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Stroke Management for the EMS Provider Alameda County Educational Module Brenda Krokoski RN (Alta Bates/Summit Stroke Center) Douglas Van Houten RN (Washington.

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Presentation on theme: "Stroke Management for the EMS Provider Alameda County Educational Module Brenda Krokoski RN (Alta Bates/Summit Stroke Center) Douglas Van Houten RN (Washington."— Presentation transcript:

1 Stroke Management for the EMS Provider Alameda County Educational Module Brenda Krokoski RN (Alta Bates/Summit Stroke Center) Douglas Van Houten RN (Washington Hospital Stroke Center)

2 Stroke Management for the EMS Provider At the completion of this module, the EMS Provider will be able to: Describe the various types of stroke and their etiology. Describe the various types of stroke and their etiology. Discuss the imperatives for best practice in regard to EMS stroke management. Discuss the imperatives for best practice in regard to EMS stroke management. List 5 or more risk factors for acute stroke. List 5 or more risk factors for acute stroke. Define “penumbra” and how this concept is important in stroke. Define “penumbra” and how this concept is important in stroke. Generally describe the major vessels involved in acute ischemic stroke. Generally describe the major vessels involved in acute ischemic stroke. Discuss the “therapeutic window” for thrombolytic therapy in stroke. Discuss the “therapeutic window” for thrombolytic therapy in stroke. Identify interventions that individual EMS providers can make to improve outcomes in stroke. Identify interventions that individual EMS providers can make to improve outcomes in stroke.

3 Instructions: Instructions: Page through the module to learn the content. Page through the module to learn the content. Complete the post test. Complete the post test. Stroke Management for the EMS Provider

4 Is STROKE a health problem in the US today? 700,000 strokes every year 700,000 strokes every year 5 million stroke survivors, but with substantial morbidity: 18% unable to return to work 4% require total custodial care Stroke is the leading cause of serious, long term disability One person dies of stroke every 3 minutes Stroke is the 3rd leading cause of death

5 Only 50-70% of stroke survivors regain functional independence Only 50-70% of stroke survivors regain functional independence Locally, African-Americans have 50% more strokes than Caucasians, and twice as many as Asians and Hispanics (Statistics from the American Stroke Association) 22% of men & 25% of women die within 1 year of their first stroke 20% are institutionalized within 3 months Is STROKE a health problem in the US today?

6 African Americans & Stroke Incidence is nearly double that of white Americans Incidence is nearly double that of white Americans Suffer more extensive physical impairments Suffer more extensive physical impairments Twice as likely to die from stroke Twice as likely to die from stroke High incidence of risk factors for stroke High incidence of risk factors for stroke hypertension diabetes obesity smoking sickle cell anemia (National Stroke Association)

7 Women & Stroke Stroke kills more than twice as many American women every year as breast cancer Stroke kills more than twice as many American women every year as breast cancer More women than men die from stroke More women than men die from stroke Women over age 30 who smoke and take high- estrogen oral contraceptives have a stroke risk 22 times higher than average Women over age 30 who smoke and take high- estrogen oral contraceptives have a stroke risk 22 times higher than average (National Stroke Association)

8 How Bad is a Major Stroke? Elders at Risk for Stroke (1183, TTO), --Samsa et al, Am Heart J 1998 Worse than death Equivalent to death Equivalent to being well

9 Is STROKE a health problem in the US today? YES, stroke is a major health problem in the US today. YES, stroke is a major health problem in the US today. EMS Providers are closely involved with this patient population and are a vital component of the “Stroke Chain of Survival”. EMS Providers are closely involved with this patient population and are a vital component of the “Stroke Chain of Survival”. Increased knowledge and personal motivation on the part of EMS providers can: Increased knowledge and personal motivation on the part of EMS providers can: Greatly reduce death and disability due to stroke. Greatly reduce death and disability due to stroke. Improve stroke centers’ ability to provide thrombolytic therapy. Improve stroke centers’ ability to provide thrombolytic therapy. Make a positive impact on communities’ strides to reduce costs for healthcare and improve outcomes. Make a positive impact on communities’ strides to reduce costs for healthcare and improve outcomes.

10 Goals for EMS Provider Care of Stroke Patients 1. Improve knowledge of identification of stroke signs and symptoms. 2. Develop a rapid assessment process. 3. Facilitate transfer of stroke victims to Primary Stroke Centers in the quickest and safest manner. 4. Pre-notify the Stroke Center, “Possible acute stroke in route.” 5. Encourage family members familiar with the patient care to either ride with the transfer vehicle or drive to the stroke center ASAP to provide more patient information.

11 Goals for EMS Provider Care of Stroke Patients 6. Obtain reliable list of meds taken or bring bag of all medications taken. 7. Obtain a set of vital signs and finger stick blood sugar at the site. 8. Reliably identify family’s best estimation of when the patient was “last seen normal”. 9. Administer the Cincinnati Pre-hospital Stroke Scale. 10. Provide the receiving facility with a quick, complete verbal report that incorporates the information obtained since arrival on scene.

12 Review: Anatomy & Physiology of Acute Ischemic Stroke What is acute ischemic stroke? What is acute ischemic stroke? What is the major vasculature involved? What is the major vasculature involved? When circulation is suddenly reduced, how quickly is brain tissue affected? When circulation is suddenly reduced, how quickly is brain tissue affected? What is “penumbra”? What is “penumbra”? What are the types and etiologies of stroke? What are the types and etiologies of stroke? What about different stroke symptoms? What about different stroke symptoms?

13 What Is Stroke ? A stroke occurs when blood flow to the brain is interrupted by a blocked or burst blood vessel.

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15 One quarter of cardiac output goes to the 5-6 pound organ—the brain. The brain needs a constant supply of: Oxygen Glucose Other nutrients Circulation is supplied via 2 pairs of arteries: Internal carotids Vertebrals

16 The Major Circulation to the Brain

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18 PENUMBRA (That tissue surrounding the infarct that is salvageable, but at risk.) Rapid transfer to the stroke center will allow for protection of penumbra through emergency interventions and medical management.

19 Cerebrovascular Disease: Pathogenesis Ischemic Stroke (83%) Hemorrhagic Stroke (17%) Atherothrombotic Cerebrovascular Disease (20%) Embolism (20%) Lacunar (25%) Small vessel disease Cryptogenic (30%) Intracerebral Hemorrhage (59%) Subarachnoid Hemorrhage (41%) Albers GW, et al. Chest. 1998;114:683S-698S. Rosamond WD, et al. Stroke. 1999;30:

20 Acute Ischemic Stroke (What do you see?) Deficits: Deficits: Unilateral (though not always) weakness Unilateral (though not always) weakness Unilateral sensory deficit Unilateral sensory deficit Visual deficits (blindness, gaze palsy, double) Visual deficits (blindness, gaze palsy, double) Speech (slurred – a motor dysfunction) Speech (slurred – a motor dysfunction) Language (aphasia – damage to the brain’s speech center) Language (aphasia – damage to the brain’s speech center) Ataxia (lack of coordinated movement) Ataxia (lack of coordinated movement) Cognitive impairment Cognitive impairment Like real estate—Location, Location, Location Like real estate—Location, Location, Location

21 What Parts of the Brain Are Affected by Stroke?

22 What Are the Effects of Stroke? Left Brain Left Brain

23 What Are the Effects of Stroke? Right Brain Right Brain

24 Stroke Assessment Scale (Cincinnati Pre-hospital Stroke Scale) “The sky is blue in Cincinnati.” Any abnormality means an abnormal Cincinnati scale for stroke. Probably accurately detects stroke 80% of the time.

25 Stroke Assessment in the Field Administer Cincinnati Scale. Administer Cincinnati Scale. If abnormal, facilitate a rapid transfer to the primary stroke center. (Alta Bates in North Alameda County—Washington Hospital in South Alameda County. If abnormal, facilitate a rapid transfer to the primary stroke center. (Alta Bates in North Alameda County—Washington Hospital in South Alameda County. Pre-notify the receiving stroke center— ”possible acute stroke in route”. Pre-notify the receiving stroke center— ”possible acute stroke in route”.

26 Identify Time “Last Seen Normal” A 75 year old man with HTN and diabetes finishes dinner with a friend at 8pm. He drives himself the short distance home that night, and a daughter stops by the next morning to find him still in bed and with right side weakness and severe aphasia. When do we assume the stoke occurred? (Answer: “last seen normal at 8pm) A 75 year old man with HTN and diabetes finishes dinner with a friend at 8pm. He drives himself the short distance home that night, and a daughter stops by the next morning to find him still in bed and with right side weakness and severe aphasia. When do we assume the stoke occurred? (Answer: “last seen normal at 8pm) A 35 year old hypertensive man who is known to be non-compliant with meds is found slumped over in his car in a job site parking area at 3pm. In the ED he was found to have a massive left hemispheric ischemic stroke. His wife said he left for work at 7am that morning as normal, and she had a clear and normal cell phone conversation with him at 12:30pm. At 1pm a co-worker stated the man said he wasn’t feeling well and was going to his car to rest. At the time the co-worker noticed his speech was slurred. What time can we use as the time “last seen normal”? (Answer: 12:30pm) A 35 year old hypertensive man who is known to be non-compliant with meds is found slumped over in his car in a job site parking area at 3pm. In the ED he was found to have a massive left hemispheric ischemic stroke. His wife said he left for work at 7am that morning as normal, and she had a clear and normal cell phone conversation with him at 12:30pm. At 1pm a co-worker stated the man said he wasn’t feeling well and was going to his car to rest. At the time the co-worker noticed his speech was slurred. What time can we use as the time “last seen normal”? (Answer: 12:30pm)

27 Types of Acute Ischemic Strokes Middle Cerebral Artery Stroke Middle Cerebral Artery Stroke Vertebral—Basilar Artery Strokes Vertebral—Basilar Artery Strokes Lacunar Strokes Lacunar Strokes

28 Types of Strokes (Middle Cerebral Artery – MCA)

29 CT Scan of Acute Ischemic Stroke (Left MCA territory stroke)

30 Types of Strokes (Middle Cerebral Artery – MCA) The most common artery occluded in AIS— can be proximal or from carotid circulation. The most common artery occluded in AIS— can be proximal or from carotid circulation. Features: Features: Motor/Sensory Deficit: face, arm, leg Motor/Sensory Deficit: face, arm, leg Speech deficit – dysarthria (slurred speech) Speech deficit – dysarthria (slurred speech) Language deficit – if in dominant hemisphere Language deficit – if in dominant hemisphere Gaze palsy – eyes directed towards side of AIS Gaze palsy – eyes directed towards side of AIS Blindness – visual field cut (homonymous hemianopsia) Blindness – visual field cut (homonymous hemianopsia)

31 Types of Strokes (Vertebral—Basilar Artery) Features: Features: Cranial nerve involvement – hearing, visual, facial, swallowing Cranial nerve involvement – hearing, visual, facial, swallowing Can have bilateral weakness Can have bilateral weakness Cerebellar signs – ataxia Cerebellar signs – ataxia Sensory deficits Sensory deficits Vertigo – often nystagmus Vertigo – often nystagmus Nausea and vomiting Nausea and vomiting Common to have waxing and waning symptoms Common to have waxing and waning symptoms

32 Lacunar Strokes These strokes are ischemic in nature. These strokes are ischemic in nature. Mainly caused by HTN. Mainly caused by HTN. Occurs in the small penetrating arteries of the brain. Occurs in the small penetrating arteries of the brain. Presentation – affects the arm, leg, and face, sometimes silent. Deficits are equal to all areas. Presentation – affects the arm, leg, and face, sometimes silent. Deficits are equal to all areas.

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34 Conditions That Mimic AIS Bell’s Palsy Bell’s Palsy Todd’s Paralysis Todd’s Paralysis Hemorrhagic Stroke Hemorrhagic Stroke Subdural Hematoma Subdural Hematoma Other conditions Other conditions

35 Conditions That Mimic AIS Bell’s Palsy Bell’s Palsy Bell’s Palsy is a viral infection of the facial nerve which causes stroke-like symptoms: unilateral facial droop, sensory deficit, dysarthria, etc.

36 Conditions That Mimic AIS Differential dx: Differential dx: Hx: women, pregnancy, viral illness Hx: women, pregnancy, viral illness Can’t close eye completely or raise forehead Can’t close eye completely or raise forehead May have facial pain May have facial pain No other stroke symptoms No other stroke symptoms May have no risk factors for stroke May have no risk factors for stroke

37 Conditions That Mimic AIS Todd’s Paralysis: unilateral weakness that occurs after a seizure. Todd’s Paralysis: unilateral weakness that occurs after a seizure. Can involve speech, language, visual and sensory Can involve speech, language, visual and sensory May be due to hyperpolarization in the area of the seizure May be due to hyperpolarization in the area of the seizure Resolves within 48 hours Resolves within 48 hours Key concern in regard to thrombolytic therapy Key concern in regard to thrombolytic therapy

38 Conditions That Mimic AIS Hypoglycemia Hypoglycemia Metabolic conditions – fever, hyponatremia, drugs, etc. Metabolic conditions – fever, hyponatremia, drugs, etc. Psychogenic Psychogenic Complex migraines Complex migraines Hypertensive crisis Hypertensive crisis

39 What are the risks factors for Ischemic Stroke? Modifiable Risks Modifiable Risks HTN HTN CAD/Carotid Disease/PVD CAD/Carotid Disease/PVD Atrial Fibrillation Atrial Fibrillation Diabetes Diabetes Weight Weight High Cholesterol/Diet High Cholesterol/Diet Lack of exercise Lack of exercise ETOH/Drug abuse ETOH/Drug abuse Coagulopathy- Cancer, Sickle Cell Anemia Coagulopathy- Cancer, Sickle Cell Anemia PFO- Patent Foramen Ovale PFO- Patent Foramen Ovale Non-Modifiable Risks Non-Modifiable Risks Age->55 Age->55 Race- African Americans have 2x the risk of death and disability. Asians have 1.4x the risk of death and disability. Race- African Americans have 2x the risk of death and disability. Asians have 1.4x the risk of death and disability. Sex- 9% greater chance in men. (61% of stroke deaths occur in women) Sex- 9% greater chance in men. (61% of stroke deaths occur in women) Previous Stroke or TIA Previous Stroke or TIA Family History of Stroke Family History of Stroke

40 Goals for Treatment in the ED EMS rapid identification & pre-notification of the Emergency Dept. EMS rapid identification & pre-notification of the Emergency Dept. Quick evaluation in ED. Quick evaluation in ED. Last seen normal < 3 hr. Last seen normal < 3 hr. Door-to-CT scan < 25 minutes Door-to-CT scan < 25 minutes CT-to-Radiologist Reading < 20 minutes CT-to-Radiologist Reading < 20 minutes IV TPA administration< 15 minutes IV TPA administration< 15 minutes (Door-to-needle within 60 minutes.) (Door-to-needle within 60 minutes.)

41 What can be done for an acute ischemic stroke? These patients may be appropriate for “clot busting” drugs. Tissue Plasminogen Activator (TPA). These patients may be appropriate for “clot busting” drugs. Tissue Plasminogen Activator (TPA). Requires a rapid, coordinated response. Requires a rapid, coordinated response. IV TPA can only be given within the first 3 hours of symptom onset. IV TPA can only be given within the first 3 hours of symptom onset. Expected response: “60 minutes from door to needle.” Expected response: “60 minutes from door to needle.”

42 Tissue Plasminogen Activator Natural body substance. Recombinant TPA converts Plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving the clot. Natural body substance. Recombinant TPA converts Plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving the clot. Dose for Stroke: 0.9mg/kg up to a dose not to exceed 90mg. 10% of dose as an IV bolus; the rest over one hour by IV drip. Dose for Stroke: 0.9mg/kg up to a dose not to exceed 90mg. 10% of dose as an IV bolus; the rest over one hour by IV drip. IV window of opportunity is < 3 hours of known symptom onset. IV window of opportunity is < 3 hours of known symptom onset.

43 Early Rx was better in the NINDS tPA Trial Marler JR, et al. Early stroke treatment associated with better outcome. The NINDS rt-PA Stroke Study. Neurology 2000;55: Minutes From Stroke Onset To Start of Treatment Odds Ratio For Favorable Outcome at 3 Months

44 Transition Hemorrhagic Stroke

45 Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Intracranial Hemorrhage (Hypertensive): Intracranial Hemorrhage (Hypertensive): > twice as common as SAH > twice as common as SAH more likely to result in death or severe disability more likely to result in death or severe disability 37,000 Americans/year 37,000 Americans/year 35-52% dead within 1 month (half of deaths in the first 2 days) 35-52% dead within 1 month (half of deaths in the first 2 days) Only 10% living independently in 1 month; improves to only 20% within 6 months Only 10% living independently in 1 month; improves to only 20% within 6 months

46 Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Risk factors: Risk factors: Hypertension Hypertension Advancing age Advancing age Coagulation disorders & therapy Coagulation disorders & therapy ETOH abuse ETOH abuse Drug use (meth, cocaine, crack, etc.) Drug use (meth, cocaine, crack, etc.) Ischemic stroke—hemorrhagic transformation Ischemic stroke—hemorrhagic transformation

47 Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Presenting signs: Presenting signs: Sudden—signs over minutes to hours Sudden—signs over minutes to hours Headache Headache Nausea and vomiting Nausea and vomiting Decreasing LOC Decreasing LOC Extremely elevated blood pressure Extremely elevated blood pressure (All of these are signs of increased ICP) (All of these are signs of increased ICP)

48 Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Differential Diagnosis: Differential Diagnosis: AIS—often high BP AIS—rare decreased LOC AIS—rare or vague H.A. AIS—rare nausea & vomiting AIS—often wake up with the symptoms ICH—usually very high BP ICH—50% of the time ↓ LOC ICH—40% of the time H.A. ICH—50% of time vomiting ICH—rarely wake up with symptoms (15%) Final diagnosis is by CT scan.

49 Weakened blood vessels in a Hypertensive Bleed

50 Autopsy of Intracerebral Hemorrhage

51 Small hemorrhagic stroke

52 Large hemorrhagic stroke

53 ICH: Goals for Early Management Airway management Airway management Assure adequate oxygenation & reduce hypercapnea (Remember: ↑ CO2 = ↑ ICP) Assure adequate oxygenation & reduce hypercapnea (Remember: ↑ CO2 = ↑ ICP) Prevent aspiration (Remember: 50% of ICH patients vomit and have ALOC) Prevent aspiration (Remember: 50% of ICH patients vomit and have ALOC) Prevent seizures Prevent seizures Acute mgt: Fosphenytoin PE (phenytoin equivalents over 3-6 minutes) Acute mgt: Fosphenytoin PE (phenytoin equivalents over 3-6 minutes) Prevention: Phenytoin mg/20-30 min Prevention: Phenytoin mg/20-30 min

54 ICH: Goals for Early Management Blood Pressure Management: Blood Pressure Management: Very poor outcomes if BP is allowed to stay very high—more bleeding Very poor outcomes if BP is allowed to stay very high—more bleeding Very poor outcomes if BP is allowed to drop precipitously—removes the brain’s attempt to perfuse a “tight” brain Very poor outcomes if BP is allowed to drop precipitously—removes the brain’s attempt to perfuse a “tight” brain Guidelines: Guidelines: In general, keep BP about 160/90 or MAP <130 In general, keep BP about 160/90 or MAP <130 In the first 48 hours: no BP drop > 15-25% of presenting value In the first 48 hours: no BP drop > 15-25% of presenting value

55 Hemorrhagic Stroke (Subarachnoid Hemorrhage) Acute bleeding around the outside of the brain and into the subarachnoid space. Acute bleeding around the outside of the brain and into the subarachnoid space. Usually from an aneurysm or arterio- venous malformation. Usually from an aneurysm or arterio- venous malformation. Statistics: Statistics: 50% are fatal 50% are fatal 1--15% die before reaching the hospital 1--15% die before reaching the hospital Those who survive are often impaired Those who survive are often impaired 1-7% of all strokes 1-7% of all strokes

56 Hemorrhagic Stroke (Subarachnoid Hemorrhage) Diagnosis: Diagnosis: “Thunderclap” headache. “It is the worst headache of my life!” “Thunderclap” headache. “It is the worst headache of my life!” Xanthochromic lumbar puncture (blood in the CSF not due to traumatic tap) Xanthochromic lumbar puncture (blood in the CSF not due to traumatic tap) “Star pattern” on CT scan “Star pattern” on CT scan

57 Aneurysmal bleed

58 Classic “Star Pattern” of Subarachnoid Hemorrhage

59 Magnified view of cerebral aneurysm.

60 Subdural Hematoma (Not a true stroke but symptoms can mimic stroke.)

61 Subdural Hematoma Symptoms: Symptoms: Unilateral weakness, sensory deficit Unilateral weakness, sensory deficit Facial weakness Facial weakness Dysarthria Dysarthria Altered level of consciousness Altered level of consciousness Onset: Onset: Can be rapid Can be rapid Can take months to show symptoms Can take months to show symptoms

62 Subdural Hematoma Causes Anticoagulation (Heparin, Coumadin) Anticoagulation (Heparin, Coumadin) Antithrombotics (Aspirin, Plavix) Antithrombotics (Aspirin, Plavix) ETOH abuse ETOH abuse Trauma (could be recent or months ago) Trauma (could be recent or months ago) Advanced age (most common cause) Advanced age (most common cause)

63 Subdural Hematoma Small bridging veins from the dura mater to the brain are stretched and can rupture releasing blood into the subdural space and causing pressure on that part of the brain. This leads to the deficits seen.

64 Subdural Hematoma on CT Scan

65 Subdural Hematoma Treatment Options Medical Management: Medical Management: Correct Coags Correct Coags Monitor neuro signs Monitor neuro signs Surgical Management: Surgical Management: Correct Coags Correct Coags Burr hole drainage Burr hole drainage Craniotomy for removal of solid clot Craniotomy for removal of solid clot

66 Summing Up The best stroke care is a coordinated approach and developed in a stroke center system of care. The best stroke care is a coordinated approach and developed in a stroke center system of care. Requires everyone to be on board: Requires everyone to be on board: Patients/Families Patients/Families EMS EMS ED ED Stroke Unit Stroke Unit Stroke Rehabilitation Stroke Rehabilitation

67 Summing Up How well a patient does; whether a patient has a life-long serious disability; whether he/she lives or dies; may depend on you and how you respond. How well a patient does; whether a patient has a life-long serious disability; whether he/she lives or dies; may depend on you and how you respond. A few minutes delay may make a very big difference. A few minutes delay may make a very big difference. What you do really matters! What you do really matters!

68 Emergent Stroke Care and the Chain of Survival Patient Calling EMS ED Stroke Stroke Knowledge 911 System Staff Team Unit

69 Module is Completed Proceed to Post Test

70 Post Test 1. Which of the following are types of ischemic strokes? a. Middle cerebral artery occlusion b. Vertebral-basilar occlusion c. Lacunar stroke d. All of the above 2. A vertebral-basilar stroke might have bilateral weakness as a symptom. (True or False) 3. This quick stroke assessment scale accurately identifies stroke 80% of the time. ________________

71 Post Test 4. The family states the patient woke up at 6:30am and exhibited signs of acute stroke. We should assume that the stroke started at 6:30am. (True or False) 5. List 4 things the EMS Provider should be able to tell the Stroke Receiving Center ED about the possible stroke patient who just arrived. 6. The IV TPA window of opportunity for treatment is how long from symptom onset? 7. The most common type of hemorrhagic stroke is caused by a cerebral aneurysm. (True or False) 8. List 5 conditions that can mimic acute ischemic stroke.

72 Post Test 9. Which of the following is not a true hemorrhagic stroke? a. Subarachnoid Hemorrhage b. Subdural Hematoma c. Intracerebral Hemorrhage (Hypertensive Bleed) 10. The Stroke Receiving Center Emergency Room is the stroke system of care. (True or False)

73 Post Test (Answers) 1. d. –all of the above 2. True 3. Cincinnati Pre-hospital Stroke Scale 4. False –it is the time “last seen normal” 5. VS; FSBS; time last seen normal; stroke symptoms; meds the patient takes 6. 3 hours 7. False –Intracerebral Hemorrhage (HTN bleed) 8. Bell’s Palsy; Todd’s Paralysis; Subdural hematoma; hemorrhagic stroke; Psychogenic; HTN; Complex Migraine; Hypoglycemia; etc. 9. Subdural Hematoma 10. False –all entities are equally important links in the stroke chain of survival.


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