Learn how to better prepare stroke patients for IV tPA administration by gathering information on scene.
Introduction
Within a given region, the emergency medical services (EMS) system has an important role in the management of acute stroke patients. Decisions made by EMS personnel can affect treatment and contribute to the immediate, short-term and long-term outcomes of the patient. Because the patient may require emergent treatment regardless if the stroke is ischemic or hemorrhagic, EMS personnel should manage all potential stroke patients in a time-dependent nature.1 EMS providers know in cases of stroke, “time is brain.” The typical patient loses 1.9 million neurons each minute in which stroke is untreated.2
In cases of acute ischemic stroke, EMS providers without delaying treatment or transport, can gather three pieces of critical information during the stroke patient encounter to expedite and better aid the receiving hospital clinician in the decision to administer intravenous recombinant tissue-type plasminogen activator, (tPA) (alteplase). First, the prehospital provider can gather accurate information on the last known normal. Second, when feasible, a next of kin to the patient should present in the ED in person, or by phone, to facilitate informed consent for IV tPA administration. Lastly, gathering a thorough medical history in the prehospital environment regarding recent medical procedures and surgeries, medical events, medication history, injuries and hospitalizations is paramount to aid in the timely and appropriate decision to administer IV tPA. By eliminating these three possible gaps and pitfalls the acute stroke patient should receive appropriate care not only quicker but with more accurate consideration to IV tPA inclusion/exclusion criteria.
Last Known Normal
The last known normal (LKN) is a critical piece of information used to determine eligibility for IV tPA in cases of ischemic stroke. The FDA approves IV tPA to be administered in cases of acute ischemic stroke up to 3 hours from last known normal and up to 4.5 hours in select cases.3 It should be noted that the phrase “last known normal” is interchangeable with “time last known well” which is recognized by the Joint Commission.4 The Joint Commission defines time last known well as “the time prior to hospital arrival at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her baseline state of health.4” Without a well-defined last known well, the administration of tPA may be not administered at all, delayed or delayed to a point that the patient presents outside of the recommended treatment window.3
EMS-reported LKN times were largely congruent with neurologist-determined times. Focused EMS training regarding wake-up stroke symptoms may further improve accuracy.5 EMS underestimated the LKN time by reporting the awakening time as the LKN time rather than the time the patient was known to be normal the day before.5 To clarify, last known normal in cases of wake-up strokes should be documented as the last time the patient was seen normal, usually the night or day before as they went to bed. Wake-up strokes last known normal is not the time they woke and had stroke symptoms, rather, the last known normal must be documented and reported as the last time the patient was normal and without stoke signs and symptoms. It is likely EMS providers will encounter cases where the last known normal is unclear, unwitnessed or unobtainable.3
Obtaining Consent for tPA
The use of tPA for ischemic stroke often requires consent from the patients next of kin. Consent often revolves around the inherent risk and complications from hemorrhage and injury from tPA administration. For every 100 patients treated with tPA, approximately one will experience a severely disabled or fatal final outcome as a result of tPA-related symptomatic intracerebral hemorrhage.6 In a 2018 study it was determined, “Most [hospital] clinicians always or often require informed consent for stroke thrombolysis. Future research should focus on standardizing content and delivery of tPA information to reduce delays.7”
Related
- Stroke Article Compendium
- Enhancing Stroke Management
- Acute Stroke: From Prehospital Care to In-Hospital Management
While it is further recognized there is “no standard approach to obtaining consent for stroke thrombolysis with tPA.”7 “This lack of consensus can create uncertainty amongst providers and creates the potential for delays in treatment, uneasiness amongst clinicians, and legal liability.8”
The potential delay to gather consent can be shortened or mitigated by bringing the immediate next of kin to the emergency department so that the informed consent to be explained, in person, by a qualified clinician. Another option is to instruct the next of kin to immediately and safely drive directly to the transport destination. Another option would be to obtain the next of kin’s phone number for verbal informed consent for IV tPA. Depending on institutional policy and provider discretion, informed consent for the administration of tPA can be received by both telephone and writing. “Clinicians who believed tPA required informed consent were divided on whether consent should be written (40 percent) or verbal (60 percent).8”
Anticoagulants and Medical History
A patient history of anticoagulant use can be an exclusion criterion for IV tPA in cases of acute ischemic stroke. However, compliance with the prescribed medications should be considered and evidence, such as pill bottles, pill planners and caregiver testimony should be gathered to aid the clinician who will make the treatment decisions regarding IV tPA. In certain cases, evidence supports that IV tPA can be administered even if the patient has taken an anticoagulant.3 The specific time, date, medication and dose needs to be considered by the clinician. Therefore, gathering anticoagulant information in the prehospital environment could aid in the timely and accurate administration of IV tPA.
The administration of IV tPA is contraindicated, excluded or harmful in cases of major surgery and major trauma within 14 days, active internal bleeding or history of gastrointestinal or urinary tract bleeding within 21 days, severe head trauma and recent intracranial and intraspinal surgery within 3 months.3 Therefore, gathering a through medical history in the prehospital environment regarding recent medical procedures and surgeries, medical events, and hospitalizations is paramount to aid in the appropriate decision to administer IV tPA.
Conclusion
Combining these three considerations without delaying treatment or transport along with timely recognition of stroke, early activation of the 911 system, early hospital notification, appropriate transport destination and providing the receiving hospital clinician with accurate and pertinent information in the EMS report could aid the receiving hospital clinician and likely improve patient outcomes. Thus, the acute stroke patient should receive appropriate care not only quicker but with more accurate consideration to IV tPA inclusion/exclusion criteria which could improve patient outcomes and patient safety.
References
1. Millin MG, Gullett T, Daya MR. EMS management of acute stroke-out-of-hospital treatment andstroke system development (resource document to NAEMSP position statement) [Internet]. Taylor & Francis. [cited 2021Dec29]. Available from: https://www.tandfonline.com/doi/full/10.1080/10903120701347885
2. SaverMD JL, Saver JL, Jeffrey L. Saver From the Stroke Center and Department of Neurology, Saver Cto JL. Time is brain-quantified [Internet]. Stroke. AHA Journal Stroke; 2005 [cited 2021Dec29]. Available from: https://www.ahajournals.org/doi/full/10.1161/01.str.0000196957.55928.ab
3. Demaerschalk BM, Bart M. Demaerschalk Search for more papers by this author, Kleindorfer DO, Dawn O. Kleindorfer, Adeoye OM, Opeolu M. Adeoye, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke [Internet]. Stroke. AHA Journal Stroke; 2015 [cited 2021Dec29]. Available from: https://www.ahajournals.org/doi/10.1161/str.0000000000000086
4. Specifications Manual for Joint Commission National Quality Measures (v2018A) [Internet]. Time last known well. 2018 [cited 2021Dec29]. Available from: https://manual.jointcommission.org/releases/TJC2018A/DataElem0218.html
5. Curfman D, David Curfman From the Department of Neurology (D.C., Connor LT, Lisa Tabor Connor From the Department of Neurology (D.C., Moy HP, Hawnwan Philip Moy From the Department of Neurology (D.C., et al. Accuracy of emergency medical services–reported last known normal times in patients suspected with acute stroke [Internet]. Stroke. AHA Journal Stroke; 2014 [cited 2021Dec29]. Available from: https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.113.003955
6. Saver MD JL. Hemorrhage after thrombolytic therapy for stroke [Internet]. Stroke. AHA Journal Stroke; 2007 [cited 2021Dec30]. Available from: https://www.ahajournals.org/doi/10.1161/strokeaha.107.487009
7. Mendelson SJ, Scott J. Mendelson From the Department of Neurology (S.J.M., Courtney DM, D. Mark Courtney From the Department of Neurology (S.J.M., Gordon EJ, Elisa J. Gordon From the Department of Neurology (S.J.M., et al. National practice patterns of obtaining informed consent for stroke thrombolysis [Internet]. Stroke. AHA Journals Stroke; 2018 [cited 2021Dec29]. Available from: https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.117.020474
8. Comer AR, Williams LS, Torke AM, Damush TM. The role of informed consent for thrombolysis in acute ischemic stroke [Internet]. The Journal of clinical ethics. U.S. National Library of Medicine; 2019 [cited 2021Dec29]. Available from: https://pubmed.ncbi.nlm.nih.gov/31851625/
