Hyperacute Stroke Care exam 2025-2026 latest updated version with expert solutions

What does ASLS -(Advanced Stroke Life Support) use for their primary exam?

MEND Exam - Miami Emergency Neurologic exam

What is the emergency neurological life support for ?

15 hour training curriculum teaching protocols regarding strokes

what is the difference between an EMT and paramedic?

paramedics receive much more training and can start IV's and give injections

What is the golden hour?

the time from patient arrival until IV tPA is administrated

what is the door to stroke unit admission time?

less than 3 hours

what is the only lab test required prior to thrombolytic treatment?

blood glucose - you do not need an INR!!!

What blood sugar level is associated with worse outcomes during the first 24 hours ?

Blood sugar levels greater than 200

What is the difference between TPA and TNK?

TPA is a bolus plus 1 hr infusion

TNK is the modified form of TPA

approved for MI patients not strokes; can be given in a single IV bolus in 5-10 seconds

Each 15 minute reduction in door to needle time results in what post care for strokes?

an additional month of disability free life after stroke

With patients who stroke is considered mild, NIH <4, should we still treat with TPA? Is there a risk for a bleed?

Yes administer TPA, improves outcomes, no greater risk for bleed

What CT would indicate a patient cannot recieve TPA?

Ischemic Injury involving more than 1/3 of an MCA or severe hypo density indicating irreversible damage

What platelet level is contraindicated for TPA?

<100,000

What aPTT or PT level is contraindicated for TPA?

>40sec >15sec

What time frame can we give TPA?

FDA approved to be given within 3 hours

Can be extended to 4.5

If the patient does not receive a fibrinolytic, what anticoagulant should we expect to administer?

ASA 300 mg rectally or ASA 325 by mouth after swallow eval

When TPA is finished, how should we flush the line?

Hang the NS at the same rate to completely flush the line

Tenecteplase administration

Dosage calculation: 0.25 mg/kg as IV bolus over 5 seconds

BP must be maintained <180/105 for first 24 hours post thrombolytic administration

Are all patients who have an LVO considered for a thrombectomy, who have been given TNK?

Yes

What is number one complication for IV TPA?

ICH

What medications do we give when a patient has an angioedma reaction to TPA?

Methylpredisone

Benadryl

Famotidine

Epinephrine

When would rapid intubation be required for patients who have angioedma reaction from TPA?

Rapid progression of symptoms

What is the time frame to begin the start of the procedure for a thrombectomy ?

Within 24 hours of the LKW

What is the time goal for ED to skin puncture ?

90 minutes

What is the time goal for skin puncture if patients are transferred from another stroke center?

60 minutes

What is the recommended thrombectomy device by the ASA?

Stent Retrievers

What TICI grades are considered to be successful outcomes?

TICI 2B and 3

When is intra-arterial thrombolytic therapy considered?

as an add on following mechanical thrombectomy

What is DIDO (Door in, door out)?

time from arrival to ICU admission

What is the time goal for DIDO?

2 hrs

what is telestroke?

access to acute stroke care in underserved areas

What does telestroke involve ?

A neurology expert can view and interact with the patient

How does telestroke help with initial evaluation of a stroke?

1. It is proven to shorten DTN times

2. Identifies patients who transfers are indicated and those who are not

How would a telestroke technology help out with a patient with an ischemic stroke vs a patient with a devastating hemorrhagic stroke?

A small ischemic stroke can by managed by a community hospital where a devastating hemorrhagic stroke has no acute intervention - comfort measures can be provided

What is the quickest way to get to a neurological evaluation for a suspected stroke?

911

What is the most common reason for stroke patients not getting TNK/TPA or stroke reperfusion therapy?

Delay in patients getting to the hospital

EMS should not bypass the closest non-stroke certified hospital if diversion would add more than ______ minutes to the transport time

20

How are prehospital stroke policies determined?

They vary from state to state and are divided into regions/districts that function independently

What are the 5 D's of posterior strokes?

Dipoplia, Dizziness, Dysarthria, Dysphagia, Dystaxia

Which type of stroke is most commonly misdiagnosed in the ED with what age group of people?

Posterior strokes most commonly in young patients

What is no longer a standard in stroke workup?

Chest X-ray

What is an indicator for less optimal outcomes for thrombectomy?

older than 80

What is the most effective way in improving prehospital stroke care?

Patient specific feedback

What does hyper acute care include ?

Prehospital Care and ED Care

What type of care refers to the time period where in the first 24 hours after an acute onset of a stroke a stroke patient received urgent and emergency evaluation of symptoms and is eligible IV therapies ?

Hyperacute phase I

What is the stroke chain of survival ?

Detection

Dispatch

Delivery

Door

Data

Decision

Drug

Disposition

Should we treat BP before arriving at the hospital ?

No, contact the ED en route to treat the BP

What is the on scene time of EMS?

15 minutes

When is air transport reasonable ?

When ground transport takes greater than 1 hour

What are considered designated stroke centers?

Acute Ready Stroke Center that has telemedicine and tele radiology capabilities

Primary Stroke Center

Thrombectomy capable stroke centers

Comprehensive stroke centers

What are the 3 different types of prehospital screening stroke scales?

Los Angelos Stroke Scale

Cincinnati Scale

RACE Scale

What signs and symtptoms does the Los Angelos Stroke Scale detect?

Facial droop, arm drift, grip strength, finger stick

What signs and symptoms does the Cincinnati Scale detect?

Facial droop, arm drift, abnormal speech

Which prehospital screening takes less time?

Cincinnati Prehospital Stroke Scale

Which prehospital screening is more accurate and in-depth?

Los Angelos Stroke Scale

What is the R.A.C.E. Scale?

Rapid neurological scale with increased probability of having an LVO

What does sensitivity mean on the RACE scale?

occlusion

What does specificity mean on the RACE scale

doesn't give you an exact location

During prehospital transportation, if patient is hypotensive, what should EMS do?

place head stretcher flat and and administer isotonic saline to improve cerebral edema

During prehospital transportation, if patient is hypoglycemic what should EMS do?

administer dextrose

What is "Drip and Ship?"

tPA initiated in a rural hospital and immediately transferred to a stroke center

What is Todds Paralysis/Paresis?

brief period of transient paralysis following a seizure

Why could a conversion disorder mimic a stroke?

A conversion disorder is a brief period of acute stress but during an objective exam, nothing shows up (NIH wise)

At what hypoglycemic level would glucose mimic a stroke?

Less than 45

What is the difference between Bell's Palsy and a stroke?

Bells Palsy will take awhile for symptom onset

Cranial Nerve 7 is pinched

What NIH score indicates a minor stroke?

0-4

What NIH score indicates a moderate stroke?

5-15

What NIH score indicates moderate to severe stroke?

16-20

What NIH score indicates a severe stroke?

>21

when is NIHSS performed baseline ?

Obtained rapidly in the ED

What is the score range of the NIH?

0-42

What NIH score predicts patient will have good or excellent outcomes?

NIH < 14

What is the Hunt and Hess Score associated with?

SAH

What does a 0 mean with the Hunt and Hess Scale?

no symptoms

What does a 2 mean with the Hunt and Hess Scale?

worst headache of life

What does a 3 mean with the Hunt and Hess Scale?

LOC decline

What does a 4 mean with the Hunt and Hess Scale?

Patient is posturing

What does a 5 mean with the Hunt and Hess Scale?

Deep Coma

What is the ABCD2 score?

(Age, BP, Clinical features, Duration of symptoms, & Diabetes) Used to identify pts at high risk of ischemic stroke in the first 7 days after TIA

Has a range from 1-7

What ABCD2 score indicates admission is advised ?

Greater or equal to 4

What ABCD2 score indicated discharge is advised ?

Less than 4

What does A stand for in the ABCD score?

Age greater than 60

What does B stand for in the ABCD score?

Blood Pressure >140/90

What does C stand for in the ADCD2 score?

Clinical Features

1 - Speech disturbance only

2- Unilateral weakness

What does D stand for in the ABCD2 score?

Duration of symptoms

60 minutes - 2 points

10-59 minutes - 1 point

What does D2 stand for in the ABCD2 score?

Diabetes if it is present

What score in the ABCD2 score indicates a patient is at a high risk of a stroke ?

6-7

When are ED nurses able to perform a rapid neurological assessements on patients?

During the time when the patient is in the stretcher while moving the patient to CT

If stroke symptoms completely resolves after CT and they come back, what do we consider the time of symptom onset?

Second set of symptoms

If someone "woke up" and had a stroke , what would be there time of last known normal?

When the patient to be last normal, or before falling asleep

What baseline common lab work do we perform prior to giving Alteplase ? What if the patient is on an anticoagulant?

CT and finger stick; then they will need a PTT/INR

The only thing that needs to delay a patients IV TPA:

anticoagulation use

Do we draw baseline troponin or ekg's in cardiac patients ?

no

What is considered the gold standard for detecting a stroke?

Diffusion weighted sequence MRI

Once code stroke is called, what fluids do we start on patients?

Isotonic Saline

What is the goal for fluids for a stroke patient?

To make them euvolemic

What type of breathing patterns are frequently seen in stroke patients ?

Cheyne Stokes breathing

When does BP management begin for stroke patients?

In the ED

What are the three BP medications we use to treat BP

Labetalol

Nicardipine

Clevidipine

We get our patient to CT, and we realize that on the CT is shows an ICH, what should we expect our BP goals to be changed too?

<140

Intra-arterial fibrinolysis is beneficial for patients with major strokes caused by MCA occlusion within how many hours?

6 hours