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: thithi@kku.ac.th