When I am at work, whether I am working in the intensive care unit or the emergency department, we have to be prepared for all types of emergencies. The 911- ambulance system has a way of communicating with the emergency department while in the field. This article will discuss stroke and atrial fibrillation with Tpa.
That way, the emergency department can get prepared for the arrival of the patient. Patients arrive at the emergency department from a myriad of places such as from home, nursing homes, clinics, dialysis facilities, etc.
When a patient comes in with a sudden change in mental status, that is an emergency, and we need to scan the brain immediately. We need to ask questions such as:
How to Assess if A Person is Having a Stroke
- What was the patient doing?
- Has the patient been using drugs?
- How long has the pt had a change in mental status?
- What medications is the patient on?
- What is the patient’s previous medical history?
- Where did the patient come from?
When patients present with altered mental status, elevated blood pressure, irregular heartbeat, difficulty speaking, and motor weakness, the patient needs to be evaluated for a stroke. We see many patients with atrial fibrillation diagnosed with a stroke.
Why do Patients get a Stroke from Atrial Fibrillation (AFib)?
When you have atrial fibrillation, the normal rhythm of your heart becomes irregular, due to disorganized electrical signals in the atrium. This causes the upper chambers of your heart, called the atrium to beat irregularly.
This restricts blood from being efficiently pumped from your atrium to your ventricles. When your heart can‘t pump out blood effectively, the blood can clot and go up to your brain. This is called an ischemic stroke.
How are Stroke Patients Diagnosed
Cat Scan is the gold standard diagnostic test in the initial presentation to the hospital. Many times the Ct scan is negative. A follow-up test is almost always done with an MRI /MRA.
If the CT scan is positive the patient will be considered for a clot-buster medication called Alteplase or tPA. However, there are some contraindications for when this medication can be given.
If the patient is already taking a blood thinner such as Xarelto, Coumadin, or Eliquis, they cannot receive tPA. If the patient presents with very high blood pressure, they cannot receive tPA.
A severe stroke, coma, or advanced age are contraindications to receiving tPA. Any recent hemorrhages, such as gastrointestinal bleeding are contraindications. If the brain accident occurred more than 4 hours, the patient cannot get tPA.
- It is important to note that when patients start taking these blood thinners, it is extremely important to continue taking them, and don’t stop without your doctor’s consent. Many of these drugs if suddenly stopped, will cause a stroke.
One of the main priorities is to figure out why the brain attack occurred. Patients will have a EKG, ECHO, or carotid duplex. The patient will most likely be admitted to the intensive care unit.
If the brain attack is thought to be from atrial fibrillation, the patient will be started on a blood thinner if there are no contraindications. The patient will also be started on medications to control the heart rate and rhythm.
Physical rehabilitation will be started immediately while in the hospital as evidence shows that the sooner rehab is started, the better the outcomes. If someone is exhibiting signs or symptoms of stroke you should call 911 immediately.
What is Tpa?
What is Activase?
Activase® (Alteplase), also known as t-PA, is a tissue plasminogen activator produced by recombinant DNA technology. Activase belongs to the thrombolytic class of drugs and is the first drug to be indicated for the
management of acute ischemic stroke.
All thrombolytic agents increase the risk of bleeding, including intracranial bleeding, and should be used only
in appropriate patients. Not all patients with acute ischemic stroke will be eligible for Activase therapy, as defined by the following indication and contraindications.
Indications for TpA
Activase® (alteplase) is indicated for the treatment of acute ischemic stroke (AIS). Exclude intracranial hemorrhage as the primary cause of stroke signs and symptoms prior to initiation of treatment. Initiate treatment as soon as possible but within 3 hours after symptom onset.
Activase is indicated for use in acute myocardial infarction (AMI) for the reduction of mortality and reduction of the incidence of heart failure.
Limitation of Use: The risk of stroke may outweigh the benefit produced by thrombolytic therapy in patients whose AMI puts them at low risk for death or heart failure.
Activase is indicated for the lysis of acute massive pulmonary embolism (PE), defined as:
- Acute pulmonary emboli obstructing blood flow to a lobe or multiple lung segments.
- Acute pulmonary emboli accompanied by unstable hemodynamics, e.g., failure to maintain blood pressure without supportive measures.
Warnings and Precautions
Activase can cause significant, sometimes fatal internal or external bleeding, especially at arterial and venous puncture sites. Avoid intramuscular injections and trauma to the patient. Perform venipunctures carefully and only as required. Fatal cases of hemorrhage associated with traumatic intubation in patients administered Activase have been reported.
Although patients should continue to take their prescribed medications, there are some natural things that will help.
- Evidence has shown that low magnesium contributes to stroke.
- Consumption of fish and fish oils has been shown to decrease stroke incidence.
- A low carb diet will reduce the incidence of stroke.
- A healthy weight and exercise will decrease the incidences of stroke.
Maintaining normal blood pressure is the best way to prevent a stroke.