question

Stroke is the __ leading cause of death

answer

4th (down from the 3rd starting in 2008)

question

What 2 goals were met and helped bring stroke down the list from the 3rd to 4th leading cause of death?

answer

- Improved prevention - Improved care w/in the first hours of acute stroke - goal was set by AHA/ASA for 2010, met in early 2009 to reduce stroke, coronary heart disease, CV risk by 25%

question

What does the chain of events favoring good functional outcome from acute ischemic stroke begin with?

answer

Recognition of stroke when it occurs

question

Is public's knowledge of stroke warning signs good or bad? What % of 911 calls are made w/in 1hr of onset? What % of these callers thought stroke was the cause of their symptoms?

answer

- Bad - <50% - <50%

question

Does intense and ongoing public education improve stroke recognition?

answer

Yes

question

CASPR - CA Acute Stroke Pilot Registry reported that the overall rate of tPA treatment w/in 3hrs of onset could increase from __% to __ if all pts arrived early after onset. What does this indicate?

answer

- 4.3% to 28.6% - Need to cont. campaigns to educate pts to seek treatment sooner

question

What 5 methods are effective for community education tools regarding stroke?

answer

- Printed material - Audiovisual programs - Lectures - Television - Billboard ads

question

Who should stroke education target?

answer

Prospective patients, families, caregivers

question

What specific school groups have received successful stroke education?

answer

Elementary and middle school

question

What are the 5 "suddens" that were used before 2008?

answer

- Weakness - Speech difficulty - Visual loss - Dizziness - Severe headache

question

What is the FAST campaign?

answer

face, arm speech, time message campaign that started over a decade ago and is being reintroduced

question

One or more of the FAST symptoms are present in __% of all strokes/TIAs?

answer

88%

question

In one study, 3 months after education __% recalled facial droop and slurred speech as stroke warning signs and __% recalled arm weakness or numbness.

answer

- 100% - 98%

question

What does effective public education require?

answer

Repetition regardless of the message

question

NHAMCS - National Hospital Ambulatory Medical Care Survey showed only __% of stroke pts use EMS.

answer

53%

question

911 and EMS use results in shorter __, initial __/__.

answer

- Prehospital delays - CT/MRI brain

question

EMS advanced notification of stroke pt arrival shortens time to __, __, and increases use of __.

answer

- ED dr evaluation - brain imaging - tPA

question

What does the full scope of prehospital stroke care, including 911 activation/dispatch, emergency medical response, triage/stabilization in the field, ground/air transport refer to?

answer

EMS - emergency medical services

question

EMSS refers to what and what aspects does this involve?

answer

Emergency medical service system - involves the organization of private and public resources (community, transportation, access to care, pt transfer, mutual aid, system review/evaluation

question

What must stroke systems of care incorporate to reach full potential?

answer

EMSS

question

In parameters to measure quality of an EMSS, must stroke pts must be dispatched at the highest level of care available in the shortest amount of time possible?

answer

Yes.

question

Time between call receipt and dispatch of response team should be __ seconds.

answer

<90 seconds

question

EMSS response time from call receipt to arrival on scene is __ minutes.

answer

<8 minutes

question

Dispatch time is __ minute(s).

answer

<1 minute

question

Turnout time when call is received to unit being en route is __ minute(s).

answer

<1 minute

question

On scene time is __ minutes.

answer

<15 minutes (barring unusual circumstances)

question

Travel time is __ to trauma or acute MI calls.

answer

Equivalent

question

One study showed 911 dispatchers correctly identified __% of all stroke calls if the caller reported stroke, facial droop, weakness/fall, communication problems.

answer

80%

question

Concordance of stroke diagnosis between dispatchers and paramedics __ scene time and run times.

answer

Shortens

question

Is routine supplemental oxygen recommended for stroke patients? Is this based on studies proving this is beneficial? What other patient population is this used for?

answer

- Yes - No - cardiac arrest

question

What is the goal O2 sat for stroke patients in EMS?

answer

>94%

question

Hypotensive pts (less than premorbid state or <120 systolic) should be given __ and the stretcher __.

answer

- Normal saline/isotonic saline - Flat

question

Should EMS intervene on hypertensive pts w/ BP 140-220 systolic?

answer

No.

question

For extreme HTN >220, should EMS intervene? If yes, what medications would they use.

answer

- No, call medical control to assist w/ treatment decisions - Same as in ED if available, labetolol or nicardipine.

question

What level of glucose should be given dextrose? What might treatment result in?

answer

- <60 mg/dL - Resolution of neuro deficits

question

Should non-hypoglycemic pts be given dextrose-containing fluid? Why or why not and what should be used.

answer

- No - excess dextrose-containing fluids can exacerbate cerebral injury - Use isotonic saline if rehydration is required.

question

Should an IV be placed in the field? Labs drawn?

answer

Yes, but only if it will not result in delays in getting to the hospital. Nothing non-urgent should be done if it will result in transport delays.

question

What information is needed from bystanders or pt by EMS in the field in stroke pts?

answer

- Time of onset, last known normal - PMHx - Any seizure or trauma before onset - Identify current medications (!!anticoagulants) - Phone number of contacts or even transport family w/ them

question

PMHx of stroke, DM2, HTN, afib __ the likelihood that pts symptoms are due to stroke.

answer

Increase.

question

Are there prehospital assessment tools for stroke evaluation that EMS can use? Which ones are best?

answer

- Yes, there are numerous (Los Angeles Prehospital Stroke Screen or Cincinnati Prehospital Stroke Scale) - Any that are validated and appropriate, even local tools

question

Prehospital notification by EMS of potential stroke is __ and leads to decreases in arrival to __, __, __, and associated w/ higher rates of IV tPA.

answer

- Essential - Dr assessment - CT performance - CT interpretation - Higher rates of tPA

question

Air medical transport is useful for stroke care in remote areas where ground transport to nearest stroke-capable hospital is > __.

answer

1hr

question

Should tPA ideally be given before interhospital transfer or after? What is this method referred to as? What is necessary to be sure this is safe?

answer

- Before to give the best change of a good outcome - Drip and ship - Well-designed protocols for BP, assessments of clinical deterioration/bleeding, aspiration precautions and be able to contact command/receiving facility about any change en route

question

Who are stroke education programs recommended for to improve quality of care and the number of pts treated?

answer

Physicians,hospital personnel, EMS personnel

question

Where should stroke patients be transported to?

answer

The closest PSC or CSC or if not available, the most appropriate institution that provides emergency stroke care (may need air transport and hospital bypass)

question

Integration of regional stroke facilities (ASRH w/ telemed/radiology, PSC, CSC), EMSS, publinc and government agencies and resources is done by what?

answer

Stroke Systems of Care

question

What are the goals of goals of stroke systems of care?

answer

Stroke prevention, community stroke education, optimal use of EMS, effective acute/subacute stroke care, rehab, and performance review of stroke care delivery

question

How many PSC are there since certification started in 2004 to 1/2011?

answer

>800

question

Is it mandatory for PSC to track key quality stroke care measurements?

answer

Yes

question

In cluster controlled trials comparing outcomes, pts treated in PSCs vs community hospitals w/out specialized stroke care had better __, increased rates of __.

answer

- Clinical outcomes - tPA rates

question

PSC certification improves stroke care by shortening door to __, __, and __ and increasing __.

answer

- physician contact time - CT time - IV tPA - rates of IV tPA

question

Hospitals w/ organized stroke care have improved multiple measures of stroke care quality including increased __, __, and __.

answer

- IV tPA - Lipid profile testing - DVT prophylaxis use

question

CSC must offer state of the art cerebrovascular disease care __.

answer

24/7

question

Which states have their own legislative efforts to certify PSC and CSC?

answer

NJ, Florida, Missouri

question

In orange county's CSCs within their hub and spoke model serving >3 million people, what percent of pts received acute reperfusion tx (IV tPA, endovascular tx or both)?

answer

25.1%

question

NJ CSCs looked at morbidity and mortality in 134,441 stroke pt evaluations, was there a gap between weekend and weekday admissions? Was there a gap at other stroke centers?

answer

- No - Yes

question

Finlands national stroke system reviewed 7yrs of all stroke patients, was there an association between the level of acute stroke care and patient outcomes? Which type of stroke center had the lowest rates of mortality and severe disability?

answer

- Yes - Lowest mortality and severe disability was at CSCs

question

Are neurocritical care units essential elements of CSCs?

answer

Yes

question

What 2 areas specifically have improvements in clinical outcome associated w/ neuro critical care units been found?

answer

- Reduced, earlier recognition of complications - Reduced days of hospitalization

question

Who should be considered for neurocritical care unit admission?

answer

- Severe deficits - Large-volume infarcts who may develop sig cerebral edema - Significant comorbidities - Difficult to control BP - Prior IV or IA recanalization interventions

question

What are Acute Stroke Ready Hospitals (AKA stroke-capable hospitals)?

answer

- Hospitals committed to effectively/efficiently evaluating, diagnosing, treated most ED stroke pts - Do not have fully organized stroke systems of care

question

What 8 elements must an ASRH have?

answer

- Written emergency stroke protocols - Written transfer agreement w/ hospital w/ neurosurgical expertise - Stroke director to oversee policies/procedures - Ability to administer IV tPA - Ability to perform emergent brain imaging (CT) at all times - Ability to conduct emergency labs at all times - Maintenance of stroke patient logs

question

How are Stroke expertise and neuroimaging usually handled at ASRH?

answer

Telemedicine, teleneurology

question

Are ASRHs also responsible for EMS stroke education and integration into the stroke system of care?

answer

Yes

question

Telemedicine must be able to provide __ and __.

answer

- 2 way real-time audiovisual conferencing - Share neuroimaging

question

What are 6 benefits of telestroke?

answer

- Optimizes use of tPA in hospitals w/ no on-site neurologist - Decreases time to initiate tPA - Similar safety as PSC (2-7% sICH, 3.5% in house mortality) - Immediate access to specialty consultations - Reliable neuro exams and NIHSS scores - Mortality rates and functional outcomes similar to randomized trials

question

Are the economic benefits of telemedicine established?

answer

No

question

Are neurologists w/ stroke expertise able to determine radiological IV tPA eligibility via teleradiology?

answer

Potentially, tehre needs to be more studies w/ large samples to validate one pilot study that showed this was possible

question

What is teleradiology? Is reimbursed? Is it accredited?

answer

- to obtain radiographic images at one location, transmit them to another for diagnostic/consultative purposes - Yes, CMS reimburses for both intrastate and interstate teleradiology services - Yes, by the TJC and other bodies

question

Are there studies describing the use of teleradiology for non-contrast CT Head? If so, what do they indicate?

answer

- Some studies - Mostly look at feasibility, including using personal digital assistants and smartphones

question

Is there data to support stroke care quality improvement processes such as quality databases looking at performance of quality measures?

answer

Yes

question

Are PSCs required to keep databases for performance of the 8 THN quality measures in stroke care? Is it beneficial for all hospitals to do this and why?

answer

- Yes - Yes, identify gaps and disparities to improve stroke care

question

Paul Coverdell National Acute Stroke Registry collects data from 8 states, the 4 initial prototype registries (GA, MA, MI, OH) showed __% of ischemic stroke pts received tPA on admission.

answer

4.5%

question

What other improvements were shown after use of the Coverdell Stroke Registry?

answer

- MI - documenting the reason for not giving tPA increased by 13% - hospitals participating had sig improvement in 9/10 core measures from 2005-2009, including one w/ an avg annual increase in tPA treatment of 11%

question

What is Get With the Guidelines (GWTG)? What does it focus on? How many hospitals are enrolled and is it voluntary?

answer

- pt management and data collection tool that ensures continuous quality improvement of acute stroke treatment and stroke prevention - Care team protocols using evidence based medicine - 2003-2007 there are 790 US hospitals w/ 322,847 hospitalized stroke pts - Yes it is voluntary

question

Were there improvements in stroke care by participating in GWTC during this 5yr period?

answer

- Yes - IV tPA w/in 2hrs 42.9 to 72.8% - antithrombotics w/in 48hrs of admission 91.46 to 72.84% - DVT proph 73.79 to 89.54% - Discharged on antithrombotics 95.68 to 98.89% - anticoag for afib 95.3 to 98.39% - Tx of LDL >100 73.6% to 88.29% - smoking cessation w/ meds or counseling 65.21 to 93.61%

question

Did data from GWTC more recently w/ 1 million patients at 1392 hospitals show sig improvements from 2003 to 2009 in quality of care?

answer

Yes, 44 to 84.3%

question

Did GWTC show disparities in stroke care? In which patient populations?

answer

- Yes - Women received less defect free care than men, 66 vs 71% - Women were less likely to be d/c home, 41 vs 50%

question

Every 15 min reduction of door to needle time, there is a __% lower odds of in-hospital mortality

answer

5%

question

From GWTC, out of 25,504 acute stroke pts at 1082 hospitals treated w/ tPA, what percent were treated in <=60 min?

answer

26.6%

question

Is it recommended that Stroke Centers be certified by an external body (TJC or state health department)?

answer

Yes

question

For patients with suspected stroke, should EMS bypass hospitals that do not have resources to treat stroke and go to the closest facility most capable of treating stroke?

answer

Yes

question

Are approved teleradiology systems recommended for tiemly review of brain CT/MRI in pts w/ suspected stroke? Are these teleradiology systems useful in supporting rapid imaging interpretation in time for tPA decision making?

answer

- Yes - Yes

question

What are ED based core time lines for door to which are referred to as Stroke Chain of Survival by NINDS: - physician - stroke team - CT initiation - CT interpretation - Drug (>=80% compliance) - stroke unit admission

answer

- <= 10min - <= 15min - <= 25min - <= 45min - <= 60min - <= 3hrs

question

With what priority should suspected stroke pts be triaged in the ED? For all strokes or only severe strokes?

answer

- MI and serious trauma - All strokes, regardless of severity

question

Are there specific data on stroke screening tools or scoring systems for ED triage?

answer

No, but there are for prehospital and w/in the ED and there is data that supports using these tools in this setting

question

What is the goal of the initial stroke assessment in ED?

answer

Identify stroke mimics, other conditions that require immediate intervention, and determine potential causes of stroke for early secondary prevention, and early implementation of stroke pathways and/or stroke team notification

question

Single most important piece of historical information?

answer

Time of onset/last known normal

question

If current symptoms were preceeded by similar symptoms that resolved, can the pt be given tPA?

answer

- Yes, if the symptoms completely resolved the time clock starts over again - it is unclear if this represents a cause for increased risk of hemorrhage w/ fibrinolysis (longer the TIA symptoms the greater the chance of a neuroanatomic abnormality on MRI scan)

question

Is the NIHSS only valid if performed by physicians? or can a broad spectrum of healthcare providers perform this evaluation?

answer

Yes, any trained person can perform the scale

question

List things that using a standardized assessment and stroke scale helps to quantify.

answer

- Quantify degree of neurologic deficit - Facilitate communication - Identify the location of vessel occlusion - Provide early prognosis - Help select pts for various interventions - Identify the potential for complications

question

In 2 seriesof pts w/ treated w/ tPA, __% were stroke mimics. What were the 2 most common mimics?

answer

- 3% - Seizure, conversion d/o

question

Chernyshev et al shared a registry of tPA pts treated w/in 3hrs, what percent were mimics? What were the 3 most likely mimics? Were there any symptomatic hemorrhages?

answer

- 21% - Seizures, complicated migraines, conversion d/o

question

According to an editorial, experienced stroke centers should treat <__% of mimics using non-contrast CT alone. Is there apparent harm of using IV tPA in stroke mimics?

answer

- 3% - Apparently not

question

Is there a lot of evidence regarding safety of tPA w/out a stroke neurologist present in person or via telemedicine?

answer

No

question

Do emergency physicians exhibit high sensitivity and PPV in identifying stroke? Are there many studies looking at instances of tPA for acute stroke by ED or PCPs (either alone or in telephone consultation w/ a neurologist)?

answer

- Yes, high sensitivity and high PPV - No, only 6 studies w/ only 6-53 pts treated by nonneurologists and 2 additional cautionary findings for community models of stroke care that do not use acute stroke teams w/ 1 that noted increased sICH in a series of 70pts treated by community neurologists and both showing increasead inpt mortality in tPA treated pts

question

In the Cleveland OH experience shortly after tPA was approved, what was there initial rate of sICH before and after quality improvement?

answer

- 15.7% before and 6.4% after

question

In a more recent, larger US series of 273 consecutive tPA pts was there any increases risk of mortality, ICH or reduced functional recovery w/ a variety of acute stroke arrangements (ED MDs from 4 hospitals w/out an acute stroke team over 9yrs)? What type of neurologic consultation occurred?

answer

- No - 1/3 had no neuro consultation, 1/3 had a telephone consultation, 1/3 had an inpt consultation

question

INSTINCT - Increasing Stroke Treatment Through Interventional Behavior Change Tactics showed is looking at >500 IV tPA pts from a random selection of 24 Michigan hospitals to evaluate:

answer

- The safety of IV tPA in the community setting

question

Do current data support multiple approaches to specialist/neurology consultation when needed for acute stroke? What types of arrangements can occur?

answer

- Yes - Committed local physicians, telephone or telemedicine consults (optimizing local and regional resources optimizes opportunities for acute treatment)

question

Can hypoglycemia cause focal signs and symptoms mimicking stroke?

answer

Yes.

question

Is hyperglycemia associated w/ unfavorable outcomes?

answer

Yes.

question

Pts w/ what comorbidities need a platelet count and INR/PT?

answer

On warfarin and or with liver disease

question

Cardiac markers are elevated in what percent of ischemic stroke patients? Elevation of Cardiac troponin T specifically is associated w/ __, __, and __.

answer

- 5-34% - Increased stroke severity - Increased mortality risk - Worse clinical outcome

question

What is dabigatran's mechanism of action?

answer

Direct thrombin inhibitor

question

What is Rivaroxaban/Apixaban's mechanisms of action?

answer

Direct factor Xa inhibitors

question

Is PT/INR a good indicator of dabigatran?

answer

No, pts can have significant concentrations of Dabigatran w/ no changes in PT/INR.

question

Is Thrombin Time (TT) a sensitive indicator of dabigatran activity? Can this test be influence by other anticoagulants?

answer

- Yes, and a normal TT excludes the presence of any significant activity - Yes

question

Can Ecarin clotting time (ECT) indicate director thrombin inhibitor (dabigatran) activity? Is this test influenced by other anticoagulants? Is it readily available?

answer

- Yes, a normal ECT generally excludes an sig direct thrombin inhibitor effect - No - No, some hospitals may not even offer the test

question

Should tPA be delayed while waiting for PT, aPTT, or plt count? What is the rate of unsuspected coagulopathies and thrombocytopenia that would have justified a contraindication in retrospective reviews of tPA pts?

answer

- No - Unless there is a bleeding abnormality or thrombocytopenia is suspected, the pt is on warfarin/heparin or anticoagulation is uncertain - Low

question

What is the only lab test required in all pts before tPA is initiated?

answer

Glucose, finger stick is acceptable

question

Is CXR in acute stroke evaluation useful? Based on what data? What % of xrays changed clinical management in stroke pts?

answer

- Unclear, unless there is evidence of acute pulmonary, cardiac, pulmonary vascular disease - Limited observational data are available that may help determine this - 3.8% in 2 studies

question

Should obtaining a CXR delay tPA?

answer

Not unless there is concern for acute pulm, cardiac, or pulmonary vascular disease (dissection)

question

Do all ischemic stroke pts need cardiovascular evaluations?

answer

Yes.

question

Can acute stroke and MI present at the same time or one of the cause the other? Can stroke cause EKG changes? Can stroke causes cardiac decompensation?

answer

- Yes and yes - Yes - Yes, cardiomyopathy via neuroendocrine pathways

question

Is baseline EKG recommended in stroke patients?

answer

Yes, but this should not delay tPA

question

Is baseline troponin assessment recommended in stroke patients?

answer

Yes, troponin is more sensitive/specific than CK or CKMB

Vascular Neurology Board Exam – Ischemic Stroke Guidelines pg 871 to 882 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards