The rt-PA for Acute Stroke Protocol

Rapid identification, triage, diagnosis, and treatment for acute stroke victims requires a coordinated, multi-disciplinary effort that is organized around a pre-defined protocol. The current t-PA for acute stroke protocol has been tested extensively in a wide variety of clinical situations. At each step in the development of the protocol, a team of investigators evaluated the clinical utility of each item in the protocol. The protocol assures that all critical tests and examinations occur without unnecessary delays. All patients must be stabilized rapidly and the stroke team mobilized. The team must confirm the diagnosis of ischemic stroke, eliminating stroke mimics, e.g., Todd’s paralysis, TIA, hysteria, migraine, and carpal tunnel syndrome. Urgent imaging is required to exclude hemorrhage. The stroke team has very little time to conduct extensive history taking and exploration of stroke mechanisms. Absolute certainty is not attainable. The primary goal should be to exclude patients at risk for serious hemorrhage if they receive t-PA. There are no special subgroups of patients that are particularly likely to respond to t-PA, thus it is unwise to withhold treatment from patients who satisfy the published selection criteria. Drug is mixed and administered without delay, preferably within 60 min of arrival. To coordinate such a difficult work-up requires a team of experienced experts; implementation is best accomplished with an institutional Stroke Team, comparable to a Code Blue team that rehearses, monitors performance, and uses feedback to continually improve care.