Another ENLS topic: Ischemic Stroke. But not the entire subject, and not even whether we should give tPA to stroke patients. Why not the latter topic–because I am not smart enough to know the answer. For that listen to David and Ashley and make your own decision. What we will talk about today is reducing door to tPA time.
There was a recently published study that gave an excellent description of one center's interventions to get their door to tPA time down to a ridiculously low level.
(PMID 22622858)
Here are the interventions they used:
The American Heart/Stroke Associations also have some resources on reducing door to tPA time.
The EMCrit Checklist
Here is the checklist of my interventions to reduce door-to-tPA-time:
What do you think about consent for tPA or anything else we spoke about today–leave a comment.
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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IST-3 seemed to suggest that there may not be a direct correlation between time of thrombolytic administration and outcomes (within the 6 hour window anyway). Even if we set aside the issue of whether to “believe” in tPA at all, isn’t there still an outstanding question of whether every second matters? Or do you feel that, if we posit the first, the second is a gimme?
The problem with IST-3 is due to its methodology as an equipoise enrollment study, I can’t really do anything with the data. So for me if we believe tPA works and we believe its mechanism is similar to other conditions in which tPA works, then time definitely matters.
Interesting study. It’s a great example of using some unconventional thinking to get a result. I also like the use of the EMS transport interval to register the patient, query the family about onset time, etc. That being said… One thought: they didn’t mention how these CVAs were confirmed. No mention of subsequent MRIs or other confirmatory tests. They mention (only in the discussion) that they had a “stroke mimic” rate of 1.4%, but do not mention how they figured this. It likely comes from a prior study of the same population (http://www.ncbi.nlm.nih.gov/pubmed/22000770) where they claimed a 1.4% mimic rate,… Read more »
Agree with all of that. The large number of stroke mimics would be one reason their time decreases did not translate to improved outcomes.
No need for consent, it is standard of care, AAN, AHA endorse it. Consent may delay it as well. In patients without decisional capacity (aphasia, neglect, etc) or surrogate, the emergency doctrine if implied consent can be applied… Just give it if the patient meets criteria.
Fred, Great to have you here. But that wasn’t the question at all. Agree right patient, no surrogate, pt can’t consent–give it. The question, and I’d love to hear your opinion is whether you get consent when a surrogate is there, i.e. wife is standing next to the aphasic patient. And if you do get consent, do you tell them: this medicine will help, it also has a very small risk of bleeding. Or do you tell them: this medicine has a chance of improving your neurological function in a few months, but will increase the chances of you bleeding… Read more »
Sorry or the confusion, wanted to add a comment on how to improve door to needle times. Waiting for consent seems to be one of those things that could potentially lead to delays. I don’t usually get consent for IV tpa , however, I inform family members of the benefits risk and potential outcome particularly if within 3-4.5 hour window. In my discussion, I use the approach by Howard et al: ” Of 100 patients treated with tissue-type plasminogen activator (tPA) instead of with placebo, 48 patients will be better with tPA, whereas 31 patients will be better with placebo.… Read more »
Makes complete sense. Sounds like you do consent, but don’t bother with all of the written form junk, which seems very appropriate.
TPA wonder drug for stroke.Of coarse it is, when it is being endorsed by the drug company that made it.You Wouldn’t think when it comes to money any one would care for an innocent life or lives being robbed from this drug.All that studying as a Neurologist surely would open your fucken mind.No such luck!!!TPA kills.I know!!!!I saw it first hand…..
Great recommendation to follow local facility rules despite your personal beliefs of where TPA falls on the snake oil – magic bullet spectrum. I agree that formal consent is challenging. I am working on an easy to interpret document that has neurology buy in that provides a range of potential benefit, clarifies the risk, and hopefully ensures everyone is giving the patient / relative the same numbers: “if we gave 100 people this medicine, between 1(generous bone thrown to IST3) and 11 (NINDS/ TPA package insert) more people would be alive and independent at 6 months. 4 more people would… Read more »
the pictorial representations are the ones the patients actually understand, but how you design them depends on which numbers you use. This is a great project Rob!
AAEM has a nice little pictogram on page 2 here:
http://www.aaem.org/UserFiles/file/tpaedtool-AAEM.pdf
The AAEM pictogram is considered biased by tPA advocates. There was one by some Neuro folks that the anti-tPA crew think is equally unusable.
I am one of the ED pharmacists. We are included in the stroke team pages. We have a “stroke kit” with tpa, dosing calculator, all the supplies needed to mix it, an administration set, labels etc in a small tub. There are 2 of these in the ED pharmacy at all times. This can go to the bedside for preparation or be mixed in the pharmacy which is a few steps from the patient. We are proactive in finding out where we are with the patient evaluation, getting the weight and knowing exactly what bolus and infusion dose we will… Read more »
Mary, that sounds amazing! Can you send us a picture of the tub contents–sounds like a best practice.
http://www.flickr.com/photos/21658512@N03/7737656362/in/photostream
This is the type of stroke kit we keep in the ED pharmacy and on the pharmacy satellites to respond to a tPA treatment request as quickly as possible. It should be tailored to each institution’s needs but this is a good example. It works really well for us.
Mary Shue, ED Pharmacist
University of Michigan Health System
I guess this is the logical conclusion;
http://medgadget.com/2012/06/specialized-stroke-ambulance-features-ceretom-portable-ct-scanner-to-reduce-time-to-treatment.html
Put a scanner, neuroradiologist and stroke physician inside an ambulance.
I don’t know whether to laugh or cry. What’s next? A PCI bus?
The methodology discussed will GREATLY increase the number of persons getting TPA for TIA and therefore falsely improve outcomes for TPA. Further, How does one perform COMPLETE an NIH stroke scale on a CT table (ans you don’t?)
Preston–you lost me. Not sure of what is the difference between doing your exam in CT vs. a resuscitation room. Help us understand your point. I see nothing precluding me from performing NIHSS on a CT table.
Perhaps I am the one who is lost. I envisioned performing the exam with the patient supine on a narrow ct table in a relatively dark room. Visual fields would be difficult and awkward. Having the patient review the image, and reading would be awkward as as well. At the extremes points count and alter therapy. Further is seems that the more severe the stroke the more difficult it would be to perform the exam. I work in the community were at night I am the stroke team and nobody in coming. I feel that fast administration is good but… Read more »
Our CT room is bright, not dark. In fact the lighting is better than the ED. But if you don’t like doing on the ct table, slide them back to the stretcher. If you don’t like doing the exam in the CT room, bring them back to the ED–that’s what I would do. Logistically it is difficult to tie up a CT room to save the 30 foot trip back to the ED. While I see your point re: giving the pt time to show they are improving, we can’t just can’t wait unnecessarily. But I think in the community… Read more »
I think we will have to agree to disagree on this one. I feel that the best place for examination and stabilization is the E.D. The best place to address ABC issues is in the E.D. I agree that things should be mobilized before the patients arrival. But as a practical matter….How much time is really saved in bypassing the E.D? If CT is adjacent to the ED. We are talking less than 5 minutes. If CT is far away perhaps 10-15…But if CT is that far away then valuable resources are taken from the ED to CT. Perhaps in… Read more »
Preston-I know you have no direct control over this-but is it really appropriate to give tPA in a center without neurology and without immediate reads by neurology or a neuro-radiologist?
Hi Scott
With the completion of the “Safety and efficacy of NA-1 for neuroprotection in iatrogenic stroke after endovascular aneurysm repair: a randomized controlled trial” and the success it shows in stroke after endovascular aneurysm repair. What are your thoughts on where they may go with the drug NA-1 as far as main stream stroke care?
Must admit I have never heard about this drug. Anyone else?
Door to needle time.Door to needle time.I’m Not having a stroke.I’m just wondering if anyone is taking into consideration if the the patient is a viable candidate for this drug!!And let’s make it clear door to needle time without really knowing the facts about the patient do you preform open heart surgery on a patient for just having chest pain?Do you administer TPA for mild stroke just because you have read that it’s the rite thing to do,reading all the bullshit studies on it??And then you do administer it.And as a result you go from a mild stroke to a… Read more »
this has the feel of a troll post, but just in case you are actually a medical professional, I would strongly advise listening to the podcast.
Dr. Weingart. I am an adult acute care NP with experience in critical care but am new to NCC. We respond to Code Strokes in the ER only if the patient is deemed to need ICU and frequently this is after tpa has been administered. I am having trouble with the recommendation to acutely lower BP in the setting of a suspected ischemic stroke. My understanding is that in order to improve the perfusion to the penumbra the blood pressure should not be rapidly/dramatically reduced, yet in order to infuse tpa the BP must be below 180/110. I recently watched… Read more »
the permissive hypertension is good for the penumbra and we shoot for up to 220 systolic for these patients. Unfortunately, in the setting of tPA, pts with hypertension will bleed at a much higher rate. So now we are balancing two risk/benefits. That pt whose neurologic exam deteriorated may have a massive post-tpa bleed if you let her bp go back up. It is tough!
thanks so much! I have so much to learn.