The door to needle time for acute stroke in Critical Care is a key variable when striving for good outcomes. Rhonda Cadena answers the question - Who should pull the trigger on tPA for acute ischemic stroke? Medical management of acute strokes has changed dramatically over the years. We used to rely on clinical exams for diagnosis, prescribe strange medications and undertake interventions that were scary! This has changed in recent times. We have now evolved to advanced imaging techniques, new medications and interventions including endovascular treatments. These advances have dramatically increased the likelihood of positive outcomes in stroke patients. The new problem coming to light is time. All the modern treatments that exist do wonderfully well in achieving what they are supposed to. However, the longer it takes for a stroke patient to be get the treatment equates to more deficits and less chance of having a complete recovery. The process as it currently exists can take time. A patient will notice symptoms. They then call emergency service. An ambulance is dispatched, the patient undergoes an initial assessment and is then transferred to the hospital. Here they will be triaged, connected to monitoring, have bloods drawn, have a history taken, be examined… all taking time! Stroke guidelines say the door to treatment time should be 60 minutes or less. Rhonda explains that the focus should be on reducing the time that the process takes. She highlights that most of the time savings should occur before the patient hits the door. That is in the pre-hospital setting. We should be focusing on emergent treatment in the pre-hospital period. Rhonda runs through practical examples of time saving techniques utilising technology and a few simple changes to processes to cut time and improve outcomes. The basics of tPA are spelled out and Rhonda steps you through how a lot of the steps can be expedited along the patient’s early treatment journey. So, who pulls the trigger? Rhonda explains it does not matter! So long as we are saving time in the pre-hospital period, the door to needle time for acute stroke can be reduced and outcomes improved.

1. Rhonda Cadena, MD
University of North Carolina, Departments of Neurology, Neurosurgery, and Emergency Medicine
WHO SHOULD PULL THE TRIGGER ON TPA
FOR ACUTE ISCHEMIC STROKE?

3. TIMES ARE CHANGIN’

4. TIMES ARE CHANGIN’
tPA endovascular

5. THE PROBLEM…
Saver. JAMA. 2013;309(23):2480-2488
Saver. Stroke. 2013;44:270-277

6. Time=0
Goal: DTN 60 ≤ minutes

7. THE PROBLEM…

8. Time=0
Goal: DTN 60 ≤ minutes

9. Time=0 FAST questions

10. PUSHING TPA, THE BASICS
▶ What do you need before pushing?
 Clinical suspicion of stroke
 FSBS without hypoglycemia
 BP within parameters (< 180/110)
 Minimal risk of hemorrhage, based on exclusion criteria
 Patient weight
 CT head without blood

11. STROKE SUMMARY
▶ Early treatment = Improved functional outcome
▶ Diagnosis and treatment needs to start as
soon as possible and should begin with ‘911’
▶ Pre-hospital screening, diagnosis, work-up,
decision-making, and possibly treatment will
be the future so get your weapon shined and
ready to use

12. QUESTIONS?