2020 American Heart Association and American Red Cross Focused Update for First Aid
2020; Lippincott Williams & Wilkins; Volume: 142; Issue: 17 Linguagem: Inglês
10.1161/cir.0000000000000900
ISSN1524-4539
AutoresJeffrey L. Pellegrino, Nathan P. Charlton, Jestin N. Carlson, Gustavo E. Flores, Craig Goolsby, Amber V. Hoover, Amy Kule, David J. Magid, Aaron Orkin, Eunice M. Singletary, Tammy Slater, Janel Swain,
Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoHomeCirculationVol. 142, No. 172020 American Heart Association and American Red Cross Focused Update for First Aid Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUB2020 American Heart Association and American Red Cross Focused Update for First Aid Jeffrey L. Pellegrino, PhD, MPH, Co-Chair, Nathan P. Charlton, MD, Co-Chair, Jestin N. Carlson, MD, MS, Gustavo E. Flores, MD, NRP, Craig A. Goolsby, MD, MEd, Amber V. Hoover, RN, MSN, Amy Kule, MD, David J. Magid, MD, MPH, Aaron M. Orkin, MD, MSc, MPH, Eunice M. Singletary, MD, Tammy M. Slater, DNP, MS, ACNP-BC and Janel M. Swain, BSc, BEd, ACP Jeffrey L. PellegrinoJeffrey L. Pellegrino , Nathan P. CharltonNathan P. Charlton , Jestin N. CarlsonJestin N. Carlson , Gustavo E. FloresGustavo E. Flores , Craig A. GoolsbyCraig A. Goolsby , Amber V. HooverAmber V. Hoover , Amy KuleAmy Kule , David J. MagidDavid J. Magid , Aaron M. OrkinAaron M. Orkin , Eunice M. SingletaryEunice M. Singletary , Tammy M. SlaterTammy M. Slater and Janel M. SwainJanel M. Swain Originally published21 Oct 2020https://doi.org/10.1161/CIR.0000000000000900Circulation. 2020;142:e287–e303Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 21, 2020: Ahead of Print Top Take-Home MessagesFirst aid providers can use the signs of weakness in the face (eg, droop), arm, or grip on one side of the body, or speech disturbance to identify individuals with a possible stroke and should activate emergency services when this occurs.After activating emergency services, first aid providers may encourage alert adults experiencing nontraumatic chest pain to chew and swallow 162 to 324 mg of aspirin. This recommendation applies to all adults except for individuals who have an aspirin allergy or individuals who have been advised by a healthcare provider not to take aspirin.Alert adults and children with suspected hypoglycemia should be given glucose to swallow. If symptoms worsen or do not resolve within 10 minutes, emergency services should be activated.Tourniquets should be used as soon as available for the treatment of life-threatening extremity bleeding or bleeding that cannot be controlled with direct pressure.Direct manual pressure, with the use of a hemostatic dressing if available, should be used for the treatment of injuries with life-threatening bleeding not amenable to the use of a tourniquet, or for extremity bleeding until a tourniquet is available.Immediate replantation of an avulsed tooth is best, but if this is not an option, transporting the tooth in a solution like Hanks' Balanced Salt Solution or in plastic wrap to a dental provider increases chances of tooth survival. Tap water should not be used as a transport medium.For people experiencing exertional hyperthermia or heatstroke, cold-water, whole-body immersion is the most effective technique for rapidly reducing core temperature and should be initiated as soon as possible and continued until a temperature of less than 39°C (102.2°F) is reached or resolution of signs and symptoms of heatstroke occurs. If cold-water, whole-body immersion is not available, other forms of cooling, such as commercially prepared ice packs, cold showers, and fanning, may be reasonable.PreambleFirst aid, or the initial care provided for an acute illness or injury, has the goals of preserving life, alleviating suffering, preventing further illness or injury, and promoting recovery. First aid can be initiated by anyone in any situation and includes self-care. General characteristics of the provision of first aid, at any level of training, include recognizing, assessing, and prioritizing the need for first aid; providing care using appropriate competencies; and recognizing limitations and seeking additional treatment when needed, such as activating emergency medical services or seeking other medical assistance (emergency services).1The present document incorporates systematic reviews conducted by the First Aid Task Force of the International Liaison Committee on Resuscitation (ILCOR).2 Systematic reviews and Consensus on Science With Treatment Recommendations (CoSTR) conducted by ILCOR provide up-to-date science for international use. After formulation of the ILCOR systematic reviews and CoSTRs, a North American team with representatives appointed by the American Heart Association (AHA) and the American Red Cross (Red Cross) then applies the science within these documents to update existing first aid guidelines for use in curriculum and protocol development. Beginning in 2015, the ILCOR evidence evaluation process transitioned to a continuous evidence evaluation, with systematic reviews performed as new published evidence emerges or when an ILCOR task force prioritizes a topic. In 2020, the ILCOR First Aid Task Force conducted systematic reviews on the topics of recognizing stroke, providing supplemental oxygen for individuals suspected of stroke, when to offer aspirin for those with chest pain, methods of providing glucose for individuals suspected of hypoglycemia, means to stop life-threatening bleeding, use of compression wraps for the recovery from closed extremity joint injuries, mediums to store avulsed teeth, and cooling techniques for exertional hyperthermia or heatstroke.This focused update includes new and updated recommendations for first aid organizations and providers, but written for curriculum designer and educator use. Prior first aid guidelines should be consulted and will remain in place, unless updated, and are available in these publications:"Part 17: First Aid: 2010 American Heart Association and American Red Cross Guidelines for First Aid"3"Part 15: First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid"4"2019 American Heart Association and American Red Cross Focused Update for First Aid: Presyncope"5Footnotes*This article represents the author's opinions and does not represent the official policy or position of the Uniformed Services University, Defense Department, or US government.https://www.ahajournals.org/journal/circThe American Heart Association requests that this document be cited as follows: Pellegrino JL, Charlton NP, Carlson JN, Flores GE, Goolsby CA, Hoover AV, Kule A, Magid DJ, Orkin AM, Singletary EM, Slater TM, Swain JM. 2020 American Heart Association and American Red Cross focused update for first aid. Circulation. 2020;142:e287–e303. doi: 10.1161/CIR.0000000000000900References1. Singletary EM, Zideman DA, De Buck ED, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, et al.; on behalf of the First Aid Chapter Collaborators. Part 9: first aid: 2015 International Consensus on First Aid Science With Treatment Recommendations.Circulation. 2015; 132(suppl 1):S269–S311. doi: 10.1161/CIR.0000000000000278LinkGoogle Scholar2. Singletary E, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang W-T, Charlton NP, Djärv T, et al.; on behalf of the First Aid Chapter Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations.Circulation. 2020: 142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897LinkGoogle Scholar3. Markenson D, Ferguson JD, Chameides L, Cassan P, Chung KL, Epstein J, Gonzales L, Herrington RA, Pellegrino JL, Ratcliff N, et al.. Part 17: first aid: 2010 American Heart Association and American Red Cross Guidelines for First Aid.Circulation. 2010; 122(suppl 3):S934–S946. doi: 10.1161/CIRCULATIONAHA.110.971150LinkGoogle Scholar4. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al.. Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid.Circulation. 2015; 132(suppl 2):S574–S589. doi: 10.1161/CIR.0000000000000269LinkGoogle Scholar5. Charlton NP, Pellegrino JL, Kule A, Slater TM, Epstein JL, Flores GE, Goolsby CA, Orkin AM, Singletary EM, Swain JM. 2019 American Heart Association and American Red Cross Focused Update for First Aid: Presyncope: An Update to the American Heart Association and American Red Cross Guidelines for First Aid.Circulation. 2019; 140:e931–e938. doi: 10.1161/CIR.0000000000000730LinkGoogle ScholarIntroductionMethodology and Evidence ReviewILCOR systematic reviews are conducted according to the recommendations of the National Academy of Medicine,1 by using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.2 Each ILCOR task force identified and prioritized questions to be addressed by using the PICOST (population, intervention, comparator, outcome, study design, time frame) format3 and determined the important outcomes to be reported. A detailed search for relevant articles was performed on MEDLINE, Embase, and Cochrane Library databases, with identified publications screened for further evaluation.Two systematic reviewers conducted a risk of bias assessment for each relevant study by using Cochrane and GRADE criteria for randomized controlled trials (RCTs),4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,5 and GRADE criteria for observational and interventional studies informing therapy or prognosis questions.2 The reviewers created evidence profile tables containing information on study outcomes.6 The certainty of the evidence (ie, confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,7 on the basis of study methodologies and the GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and publication bias (Tables 1 and 2).2,7aTable 1. GRADE Terminology for Strength of Recommendation and Criteria for Evidence Certainty Assessment7aStrength of RecommendationStrong recommendation = We recommendWeak recommendation = We suggestAssessment Criteria for Certainty of EffectStudy DesignCertainty of Effect Begins at This LevelLower ifHigher ifRandomized trialHigh or moderateRisk of biasInconsistencyIndirectnessImprecisionPublication biasLarge effectDose responseAll plausible confounding would reduce demonstrated effect or would suggest a spurious effect when results show no effect.Observational trialLow or very lowGRADE indicates Grading of Recommendations, Assessment, Development, and Evaluation.Table 2. GRADE Terminology7aRisk of biasStudy limitations in randomized trials include lack of allocation concealment, lack of blinding, incomplete accounting of patients and outcome events, selective outcome reporting bias, and stopping early for benefit. Study limitations in observational studies include failure to apply appropriate eligibility criteria, flawed measurement of exposure and outcome, failure to adequately control confounding, and incomplete follow-up.InconsistencyCriteria for inconsistency in results include the following: Point estimates vary widely across studies; CIs show minimal or no overlap; statistical test for heterogeneity shows a low P value; and the I2 is large (a measure of variation in point estimates resulting from among-study differences).IndirectnessSources of indirectness include data from studies with differences in population (eg, OHCA instead of IHCA, adults instead of children), differences in the intervention (eg, different compression-ventilation ratios), differences in outcome, and indirect comparisons.ImprecisionLow event rates or small sample sizes will generally result in wide CIs and therefore imprecision.Publication biasSeveral sources of publication bias include tendency not to publish negative studies and the influence of industry-sponsored studies. An asymmetrical funnel plot increases suspicion of publication bias.Good practice statementsGuideline panels often consider it necessary to issue guidance on specific topics that do not lend themselves to a formal review of research evidence. The reason might be that research into the topic is unlikely to be located or would be considered unethical or infeasible. Criteria for issuing a nongraded good practice statement include the following: There is overwhelming certainty that the benefits of the recommended guidance will outweigh harms, and a specific rationale is provided; the statements should be clear and actionable to a specific target population; the guidance is deemed necessary and might be overlooked by some providers if not specifically communicated; and the recommendations should be readily implementable by the specific target audience to which the guidance is directed.GRADE indicates Grading of Recommendations, Assessment, Development, and Evaluation; IHCA, in-hospital cardiac arrest; and OHCA, out-of-hospital cardiac arrest.The ILCOR task forces reviewed, discussed, and debated the studies and systematic review analyses, drafting a consensus on science statement—a written summary of identified evidence and evidence certainty for each outcome. When there was unanimity, the task force drafted treatment recommendations, labeled as strong or weak, and either for or against a therapy, prognostic tool, or diagnostic test. In addition to a CoSTR, each topic summary included the PICOST question and a justification and evidence-to-decision framework section, capturing the values and preferences considered by the task force and a list of knowledge gaps. Public input was sought at multiple stages.8 The task forces considered all public comments when finalizing the CoSTR summary manuscripts. All 2020 CoSTR statements were submitted for peer review before publication.Guideline FormatThe 2020 focused update is organized into modular knowledge chunks, grouped into discrete modules of information on specific topics or management issues.9 Each modular knowledge chunk includes a table of recommendations, a brief synopsis, and recommendation-specific supportive text. Hyperlinked references are provided to facilitate quick access and review.Organization of the First Aid Writing GroupThe AHA and Red Cross strive to ensure that each guideline writing group includes requisite expertise and diversity, representative of the broader medical community, by selecting experts from a wide array of backgrounds, geographic regions, sexes, races, ethnicities, intellectual perspectives and biases, and scopes of clinical practice. Volunteers with an interest and recognized expertise in first aid are nominated by the writing group chairs and selected by the AHA Emergency Cardiovascular Care Committee and the Red Cross. The First Aid Writing Group included emergency physicians, nurses, emergency medical services providers, first aid instructors, and first aid researchers. The writing group was assisted by a science editor and staff member of the AHA.Writing Group Discussions, Review, and ApprovalThe First Aid Writing Group reviewed 2020 ILCOR evidence from the CoSTR and corresponding guidelines to determine if any current First Aid guidelines recommendation should be reaffirmed, revised, or retired, or if a new recommendation was appropriate.10 On conference calls, writing group members discussed the evidence supporting each guideline recommendation. The writing group then drafted, reviewed, and approved recommendations, assigning each a Class of Recommendation (COR) (ie, strength) and Level of Evidence (LOE) (ie, certainty) (see Table 3).11 Each guideline recommendation (including the COR, LOE, and wording) was formally voted on by each writing group member. Members could express disagreement at any time and provide additional input that was reviewed by the First Aid Writing Group cochairs and brought back to the writing group for further discussion if needed. Before submission for publication, all writing group members verified the scientific integrity of the guideline recommendations and took public responsibility for the first aid focused update manuscript.Table 3. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Table 3. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*The first aid focused update was submitted for blinded peer review to 6 subject matter experts nominated by the AHA and Red Cross. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. Peer reviewer feedback was provided for the update in draft format and again in final format. The update was reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee, AHA Executive Committee, and the American Red Cross Scientific Advisory Council.Management of Potential Conflicts of InterestILCOR, the AHA, and the Red Cross have rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the CoSTR summaries and the guidelines. All organizations followed these policies throughout the 2020 evidence evaluation and document preparation process, and anyone involved in any part of this process disclosed all commercial relationships and other potential (including intellectual) conflicts.12 These disclosures were reviewed before assignment of task force chairs and members, writing group chairs and members, consultants, and peer reviewers. In keeping with the AHA and the Red Cross conflict of interest policies, the chairs and a majority of the members of each ILCOR task force and the combined AHA and Red Cross writing group had to be free of relevant conflicts. Disclosure information for writing group members is listed in Appendix 1. All peer reviewers were also required to disclose relationships with industry and any other potential conflicts of interest. Disclosure information for peer reviewers is listed in Appendix 2.AbbreviationsAbbreviationMeaning/PhraseAHAAmerican Heart AssociationCORClass of RecommendationCoSTRConsensus on Science With Treatment RecommendationsGRADEGrading of Recommendations, Assessment, Development, and EvaluationILCORInternational Liaison Committee on ResuscitationLOELevel of EvidenceMImyocardial infarctionPICOSTpopulation, intervention, comparator, outcome, study design, time frameRCTrandomized controlled trialsRed CrossAmerican Red CrossReferences1. Institute of Medicine (US) Committee of Standards for Systematic Reviews of Comparative Effectiveness Research. Finding What Works in Health Care: Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S, eds. Washington, DC: The National Academies Press; 2011.Google Scholar2. Schünemann H, Brożek J, Guyatt G, Oxman A, eds. GRADE Handbook; 2013. https://gdt.gradepro.org/app/handbook/handbook.html. Accessed December 31, 2019.Google Scholar3. Cochrane Training. Chapter 5: defining the review questions and developing criteria for including studies.O'Connor D, Higgins J, Green S, eds. In: Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. 2011. https://handbook-5-1.cochrane.org/chapter_5/5_defining_the_review_question_and_developing_criteria_for.htm. Accessed December 31, 2019.Google Scholar4. Cochrane Training. Chapter 8: assessing risk of bias in included studies.Higgins JPT, Altman DG, Sterne J, eds. In: Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. 2011. https://handbook-5-1.cochrane.org/chapter_8/8_assessing_risk_of_bias_in_included_studies.htm. Updated December 31, 2019. Accessed December 31, 2019.Google Scholar5. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM; QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.Ann Intern Med. 2011; 155:529–536. doi: 10.7326/0003-4819-155-8-201110180-00009CrossrefMedlineGoogle Scholar6. Evidence Prime. GRADEpro GDT—an introduction to the system.https://gdt.gradepro.org/app/help/user_guide/index.html. Accessed December 31, 2019.Google Scholar7. Schünemann HJ, Schünemann AH, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Williams JW, Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH; GRADE Working Group. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies.BMJ. 2008; 336:1106–1110. doi: 10.1136/bmj.39500.677199.AECrossrefMedlineGoogle Scholar7a. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, et al.. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.Circulation. 2019; 140:e826–e880. doi: 10.1161/CIR.0000000000000734LinkGoogle Scholar8. ILCOR Consensus on Science with Treatment Recommendations (CoSTR). Frequently asked questions.https://costr.ilcor.org/faq. Accessed December 31, 2019.Google Scholar9. Levine GN, O'Gara PT, Beckman JA, Al-Khatib SM, Birtcher KK, Cigarroa JE, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Hlatky MA, Joglar JA, Piano MR, Wijeysundera DN. Recent Innovations, Modifications, and Evolution of ACC/AHA Clinical Practice Guidelines: An Update for Our Constituencies: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2019; 139:e879–e886. doi: 10.1161/CIR.0000000000000651LinkGoogle Scholar10. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang W-T, Charlton NP, Djärv T, et al.; on behalf of the First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations.Circulation. 2020; 142(suppl 1)S284–S334. doi: 10.1161/CIR.0000000000000897LinkGoogle Scholar11. Applying class of recommendations and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care.https://eccguidelines.heart.org/tables/applying-class-of-recommendations-and-level-of-evidence-to-clinical-strategies-interventions-treatments-or-diagnostic-testing-in-patient-care/. Accessed December 31, 2019.Google Scholar12. American Heart Association. Conflict of interest policy.https://www.heart.org/en/about-us/statements-and-policies/conflict-of-interest-policy. Accessed December 31, 2019.Google ScholarMedical EmergenciesStroke Recognition in First AidThe 2015 Guidelines Update for stroke recognition1 is being replaced with this updated guideline:SynopsisStroke is a leading cause of disability and death, and stroke outcomes improve with the prompt recognition of stroke signs and early access to time-sensitive interventions.7,8 Several tools have been developed to improve stroke recognition in the prehospital setting when implemented by emergency medical services personnel or nurses.9 Observational studies of stroke recognition tools found reductions in the time from symptom onset to treatment among stroke patients, improved stroke diagnosis rates, and improved time to definitive treatment, especially thrombolysis.10–12 Several stroke recognition tools, which have been evaluated in large populations, identify stroke on the basis of the following signs: weakness in the face, arm, or grip on one side of the body or speech disturbance.2–6 Some of these tools achieve greater specificity by incorporating blood glucose measurement to exclude individuals whose symptoms are due to hypoglycemia.2,5 Though stroke recognition tools have not been evaluated directly among lay first aid providers, first aid providers can use weakness in the face (eg, droop), arm, or grip on one side of the body or speech disturbance to identify signs of potential stroke and activate emergency services immediately when an individual exhibits any of these symptoms. After activating emergency services, first aid providers who are able to measure blood glucose may do so and report this number to emergency services.Recommendation-Specific Supportive TextFour stroke recognition tools (Los Angeles Prehospital Stroke Screen, Cincinnati Prehospital Stroke Scale, Melbourne Ambulance Stroke Screen, F.A.S.T. [face drooping, arm weakness, speech difficulty, time to call 9-1-1]) have been more extensively studied in a larger number of participants. In 5 observational studies in the prehospital setting, enrolling 5422 total participants, stroke recognition tools (each incorporating 1 or more of the signs of facial weakness, arm weakness, reduced grip strength, or speech disturbance to assess for possible stroke) had a sensitivity that ranged from 0.64 to 0.95 and a specificity that ranged from 0.48 to 0.90.2–6 In addition, observational studies evaluating the impact of stroke recognition tools found that the use of these tools was associated with a reduced time from symptom onset to thrombolysis (115 participants, mean difference –32 minutes, P<0.01)10 and increased stroke diagnosis (356 participants, risk ratio [RR] 3.3; 95% CI, 2.3–4.8)11 and an increased correct stroke diagnosis by paramedics (1518 participants; RR, 1.29; 95% CI, 1.18–1.42).12Some stroke recognition scales incorporate blood glucose measurement. These have equivalent sensitivity but greater specificity in comparison with stroke recognition tools that do not incorporate blood glucose measurement.2,5References1. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al.. Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid.Circulation. 2015; 132(suppl 2):S574–S589. doi: 10.1161/CIR.0000000000000269LinkGoogle Scholar2. Asimos AW, Ward S, Brice JH, Rosamond WD, Goldstein LB, Studnek J. Out-of-hospital stroke screen accuracy in a state with an emergency medical services protocol for routing patients to acute stroke centers.Ann Emerg Med. 2014; 64:509–515. doi: 10.1016/j.annemergmed.2014.03.024CrossrefMedlineGoogle Scholar3. Berglund A, Svensson L, Wahlgren N, von Euler M; HASTA collaborators. Face Arm Speech Time Test use in the prehospital setting, better in the ambulance than in the emergency medical communication center.Cerebrovasc Dis. 2014; 37:212–216. doi: 10.1159/000358116CrossrefMedlineGoogle Scholar4. Chen S, Sun H, Lei Y, Gao D, Wang Y, Wang Y, Zhou Y, Wang A, Wang W, Zhao X. Validation of the Los Angeles Pre-hospital Stroke Screen (LAPSS) in a Chinese urban emergency medical service population.PLoS One. 2013; 8:e70742. doi: 10.1371/journal.pone.0070742CrossrefMedlineGoogle Scholar5. Bray JE, Coughlan K, Barger B, Bladin C. Paramedic diagnosis of stroke: examining long-term use of the Melbourne Ambulance Stroke Screen (MASS) in the field.Stroke. 2010; 41:1363–1366. doi: 10.1161/STROKEAHA.109.571836LinkGoogle Scholar6. Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin C. Paramedic identification of stroke: community validation of the Melbourne Ambulance Stroke Screen.Cerebrovasc Dis. 2005; 20:28–33. doi: 10.1159/000086201CrossrefMedlineGoogle Scholar7. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association.Circulation. 2019; 139:e56–e528. doi: 10.1161/CIR.0000000000000659LinkGoogle Scholar8. Centers for Disease Control and Prevention. Awareness of stroke warning symptoms–13 States and the District of Columbia, 2005.MMWR Morb Mortal Wkly Rep. 2008; 57:481–485.MedlineGoogle Scholar9. Rudd M, Buck D, Ford GA, Price CI. A systematic review of stroke recognition instruments in hospital and prehospital settings.Emerg Med J. 2016; 33:818–822. doi: 10.1136/emermed-2015-205197CrossrefMedlineGoogle Scholar10. O'Brien W, Crimmins D, Donaldson W, Risti R, Clarke TA, Whyte S, Sturm J. FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke.J Clin Neurosci. 2012; 19:241–245. doi: 10.1016/j.jocn.2011.06.009CrossrefMedlineGoogle Scholar11. Harbison J, Hossain O, Jenkinson D, Davis J, Louw SJ, Ford GA. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test.Stroke. 2003; 34:71–76. doi: 10.1161/01.str.0000044170.46643.5eLinkGoogle Scholar12. Wojner-Alexandrov AW, Alexandrov AV, Rodriguez D, Persse D, Grotta JC. Houston paramedic and emergency stroke treatment and outcomes study (HoPSTO).Stroke. 2005; 36:1512–1518. doi: 10.1161/01.STR.0000170700.45340.39LinkGoogle ScholarNew—First Aid Use of Supplemental Oxygen in Suspected StrokeSynopsisStroke is a time-critical condition for which early advanced care is associated with improved outcomes. In the first aid setting, the diagnosis of stroke may only be suspected because a higher level
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