Stroke Fast Track in Thailand
Nichapatr Phutthikhamin, RN, Ph.D.
Faculty of Nursing, Khon Kaen University, Thailand
April 2, 2019 at University Muhammadiyah Lamongan, Indonesia
Stroke Fast Track in Thailand
Stroke situation
Contents Campaigns of stroke
fast track in Thailand
Save penumbra with r-TPA
Stroke Situation
2nd leading cause of death1
17 millions worldwide; 6.5 millions dead1
Est. next 2 years will double the number1
Est. every 6 minutes 1 dead from stroke1
In Thailand, 3rd leading cause of death after heart
disease & cancer2
The first premature death in female>male2
1. World Stroke Organization:WSO
2.Ministry of Health, Thailand
Types of Stroke
Ischemic stroke 80-85%
thrombotic stroke-clot form in BV
Embolic stroke-clot travel
Hemorrhagic stroke 15-20%
Aneurysm
AVM
Risk Factors of Stroke
Age > 45 years
Male > female
Family history of stroke
U/D>>DM HT DLD AF VHD
Obesity/inactivity
Smoking
alcohol
Warning Signs of Stroke: FAST
* In Thailand, call EMS 1669, 24 hours
Effective Treatment
Speed diagnosis & Immediate treatment
can reduce mortality & stroke
complications
Goal>>achieve a Door to Needle (DTN)
Time within 60 minutes of ischemic
stroke patients treated with IV tPA
Need close observation in stroke
unit/stroke corner/ICU
Acute Stroke Evaluation and
Treatment: 60 Minute or Less Protocol
Door to MD ≤ 10 minutes: Patient complaint, vital signs,
ECG
ED Physician ≤ 15 minutes: Focused history and
physical exam, laboratories, stroke team activation,
transport for CT Scan…Vital sign monitoring, neurologic
checks, seizure and aspiration precautions
CT Scan and Stroke Neurology Consult ≤ 20 minutes:
Review history, physical exam, interpret CT Scan
Treatment Decision and Initiate IV rt-PA infusion ≤15
minutes: per guideline based protocol
Time Interval Goals
Perform initial patient evaluation within 10 minutes
of arrival in emergency department
Notify the stroke team within 15 minutes of arrival
Initiate CT scan within 25 minutes of arrival
Interpret CT scan within 45 minutes of arrival
Ensure door-to-needle time for IV r-TPA within 60
minutes from arrival
Raise Public Knowledge about Stroke
Warning signs of stroke-FAST
Opportunity time 3-4.5 hours
Call 1669 immediately
Rush the patient to nearby hospital
If the hospital doesn’t have the system,
they will transfer the patient immediately
‘Stroke fast track is equity’ all can access
Free-of-charge
Sponsored by National Health Security
Office (NHSO)
Stroke Campaigns in Thailand
many organizations put a lot efforts to save
people from stroke
include both government & non private
hospitals & volunteer EMS 1669
aim to increase r-TPA receiving rate &
decrease Door to Needle Time
CPG & CNPG have been developed in
macro-micro settings
Raise the awareness of stroke unit
establishment
Campaign-Know FAST
Fast is Life, Safe from Stroke
r-TPA is FREE
Sponsored by the
National Health
Security Office
Stroke Fast Track Applications
Fast Track (Stroke KKU)
Siriraj Stroke Fast Track
CU Stroke Fast Track
r-TPA Receiving Rate
In 2013, 0.1% of ischemic stroke patients
received r-TPA
In 2017, 1.95% received r-TPA
USA, 3.0-8.5%
Canada, 8.9%
Inadequate of neuro doctors
Approx. 500 neuro doctors all over Thailand
50% of them give service in Bangkok
< 10% give service in N/E Thailand, need to
serve 22 millions of population
Fast is Life, Save Penumbra
Fast is Life, Save Penumbra
Time is Brain
Time is Brain: Save the Penumbra
Save Penumbra
Types of Thrombolytic Drugs
Non fibrin specific-USA Fibrin specific-ART
Urokinase Tissue plasminogen activators
(t-PA)
Streptokinase Alteplase
Anistreplase Reteplase
Tenecteplase
Fibrin-specific Agents
are tissue plasminogen activators
e.g. Alteplase-Reteplase-Tenecteplase>>>ART
Selective in action (clot-specific fibrin)
Activity is enhanced upon binding to fibrin
binds preferentially to plasminogen at the fibrin
surface (non-circulating) rather than circulating
plasminogen
Risk of bleeding is less than non-specific agents
Mechanism of Action of
Thrombolytic Drugs
They have common mechanism of
action by stimulating plasminogen
activation via converting plasminogen
(proenzyme) to plasmin (active enzyme)
Lysis of the insoluble fibrin clot
into soluble derivatives
MoA of Thrombolytic Drugs
Thrombolytic Therapy Checklist
>18 years of age with ischemic stroke < 3 hour
CT shows no bleeding
Stroke deficit assessment
Severity quantified with NIHSS (0 - 42 scale)
No evidence of coagulopathy
INR < 1.8 & normal PTT
Platelets > 100,000/mm
Blood Pressure SBP < 185 mm Hg, DBP < 110 mm Hg
Glucose > 50 mg/dl, <400 50 mg/dl
r-TPA: Potential Benefits
The National Institute of Neurological Disorders and
Stroke (NINDS) suggested that stroke patients who
receive r-tPA according to a strict protocol will recover
by three months without significant disability
The sooner r-tPA is given to stroke patients, the
greater the benefit, especially if started within 90
minutes of symptom onset
Many studies have shown that treatment within 60
min of symptom produces excellent outcomes with
significantly lower rates of morbidity & mortality in
young patients…So called 60 min as Golden Hour
NINDS TPA Stroke Trial
Excellent outcome at 3 months on all scales
60%
52%
50% 45%
43%
38%
40% 34%
31%
30% 26%
21% TPA
20% Placebo
10%
0%
Barthel Rankin Glasgow NIHSS
Index Scale Outcome score
Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit
N Engl J Med 1995;333:1581-7
Potential Risks of r-TPA
Bleeding
Major bleeding: brain
Minor bleeding: GI
Death
Management of Bleeding
Stop r-TPA
Urgent CT
Notify neuro surgeon
Check blood coagulation
Prepare FFP, platelets
Post Fast Track Needs Continuing Care
Prevent recurrent stroke
Continue antiplatelet/anticoagulant for
lifetime
Control risk factors
Modify unhealthy behaviors
Thank you!
Contact Address:
Dr.Nichapatr Phutthikhamin
Email: [email protected]
