tPA and Beyond: 6 Stroke Care Tips That Could Save Your Next Patient's Life.

tPA for stroke patients? No way. I’m not killing them.

Have you heard that before? It’s a common mantra in the emergency setting - and with good reason. However, the stroke world is rapidly changing and we all adopt the new science. Unfortunately, many organizations and practitioners are not aggressive with stroke treatment.

While comprehensive stroke centers are well-positioned to treat a lot of patients for Acute Ischemic Stroke, it is a regional system partnership. New trials released last year at the International Stroke Conference have concluded that endovascular treatment of stroke is the real deal.

Timely treatment of the AIS patient with tPA is more important than ever. Regardless of the patient's eligibility for endovascular treatment, we must consider whether they are a candidate for tPA and treat immediately if appropriate. I've had many conversations with ED physicians who aren't comfortable giving tPA. I know the controversy and we’re not going to solve it with this blog post.

BUT, HERE’S WHAT I DO KNOW …

It’s important to define your stance of tPA as an institution. How a stroke is treated at your facility can’t depend on individual practitioners in the ED. It must be standardized - and care must be given as quickly and as safely as possible.

Using the American Stroke Association’s - Target Stroke Initiative and my observations as I visit stroke hospitals around the nation, here are a few practical things to help streamline stroke care:

SHANE ELMORE’S TOP 6 TIPS

1. First, EMS must be involved in your Code Stroke process. It’s essential. Too many hospitals choose not to allow EMS to activate a stroke prior to arrival. This is unacceptable and needs to change. And, something needs to happen when EMS does activate prior to arrival. Often when I ask if EMS is able to activate a Code Stroke the answer is “yes,” but when I ask what EMS’s prenotification does, I’m met with silence. In other words, EMS notifies that they are transporting a stroke patient, but it doesn't change anything.
   
   
2. If EMS has activated a Code Stroke, maximizing the transport time is critical. That medic must obtain a thorough history and securing two large bore peripheral IVs.
   
   
3. With advanced warning, a number of people need to be notified. Are you notifying the Stroke Team? The following people should be alerted …
• Lab
• CT
• Neurology
• Stroke Coordinator
• Pharmacy
• House Supervisor
• Transportation
• Registration
4. EMS should bypass the ED straight to CT. With some advanced warning, CT can have the table cleared so the patient can move directly from the EMS stretcher to the CT table without stopping at the front door for registration. Instead, registration can meet the patient in radiology. (NOTE: If your protocol mandates the patient stop in the ED, putting the patient on a portable monitor will save a couple of minutes when you leave for CT.) 
   
   
5. A rapid neuro assessment can happen in the CT suite. We all know that the time-limiting step is CT, making it important to minimize other steps before the CT as much as possible. Remember, a more detailed assessment can happen after the CT is complete.
• (EXTRA CREDIT: If you have a neurologist and you really want to show off, have the neurologist read the CT instead of waiting for radiology to read. Make sure to get your non contrast head CT first and then you can do advanced imaging after that.)
6. Once the CT is complete, this would be a great time to divide and concur. If the neurologist is there, the ED physician can split off and start talking with the family to gather crucial pieces of information including:
• Last seen normal
• Medical history
• Inclusion/exclusion for tPA

SHANE’S BONUS STROKE CARE TIPS!

WHAT ABOUT LAB WORK?

Don't wait for labs. Get a quick d-stick, tPA doesn't do much for hypoglycemia. You can use POC testing to obtain an INR.

WHAT ABOUT PHARMACY?

Work with the pharmacy to have a Stroke Kit in the ED. A simple kit can have everything you need to mix and give tPA. If you plan for the unexpected, it saves time when it happens. It's sad to get to this point and miss your time window because you didn't anticipate that the patient would be hypertensive. The Stroke Kit should have Cardene in it.

Learning how to mix tPA should happen much earlier than when there’s a patient in need and in crisis. Part of being prepared is training and learning how to mix this medication. It isn't hard, but it does require some know how so practice ahead of time.

MEDICATION TIDBIT: Cardene: This is a drug designed to be rapidly titrated to effect as a loading dose and when the goal BP is reached you titrated down to 3mg/hr and slowly titrated back up to maintain the blood pressure within the target range.

We are 20 years into this type of stroke treatment. It’s the standard of care … yet, it's still lacking in many US hospitals. After the decision is made to give or not give tPA, we need to move on to endovascular. If we don’t secure this decision early on in the treatment, it makes things difficult for newer stroke treatments.

Welcome to a new era of stroke care. Are you with us? Pulsara can help fix your pre-puncture problem.