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This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers. Describe the neurological examination and imaging techniques used to locate and define the type of acute stroke. Describe the role of the acute care nursing staff both immediately post-stroke and during the initial post-stroke rehabilitation period. Identify the complications and associated interventions that may occur during the ICU care of acute stroke patients.
Discuss the goals and methods of rehabilitation therapists who specialize in post-acute stroke rehabilitation. Ischemic stroke, which may occur as a transient ischemic attack (TIA), occurs when a clot, either of local or distant origin, blocks a cerebral artery and causes oxygen deprivation with subsequent tissue damage. Hemorrhagic stroke occurs as a bleed within the brain, often causing tissue damage due to pressure-related changes. In the United States, most strokes are ischemic and caused by the sudden blockage of a cerebral artery.
Cerebral emboli, causing embolic strokes, are due to clots that arise from outside the cerebral arterial tree and travel through the arterial system until they become lodged within smaller arteries. Ischemic strokes typically give rise to specific (focal) and often painless neurological symptoms. Because advances in diagnostic imaging techniques allow the rapid diagnosis of TIAs and because TIAs have been associated with an increased risk of acute stroke, it is currently recommended that all patients showing symptoms of TIA be treated as stroke patients. There are about 140,000 stroke deaths each year, and stroke is listed as a contributing factor to an additional 100,000 deaths.
Different sectors of the population have been shown to have differing levels of risk of having a stroke. Before discussing the assessment, treatment, and care of acute strokes, it is important to review the anatomy and physiology underlying the disease. Two large arteries, the right and left internal carotid arteries, ascend from the chest in the anterior portion of the neck.
Two smaller arteries, the right and left vertebral arteries, ascend via the posterior portion of the neck. The carotid arteries supply blood to about 80% of the brain, including most of the frontal, parietal, and temporal hemispheres and the basal ganglia.
The anterior circulation of the brain is formed by those cerebral blood vessels that are branches of the internal carotid arteries, while the posterior circulation of the brain is formed by those cerebral blood vessels that are branches of the vertebral arteries. One characteristic of the brain is that many of its functions are not spread diffusely; instead, specific neurological functions are dependent upon specialized brain regions.
In a stroke patient, it is easier to assess the external neurological problems than it is to see the internal arterial damage.
Another useful functional distinction arises from the fact that the first branch of the internal carotid artery is the ophthalmic artery to the retina. Beyond the ophthalmic arteries, the internal carotid artery circulation supplies the inferior, lateral, and medial surfaces of the cerebral hemispheres. In contrast, the vertebral arteries supply the brainstem, cerebellum, occipital cortices, and thalamus. Injuries to branches of these major cerebral arteries also produce specific and characteristic stroke syndromes, and these syndromes help to infer which brain areas have been damaged in a specific patient’s stroke. Cutting off the blood supply to the entire field of one ACA will affect frontal regions on the medial surface of one half of the brain, much of the corpus callosum, part of the internal capsule, and regions of the basal ganglia. In addition, unusual symptoms such as alien-hand syndrome and callosal disconnection syndromes can occur with ACA strokes (Bartolo, 2011). Cutting off the blood supply to the entire field of one MCA will affect the primary sensory and motor cortices on the lateral surface of the cerebral hemisphere, sections of the internal capsule, and parts of the inferior parietal and lateral temporal lobes. Cutting off the blood supply to only the superior branches of the MCA will lead to a subset of these deficits. Cutting off the blood supply to only the inferior branches of the MCA will lead to a subset of deficits, with little sensory or motor loss on the contralateral body side but with a full or partial contralateral homonymous hemianopia. Cutting off the blood supply to the entire field of one vertebral artery will affect the medulla of the brainstem. Cutting off the blood supply to the entire field of one PCA will affect the thalamus, hippocampus, underside of the temporal lobe, medial surface of the occipital lobe, and motor areas of the midbrain (Searls et al., 2012). For decisions about acute treatment, the particular stroke syndrome is usually less important than the type of vascular injury that has occurred. Ischemic strokes result from injuries that reduce blood flow to a region of the brain without initially causing significant cerebral bleeding; usually, the vascular damage is a blockage in an artery. Hemorrhagic strokes result from injuries that cause bleeding into the brain or the cerebrospinal fluid (CSF) from the outset; usually, the vascular damage is a tear in an artery or the rupture of an aneurysm. The term ischemia indicates oxygen and nutrient deprivation due to an insufficient supply of blood. When cerebral blood flow is reduced, the affected regions of the brain begin to stop functioning, and the patient begins to lose the ability to perform the tasks that are localized in those regions. If the blood supply to a brain region is cut off entirely, as occurs during cardiac arrest, cell damage is widespread and neurons begin to die quickly. In most strokes, patients lose neurologic functions early, before all the neurons in the affected area are irreversibly damaged.
After an ischemic stroke, the amount of irreversible damage increases steadily as long as regions remain without sufficient blood supply.
Empirically, it has been found that collateral and residual blood flow can preserve neurons in the penumbral and border areas for as long as six hours after an ischemic stroke.
Hemorrhagic strokes release blood into the brain parenchyma or into the cerebrospinal fluid (CSF) and produce damage by three mechanisms: ischemia, physical destruction, and increased pressure. Acute treatments attempt to reverse ischemia and to reduce local force and intracranial pressure.
When a stroke is embolic, acute stroke treatments only work on the immediate problem, rather than the cause. Cryptogenic strokes are ischemic strokes in which a comprehensive evaluation cannot define the cause. In older people, one common cause of ICH is a metabolic dysfunction called cerebral amyloid angiopathy. ICH, which accounts for approximately 20% of strokes worldwide, is most commonly found in the basal ganglia (specifically, the putamen) and the adjacent internal capsule.
Many subarachnoid hemorrhages are due to trauma, but spontaneous ruptures of a cerebral aneurysm are also common. In addition, daily aspirin is often recommended for adults who are at high risk for cardiovascular disease. Strokes produce the sudden loss of neurocognitive function, including motor and sensory dysfunction. Recognizing that a stroke may be taking place is the first step in caring for the patient, so public education and information is required in order to increase the recognition of potential strokes.
Health professionals cannot assume that their patients know how to recognize potential strokes.
Patients should be told that if they are having any of these symptoms, they should call 911 or get someone else to call 911.
However, even people who have been taught the warning signs may not realize that they are having a stroke. Stroke victims with damage to their nondominant parietal lobe can lose the ability to recognize that they are ill.
For these reasons, it is often the family or a bystander who first realizes that a medical problem is occurring. The sudden appearance of any one of these three symptoms indicates a possible stroke, and members of public are advised to immediately call 911 (Jones et al., 2010). In addition, the one critical medical step that the public should know is how to control external bleeding.
In an emergency, people often feel that time is being lost by waiting for an EMS team to arrive, and family members or bystanders often hurriedly drive patients to the hospital. Besides stabilizing patients, dispatchers and EMS technicians make the first triage of potential stroke victims, collect critical background information, and expedite transport to the nearest hospital equipped to handle strokes.
Divide the EMS unit’s region into districts according to the nearest emergency department capable of treating acute strokes. When assigning response teams, EMS dispatchers need to assess the type and severity of the emergency. Since strokes account for only 2% of all 911 calls, this translates to only four to ten stroke patients each year for the typical EMS team. When available, an ALS team is sent, “fully equipped with ventilation and oxygenation capabilities, including the ability to provide advanced airway maintenance, endotracheal tube checks, end-tidal CO2 monitoring, and ECG monitoring. If a choice has to be made, however, speed of transport to a stroke center is the first consideration. When patients having a stroke are more than one hour’s travel time by ambulance from a hospital that is equipped to treat acute strokes, then air transport should be considered. When an EMS operator suspects that a call concerns a stroke victim, the operator begins collecting critical background information. Note the time when the symptoms first appeared and the last time that the patient did not have the symptoms. Written records of the information collected during the first contact with the patient can be critical for emergency department (ED) providers when they are making decisions about treatment. As an EMS instructor, a nurse needs to be able to tailor the emergency response protocols to the local region.
A typical EMS team responds to only four to ten stroke patients per year, and it has been estimated that emergency personnel forget about one half of the stroke care instructions by 12 months after a training session.
When they reach the victim, members of the EMS response team follow the standard protocol by assessing the situation and stabilizing the patient. Responders first state their name and tell the patient that they are part of the emergency team that has come to help.
After stabilizing the patient, EMS responders assess the patient’s level of consciousness, document any signs of stroke, and collect critical background information. Second, determine the likelihood that the patient has had a stroke using the Cincinnati Prehospital Stroke Scale.
One of the simplest and most widely used stroke assessment tools is the Cincinnati Prehospital Stroke Scale (CPSS), developed by Kothari et al. A stroke that affects the motor system can cause weakness in the muscles of only one side of the face. Because time is of the essence, responders should gather telephone numbers of relatives and witnesses. Later that evening, while reflecting on her first day as an EMS professional, Marcella realizes the importance of her stroke training.
As they manage the patient, members of the EMS team should make contact with the destination ED.
Recently trained as an EMS provider, John takes a call from the dispatcher about an 83-year-old female patient with a possible stroke. When John asks about the potential dangers of the patient’s high blood pressure, the supervisor tells him that during an acute stroke, the current recommendations are to avoid attempting to control blood pressure until the patient can be fully evaluated by medical personnel. EMS teams ideally attempt to transport potential stroke victims to hospitals that have been designated as stroke centers. When a potential stroke patient enters any ED, staff must begin a protocol that can lead directly to the administration of a thrombolytic drug at the present hospital or at a stroke center.
The time sheet then follows the patient to keep providers, nurses, and technicians on schedule. The Emergency Nurses Association and the American College of Emergency Physicians recommend a 5-level Emergency Severity Index (ESI) as a preferred system for triage in a busy ED (Gilboy et al., 2011).
Level 3 is a patient who requires urgent care and requires one or more resources but has stable or noncritical vital signs. When a potential stroke patient has been identified, a stroke page is initiated from the incoming EMS vehicle or from the ED triage nurse. The first parts of the stroke protocol include drawing blood and taking a medical history; these can be done immediately by the nurses, who should have standing orders. For speed and efficiency, the ED nurses should have standing written orders for as many steps in the acute stroke protocol as possible. Eleanor, a 62-year-old African American female patient, arrives to the emergency department accompanied by her daughter.
The nurse in the ED, Joan, asks the patient if she has had a headache, weakness, dizziness, tingling, fatigue, or slurred speech in the past. Based on Eleanor’s symptoms, medical history, and family history, the nurse immediately consults with the ED physician and alerts the stroke team. For all potential stroke patients, a comprehensive metabolic panel, a CBC, coagulation studies, and urinalysis are appropriate.
For blood work of a potential stroke victim, the minimum stat tests are listed in the box below.
To get laboratory results quickly, blood tests are drawn early in the evaluation, before sending the patient for imaging. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S.
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This Handbook provides instructions, information and reference material related to the work of panel members and to the IME process.
Issues affecting the health of immigrants and the immigration process itself are subject to change. Client A foreign national who is seeking to enter Canada, and in accordance with the Immigration and Refugee Protection Act and its Regulations, is required to submit to an IME.
Clinic staff Persons who are working in the panel member’s clinic and may be involved in the immigration medical process. EDE Excessive demand exempt is a category of client who is exempt from assessment of excessive demand.
ELISA Enzyme-linked immunosorbent assay, also known as enzyme immunoassay, which is a blood test for HIV.
Furthered cases Cases that require supplemental medical reports to complete the medical assessment.
Guardian A legal guardian is a person who has custody or who is empowered to act on behalf of another person and has been recognized as such by the competent authorities in the jurisdiction where the status was either recognized or granted. Handbook This Handbook is the standard reference for the orientation and training of panel members. IFHP Interim Federal Health Program: a program funded by CIC that provides limited, temporary coverage of costs related to health care for specific categories of people, including protected persons, refugee claimants, rejected refugee claimants, certain persons detained under the Immigration and Refugee Protection Act (IRPA) and other specified groups.
IMM 0535 Medical Surveillance Undertaking Form, issued to individuals who have undergone their IME in Canada or abroad and have been determined to require medical surveillance by Canadian Public Health Authorities.
IMM 1017 An IME form containing the client’s biodata, IME grading and panel physician declaration. IMM 5544 Supplemental medical and resettlement needs assessment form providing information on the special needs a client may have while settling in Canada. Locum tenens Medical practitioners who replace panel physicians for a short period while they are on vacation, taking training or unable to provide service for other reasons. Panel member A general term that refers to a panel physician, panel radiologist or panel laboratories or specialists authorized by CIC to perform IME-related activities.
Panel physician New term used for a medical doctor designated to perform, grade and submit IMEs.
Panel radiologist A radiologist designated to perform, grade and submit chest x-rays for IMEs. PHLU Public Health Liaison Unit, located in the Health Branch, CIC (the former term was Medical Surveillance Unit). Protected person – In Canada People who have been determined to be protected persons by the Immigration and Refugee Board of Canada (IRB), or in a Pre-Removal Risk Assessment, and who have been granted permanent residence as a result. RMO Regional medical office is the location of operations for medical officers who are CIC officials with responsibility for the Canadian immigration health program in a given region. The IRPA and its accompanying regulations set out the medical requirements that clients must meet in order to come to Canada as temporary or permanent residents. In addition, the legislation sets out the grounds on which a person may be found to be inadmissible to Canada, including inadmissibility on health grounds.
The purpose of this Act is to protect the privacy of individuals with respect to personal information collected by the government and to provide individuals with a right of access to their personal information. Under the Privacy Act, all individuals have the right to the protection of their personal information held by a federal institution. Pursuant to paragraph 8(2)(f) of the Privacy Act, Health Branch has concluded Memoranda of Understanding with certain partner countries on information sharing in order to align our network of panel members, which allows Health Branch to share information about our network with partner countries. The Access to Information Act gives every Canadian citizen, permanent resident and individual or corporation present in Canada the right to access records, in any format, held by a government institution, subject to certain exceptions. The Act is used to access information held by the government apart from an individual’s own personal information. It is not necessary for clients to use the Act to obtain a copy of the results of their own IME. Completion of orientation, which includes reading and understanding this Handbook and participating in discussions with CIC medical personnel. Completion of training, including eMedical training where and when relevant, which may be done individually or through group activities involving several panel members in locations where they operate in geographic proximity. Designation is not a permanent status and completing the designation process does not create any contract or agency relationship with CIC.
CIC immigration officials and medical officers consult one another regularly in order to determine the number of panel members required in a given location. If a panel member relocates his or her practice, that relocation must be brought to the attention of the RMO, as designation as a panel member is related to your location.
Complaints or disputes regarding a panel member’s performance may result in termination, depending on the situation. Panel members, depending on their field of work, are authorized to perform IMEs, arrange for diagnostics and investigations, and complete immigration medical forms.
Panel members performing IMEs should ensure that they meet CIC-mandated service standards and that there are no conflicts of interest in providing services.
For all clients, the Canadian IME will include an examination by a panel member and a medical assessment by a CIC medical officer.
The assessment of whether or not a client is inadmissible on health grounds is based on the health findings identified during the examination by a panel member. Once CIC has designated a laboratory in your area, panel physicians will be required to use this facility. The eMedical system is a Web-based system implemented by CIC and the DIAC for the electronic recording and transmission of IMEs. Panel physicians are to provide appropriate and timely advice to the client when they discover a serious disease not known to the client. In doing so, they are to uphold professional and ethical standards by referring back to the client’s usual physician or to an appropriate specialist, upon request. The panel member discovers inappropriate activity relative to the provision of IMEs by clinic, office, laboratory or radiology centre staff.
To support fraud prevention and the integrity of the IME process, panel members must confirm the identity of the client using an identification document acceptable for the Canadian Immigration medical examination. Panel members or clinic staff must also inform CIC if they suspect that clients are providing false information or attempting to falsify any aspect of the IME.
Panel members can proceed with the IME, and CIC will follow up on the concern raised about the individual’s identity and any other report of possible fraud. Panel members should help prevent fraud by educating their staff on procedures used to verify client identity (refer to Section 4.1 for additional information). Panel members must be aware that clients from some cultures may request special accommodation during the IME. Panel members should try to accommodate personal and cultural sensitivities, while keeping in mind that IME standards must be respected.
A panel member who fails to meet the IME performance standards reflects badly on the immigration medical program. If the panel member will have a locum tenens replacing him or her during extended absences, the panel member must give the RMO at least 14 days’ notice, preferably by email. Panel members cannot submit IMEs if their leave information indicates that they are on leave. Extended or repeated unapproved absences may result in termination of a panel member’s status. For personal and program integrity, they must enter leave dates directly in their personal record.
The RMO will update the information in their record in order to track the leave in their system.

A statement from the proposed locum indicating that he or she has read this Handbook and agrees with the standards and requirements defined herein. Note: Prior to recommending a particular physician or radiologist as a prospective locum, the panel member must be satisfied that the proposed locum has the qualifications and experience to perform IMEs.
If the RMO approves the request, a written response (by letter or email) will be sent to the panel member. The panel member must give the RMO at least 14 days’ notice, preferably by email, for every period of time where the locum will be acting on behalf of the panel member. Panel members must ensure that the locum has adequate training in IME requirements, reporting procedures and any updates.
The termination of a panel member will automatically cancel prior approvals of a locum for this panel member.
English and French are the official languages of Canada and panel members must be able to communicate with Canadian officials in at least one official language.
Panel members should inform CIC of the official language they prefer to use in correspondence. Panel members should inform CIC of the official language and any other language they speak. Panel members should also indicate in the drop-down list in eMedical other languages they speak. When performing IMEs, panel physicians may examine clients who speak neither of the two official languages, nor any other language that the panel physician speaks. If an interpreter is used, panel members must select and ensure that the interpreter is unbiased and has no connection to the client. The panel member’s unique identifier should be included in all correspondence with CIC. For panel members or their locum tenens performing a paper-based IME, the unique identifier, along with their name, must be clearly readable on each Medical Report (forms IMM 1017 and IMM 5419) and on each chest x-ray. Each photo attached to the Medical Report (IMM 1017) must be stamped to confirm the identity of the client. Panel radiologists may embed this information on the chest x-ray along with other required information about the client.
Forms, documents and results of investigations required for the completion of IMEs are the property of CIC.
Panel members who perform IME-related activities must follow the procedures below for copies and files as well as for original documents and information.
Original documents and information related to an IME must be forwarded to the responsible RMO electronically.
Original documents and information related to an IME must be forwarded to the responsible RMO by regular mail or commercial courier and must never be given to the client for delivery to the RMO. Panel physicians are required to keep copies and records of files for at least 2 years and in compliance with their local regulatory and licensing requirements. Regular contact will be maintained between panel members and RMOs regarding both medical and administrative issues. Written correspondence, such as letters, faxes or email, is preferred, but the telephone can be used when necessary (see Appendix I for RMOs’ addresses and contact information). Information about IME fees, services included in the fees, clinic’s address and contact information may be included in the advertisement. On occasion, the media may become interested in the IME of a particular individual and contact the panel member for information.
Panel members should never communicate confidential information they are privy to with respect to the immigration system or to individual clients.
Clients may have questions about the immigration process, particularly when CIC officials request additional medical information or investigations. These questions should be addressed to the immigration or visa office responsible for the case.
If panel members have non-eMedical-related questions regarding IMEs, they may contact their RMO listed in Appendix I. Panel members who have questions about eMedical should consult the eMedical System User Guides and Quick Reference Guides. Panel members in Canada should refer to Chapter 5 for instructions regarding requirements and fees for refugee claimants under the Interim Federal Health Program (IFHP).
Clear and transparent procedures for responding to complaints and resolving disputes improve client service and the integrity of the immigration medical program. If, during an IME, a panel member has a disagreement with a client, or confusion arises or an event occurs that might compromise client service, panel members should report these incidents to the RMO. The panel member feels that reporting a one of a kind situation may benefit the program or increase other panel members’ knowledge. Reports to the RMO should include the date of the incident, the client’s IME, UMI or UCI number and a brief description of the incident.
CIC’s Health Branch will consider the opinions and viewpoints of panel members and of anyone submitting a complaint or critical comment. Health Branch officers will occasionally visit panel members to ensure the quality of their work. Failure to meet performance standards may result in termination of the panel member’s designation. Continued failure to maintain an acceptable level of performance as set out in this Handbook or in accordance with written instructions from the RMO. For serious complaints, such as harassment, sexual misconduct or illegal activities, the RMO will suspend the panel member, issue a letter summarizing the facts that gave rise to the complaint and provide the panel member with an opportunity to reply. However, if the panel member’s designation is terminated because of performance deficiencies or complaints, there is no transition period and the termination is effective as of the date of the notification letter sent by the RMO. CIC will consider all requests for reconsideration and make every effort to provide panel members with a written reply within 30 days of the receipt of their request for reconsideration.
This chapter provides panel members with a step-by-step method for completing an IME and associated forms.
The IME consists of a medical history, physical examination, age-specific laboratory tests and age-specific chest x-ray.
With the launch of eMedical, the IME will be conducted, where technologically feasible, in a Web-based computer program designed for the electronic recording, transmission, processing and temporary storage of the IME and its associated results.
Panel members performing IMEs in a region where eMedical has been implemented must use the system to complete and submit all IMEs. Differences between the paper process and the eMedical process have been pointed out throughout this document. IME paper forms have been redesigned to ensure consistency between eMedical IMEs and paper-based IMEs. Client photographs are essential for ensuring that there is no substitution at any time during the lifecycle of the IME and that the person who undergoes the IME is the same person who is applying for entry to Canada. The eMedical system will include the photograph on all requisitions and referrals (laboratory, radiology, specialists and others). If the photographs do not meet the specifications, ask the client to provide new photographs before their IME can be completed. The photograph on the Medical Report (IMM 1017) must be stamped in the top right corner with the panel physician’s ID stamp. The client must submit a passport or other identification document acceptable for the Canadian Immigration medical examination.
Important: To ensure the integrity of the IME process, the same identity document must be used for all components of the IME, including laboratory, radiology and specialist referrals.
If the client provides personal details that seem inconsistent with the information on the submitted identity documents, panel members must identify the concern in the eMedical system or on the IMM 1017 – Medical Report (Client Biodata and Summary) for paper-based IMEs. Photocopies of the identification document concerned must be attached to the IME and submitted to CIC. Consent for the collection and release of IME information related to the administration of Canada’s IRPA or to the protection of the health and safety of Canadians. If a client does not give consent, the IME cannot be carried out and the panel physician must notify the responsible RMO. Clinic staff or a panel member should review the Consent and Declaration form with the client and answer any questions.
CIC has implemented one standard form, the Medical Report: Client Biodata and Summary (IMM 1017), for all immigration categories.
EDE clients are those who are exempted from assessment of excessive demand on the Canadian health care system.
Note: Panel physicians must complete and submit, either electronically or on paper, the IMM 5544 Resettlement Needs Assessment Form.
Note: EDE clients include refugees, refugee claimants and certain family classes and individuals with protected person status. The Medical Report (IMM 1017) form is typically issued by CIC with the client information and immigration information sections completed. Clients who have been issued a Medical Report (IMM 1017) must present the form to the panel clinic when presenting themselves for their IMEs. Clinic staff will search for the client health case in eMedical using the IME# (search may also be done using client name and passport number, or UCI# or UMI#). A live photo of the client is taken and uploaded to eMedical to verify identity throughout the life cycle of the IME.
Clinic staff must attach a client photo (provided by the client) to the Medical Report (IMM 1017). The Medical Report (IMM 1017) will be completed and submitted along with all other IME forms. Clients who are being processed as refugees overseas will have a Resettlement Needs Assessment (IMM 5544) form issued to them along with their IMM 1017 by a Visa Office (VO). Refer to the IMEI on the Resettlement Needs Assessment (IMM 5544) for detailed instructions on completing the form. UFM examinations are performed when clients report to a panel physician for their IME before a visa application has been submitted to CIC.
Panel physicians must ensure that they provide the client with the proof of having completed their upfront medical examination. Since an IME is valid for 12 months, panel physicians should remind clients to submit their visa application along with the proof of having completed their upfront medical examination well before the expiration of the 12 months; otherwise, the client may have to undergo a second IME.
Enter the Client personal details (mandatory fields include Title, Family name, Gender, Date of birth and Country of birth).
Panel physicians will use IMM 1017B Upfront paper forms, which have been provided to them and that are pre- populated with a UMI# and a barcode (see sample form in Appendix III).
Clinic staff must select the immigration category by checking the appropriate box (student, worker, visitor, family EDE or refugee claimant (in Canada only)).
Note: It is very important to ensure the correct page goes to the client and the correct page goes to your RMO.
Grade A indicates that there are no abnormal findings present and no significant abnormal history. Panel physicians must provide this information in the comments section or they may attach a report to the IME. The following table lists additional requirements when the answers to medical history questions show abnormality, whether the IME is completed in eMedical or on paper.
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
Most commonly, intracerebral hemorrhages are caused by rupture of vessels due to long-term atherosclerotic damage and arterial hypertension. Such ruptures may occur due to weakened vascular walls (aneurysms) or as a result of congenital arteriovenous malformations (AVMs), with subsequent bleeding into the brain or the subarachnoid space surrounding the brain. On the average, someone in the United States has a stroke every 40 seconds (Go et al., 2013). The American Heart Association estimated stroke costs of $74 billion in 2010, including the cost of healthcare services, drugs, and lost productivity (Lloyd-Jones et al., 2010). Those at higher risk include the elderly, African Americans, those of lower socioeconomic status, and residents of the southeastern United States.
For more than 600,000 Americans, this will be their first stroke, but almost 200,000 of the yearly strokes are recurrences (Sidney et al., 2013). Thus, stroke is the third leading cause of death in this country, after heart disease and cancer (CDC, 2010a, b). Stroke is most common in people older than age 75, and because women live longer than men, overall about 1.5 times more women than men die of stroke in the United States each year. In the United States, living in the Southeast carries with it the highest risk for stroke compared to the rest of the nation’s population. The vertebral arteries supply blood to the remaining 20% of the brain, including the brainstem, cerebellum, and most of the posterior cerebral hemispheres. The common carotid artery leaves the aorta on the left and the brachiocephalic artery on the right.
The anterior and posterior circulations connect through a circular anastomosis of arteries called the Circle of Willis. Symptoms of a ruptured aneurysm in the Circle of Willis are similar to other hemorrhagic stroke symptoms and can include a sudden headache, nausea, vomiting, neck pain, fainting, light sensitivity, or a loss of consciousness and seizures.
Therefore, a blockage of the internal carotid circulation on one side of the brain will often produce a characteristic sudden and painless blindness in the eye on the side of the blockage, which would be termed an ipsilateral blindness. These regions include the primary motor and sensory cortices; therefore, a blockage of the internal carotid artery circulation often produces unilateral motor weakness or sensory loss. Blockages of the vertebral circulation can produce problems of vegetative functions, such as consciousness and respiration, and problems of balance, hearing, motor coordination, and visual perception (Judd et al., 2013). For example, there is often less effect on the contralateral leg and foot, and the communication difficulties are typically limited to expressive (Broca’s) aphasias.
Vertebral artery strokes can produce a wide variety of symptoms, including vertigo, nystagmus, vomiting, ipsilateral (same-sided) ataxia, and hypoglossal nerve dysfunction.
Ischemic stroke is the name used for nonbleeding strokes due to clots, but both ischemic and hemorrhagic strokes cause ischemic damage.
The brain uses energy at a high rate, but it can only store a small back-up supply of energy. The depolarization also sets off the release of unusually large amounts of extracellular excitatory neurotransmitters. In a stroke, as soon as cerebral blood flow is reduced, electrical activity stops in the affected region of the brain and neurological deficits appear. Typically, strokes leave enough arterial perfusion that many neurons can maintain a low level of energy production sufficient to slow the onset of their deaths (Oechmichen & Meissner, 2006). In those parts of the affected region that have no blood flow, neurons begin to die in less than 10 minutes. Within this six-hour window, certain treatments can reduce the amount of brain damage that is irreversible. The administration of rtPA has produced an eightfold improvement in the outcomes of ischemic strokes when the drug was given within the first three hours after symptoms appeared. The force of blood flowing extracellularly in the brain parenchyma pushes cells apart, dissects brain tissue, destroys connections, and injures brain cells. An expanding hematoma, in combination with cerebral edema, can push portions of the brain through intracranial narrow spaces, such as the dural openings or the foramen magnum. The long-term treatments for stroke focus on preventing recurrences and maximizing motor and functional capabilities.
Small vessel damage usually results from lipohyalinosis, which thickens the media in the walls of small arteries and eventually leads to small artery occlusions and stroke. Other ischemic strokes are caused by emboli (debris and clots that arise elsewhere and are subsequently swept into the cerebral circulation). For long-term treatment, both the site of the extracranial arterial pathology and the source of the emboli must be discovered and treated if future strokes are to be prevented. The causes of cerebral hypoperfusion range from arrhythmias to cardiac arrest and from respiratory failure to bleeding or shock. When the injured arteries are inside the brain tissue, the strokes are called intracerebral hemorrhages.
The most common concomitant problems are hypertension, trauma, amyloid angiopathy, bleeding diatheses (including anticoagulant or thrombolytic drugs), cocaine or amphetamine use, and ruptured vascular malformations or aneurysms (Hays, 2011).
In this disorder, beta-amyloid, a 42-amino-acid proteolytic product of amyloid precursor protein (APP), accumulates in the walls of small and medium-sized arteries, leading to a progressive weakening and erosion of the vascular wall.
Most of these aneurysms are on or near the anterior portions of the Circle of Willis (Sunderrajan et al., 2013). Rupture of a cerebral aneurysm is most often a condition of middle age, peaking in people aged 35–65 years. The average cerebral aneurysm is 7.5 mm in diameter, but ruptured aneurysms tend to have been larger than 10 mm in diameter.
The risk of having a stroke can be reduced in the same way that all cardiovascular disease risks can be reduced. Many things can be done to reverse or to temper the effects of a stroke, but successful medical therapy depends on immediate medical attention. Even people who have suffered one or more strokes need education: a survey by the American Heart Association (2010) found that only 55% of patients who had had a stroke could identify even one stroke warning sign.
The public should understand that if there is the possibility that someone is having a stroke, they should not hesitate—they should call 911 immediately. The best first aid is professional transport to a hospital, and getting an ambulance is the most important thing that a bystander can do for a stroke victim. First aid providers should be taught to press on a bleeding area until the bleeding stops or an emergency medical services (EMS) team arrives.
In fact, however, patients usually get to the appropriate hospital faster if they use the EMS system by calling 911. Strokes account for about 2% of all 911 calls, but those calls should set off a well-planned and speedy treatment protocol. To make decisions for stroke victims, 911 operators should be taught how to identify likely stroke symptoms. The infrequency of stroke calls means that EMS operators may not have stroke-appropriate questions committed to memory, so a written set of screening questions should be on each operator’s desk. Helicopters or other aircraft can be used to take the EMS team to the patient and then to transport the patient and the EMS team to a stroke center. EMS operators should have a blank checklist that can be filled in with essential background information.
The basic information to be covered is found in the American Heart Association’s ACLS provider manual and online (AHA, 2010).
First, the nurse must know which medical techniques can be performed by paramedics and emergency medical technicians under local regulations. Moreover, the needs of a community, the availability of acute stroke care, and the recommended prehospital assessments and care protocols continue to be updated.
In cases in which there is a question of stroke, paramedics then determine the likelihood of stroke and collect critical background information.
It is essential to use a standardized screening test for stroke, as studies have shown that a prescreening test is significantly useful in identifying stroke patients (Berglund et al., 2012).
An abnormal response to any of the three indicates that it is likely that the patient is having or has recently had a stroke.
This task requires the patient to strongly contract facial muscles on both the right and the left sides of the mouth. If knowledgeable acquaintances are available, they are asked to meet responders at the receiving hospital, or if necessary, to travel with responders. Ideally, EMS teams will use developed checklists with the essential questions to capture all the critical information. She performed well in all the training classes, but she is still quite nervous about her first call as a full-fledged EMS professional. Marcella does an initial visual assessment and notices that the woman’s face appears to be sagging on the right side.
Within 30 minutes of the onset of symptoms, the woman was examined by stroke specialists and now has a good prognosis for eventual recovery.
As soon as possible, begin transporting the patient to the appropriate ED and continue the rest of the prehospital care en route. Simply notifying the receiving hospital that a potential acute stroke patient will be arriving has been shown to shorten the eventual time between delivery to the hospital and receipt of treatment (Abdullah et al., 2008). The hospital stroke team can tell the paramedics about the size and placement of the IV access that will be needed, and hospital specialists can advise the paramedics about managing complications, such as severe hypertension, hyperglycemia, or cardiac dysfunction. Strokes are crises of insufficient oxygen delivery to the brain, so it is important to keep the patient’s blood oxygen saturation at normal levels. Treat shock or significant dehydration with balanced salt solutions (isotonic crystalloids, such as normal saline). Hypoglycemia produces symptoms that look like stroke, and persistent hypoglycemia will cause brain injury. Strokes can be caused by preexisting atrial fibrillation or by atherosclerosis, which can already have caused heart damage that can be seen in ECG recordings. John continues to monitor the patient’s blood pressure, which remains the same, and her other vital signs.

Stroke centers, by definition, have well-rehearsed protocols for dealing efficiently with stroke patients. The EMS team ideally will have identified any potential stroke victims that it is bringing, but approximately one half of all stroke patients will not use an EMS service for transportation to the ED.
This will ensure that any triage nurse can quickly channel potential stroke victims into the ED’s stroke protocol. Therefore, patients with suspected acute stroke are assigned the same high priority as patients with acute myocardial infarction or serious trauma, regardless of the severity of the neurological deficits.
Resources include laboratory tests, imaging studies, medications needed (IV, IM, nebulized), consultations required, and whether simple or complex procedures are needed.
It is important to remember that it is not a full assessment but gathers the necessary information for a rapid response.
The stroke code team then reports to the ED, joins the ED receiving team, and begins the acute stroke protocol once the patient is medically stable. Next, the patient needs a selected physical examination and a complete neurological examination with a formal stroke assessment—the NIH Stroke Scale and, for patients with a reduced level of consciousness, a Glasgow Coma Scale Score. These orders can be enacted while the code stroke team is reporting to the ED (Gilboy et al., 2011). Eleanor presents with sudden onset of left eye blindness, beginning 30–45 minutes ago while she was at home reading a magazine.
Beyond occasional headaches, Eleanor denies any of these symptoms and adds that this blindness has never happened to her before.
Increased intracranial pressure can suppress the respiratory reflex and control mechanisms in a stroke victim, and intubation may be needed to ensure sufficient ventilation.
Oximeter readings of blood oxygen saturation can be taken immediately, and a finger stick for blood glucose level will rule out hypoglycemia. For certain patients, hepatic function tests, lipid profile, toxicology screening, blood alcohol level, or pregnancy test will also be appropriate. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
It leads to the title in accordance with the Wikipedia naming conventions for capitalisation, or it leads to a title that is associated in some way with the conventional capitalisation of this redirect title. 2, 2016, the United States Air Force declared Initial Operational Capability for the F-35A Lightning II. These responsibilities include management of the panel members (including panel physicians, panel radiologists and laboratories) who perform immigration medical examinations (IMEs) in Canada and abroad. In providing these services, the RMOs rely on the IMEs that panel members conduct on clients for permanent residency and some categories of temporary residency in Canada.
As part of its modernization agenda, CIC has implemented an electronic IME Web-based processing system called eMedical.
Panel members may include physicians, radiologists, laboratories and other designated health care professionals involved in the IME process.
All panel members must ensure that they remain familiar with it and with departmental instructions, including interim changes and updates provided by CIC. Panel members should be aware of the following legislation as it relates to immigration and the requirements with respect to medical examinations and inadmissibility on health grounds. One of the objectives is to ensure that the movement of people into Canada contributes to the country’s cultural, social, and economic interests and affirms its humanitarian commitments, while protecting the health, safety and security of Canadians. Moreover, Canadian citizens, permanent residents and other individuals present in Canada have the right of access to their own personal information held by government institutions.
Subsection 8(1) states that the government institution shall not disclose personal information without the consent of the individual to whom the information relates except under the circumstances provided under subsection 8(2). Health Branch requests that all panel physicians sign a consent form to share information with other immigration health authorities. Panel physicians are authorized to provide clients with a copy of their own IME upon the clients’ request. Based on CIC’s operational requirements, the number of designated panel members in any given location may be reduced or increased. They do not have the authority to assess or determine whether the medical conditions of clients are grounds for inadmissibility. They are also required to help prevent fraud and abuse of Canada’s immigration laws, submit to performance evaluations, follow proper procedures for absences, and use English or French in their communications with CIC.
Where necessary to establish compliance with the IRPA and the Immigration and Refugee Protection Regulations, clients will be asked to undergo further medical examinations. In regions where eMedical is available, panel members and their clinic staff will be required to complete all IMEs and enter the results in the eMedical system, unless otherwise specified by the responsible RMO. Panel members are expected to exhibit professional behaviour and perform their IME-related activities in a manner that is in keeping with the principles of proper medical practice and with CIC policy. Female clients, for example, may be uncomfortable with a male examiner, in which case panel members should offer to have a chaperone present during the examination. In such cases, panel members will indicate on the examination form the type of accommodation provided and the names of other persons present during the examination. Consequently, the panel member’s inclusion in the panel member network may be terminated. The procedure for completing the IME is discussed in Chapter 4 and is also subject to performance evaluation. This will allow the RMO to activate the locum’s P number allowing him or her to use eMedical.
The panel member will then notify the locum that he or she has been authorized to provide services.
This unique identifier will replace the designated medical practitioner stamp that was previously used.
For panel members, the eMedical logon information will be linked electronically to the panel member’s unique identifier. When documents are sent by courier, panel physicians must ensure that the IME forms and results are sent in appropriate order (refer to Appendix V for instructions) and should retain shipment tracking numbers for six months.
It may not be used for other purposes, including research, clinical studies or investigations, without appropriate consent of the client and CIC. RMOs are the points of contact for panel members to address inquiries, questions and comments about individual immigration medical cases, examinations and about the immigration medial program. These officials may be seeking information about local health conditions, medical resources for consular services or help with a personal medical condition. Under no circumstances should a panel member provide the media with information about a particular case. This section explains how CIC will deal with incidents, complaints and quality assurance concerns. Complaints regarding the IME and related services may arise from clients or other persons outside CIC. While the panel member’s designation is suspended, IME activities by the panel member cease until the panel member is notified that he or she has been reinstated by CIC. If the response is deemed satisfactory, the panel member will be informed of the decision and be reinstated with appropriate recommendations. Panel members should send written notification to the RMO, including the anticipated date on which activity will cease.
Photographs must be attached and submitted with the IME whether the IME is completed in eMedical or on paper. Clients who are eligible for UFM examinations will not have a Medical Report (IMM 1017) issued by CIC nor will they have an existing file in the eMedical system. Note: For refugee claimants in Canada, select the category family EDE, and scan and attach the document provided by the client.
Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The most common extracranial source of emboli is the cervical bifurcation of the common carotid artery, while the most common sources of intracranial thrombi are the main trunk and branches of the middle cerebral artery. More commonly, however, the patient presents with an acute completed stroke, and the focus can quickly shift to care and rehabilitation (Langhorne et al., 2011). TIAs often present as amaurosis fugax, a transient loss of vision in one eye (Panagos, 2012). Presented below are some relevant data compiled by the National Center for Health Statistics (NCHS) for stroke in the United States.
It is estimated that approximately 17% of these survivors have residual difficulty performing the basic functional activities of their daily lives (CDC, 2010a). Additionally, the chance of dying from a stroke increases with the patient’s age (NCHS, 2012). However, men younger than 75 have a higher incidence of stroke than women of the same age (CDC, 2010a, b). A lower level of educational achievement is also associated with an increased risk of stroke (CDC, 2012). It bifurcates into the internal and external carotid arteries about halfway up each side of the neck. Beyond ischemic damage, hemorrhagic strokes cause additional physical damage due to the pressure that builds from the excess blood that has been released into the brain or the CSF. Complete ischemia immediately decreases the available oxygen and glucose in the affected region of the brain, and without continual nourishment, local neurons will run low on their internal back-up stores of adenosine triphosphate (ATP) within seconds.
These events cause the influx of calcium ions, which set off an unregulated intracellular cascade of calcium-triggered processes, including the activation of catabolic enzymes, such as proteases, phospholipases, and endonucleases. Even when an artery is entirely occluded, the cerebral circulation has some collateral coverage with overlap and interconnections, and some blood usually gets to the affected brain regions via other routes. For a time, the silent neurons remain alive, but they no longer have the energy to generate membrane potentials that are sufficient to respond to stimuli or to transmit signals. In those areas with <30% of the normal blood flow, neurons begin to die within an hour. Ischemia is also produced when pressure from a hematoma or from brain edema constricts cerebral arteries. To plan long-term treatment, physicians must determine the location of the primary vascular injury and its underlying or predisposing causes.
It is helpful to divide the conditions leading to such locally generated obstructions into large vessel pathologies and small vessel pathologies. Lipohyalinosis, which is produced by hypertension combined with atherosclerosis, is especially destructive to those branches of the middle cerebral, vertebral, basilar, and Circle of Willis arteries that come off at right angles to the parent artery and that dive into the brain parenchyma. Extracranial stroke emboli are formed by large vessel pathologies and by other conditions that foster the formation of blood clots that can crumble or be dislodged. The symptoms of a global reduction of blood flow to the brain are diffuse, bilateral, and nonfocal, and they include the signs of circulatory compromise—pallor, sweating, tachycardia, and hypotension. When the injured arteries are outside the brain (where they run in the subarachnoid space), the strokes are called subarachnoid hemorrhages.
The specific location of ICH has genetic linkages with lobar ICH associated with APOE-epsilon2 or -epsilon4 genotype, while non-lobar ICH is associated with hypertension (Martini et al., 2012). Therefore, patients having a stroke need to be taken immediately to an emergency department that has the personnel and equipment to provide comprehensive acute stroke treatment, preferably at a primary stroke center.
EMS teams are trained to choose the most appropriate hospital in the region, and this is not necessarily the closest hospital.
It is also important that the caller’s number and location be displayed automatically for dispatchers. When a dispatcher is able to flag a possible stroke victim, the EMS team can be given time to review and plan during their outbound trip and to notify the nearest stroke center.
Helicopters can also be used for secondary transport of patients from a remote receiving emergency department to a stroke center. This document, along with the results of stroke screening questions, is then faxed or sent by computer to the ED that is receiving the patient. Second, the nurse must learn which area hospitals are equipped and staffed for treating acute strokes. Hemorrhagic strokes, however, can worsen quickly and deteriorate into stupor or coma with respiratory depression or breathing irregularities. In order to make this assessment, some health professionals ask potential stroke victims to try to smile.
Weakness on one side produces a lopsided grin that reveals more upper teeth on the stronger side. For emergency treatments, it will be helpful if next-of-kin are immediately available for consent. Within the first half hour of her first shift, Marcella hears the call from the dispatcher about a likely stroke victim. Each EMS unit should be provided with maps showing the nearest appropriate ED for stroke management in any area (Jauch et al., 2013). Describing the patient’s condition, time of onset of symptoms, and medical history allows the mobilized physicians, nurses, imaging specialists, and pharmacists of the acute stroke team to begin planning. Attach a pulse oximeter and treat hypoxemia (in this case, oxygen saturation <95%) with supplemental O2. Otherwise, saline lock the IV or set the IV to drip the minimum amount of balanced salt solution to keep the line open. Therefore, as soon as possible, check the patient’s capillary blood glucose level and treat hypoglycemia with glucose. However, blood pressure management is a delicate matter in the acute phase of strokes, and the choice of treatment depends on a detailed diagnosis that can only be made in a hospital. After five minutes on oxygen, John notices the patient’s color and her respiration rate normalizing. However, not all regions are served by stroke centers, and even when stroke centers are accessible, approximately one half of all stroke patients coming to emergency departments do not use EMS transportation.
The larger support team is a task force that keeps the stroke program organized, efficient, and up-to-date. This is true whether or not the patient is confused, lethargic, or disoriented and whether or not the patient is in pain. Resources do not include needing a history and physical, saline or heplock, oral medications, immunizations, primary call provider, simple wound care, or items such as crutches, slings, or splints. In this time-limited evaluation stage, a chest x-ray is warranted only when needed for immediate decisions about heart or lung problems. Eleanor’s health history reveals that she has well-controlled type 2 diabetes and hypertension, with untreated hyperlipidemia that was recently diagnosed. Vomiting can be another consequence of increased intracranial pressure, and intubation can protect the lungs from aspiration. In addition, in the case of an intracerebral hemorrhage, blood typing and cross matching should be done if fresh frozen plasma may be needed to reverse a coagulopathy.
1, 2016The World's Strongest Man attempts to pry Old Glory from The Bulgarian Brute's clutches. Health findings on the IMEs allow CIC medical officers to make recommendations on the medical admissibility of persons requesting entry to Canada.
The information to be shared will not be related to individual clients or a specific type of care; rather it will be generic information concerning administrative (such as email, contact addresses) and operational activities (such as electronic capabilities, locations) as well as information gathered during evaluations, assessments or onsite visits by CIC officers.
Upon examination of the new location of the practice and an assessment of the operational requirement for panel members in that location, the affected panel member will be informed of a decision confirming his or her status and given an opportunity to respond. More specifically, panel members do not have authority to give clients an opinion on their medical admissibility. The panel member’s unique identifier will be embedded electronically in each IME or chest x-ray they submit through eMedical. The eMedical logon ID must not be disclosed to any other person or used by any other person to submit IMEs or chest x-rays. Such requests are not related to the immigration medical program and panel physicians may respond to these inquiries as they choose. Consequently, the fees for IMEs may vary from country to country and even within a country.
In addition, CIC personnel may provide critical comments or notifications of errors, performance issues or situations of concern regarding the IME and related services. If the response is unsatisfactory, the panel member’s designation will be terminated. Panel physicians who are terminated because of operational needs will be notified in writing by the RMO at least 30 days prior to any such change in the network.
Only in the event of a system outage should paper IMEs be used by eMedical-enabled panel members.
If the client or clinic staff completes it, the panel physician must review and confirm the information provided. The internal carotid artery continues upward, passes through the foramen magnum, and joins the arterial Circle of Willis. This increase in intracranial pressure presents additional problems for the hemorrhagic stroke patient, particularly in the acute phase and within the early recovery period. In those areas with 30%–40% of the normal blood flow, some neurons begin to die within an hour, but others can be revived for many hours. Likewise, bleeding into the CSF raises intracranial pressure, and this too will reduce cerebral blood flow. Herniation can irreversibly damage brain regions, and when vegetative brain centers, such as the reticular activating system or the respiratory control nuclei, are compressed, the result can be coma or death. Atherosclerotic thrombi can enlarge in situ and reduce distal blood flow, or they can break off and occlude smaller arteries upstream.
One common source of stroke emboli is the left atrium of the heart, where thrombi can form during atrial fibrillation. In addition, the care and assessment that an EMS team gives a stroke victim shortens the time lag between the onset of stroke symptoms and the evaluation and treatment of the stroke. At the moment, two telephone systems do not always give 911 operators the detailed locations of callers: Multiline Telephone Systems (MLTS), which are used by many large organizations, and Voice over Internet Protocol (VoIP) services. Studies have indicated that notifying a primary stroke center significantly improves outcomes (Patel et al., 2011).
Therefore, even when a potential stroke victim appears to need no airway care, the EMS response team must be alert to the sudden appearance of breathing problems. However, the normal smile of a healthy person is often asymmetric, and an asymmetric smile in a patient can be the result of habit rather than a sign of a stroke.
Rushing to the scene, Marcella and her team are greeted at the door by the patient’s daughter, who is frantic with worry.
Currently, there is no indication that supplemental oxygen will benefit a patient who already has normal levels of blood oxygen saturation. In general, the goal is to add only a minimal amount of extra fluid, because overhydration can cause cerebral edema.
Therefore, current recommendations are that EMS and nursing personnel not attempt to treat high blood pressure en route to the hospital. Another five minutes later, the EMS team and the patient arrive at the hospital, where the stroke team takes over the patient’s care. If more than one resource is required but the patient’s vital signs are stable, the patient is considered Level 3.
The ED’s stroke protocol should explain how to determine whether any of these extra tests are necessary.
Panel members working in countries where eMedical is implemented will need to complete and transmit all IMEs through this Web-based system. In all cases, the online version of the Handbook will be the most current and is the version that should be consulted. Questions and information on specific cases should always include identification details, such as the IME, unique medical identifier (UMI) or unique client identifier (UCI) number along with the client’s date of birth. If a panel member is completing a paper-based IME that must be mailed to the RMO, he or she should discuss the method and cost of sending the documents with the client beforehand.
Affected panel members will receive a letter of concern from the RMO and be given an opportunity to reply to the complaint.
A common pattern is severely reduced perfusion in the core of an ischemic region, with gradually increasing perfusion toward the edges. Besides atherosclerosis, other occlusive conditions of large cerebral vessels include vasoconstriction (as in migraine disease) and arterial dissections.
If the receiving hospital will need a specialized IV line, placing the appropriate line in advance can save time. To avoid possible breaches of confidentiality, information requests should never identify a client by name.
In accordance with the principles of natural justice and procedural fairness, privacy rules will not be breached when sharing the content of the complaint.
Her pertinent family history includes a mother who had a cerebrovascular event at age 82 years. The team is able to quickly transport the woman, whose vital signs remain stable, in under 10 minutes to the stroke center.

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