William Dalsey, MD, FACEP Organizations’ Official Statements/Guidelines on IV tPA Use: What Do They Suggest is the Emergency Medicine Standard of Care?

William Dalsey, MD, FACEP 2006 Advanced Emergency & Acute Care Medicine and Technology Conference 2006 Advanced Emergency & Acute Care Medicine and Technology Conference

William Dalsey, MD, FACEP Emergency Medicine Associates Atlantic City, NJ September 26-27, 2006

William Dalsey, MD, FACEP William Dalsey, MD, FACEP Chairman Department of Emergency Medicine Kimball Medical Center Lakewood, NJ

William Dalsey, MD, FACEP Disclosures All past advisory board or speakers’ bureau activities have expired within the past year All past advisory board or speakers’ bureau activities have expired within the past year

William Dalsey, MD, FACEP Global Objectives Maximize patient outcomes Maximize patient outcomes Utilize health care resources well Utilize health care resources well Optimize evidence-based medicine Optimize evidence-based medicine Enhance ED practice Enhance ED practice

William Dalsey, MD, FACEP Case Presentation Case Presentation 52 year old male 52 year old male Dysarthria and right-sided weakness Dysarthria and right-sided weakness Sudden onset without progression Sudden onset without progression BGM 80 BGM 80 VS: HR 85 BP 185/95 RR 16 VS: HR 85 BP 185/95 RR 16

William Dalsey, MD, FACEP Case Presentation… Minimal dysarthria and slight dominant right hand/leg weakness Chairman of Plastic Surgery Hx: Hypertention, smoker Hx: Hypertention, smoker FH: CAD and CVA No evidence trauma or toxicity ECG NSR without evidence of AMI or arrythmia

William Dalsey, MD, FACEP CVA Management What would you do? What would you do? What did the EP do? What did the EP do?

William Dalsey, MD, FACEP ACEP tPA Policy tPA may be efficacious therapy when used incorporating the guidelines established by the NINDS Trial Commitment of hospital administration, neurology, neurosurgery, ED, radiology and laboratory to ensure the systems necessary for safe use

William Dalsey, MD, FACEP What Policies/Statements From Other EM Organizations Say? Society of Academic Emergency Medicine 2003 Insufficient Data for SOC, Barriers, Research Canadian Assoc of Emergency Physicians 2001 CT Interpretations, Cleveland, Time to Rx American Academy of Emergency Medicine Not SOC-Selection Bias

William Dalsey, MD, FACEP What About Non-EM Organizations ? NINDS 2002/2005 AHA 2000/2005 ACCP2005 ACCS 2004 AAN,ASA 2002

William Dalsey, MD, FACEP Additional Literature? NINDS Reanalysis, subanalysis Additional Prospective Data Data Registry Reports Meta Analysis Cochrane Collaboration the astonis hing results Compare the results with a conventional training protocol. Most people do at least two exercises per muscle group, perform three sets and perhaps 12 or 15 reps per set. Allowing just five seconds per rep, that makes for at least 36 minutes of exercise per workout. This is usually done three times per week. So in six weeks, a conventional program would involve 648 minutes of exercise. That's 42 times more than the subjects in our study. Are your results in the last six weeks 42 times better than theirs? I doubt it. perform ance improve ment Remember, these golfers were exercising in a way that did not involve stretching or moving the weight over a full range of motion. So how did this affect a full range of motion activity like a golf drive? Every one of them showed an improvement. The increase in drive distance varied from 5 to 31 yards. Keep in mind that these subjects had been golfing for up to 40 years and had handicaps as low as eleven. So getting any improvement in golfers who already play at this level is impressive. Getting it with 14 minutes of exercise spread over six weeks is truly revolutionary. The fact is every sport -- even a finesse sport like golf -- is improved by an increase in strength. Muscles are responsible for all movement in the body and stronger muscles deliver more power to every aspect of movement, irrespective of its range of motion.increase in strength Since this study, I've gone on to improve this method of training. Further research showed that static hold times could be reduced to even less than what the golfers used. Workouts can be spaced further apart as a trainee gets stronger. I work with advanced trainees who train once every six weeks, yet they gain strength on every exercise each time they work out. The weights they hoist are enormous. I believe the time is coming when most people will have a better understanding of the role of proper, efficient strength training methods and frequency. For the guy who wants maximum results with minimum time invested, an ultra-brief but ultra-intense workout will be performed about as often as he gets a haircut. Anything more is just lifting weights as a busy work hobby. Train smart!

William Dalsey, MD, FACEP Impact of Guidelines/Policies Education and Training Litigation Resource Support System Development Public Notification Stroke Center Certification the astonis hing results perform ance improve ment

William Dalsey, MD, FACEP What Other Issues Do the Guidelines/Policies Address? Designated Stroke Teams/Systems Use of Clinical Pathways/Protocols Training Dedicated Stroke Nurses Time to CT and Interpretation Use of Aspirin BP Control Prevention Recurring Stroke Cephalgia Migraine or temporal arteritis Seizure disorders Akinetic seizure or partial lobe epilepsy CNS space-occupying lesions ENT, ophthomologic pathology

William Dalsey, MD, FACEP What Other Issues Do the Guidelines/Policies Address? ? Prevention of UTI, skin ulcers, aspiration pneumonia, DVT and PE Prevention of UTI, skin ulcers, aspiration pneumonia, DVT and PE Early Rehabilitation and Physical Therapy Early Rehabilitation and Physical Therapy Lack of Efficacy Heparin Lack of Efficacy Heparin Blood Glucose Control Blood Glucose Control Lack of Efficacy Neuroprotective Agents Lack of Efficacy Neuroprotective Agents

William Dalsey, MD, FACEP Where Do I Believe the Guidelines/Policies Leave Us? tPA should be considered for appropriate patients when the NINDS criteria for safe use can be achieved Patients and families should know the risks/benefits of tPA before it is given Careful documentation of the medical record in necessary for every case

William Dalsey, MD, FACEP Case Presentation So what happened? So what happened?

William Dalsey, MD, FACEP Questions? ferne_ema_2006_dalsey_tpastatements_092606_final.cd 5/18/2015 9:23 AM