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Neurological problems represent a wide range of presentations. The complaint may be as vague as confusion or lethargy or as specific as hemiparesis or aphasia. The underlying pathologies are numerous and encompass primary neurologic disorders as well as sequelae of metabolic, infectious, and toxic causes. Psychiatric disorders are complex and may also masquerade as a neurological issue. In the prehospital setting, it is very challenging and can be very difficult to elicit the etiology of the neurologic presentation. Historical information from the patient if possible, family, and bystanders is important for the early differentiation and treatment of these patients (Table 38-1).

TABLE 38-1

Neurological Problems in EMS

Neurological emergencies require transport to hospitals for definitive care. Depending on the region and hospital system in the area, undifferentiated neurologic presentations should ideally be sent to the hospital system with stroke care. Protocols and interfaculty agreements are important for efficient, quality transports. Delays in transport can be deleterious. In events where delays occur, medical control should be involved to assist with timely and appropriate patient care.


The incidence of stroke in the United States is 178,000 strokes per year.1 Stroke affects about 3% of adults2 and is the third leading cause of death in the United States, accounting for 137,000 deaths annually.3 Approximately 29% to 65% of stroke patients utilize EMS systems,4 and the EMS system is integral to care for stroke patients. The American Heart Association recognizes the chain of survival for stroke treatment (Table 38-2). In cases of alteration in mental status, the diagnosis may be difficult to make in the field. One study showed a correlation with elevated blood pressure in altered mental status patients in the field and an increased risk of stroke.5

TABLE 38-2

Stroke Chain of Survival

In December 1995, The NINDS trial6 was published in the New England Journal of Medicine. This study was a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA). This study suggested that t-PA was beneficial when given within 3 hours of onset of the ischemic stroke. This study established the commonly accepted protocol for administration of ...

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