Ed. Note: In response to our review, the developer updated this app to fix the main problem we highlighted with the app – the error with weights above 300 kg. We have not tested this update ourselves but wanted our readers to be aware.
The developer has added a comment to this review explaining the update.

The IV Stroke Thrombolysis app was developed to reflect the National Institutes of Health stroke scale. It provides a fast method to calculate the stroke scale to guide whether or not a patient may be a candidate for IV thrombolysis with tissue plasminogen activator. This time-critical decision is made frequently by neurologist and ED providers who may benefit from the use of an app to calculate the score at a moments notice, and guides a focused clinical review to determine inclusion and exclusion criteria. Though this app provides these tools, it does not make a final recommendation on whether or not to give tPA, leaving this to the clinician’s judgment.

“Time is brain” is a core principle of stroke neurology. As a neurology resident, this application has been my tool for rapidly calculating stroke scales on patients, and storing the data for retrieval. In a busy call night with 5+ stroke codes (aka “brain attacks”), being able to store each patient’s inclusion and exclusion data along with their stroke scale has been invaluable.

The developer Mohan Noone designed the app with two different modes of interaction. When opening the app, on the top half of the page, there are useful links related to the app’s patient database, including the ability to add a new patient or review prior patients. The lower half includes direct links to the checklist and calculators included in the app.

IV Stroke Thrombolysis 1

Patient Database Method

Clicking on “New Patient” brings the user to a database entry form. (Quick tip: enter the patient’s initials only to expedite setup). Required fields are “name”, “age”, “weight” and “mts” which is minutes since last known normal. One nice feature is that if the duration of symptoms is longer than 4.5 hours, a helpful pop-up reminds the user that it is beyond the typical window period for tPA. By design, this pop-up can be bypassed, since there are other reasons to calculate stroke scale, such as for interventional treatment candidates.

IV Stroke Thrombolysis 2

This connects to the inclusion/exclusion checklist to evaluate criteria for tPA candidacy. Of note, these are not absolute criteria and may vary between institutions. Clinicians are expected to use their clinical judgment in determining eligibility for tPA on a case-by-case basis. The play button in the upper right brings the user to the NIH Stroke Scale calculator, with a running tally shown at the bottom of the page. The sections and explanations are standard; however, there are no annotations for what to do in special situations like when the patient is comatose, unresponsive, or intubated.

IV Stroke Thrombolysis 3

The final page is a dose calculator for bolus and infusion doses of tPA according to the standard 0.9 mg/kg dosing regimen (maximum 90 mg). In general, it is not recommended to trust an app for dose calculation; rather, the physician and pharmacist should do their own calculation prior to administration. I tried the calculator with different weights, and it was accurate up to a weight of 300 kg; however, beyond 300 kg the calculator gives inaccurate results. There is no feedback to the user that this is occurring. For example, if I enter 350 kg, the calculator interprets this as 35 kg, and gives a tPA dose of 32 mg, when it should be the maximum dose. Despite being an otherwise well designed app, this is a critical design flaw that raises serious concerns about the quality of this app.

Once a patient’s NIH Stroke scale is filled in, their data is saved to the patient database for subsequent retrieval. If desired, subsequent NIHSS and MRS values can be added for later reference. Unfortunately, these tables are not linked to their respective calculators.

Direct Link Method

As mentioned above, the app can also be used as a quick, impermanent checklist app. From the front page, click on the checklist for the inclusion/exclusion criteria, or the respective calculators for quick access. Results are not stored in the patient database. This method is the fastest mode to use the app, particularly in cases where time is critical. It is also useful for more advanced users who have a good sense of the inclusion/exclusion checklists, criteria for tPA, and with no need for a subsequent review of the data.

Evidence Supporting App

The app is based on the NIH Stroke scale and references the modified Rankin scale. The checklist for stroke thrombolysis and dose calculator are based on internationally accepted IV Stroke thrombolysis guidelines and published clinical trials [1, 2, 3].

Similar, previously reviewed app(s): Brain Attack

Similar apps on the iOS App Store: NIH Stroke Scale from StatCoder

  • Price
    • Free; No Ads; Option to give 0.99$ to support future development.
    • Fast.
    • Compact design.
    • Option to save patients for later reference and follow-up.
  • Dislikes
    • Standard images used for NIHSS not available in the app.
    • No option for pediatric stroke scale.
    • No explanation for special situations like comatose, unresponsive, or intubated patients.
    • Calculator inaccurate for weights greater than 300 kg.
  • Overall

    On first glance, the IV Stroke Thrombolysis app is a simple and easy to use medical app, perfect when the intended use is in time critical situations. However, the error identified in dosing calculations is a critical design flaw and raises concerns about use of this clinical calculator.

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