Date: April 21st, 2020

Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019

Guest Skeptic: Dr. Chuck Sheppard is an attending Emergency Department Physician at Mercy Hospital in Springfield, Missouri and the medical director for Mercy Life Line air medical service.  He has been practicing in Emergency Medicine for over 40 years and involved in EMS services for over 30 years.

Case: 56-year-old female with sudden onset of left arm and leg weakness with slurred speech presents to the emergency department (ED). She was last seen well two hours prior. Her past medical history includes hypertension and type II diabetes. She is not on any anticoagulation except ASA. There is no previous history of stroke. The neurology led stroke team is not available and you wonder if that will affect her outcome.

Background: Treatment for acute ischemic stroke has been debated between neurologists and emergency physicians for years now. A recent PRO/CON debate on the subject was published in CJEM April 2020 with Dr. Eddy Lang and myself.

It was the legend of emergency medicine, Dr. Jerome Hoffman that really raised the concern about the lack of evidence for using thrombolytics in acute ischemic stroke. He was interviewed on an SGEM Xtra segment called No Retreat, No Surrender.

We have covered acute ischemic stroke many times on the SGEM.

* SGEM#29: Stroke Me, Stroke Me

* SGEM#70: The Secret of NINDS

* SGEM Xtra:Thrombolysis for Acute Stroke

* SGEM Xtra: Walk of Life

* SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients?

Clinical Question: Does the presence of a neurologist led stroke team affect the likelihood of receiving tPA and does that improve a patient-oriented outcome?

Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019

* Population: All patients presenting to the ED meeting stroke activation criteria

* Intervention: Neurologist led stroke team

* Comparison: No neurologist led stroke team

* Outcomes:

* Primary Outcome: Rate of tPA administration

* Secondary Outcomes: Door-to-needle times, modified Rankin Scale (mRS) at discharge, change in National Institutes of Health Stroke Scale (NIHSS), and discharge disposition

Authors’ Conclusions: “Emergency physicians administered significantly less thrombolytics than did neurologists. No significant difference was observed in outcomes, including mRS and admission-to-discharge change in NIHSS.

Quality Checklist for Observational Study:
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