patients from Bern, Switzerland, all treated with endovascular therapy. Their registry includes 372 patients since 2004, all treated for MCA or ICA … Continue reading “Endovascular Sans tPA in Bern”
There are a few moments you pat yourself on the back in Emergency Medicine. The good save. Shared decision-making that goes well. And, the small victory when you’ve utilized an evidence-based pathway for pulmonary embolism, and received positive results for the leviathan of over-utilization and over-diagnosis: the CT pulmonary angiogram. Well, it’s time to deduct … Continue reading “Your CTPA is Lies”
Ah, but this is not one of those rants about the inefficacy of tPA. This is just an amuse-bouche of a mention of an article from Stroke, regarding a line of investigation in Asian countries. In these countries, particularly Korea and Japan, there is some substantial thought given to “low dose” tPA being just as … Continue reading “Better Less than More for tPA”
Released with minimal fanfare, approved by the ACEP Board of Directors on June 24th, the revised ACEP Clinical Policy regarding the use of TPA for acute ischemic stroke has gone final. It is, of course, a vast improvement over the 2012 version – but has, unfortunately, changed for the worse since the draft was posted. … Continue reading “The New, Improved, ACEP Clinical Policy for tPA in Stroke”
As I’ve wondered many times before – given the theoretical narrow therapeutic window for tPA in stroke, paired with the heterogenous patient substrate and disease process – why do we consent all patients similarly? Why do we not provide a more individualized risk/benefit prediction? Part of the answer is derived from money & politics – … Continue reading “Attempting Decision-Support For tPA”