Monday, September 21, 2009

Emergency medicine's push-back on TPA for ischemic stroke continues

---but new evidence may be making a dent.

Emergency physicians have long been among the most vociferously opposed to tPA for stroke, but some are now reconsidering that stance. Most notable in that group is the Society of Academic Emergency Medicine, whose Board of Directors officially retired its policy questioning the use of thrombolytics in patients with acute ischemic stroke in January....

It is a stunning turnaround from the tumult surrounding the use of the clot-buster in stroke just six years ago when all of the major professional emergency medicine organizations - the American College of Emergency Physicians, the American Academy of Emergency Medicine, and SAEM - passed similar policies of no confidence in the emergency use of thrombolytics for stroke. ACEP is now reviewing its policy statement to determine if revisions are needed...

AAEM has not changed its policy, said the group's former president Robert McNamara, MD. He said the issue remains controversial, and will become more so as information emerges.

So where do emergency medicine physicians in the trenches stand?

In a study presented in May 2008 at SAEM's annual meeting, Dr. Scott and his colleagues found that 83 percent of the 199 emergency physicians who completed the survey would use tPA in an ideal setting. Seventy-two percent said its use in eligible patients represented ideal care but was not a legal standard of care while 27 percent said its use was ideal care and the legal standard. Forty-nine percent said existing data on the use of tPA in stroke are convincing, but 65 percent said they were uncomfortable treating without consultation. Sixty-six percent said a telephone consult was sufficient. Fifty-nine percent said they were concerned about the liability of not using tPA. On a 15-item test of knowledge about tPA, the median score was eight correct answers.

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