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(Stroke. 2003;34:e19.)
© 2003 American Heart Association, Inc.

Letters to the Editor

Danger of Treatment Protocols

Department of Neurology, Comprehensive Stroke Center, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

An extract of the first 250 words of the full text is provided, because this article has no abstract.

To the Editor:

A recent AHA Scientific Statement on medication errors in acute cardiovascular care suggested that streamlined protocols and standardized order forms may be useful in reducing medical errors.¹ We would like to draw attention to a potential danger of such measures, namely the erroneous application of tPA treatment protocols for acute myocardial infarction (MI) to patients with acute stroke. We report a case of such a misapplication that possibly contributed to development of an intracerebral hemorrhage (ICH).

A 68-year-old man with a history of aortic valve replacement presented to an emergency department 90 minutes after onset of aphasia and right hemiparesis. Initial head CT and laboratory studies were normal. The patient was treated with intravenous tPA according to the NINDS stroke thrombolysis protocol.² The treating neurologist wrote orders consistent with this protocol, including avoidance of antithrombotic or anticoagulant therapies for 24 hours. Unfortunately, the nursing staff caring for the patient erroneously implemented the hospital’s standardized prewritten acute MI thrombolysis protocol, and the patient was given a bolus of intravenous heparin followed by a maintenance infusion. One hour later the error was noted and heparin was discontinued. A repeat head CT was immediately performed and showed a new left thalamic ICH as well as early signs of left temporal-parietal infarction. Over the next 24 hours, the patient’s right-sided weakness improved significantly, although he remained markedly aphasic. The patient was transferred to our institution where subsequent evaluation revealed a high-grade left carotid stenosis. Follow-up head CT showed a stable left . . . [Full Text of this Article]