AAEM Position Paper TISSUE PLASMINOGEN ACTIVATOR AND STROKE: REVIEW OF THE LITERATURE FOR THE CLINICIAN

, Abstract-Background: Alteplase (tPA) is a United States (US) Food and Drug Administration-approved treatment for acute ischemic stroke, though there are significant barriers to thrombolytic use, including Emergency Physicians' (EPs') concern for level of supporting evidence. Study Objectives: To review the medical literature on the topic of acute cerebrovascular accident (CVA) management and to offer EPs evidence-based recommendations for patients who present to the Emergency Department with an acute CVA. Methods: A MEDLINE literature search from 1990 to 2011 and limited to human studies written in English for articles with keywords of: CVA AND (thromboly* OR alteplase). Guideline statements and non-systematic reviews were excluded. Studies targeting differences between specific populations (males vs. females) were excluded. Studies identified then underwent a structured review from which results could be evaluated. Results: There were 407 papers on thrombolytic use screened, and 15 appropriate articles were rigorously reviewed and recommendations given. Conclusions: tPA is an effective treatment for stroke when given in prepared stroke centers; EPs and hospitals treating stroke patients with tPA need to have the necessary resources in place and a specific plan for timely care of patients with acute stroke.

BRIEF REPORTS Assessment for Deaths in Out-of-hospital Heroin Overdose Patients Treated with Naloxone Who Refuse Transport

Abstract Naloxone frequently is used to treat suspected heroin and opioid overdoses in the out-of-hospital setting. The authorsÕ emergency medical services system has operated a policy of allowing these patients, when successfully treated, to sign out against medical advice (AMA) in the field. Objectives: To evaluate the safety of this AMA policy. Methods: This is a retrospective review of out-of-hospital and medical examiner (ME) databases over a five-year period. The authors reviewed all ME cases in which opioid overdoses were listed as contributing to the cause of death. These cases were cross-compared with all patients who received naloxone by field paramedics and then refused transport. The charts were reviewed by dates, times, age, sex, location, and ethnicity when available. Results: There were 998 outof-hospital patients who received naloxone and refused further treatment and 601 ME cases of opioid overdose deaths. When compared by age, time, date, sex, location, and ethnicity, there were no cases in which a patient was treated by paramedics with naloxone within 12 hours of being found dead of an opioid overdose. Conclusions: Giving naloxone to patients with heroin overdoses in the field and then allowing them to sign out AMA resulted in no identifiable deaths within this study population