The patient who was forced to play God

Please consent this patient for thrombolysis following his ischaemic stroke.

He is a previously well man in his early 30s accompanied by his wife. He has suddenly lost all movement down the left of his body. He has now got global aphasia.

This happened about 1 hour ago. Please explain to him in his current state all the risks and benefits. Explain this to a man who for the first time since the age of 11 months cannot say a word.

Overall, of every 100 patients treated, 32 will have a better and 3 will have a worse final global disability outcome as a result of therapy. Please explain this to his wife, who has not stopped crying since being at the hospital.

Please also explain that the longer they wait, the less likely it is to be successful.

On the weekend, I saw this patient thrombolysed for stroke. His power on the right at admission was 0/5, and after thrombolysis climbed to 4/5.

1 hour later it was back to 0/5, and he was becoming confused and vomiting.

An urgent CT head was requested and I will report the results tomorrow. I have some reservations about getting too academic about what must have been amongst the hardest decisions a patient will ever take in this age of medicine. It is literally a life or death decision, with immense time pressure.

However, it is this emotional detachment that allows us to make rational plans, and present the options to the patient as clearly and objectively as possible. Were it one of our loved ones, the fear of causing their death would probably cloud any attempt to really weigh up the options.

I really like the way this information is presented here:

Patient information presented brilliantly. Give information in the format you would like to receive it in.

In many ways, this patient was the ideal candidate for thrombolysis. You want someone who has potentially much to gain from thrombolysis, without any cautions or contradictions. NICE recommends alteplase for thrombolysis for stroke provided that the following three criteria are met:

  1. Haemorrhagic stroke has been excluded.
  2. The patient presents within three hours of having the event.
  3. Access to specialised services is available.

Excluding hemorrhagic stroke is a job for experienced radiologists, who must be on call 24 hours a day if the hospital is a stroke centre. CT head will do, though MRI can be used (and is better for more chronic bleeds).

The specialized services include nursing staff experienced with stroke and thrombolysis, and in particular what the warning signs are post thrombolysis. There must also be immediate access to further neuroimaging services.

As for what happens to aspirin after thrombolysis, it is held off for 24 hours, but then given at 300mg for the remainder of the 14 days after the stroke started.

SIGN guidelines require the documentation of the NIHSS scale pre and post thrombolysis. The greater the NIHSS score, the worse the stroke has been. It follows that those with minor strokes (NIHSS<4) or those with improving symptoms have not got much to gain from thrombolysis, but potentially much to lose. They are usually excluded from thrombolysis even if they meet the 3 NICE criteria.

You can get certified as competent in using the NIHSS scale for free here.

There are of course many contraindications to thrombolysis. In particular, I had never thought of acute pericarditis as a contraindication. I know now that the risk of haemorrhagic tamponade is the concern.

Fingers crossed for our man.

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