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Teaching Time 90 minutes 1.

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1 Teaching Time 90 minutes 1

2 At the end of this participant you will be able to:
Know the differences between ischemic and hemorrhagic stroke Recognize signs and symptoms of stroke Be able to use the Cincinnati Prehospital Stroke Scale Discuss major principles of prehospital assessment and treatment for acute stroke Appreciate importance of rapid transport to Accredited Stroke Center Review the learning objectives. 2 2

3 Discuss major principles of ED stroke care
Appreciate importance of notifying ED before arrival (Calling Stroke Alert) Discuss major principles of ED stroke care Importance of rapid triage and early CT for stroke victims Understand the potential use of thrombolytics (IV-tPA) for selected patients with acute ischemic stroke Appreciate importance of rapid transport from an ED to an Accredited Stroke Center Review the learning objectives. 3 3

4 Use of National Institutes of Health Stroke Scale (NIHSS)
Guidelines for managing hypertension in stroke patients Clinical differences between ischemic and hemorrhagic stroke Treatment differences between ischemic and hemorrhagic stroke Appreciate importance of rapid transport from an ED to an Accredited Stroke Center Review the learning objectives. 4 4

5 One-third of strokes occur in patients younger than 65 years.
According to the American Heart Association stroke is the third leading cause of death in U.S. and leading cause of disability Approximately 700,000 people each year will suffer from a stroke, either for the first time or with a history of stroke; Of those patients, approximately 158,000 will die as a consequence of the stroke. One-third of strokes occur in patients younger than 65 years. Men are at higher risk than women. About 85% of strokes are ischemic in nature About 15% of strokes are hemorrhagic in nature EMS plays a large role as early recognition and treatment. This is key in reducing the mortality rates from strokes. 5

6 This could be a medical or traumatic cause
A stroke or Cerebral Vascular Accident (CVA) or “Brain Attack” is a neurologic deficit that causes a change in the patient’s ability to speak, feel, or move. When these changes are noted, the EMT should recognize that something has affected the patient’s central nervous system. This could be a medical or traumatic cause This power point will be limited to the presentation of a nontraumatic brain injury, or stroke. Talking Points A stroke is very similar to a heart attack (myocardial infarction). A blood clot obstructing a blood vessel in the brain causes an inadequate amount of blood to be delivered to a portion of the brain. Thus, the stroke is often described as a “brain attack,” to imply the same general cause and the same level of seriousness as a heart attack. The difference between a stroke and heart attack is the location of the vessel that is occluded by the clot. In a heart attack, a coronary artery is occluded; whereas in a stroke a cerebral (brain) artery is occluded. Atherosclerosis is usually a contributing factor to the formation of the clots and narrowing of the cerebral arteries. Stroke was formerly known as a cerebrovascular accident or CVA. 6

7 Stroke The symptoms that the patient presents with is a reflection of the area of the brain that has had a disruption of blood flow. Most commonly, strokes affect the regions of the brain that control speech, sensation, and muscle function. Paralysis, facial droop, monoplegia, hemiplegia, and speech disturbances are common findings. 7

8 8

9 Stroke is classified as hemorrhagic or ischemic and further subdivided by etiology
Ischemic stroke Embolic Thrombotic Hypoperfusion Hemorrhagic stroke Intracerebral hemorrhage Nontraumatic subarachnoid hemorrhage Point to Emphasize Strokes may be caused by either blood clots blocking blood flow through cerebral arteries or rupture of a cerebral artery. 9

10 Ischemic Stroke – This type of stroke is caused by a sudden occlusion of a blood vessel in the brain, a similar mechanism that is seen with a heart attack. Ischemia, Infarction, and Collateral Flow Brain tissues distal to a rupture, thrombus, or embolus receive little or no perfusion and become ischemic (starved of oxygen) and eventually infarcted (dead). When a thrombus grows slowly enough, collateral arteries may form parallel to the blocked artery to perfuse or partially perfuse the oxygen-starved area of the brain. 10

11 Hemorrhagic Stroke – This type of stroke occurs when a blood vessel in the brain bursts and allows blood to collect in or around the brain tissue. 11

12 In either instance, it is the lack of blood flow and oxygen that causes the dysfunction in the brain, and the accompanying signs and symptoms. 12

13 Difficulty speaking, swallowing Abnormal gait, weak extremities
Nausea/vomiting Dizziness, weakness Headache Impaired vision Vertigo, tinnitus Difficulty speaking, swallowing Abnormal gait, weak extremities Hemiparesis, quadriparesis Sensory loss, seizures Pupil abnormalities Dilated Constricted Unreactive Sluggish Stroke and transient ischemic attack (TIA) are conditions that may result from nontraumatic brain injury. Loss of speech, sensory, or motor function and altered mental status are among the possible signs and symptoms. Facial asymmetry is a common sign. 13

14 “Hey you ….. Don’t spend a lot of time to determine the specific cause! Do Prehospital Clinical Assessment 14

15 Cincinnati Prehospital Stroke Scale (CPSS)
Assess for Facial droop Arm drift Abnormal speech 15

16 Assess Facial droop (have patient smile)
Normal: Both sides of the face move equally Abnormal: One side of face does not move as well 16

17 Assess Arm drift (have patient hold arms out for 10 seconds)
Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other, or does not move at all 17

18 Assess Abnormal speech (Have the Pt. say)
“you can’t teach an old dog new tricks” Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words, or mute 18

19 STROKE ALERT If positive on one or all of the three tests
Transport to the closest Accredited Stroke Center and call a STROKE ALERT 19

20 CHRISTUS Spohn Shoreline1-361-881-3811
600 Elizabeth St. Corpus Christi, Tx CCMC Doctors Regional 3315 S. Alameda Corpus Christi, TX CCMC Bay Area 7101 S. Padre Island Dr. Corpus Christi, Tx 20

21 Time = Brain! Assessment and Treatment of a stroke patient by EMS can make a difference! 21

22 “SAMPLE history/Vital signs/Check the blood glucose level”
Scene evaluation Initial assessment Focused History “SAMPLE history/Vital signs/Check the blood glucose level” Detailed Physical examination (as needed) Ongoing Assessment Treatment 22

23 Assessment: Scene Size-Up
Dispatch information may alert you to this emergency if there is knowledge of neurological deficits or altered mental status. Look for evidence of trauma, drug use, or alcohol. The patient’s clothing may indicate approximately when the symptoms started. Call for backup if extrication from the residence will be difficult. Remember to take BSI precautions. Talking Points As you arrive, scan the scene to try to determine whether the neurologic deficit is due to trauma or to a medical condition. Look for any signs that would make you suspect that the patient’s head or spine has been injured. Scan the scene for alcohol, drugs or drug paraphernalia, and prescription or illegal drugs, which are other possible causes of altered function. Look for evidence of amphetamines, cocaine, and other stimulants. Note where the patient is found and how he is dressed. Many strokes occur at night, and the patient awakens with the neurologic deficit. You would expect that a patient who is found in bed or wearing nightclothes is more likely to be suffering from a stroke than from a traumatic brain injury. Another clue that the patient has suffered a stroke is a bucket or ice pack next to or near the patient. This could be considered evidence that the patient has experienced nausea, vomiting, or headache, common complaints of many patients with stroke. 23

24 Assessment: Initial Assessment
Establish mental status level (AVPU). In-line immobilization if trauma is suspected or I is unknown. Open the airway manually if needed, and provide oropharyngeal suctioning of secretions as necessary. Assess breathing adequacy, being particularly attentive for inadequate breathing as evidenced by an abnormal rate, regularity, or depth. Determine quality of pulses and perfusion. Assign patient priority status. Talking Points Immediately inspect the patient’s airway and suction any vomitus and secretions. If spine injury is not suspected, place the patient in a lateral recumbent position. If spine injury is suspected, perform a jaw-thrust maneuver to open the airway and provide manual in-line stabilization with the patient in a supine position. Insert an oropharyngeal or nasopharyngeal airway if needed. If the patient requires ventilation, place the patient in a supine position and begin positive pressure ventilation with supplemental oxygen connected to the device. Do not hastily jump to conclusions when assessing the patient’s responsiveness. If you pinch the patient’s hand and he does not respond, don’t assume he is unable to feel pain or sensation. He may be paralyzed on that side. Check the other extremity. 24

25 Rate, depth, and adequacy of respirations Circulation Check pulse
Airway Ensure an open airway Breathing Present Rate, depth, and adequacy of respirations Circulation Check pulse Disability Are circulation, sensation, and motor function intact in all extremities? What is the patient’s mental status? Can the patient answer questions appropriately? GCS score 25

26 SAMPLE history, continued
OPQRST Onset Provocation/palliative measures Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives 26

27 Assessment: SAMPLE History
Along with the normal SAMPLE questions, consider the following: When did the symptoms begin? Is there any recent history of trauma to the head? Does the patient have a history of strokes? Was there any known seizure activity prior to arrival? What was the patient doing at symptom onset? Is there a history of possible diabetes? Any history or presence of a stiff neck or headache? Any dizziness, nausea, vomiting, or weakness? Has the patient experienced any slurred speech? 27

28 SAMPLE history Past medical history of interest Hypertension
Hypercholesterolemia Coronary artery disease Diabetes Atrial fibrillation, valve replacement, recent acute myocardial infarction (AMI) History of smoking Transient ischemic attack (TIA) Do not assume that a patient is unconscious or has an altered mental status simply because he or she does not respond to your questions. 28

29 Assessment: Detailed Physical Exam
Do not delay transport to obtain a physical exam. Sensory and motor function should be assessed in all extremities. Document and report any alterations from earlier assessment findings, to include the patient’s mental status, speech, sensory capabilities, and motor function. Talking Points The physical exam will be a rapid head-to-toe assessment. Any one of these findings is strongly suggestive of stroke: Facial droop of one side when the patient is asked to smile or show his teeth. One arm does not move or one arm drifts downward when the patient’s arms are extended outward for ten seconds with his eyes closed. The patient slurs his words, uses wrong words, or is unable to speak when asked to repeat the phrase “You can’t teach an old dog new tricks.” Weak or no grip on one side of body when asked to squeeze your fingers. Use one of the validated stroke screening evaluation tools: – The Cincinnati Prehospital Stroke Scale 29

30 Assessment: Ongoing Assessment
Perform an ongoing assessment every 5 minutes. Stroke patients deteriorate rapidly, watch for airway, breathing, circulation, and mental status changes. Repeat and record the baseline vital signs. Communicate any changes in the patient’s condition to the receiving medical facility. Talking Points Perform a reassessment every five minutes. Pay special attention to the status of the airway, breathing, circulation, and mental status. This is extremely important since many stroke patients deteriorate rapidly and significantly. Pay particular attention to the patient’s airway as the mental status changes. Repeat and record vital signs. Communicate any changes in the patient’s condition to the receiving facility. 30

31 Place in recovery position Have suction available
Maintain the ABC Place in recovery position Have suction available Treat underline cause Ongoing assessment Talking Points If your assessment reveals a traumatic injury, perform the appropriate emergency medical care for that injury, including spine stabilization. If the patient displays an altered mental status or a loss of speech, sensory, or motor function, or if stroke is suspected, follow the emergency care plan on the next slide. Discussion Question What are important considerations in the management of a patient who may be having a stroke? 31

32 32

33 Maintain scene and personal safety
Support airway, breathing, circulation Consider need for BLS/ALS airway. Oropharyngeal (OPA), nasopharygeal (NPA) Endotracheal intubation Ensure adequate ventilation. BVM ventilation if needed Oxygen 2-4 lpm/NC or 15 lpm/NRB Monitor oxygen saturation with pulse oximetry keeping Spo2 >92% Continuous Cardiac Monitoring/12 lead ECG Cardiac dysrhythmia and AMI can occur with stroke. Assess ABCs and vital signs. Support airway and ventilation if needed. Provide oxygen by nasal cannula. Initiate ECG monitoring and pulse oximetry. Obtain IV access if not established. Administer normal saline at keep-open rate. Check blood sugar and administer glucose if necessary. Verify time of symptom onset if possible. If family members have difficulty remembering the time, relate it to daily activities (eg, meals), television programs, or call to EMS. 33

34 IV Access x 2 of NS/LR (This should not delay transport)
Administer fluids, if patient is hypotensive. Note: Over administration of IV fluids can create or worsen existing cerebral edema. Blood Glucose Level Correct hypoglycemia with glucose administration. DO NOT administer glucose if hypoglycemia is not identified. Monitor V/S every 5 minutes. Keep patient warm. 34

35 Elevate head, if no hypotension.
If high BP SYS >200 or DIAS >110 treat with LABETALOL 10 mg IV over 1–2 min may repeat q 10 min to max 300mg Nitroglycerin may be used (Check with your Protocol) EMS Treatment Guidelines Follow the CBRAC 2010 Stroke Algorithm Place patient in position of comfort. Protect paralyzed extremities since the patient cannot move the extremity, ensure that it is protected from injury. Reassure patient. Rapid transport to an Accredited Stroke Center 35

36 RAPID TRANSPORT TO THE APPROPRIATE FACILITY
CBRAC STROKE ALGORITHM These are guidelines; they do not supersede the Medical Directors order set. Critical EMS Assessment and Actions Support ABCs Oxygen 2-3 L NP or 15L NRB keep spo2 >92% Perform Prehospital Stroke Assessment Early Notification to Stroke Center Establish SYMPTOM ONSET < 4.0 hours RAPID TRANSPORT TO THE APPROPRIATE FACILITY ACTIVATE/Transport closest Accredited Stroke Center if <30 minutes by ground or air transport; CALL STROKE ALERT CHRISTUS Spohn Shoreline CCMC Bay Area CCMC Doctor’s Regional ACTIVATE/Transport closest facility capable of treating stroke with t-PA if >30 minutes HALO Flight (Corpus Christi) AirLIFE (San Antonio) PHI (Victoria) Valley Air (Harlingen) In Transit: Continuous Cardiac Monitoring Blood Glucose Level IV Access x2 (Should not delay transport) CINCINNATI PREHOSPITAL STROKE SCALE Facial Droop/Smile Normal Abnormal TX for H-BP for SYS >200 or DIAS >110 Arm Drift Normal Abnormal LABETALOL 10 mg IV over 1–2 min Speech may repeat q 10 min to max 300mg Say “you can’t teach an old dog new tricks” Normal Abnormal EMS Treatment Guidelines: CBRAC 2010 Stroke Algorithm 36

37 Time = Brain! Transport to and Treatment at an established Stroke Center can make a difference in pt outcome! Drugs are now available to administer to certain stroke patients that could reduce or even reverse the consequences of the stroke by breaking up the clot causing the obstruction. However, time is critical, and these drugs must be administered within four hours from the first sign or symptom of the onset of the stroke. EMS must immediately recognize the signs and symptoms of stroke, assess the patient, provide initial emergency medical care, prepare the patient for rapid transport, and notify the receiving medical facility of transport of a possible stroke patient. The American Heart Association has identified 7 “Ds” to describe the best care for the stroke patient. The 7 Ds, which address the issue of time as a critical factor in reducing permanent disability and death in the stroke patient, are Detection, Dispatch, Delivery, Door, Data, Decision, and Drug. 37

38 38

39 Decision Criteria: The bypass protocol is intended to ensure that patients with a witnessed acute stroke be transported to an accredited stroke center. Exceptions to the bypass protocol requiring the patient to be transported to the NEAREST facility are: Inability to establish and/or maintain an airway or in the event of a cardiac arrest. If transport time to the indicated accredited stroke center exceeds 30 minutes; the patient should be transported to the nearest facility capable of treating stroke with Activase (t-PA) if indicated, then transferred to an accredited stroke facility. 39

40 The activation of the Bypass Protocol for the symptomatic acute stroke patient should be initiated upon the recognition of confirmed witnessed changes in patient condition as to “Last Known Well” in less than 4 hours. If “Last Known Well” temporarily unknown due to patients inability to talk or the lack of a witness, transport to an accredited stroke center and activate a stroke alert. 40

41 HALO Flight (Corpus Christi) 1-800-776-4256
Hand off of the acute stroke patient to advanced life support “Mobile Intensive Care Unit” or Air Transport will be initiated in the following circumstances: Basic life support unit is first responder only and/or unable to leave service area If air transport/pick-up total time is less than ground transport time. HALO Flight (Corpus Christi) AirLIFE (San Antonio) PHI (Victoria) Valley Air (Harlingen) 41

42 If >30 minutes by ground to an accredited stroke center or no air medical then transport to the closest facility capable of treating stroke pts. with (t-PA) 42

43 43

44 Continue airway maintenance and administration of supplemental oxygen.
Obtain IV access if not done prehospital Central venous catheter Blood glucose determination Cardiac monitoring, 12-Lead ECG Foley catheter 44

45 Lab studies Imaging studies NIH Stroke Scale
Complete blood count (CBC) with platelet count Coagulation profile Serum glucose Electrolytes, cardiac enzymes NIH Stroke Scale Imaging studies Noncontrast CT of the brain Differentiates between hemorrhagic and ischemic stroke Chest X-Ray NIHSS Review the patient’s history, verify time of symptom onset, and perform brief physical and neurologic examinations and NIHSS The NIHSS measures neurologic function, which correlates with ischemic stroke severity and long-term outcome. It can be performed in 7 minutes and can be performed simultaneously with initial admission procedures, so it should not delay other assessment or therapy. It enables performance of serial standardized neurologic evaluation over time by a nurse or physician. The NIHSS is not a comprehensive neurologic exam, and further studies may be required. The NIHSS evaluates the following 5 areas, and the resulting score (0-42) will guide decisions about therapy: Level of consciousness Visual assessment Motor function Sensation and neglect Cerebellar function Training in the NIHSS is beyond the scope of this course. 45

46 Treatment for ischemic stroke may include
Anticoagulants Antiplatelet agents Fibrinolytics Recombinant tissue-type plasminogen activator (rtPA) Patients with ischemic stroke and hypertension may receive Labetalol Enalaprilat Nicardipine Nitroglycerin 46

47 Treatment of intracerebral hemorrhage
Severe hypertension (MAP >130 mmHg) may be treated. Labetalol Enalapril Nicardipine Nitroprusside Increased ICP treated with Hyperventilation Mannitol, furosemide Surgical intervention dependent on patient neurological status plus size and location of hemorrhage 47

48 Treatment of subarachnoid hemorrhage
Head elevated to 30 degrees Maintenance of blood pressure to prehemorrhagic levels Seizure prophylaxis Ventriculostomy Surgical clipping of ruptured aneurysm 48

49 Door to Triage by Doctor – 10 minutes Door to CT Scan – 25 minutes
Door to CT Read/Lab Results – 45 minutes Door to (t-PA) – 60 minutes 49

50 50

51 Inclusion criteria Older than 18 years
Clinical diagnosis of ischemic stroke Time of onset well established to be less than four hours 51

52 Exclusion criteria Past medical history of Warnings:
Intracranial hemorrhage, aneurysm, or arteriovenous malformation Internal bleeding within preceding 21 days Head trauma, intracranial surgery, CVA within past three months Warnings: Major surgery within past 14 days Recent myocardial infarction Lumbar puncture within past seven days Recent arterial puncture 52

53 Exclusion criteria Known bleeding disorder
Platelet count <100,000/mm3 Current use of oral anticoagulants and/or prothrombin time (PT) >15 seconds Heparin used in past 48 hours and/or elevated partial thromboplastin time (PTT) Evidence of intracranial hemorrhage on noncontrast CT scan High clinical suspicion of SAH even with normal CT scan (If all exclusion criteria “NO” the patient is a potential candidate for IV-tPA) 53

54 “Hey you ….. Some exclusion criteria are “warnings”
Any EXCLUSION will be done by the NEUROLOGIST” 54

55 55

56 Perform and record baseline GCS Continuous cardiac monitoring/12 Leads
All post t-PA patients should be sent by Critical Care Transport (MICU) Document vital signs prior to transport and verify that SBP <180, DBP <100. If BP above limits, sending hospital should stabilize prior to transport Obtain contact method for family or caregiver (preferably cell phone) to allow contact during transport or upon patient arrival Obtain and record Vitals Signs and Neurological checks (CPSS) every 15 minutes Perform and record baseline GCS Continuous cardiac monitoring/12 Leads Strict NPO – this includes all PO medications 56

57 If IV t-PA dose administration will continue en route:
Verify total dose and time of IV t-PA bolus (if t-PA is completed prior to transfer) If IV t-PA dose administration will continue en route: Verify estimated time of completion. Verify with the sending hospital that the excess t- PA has been withdrawn and discarded (for example, if the total dose of t-PA to be given is 70mg, then verify the remaining 30cc has been wasted since a 100mg bottle of t-PA contains 100cc of fluid) 57

58 If SBP >180 or DBP >100, and if antihypertensive medication started at sending facility, then adjust as follows: If Labetalol IV drip started at the sending hospital, increase by 2mg/min every 10 minutes (to a maximum of 5mg/min) until SBP <180 and DBP <100; If SBP <150 or DBP <80 or HR <60, turn off drip and call receiving hospital for further instructions. If Nicardipine IV drip was started at the sending hospital, may increase dose by 2.5mg/hr every 5 minutes. To a maximum of 15mg/hr until SBP <180 and DBP <100; If SBP <150 or DBP <80 or HR <60, turn off drip and call receiving hospital for further instructions. 58

59 For any acute worsening of neurologic condition, or if patient develops severe headache, acute hypertension or vomiting (suggestive of intracerebral hemorrhage) or profuse bleeding not controlled by pressure: 1. Discontinue t-PA infusion (if still being administered) 2. Call receiving facility for further instructions including decision to adjust blood pressure medication and/or divert to nearest hospital. 3. Continue to monitor vitals and neuro checks every 5 mins. 59

60 Rapid Assessment, Management and Transport by EMS to an Accredited Stroke Center can help reduce mortality and morbidity, and produce maximal potential for rehabilitation and recovery. 60

61 Arnold, J. L. “Stroke, Ischemic. ” WebMD, www. emedicine
Arnold, J.L. “Stroke, Ischemic.” WebMD, (accessed June 1, 2006; last updated March 24, 2005). Bledsoe, B.E., R.S. Porter, and R.A. Cherry. Paramedic Care: Principles and Practice, 2nd ed. Upper Saddle River, NJ: Pearson Prentice Hall, 2006. Hughes, R. L., and M.P. Earnest. “Transient Ischemic Attack and Cerebrovascular Accident.” In Emergency Medicine Secrets, 3rd ed., edited by V.J. Markovchick and P.T. Pons. Philadelphia, PA: Hanley & Belfus Inc., 2003. Jallo, G., and T. Becske. “Subarachnoid Hemorrhage.” WebMD, (accessed June 4, 2006; last updated August 15, 2005). Kazzi, A.A., and R. Zebian. “Subarachnoid Hemorrhage.” WebMD, (accessed June 20, 2006; last updated June 20, 2006). Nassisi, D. “Stroke, Hemorrhagic.” WebMD, (accessed June 6, 2006; last updated November 18, 2005). Perreault, D. J. “Neurologic Emergencies.” In Mobile Intensive Care Paramedic by B.E. Bledsoe and R.W. Benner. Upper Saddle River, NJ: Pearson Prentice Hall, 2006. 61

62 Scott, P. A. , and C. A. Timmerman
Scott, P.A., and C.A. Timmerman. “Stroke, Transient Ischemic Attack, and Other Central Focal Conditions.” In Emergency Medicine: A Comprehensive Study Guide, 6th ed., edited by J.E. Tintinalli, G.D. Kelen, and J.S. Stapczynski. New York: McGraw-Hill, 2004. Smith, W.S., S.C. Johnston, and J.D. Easton. “Cerebrovascular Diseases.” In Harrison’s Principles of Internal Medicine, 16th ed., edited by D.L. Kasper, E. Braunwald, A.S. Fauci, S.L. Hauser, D.L. Longo, and J.L. Jameson. New York, NY: McGraw-Hill, 2004. Thom, T., N. Haase, W. Rosamon, et al. “Heart Disease and Stroke Statistics— 2006 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.” Circulation 113, no. 6 (February 14, 2006): Also available at Wechsler, L. R. and C. A. Barch. “Management of Acute Ischemic Stroke.” In Textbook of Critical Care, 5th ed., edited by M.P. Fink, E. Abraham, J- L.Vincent, and P.M. Kochanek. Philadelphia, PA; Elsevier-Saunders, 2005. Yamada, K.A. and S. Awadalla. “Neurologic Disorders.” In The Washington Manual of Medical Therapeutics, 31st ed., edited by G.B. Green, I.S.Harris, G.A. Lin, K.C. Moylan. Philadelphia, PA: Lippincott Williams & Wilkins, 2004. 62


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