Emergency physicians providing stroke ‘lysis in the UK

September 17, 2012 by  
Filed under Acute Med, All Updates, Resus

Although the worldwide emergency medicine community is split in its support for stroke thrombolysis, those who work in centres where it is provided might be interested in systems to optimise its effectiveness.
A study from the UK showed that emergency physicians can provide the majority of the service, with outcomes similar to the SITS-MOST data.
Interestingly there was only one (suspected) major intracranial haemorrhage case.

The best resource for reducing door-to-tPA time in ischaemic stroke, with heaps of related discussion, is here at EMCrit

Image from EMJ Open Access. Click for PubMed image source


BACKGROUND: Stroke thrombolysis is strongly supported as an effective therapy for selected cases of early stroke. The absence of 24 h stroke specialists in district general hospitals (DGHs) has led to the suggestion that regional hyper-acute stroke centres should be developed. This paper describes a cooperative model that uses the skills already present in a DGH to deliver a thrombolysis service initiated in the emergency department by the emergency physicians, and describes the outcomes of that service in comparison with the SITS-MOST trial.

METHOD: The outcomes of all stroke patients thrombolysed at Scarborough DGH from 2004 to January 2009 were reviewed. Outcome was defined using a three-part scale. Data at Scarborough DGH were compared with data from the SITS-MOST European-wide study of stroke thrombolysis.

RESULTS: Data were available for 98 of 110 patients thrombolysed during the study period. Fifty (51%) had a good outcome, seven (8%) had partial resolution of their symptoms, and 41 (42%) showed no improvement or deterioration. These outcomes were comparable to those in the European database.

CONCLUSION: Stroke thrombolysis can be effectively delivered in a non-specialist (a non-hyper-acute stroke centre) DGH in the UK. An audit of cases completed describes complications seen.

An analysis of outcomes of emergency physician/department-based thrombolysis for stroke
Emerg Med J. 2012 Aug;29(8):640-3
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Comments

3 Responses to “Emergency physicians providing stroke ‘lysis in the UK”

  1. Pierre on September 20th, 2012 21:40

    Why provide advice on how to thrombolyse strokes better when the vast preponderance of DBRCTs ( I think 10 of 13 so far) show no benefit or harm? Only NINDS (flawed), ECASS 3 (exclusion criteria very extensive and outcomes middling at best) and IST-3 (an absolute embarrassment) have shown benefit. IST-3 showed no difference in the primary outcomes yet the authors and editorialists claim te exact opposit. It is disgustng. Why do we continue to pretend these drugs have legitimate benefit? Finally, SITS-MOST is a registry not a study so provides exactly zero helpful information beyond “this s what we did and we like it”. This is insane!

    Pierre

  2. Cliff on September 20th, 2012 22:08

    Thanks for your comment and your opinion. I haven’t provided any advice, so you may wish to air your views to the primary sources I quoted, which I think are of interest to all emergency physicians working at centres where this intervention is provided, whether or not they agree with it.
    Best wishes
    Cliff

  3. Cliff on September 20th, 2012 22:37

    The latest Lancet issue (22–28 September 2012) has a collection of letters criticising IST-3 which is a fascinating read.