5 
55Hyperacute Stroke Care: Prehospital and Emergency Department
ANSWERS
1. B IV antihypertensive is the quick action needed with such a high BP, and checks should be within 5 to 10 minutes; answer D is incorrect because 30 minutes is too long an interval between dose and recheck.
2. A The LKW time is the time the patient was awake and normal, so even though the husband was awake at 2 a.m., she was asleep, so there is no way of knowing if the stroke had occurred yet or not. You must go with the time they went to bed; 6 a.m. is the time it was discovered, but not the LKW time.
3. D Fifty percent of patients with dysphagia will experience aspiration, and 33% of those who aspirate will develop pneumonia (Hinchey et al., 2005).
4. C Telemedicine refers to a two-way audio and video connection between two different locations. In stroke care, it is used to provide neurology/neurosurgery consult expertise to hospitals that do not have onsite consultants experienced with diagnosing and treating acute stroke (Schwamm et al., 2009).
5. 56B Paramedics receive more education and are able to perform more critical care functions than an EMT. Not all EMTs are volunteers; there are many paid EMTs. Both paramedics and EMTs can do the prehospital stroke severity score (Morrison, 2014).
6. D The Golden Hour was first described by R. Adams Cowley, known as the father of trauma medicine, in the 1960s based on his observation that the sooner trauma patients reached definitive care—particularly if they arrived within 60 minutes—the better their chance of survival. The term has come to represent the critical first 60 minutes for many populations (Morrison, 2014).
7. C The American Heart Association/American Stroke Association guidelines include recommendation for ED LOS benchmark to be 3 hours or less. The intent is for the patient to be admitted to a stroke unit where staff is specifically educated and trained to meet the needs of the stroke patient (Jauch et al., 2013).
8. D It has been proven in numerous studies that the quickest way to get a neurologic evaluation for suspected acute stroke is through the emergency medical services (EMS) system (Higashida et al., 2013).
9. C Critical actions by EMS that will facilitate rapid evaluation and treatment do not include knowing the last time the patient had any lab work done (Higashida et al., 2013).
10. A Enroute prenotification of the arrival of a suspected stroke is important for the EMS so that the CT scanner can be cleared, and the stroke team can be ready to assess on arrival.
11. B Delay in patients getting to the hospital after symptom onset is the most common reason for the medication not being given. Symptoms too mild or rapidly improving is also a common reason, but becoming less so as providers are moving toward the policy of asking the patient if he or she can live with a deficit that is deemed mild by the National Institutes of Health Stroke Scale (NIHSS). As the use of the new oral anticoagulants is becoming more prevalent—and until there are reversal agents for those medications—we see increasing numbers of patients not treated with IV tissue plasminogen activator (tPA) due to oral anticoagulants (Higashida et al., 2013).
12. 57D Prehospital notification by EMS has been recognized as contributing to reduced door-to-imaging, reduced door-to-needle, and reduced interfacility transport times (Higashida et al., 2013).
13. C Many states have protocols requiring their EMS personnel to bypass non–stroke-certified hospitals. However, if it adds more than 15 to 20 minutes to the transport time, they should not bypass. This is based on the consideration that the patient should first be evaluated and stabilized and then disposition determination can be made (Higashida et al., 2013).
14. D All three tools are validated and standardized tools used by prehospital personnel (Higashida et al., 2013).
15. C Many state protocols have wording indicating that if travel and transport time will exceed 30 minutes, air transport should be considered. It is no longer just for interfacility transport.
16. A The use of telemedicine brings expert consultants into the community ED and has resulted in a significant increase in the number of patients who receive IV tPA (drip) and are then transferred to a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). Education of ED providers and EMS has shown an increase as well, but not as significant as telemedicine (Higashida et al., 2013).
17. D Unfortunately prehospital policies vary from one state to another, and most states even have regional variations. Some prehospital personnel are unpaid—and most are underpaid for the important work they do. There are still some areas of the country where stroke is not a high-urgency call (Higashida et al., 2013).
18. A In 2005, efforts to increase the number of patients who were treated with tPA included increased reimbursement to cover the high cost of the drug (Higashida et al., 2013).
19. B The majority of lawsuits in the United States related to the ED phase of stroke care are regarding the failure to offer tPA. It is the standard of care and must be made available if the patient qualifies (Higashida et al., 2013).
20. A Posterior circulation strokes do not produce such classic symptoms as hemispheric strokes, and are often misdiagnosed, particularly in younger people who are not expected to have strokes (Arch et al., 2016).
21. 58D Based on multiple research study data, it has been estimated that each 15-minute reduction in door-to-needle time results in an additional disability-free life after stroke (Middleton, Grimley, & Alexandrov, 2015).
22. C The first D in the Stroke Chain of Survival is detection, as that is essential for the rest of the chain to occur (Jauch et al., 2010).
23. A A CXR is no longer a standard part of most acute stroke workups. It is at the discretion of the stroke team to order if they suspect an underlying cardiac or lung problem for which a CXR would be helpful. The guidelines state that if done, it should not delay the administration of tissue plasminogen activator (tPA; Jauch et al., 2013).
24. C The Cincinnati Prehospital Stroke Scale includes assessment of facial symmetry, arm drift, and speech. Research has shown that if two of those three are abnormal, there is an 85% chance that the patient is having a stroke (American Heart Association, 2011).
25. A Crescendo TIAs is a term used to describe a series of three or more TIAs in close succession. It is considered to be a strong predictor of impending stroke.
26. B If the NIHSS returns to 0 and the patient’s symptoms have all resolved, and then the symptoms return, that is the new LKW time and the clock starts again.
27. B With a hemorrhagic stroke, the most important thing for the transport team is to monitor for signs of increasing ICP; answer A is incorrect because the BP parameter for ICH is 140 systolic or lower.
28. D It has been proven in numerous studies that the quickest way to get a neurologic evaluation for suspected acute stroke is through the emergence medical services (EMS) system (Higashida et al., 2013).
29. C For endovascular intervention, patients need to be able to lie still. In this situation, they will need to be intubated and sedated, so preparation for that is correct.
30. A Consideration of the extended time window for tPA does not involve a specific INR—if the patient is on Coumadin, regardless of INR, they are not a candidate for the extended window (Del Zoppo, Saver, Jauch, & Adams, 2009).
31. 59D There are numerous tools being used by the EMS across the country to help determine if there is an LVO, which would indicate the need for transport to a Comprehensive Stroke Center (CSC) or Primary Stroke Center (PSC) with mechanical thrombectomy capability. There is no tool called FAR.
32. D For SAH, the goal is to keep the SBP under 160. The first two answers are incorrect because the BP parameters stated are for ischemic and intracerebral hemorrhage (ICH), respectively. Answer C is wrong because the dose of 40 mg labetalol is too high (Connolly et al., 2012).
33. B After an ischemic stroke, swelling produces compression of the surrounding tissue, and facilitation of perfusion to the brain is helped with the head of the bed kept flat.
34. C Evidence-based guidelines indicate that for best oxygenation of the brain, an O2 saturation of less than 92% should be supplemented with oxygen.
35. A The studies regarding mechanical clot retrieval did not include age over 80 years, and there has been further evidence that advanced age may be an indicator of less-than-optimal outcome.
36. D Prehospital personnel have reported that getting patient-specific feedback on outcomes has provided them valuable information on which to base expectations and accountability. It has also raised the level of interest in stroke.
37. B Amyloid angiopathy is a condition in which there is accumulation of abnormal proteins (amyloid) in the small cerebral arteries. This accumulation weakens vessel walls leading to intracerebral hemorrhage. It is frequently associated with Alzheimer’s disease. This patient collapsed before having any possible trauma. It could have been an AVM, but the declining memory was the clue for the correct answer of amyloid angiopathy.
38. C A simple explanation of the fact that alteplase is not appropriate for a bleed—reinforcing what the provider had just told the husband—is enough.
39. D Foot surgery 5 days ago is not an exclusion for alteplase. As it is a compressible site, it is not unreasonable that this patient could get alteplase safely.
40. 60A Arm drift, facial symmetry, and speech ability are the components of the Cincinnati Prehospital Stroke Scale. The assessment does not include arm strength against resistance; it is simply the ability to hold the arm up against gravity, and note any drift.
41. B The inability to say the words you want to say—whether because of inability to speak, or because of inability to say the correct word—is aphasia. Ataxia is uncoordinated movements. Dysphagia is swallowing dysfunction. Dysarthria is slurred speech.
42. D The most common cause of ICH is hypertension.
43. B Placing the patient in the left lateral recumbent position is the most appropriate thing to do right away to protect against aspiration. As long as the patient is conscious, an oral airway would not be appropriate. The patient may, in fact, eventually need to be intubated, but there are not enough indicators for that yet.
44. D Expressive aphasia is the inability to express, or speak. The only suitable answer would be to provide pen and paper to see if the patient can write, which the patient may not be able to do either with certain types of expressive aphasia.
45. B INR is not a contributing factor for ischemic brain injury, but blood pressure, glucose, and temperature are.
46. C Cerebral vasodilatation is the expansion of the lumen of the vessels so it would not interrupt cerebral blood flow. A thrombus or embolus would be capable of interruption of flow, and vasospasm can narrow the vessel to the point of interruption of blood flow.
47. D Hyponatremia produces symptoms of lethargy, thirst, and confusion, which are not classic for a stroke, so not likely to be considered a mimic. Bell’s palsy results in facial droop; hypoglycemia results in confusion and slurred speech; complex migraine can produce symptoms such as hemiplegia, visual changes, and headache.
48. D EMS personnel who are educated about TIA have the opportunity to help the patient understand that even if the symptoms resolved, they should still go to the hospital for a workup.
49. 61C Transport personnel should assess for neurologic status and notify medical command, in anticipation of an order for an antihypertensive. Answer A is wrong because it does not involve notification or treatment; answer B is wrong because the nurse simply stopped the tPA, but did not treat.
50. A Permissive hypertension in an acute ischemic stroke without tissue plasminogen activator (tPA) allows for systolic BP up to 220 with the intent of ensuring perfusion and avoidance of hypoperfusion. Answer C is wrong because it states that rapid lowering would result in respiratory arrest.
51. C Acute ischemic stroke can take several hours to show up on a CT scan, so it would be most likely a stroke, not a TIA with persistent symptoms. Peripheral neuropathy is usually in the setting of other comorbid conditions such as diabetes, and carpal tunnel syndrome would be related to hand use/position.
52. A There have been many studies done, and some are ongoing regarding the high incidence and mortality from stroke in the Stroke Belt. Lifestyle factors such as diabetes, hypertension, and smoking are thought to be the cause, but genetics likely plays a role as well.
53. A Change in LOC is usually the earliest sign of rising ICP. Rising pulse oxygen is not a sign of increased ICP; pulse pressure would be widening in increasing ICP; decreased hearing can be seen with chronic high ICP as with hydrocephalus, but not with acute increase in ICP (Alexander, 2013).
54. B Patients with history of hypertension often have a limited tolerance for “normal” BP. Further neurologic assessment is warranted, along with notification of the provider.
References
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62Connolly, E., Rabinstein, A., Carhuapoma, R., Derdeyn, C., Dion, J., Higashida, R. T., . . . Vespa, P. (2012). Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 43, 1711–1737.
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Hinchey, J., Shephard, T., Furie, K., Smith, D., Wang, D., & Tong, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), 1972–1976.
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Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J., Demaerschalk, B. M., Khatri, P., . . . Yonas, H. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44, 870–947.
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Morrison, K. J. (2014). Fast facts for stroke care nursing: An expert guide in a nutshell. New York, NY: Springer Publishing.
Schwamm, L., Audebert, H., Amarenco, P., Chumbler, N., Frankel, M., & George, M. G. (2009). Recommendations for the implementation of telemedicine within stroke systems of care: A policy statement from the American Heart Association. Stroke, 40, 2635–2660.