A stroke occurs when the blood flow to part of the brain is interrupted. This can be caused by bleeding in the brain, or a blockage of a blood vessel such as by a blood clot. It can be very serious and requires immediate medical care. Stroke is the second leading cause of death and the third leading cause of disability (loss of vision, speech or partial or complete paralysis) (Johnson et al., 2016). Early admission to a medical facility greatly increases the chance of a positive outcome so it is important for first aid providers to quickly recognise stroke symptoms and access emergency medical services (EMS).
Guidelines
- First aid providers should use a stroke assessment system to recognise the symptoms of a stroke.**
> First aid providers should use a stroke assessment system, such as FAST or CPSS (see below), to recognise the symptoms of a stroke.*
> First aid providers may use stroke assessment systems that include blood glucose measurement, when available, such as MASS or LAPSS, to increase specificity of stroke recognition.* - First aid providers should NOT administer oxygen to a person experiencing a suspected stroke. *
Good practice points
- Mild stroke-like symptoms that last less than a few minutes indicate a transient ischemic attack (TIA) or “mini stroke”. The person experiencing these symptoms should seek medical care as soon as possible to decrease the risk of more permanent outcomes.
- For a person showing stroke signs and/or experiencing stroke symptoms, EMS must be accessed as soon as possible.
- First aid providers should help the person get into the best possible position, keeping in mind the person’s comfort, and physical and cognitive abilities. This may include lying on their back or sitting.
Chain of survival behaviours
Prevent and prepare
- There are national and global organisations that conduct research on how to reduce the likelihood of stroke. Refer to your country’s health authority for more information.
- Make healthy lifestyle choices to minimise certain risk factors such as high blood pressure, obesity, blood sugar level, hyperlipidaemia and renal dysfunction. Avoid activities such as smoking.
Early recognition
- There are a variety of acronyms in the English language to help recognise the signs and symptoms of stroke. FAST is recognised as an effective acronym for first aid providers. It reflects the need for early recognition and medical care, which improves the person’s chances of a positive outcome.
FAST
FACE – Facial numbness or weakness, especially on one side: ask the person to smile or show their teeth. Check if the person’s mouth is crooked and whether one corner of their mouth is drooping.
ARM – Arm numbness or weakness, especially on one side: ask the person to extend both arms at the same time, straight out in front of them and ask them to turn their palms upwards. Carefully look if one arm is sagging or drifting around.
SPEECH– Abnormal speech, difficulty speaking or understanding others or a loss of speech: ask the person or companions if there are any changes in their speech
TIME – Time is important: try to find out how long the symptoms have been going on (when the symptoms started or when they were seen acting normally by others). Access EMS immediately.
CPSS
The CPSS (Cincinnati Prehospital Stroke Scale) tests three signs for abnormal findings which may indicate that the person is having a stroke (FACE, ARM and SPEECH).
Signs of stroke
- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The probability of stroke is likely if the person, when asked to:
> show their teeth, the corner of their mouth droops
> lift both arms with palms turned upwards while eyes are closed, one arm drifts or droops. - Sudden confusion, trouble speaking or understanding. The probability of stroke is likely if the person, when asked to:
> repeat a simple sentence, speech is unclear or slurred, or the words do not come easily. - Sudden trouble in seeing with one or both eyes.
- Sudden trouble walking or experiencing dizziness, loss of balance or coordination.
- Sudden, severe headache with no known cause.
- Seizure (of a non-epileptic person).
First aid steps
- Use a stroke assessment system to recognise the symptoms of a stroke.
- If you suspect a stroke, access EMS immediately. Note the time it started.
- Help the person get into the best possible position, keeping in mind the person’s comfort, physical and cognitive abilities. Support them if they are at risk from falling.
- Monitor the person’s breathing and reassure them. Keep talking to the person.
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NOTE
- If the person becomes unresponsive, open their airway and check their breathing. See Unresponsiveness.
- Note that similar symptoms may be caused by high or low blood sugar. See Diabetic emergency.
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Access help
- Emphasise the signs and symptoms of stroke to the medical professional.
- The faster the person can get medical help, the less damage to the brain there may be, so it is important to get help quickly.
Recovery
- The signs of stroke indicate brain injury. Even if the person seems to have recovered, they should still access medical care.
Education considerations
Context considerations
- Learners’ access to care, such as available transport or distance to the nearest medical facility, will vary depending on their local context. Work with learners to define what EMS access looks like in their community. In some settings, an ambulance will arrive within minutes after EMS is called, while in others, the ill or injured person may need to wait for a medical professional to come to them. In some cases, the first aid provider must transport the person to the medical facility by car, boat, or other means.
- A quick response time is critical to caring for someone who is having a stroke. Understanding the EMS in their community builds learners’ confidence to act quickly and determine the fastest method to transport the person to a medical facility.
- In many homes there are ways to measure blood glucose because a family member has diabetes. If possible, the first-aid provider may be able to perform a blood glucose test for the person who has had a stroke and may use a stroke scale assessment including glucose measurement in relation with the EMS system.
Learner considerations
- Stroke knowledge, risk perception and effectiveness of educational media may differ between genders. Consider different educational interventions depending on the learner group (Marx et al., 2010).
- Use appropriate language levels according to the audience (e.g., adults or youth) and cultural context. Depending on learners’ context, you may need to replace the phrase “call EMS” with “call a healthcare professional” or “ensure it is safe to travel to the medical facility” (Caminiti et al., 2017).
Facilitation tips
This section focuses on the following points:
- Challenges learners may encounter when applying their knowledge of stroke in a real situation.
- How the facilitator can support learners in overcoming these challenges and confidently care for someone experiencing stroke.
After leaving the learning environment, learners may struggle to recognise the signs of stroke or connect their recognition with the need to access EMS. This gap between their knowledge and application may be due to the following reasons:
- A stroke’s visual cues are not the same in every person.
- Learners may not recognise the mild, temporary stroke-like symptoms that indicate a transient ischemic attack (TIA) or “mini stroke”. Recognising the possibility of a TIA allows for early treatment and reduces the risk of a major stroke.
- Signs and symptoms may present gradually or be confused with another condition (e.g. a diabetic emergency).
- Learners often require more than one indicator to recognise stroke.
- The ill person may think the symptom they are experiencing is nothing serious (e.g., they may experience numbness but are still able to move). It is often a perceived seriousness of warning signs, rather than recognition that prompts first aid providers to access EMS.
- Many media campaigns and training videos only show severe strokes. This leads learners to believe that a stroke only occurs when several or all warning signs are severe or happen at the same time (Dombrowski et al., 2013).
The result of these challenges is a delay in accessing EMS, which can have negative results and limit care options. Because there is a limited timeframe to administer some medications and other treatments associated with caring for stroke, response time is critical. Emphasise that quick recognition and care links to the highest chance for a positive outcome (Maze et al., 2004).
The following actions will help to connect understanding with action and build learners’ confidence to act quickly.
Design activities that will help learners to:
- Understand that their job as the first aid provider is to recognise the signs of a stroke and call EMS or get the person to a medical facility (Maze et al., 2004).
- Develop an understanding of stroke (beyond using FAST) and to recognise minor symptoms, such as impaired vision, unsteadiness and headache.
- Develop critical-thinking skills to determine when and how to respond.
- Understand the chain of people involved in providing immediate care to the person experiencing stroke.
- Engage in the decision-making process of providing care.
- Consider the perceived risks, benefits and barriers to accessing EMS.
- Understand that a quick response time increases the possibility of treatment and recovery (Caminiti et al., 2017).
Design activities and training that support the above learning to help first aid providers trust in their ability to act quickly and effectively. This will help to reduce delays in care.
Facilitation tools
The intent of the learning activities developed for this topic is to build learners’ confidence and connect their understanding of warning signs with actions (Caminiti et al., 2017). These activities are also an opportunity to reinforce positive behaviours.
- Use acronyms such as FAST help to quickly recall sequenced information (Bietzk et al., 2012; Robinson et al., 2012; Wolters et al., 2015).
> The CPSS assessment tool contains similar physical signs to check (face droop, arm weakness, speech abnormalities. Therefore, you may want to consider adapting the acronym (while maintaining the signs, symptoms and actions to take) into a word that is more suitable in your language and therefore more accessible to your learners.
Where educators wish to use alternative stroke scale assessment tools such as MASS or LAPSS (because of the likelihood of a first aider being able to take a blood or glucose measurement, for example), ensure that this is both appropriate for your learners and authorised in your country.
- Use multiple resources such as media, community education and professional education when developing the lessons for this topic. A layered approach has shown to successfully reduce pre-hospital delays (Becker et al., 2010; Caminiti et al., 2013; Flynn et al., 2014; Wall et al., 2008).
- Stories (either read or performed) and shared personal experiences can support learners’ understanding of the topic, especially at low levels of education and literacy (Caminiti et al., 2013).
- Facilitate a session where learners build case studies and include details such as recognising the early signs of stroke, accessing EMS and caring for the person while waiting for medical care (Wall et al., 2008).
- Facilitate a game where learners move to different parts of the room based on how much they agree or disagree with a statement. You can use this game to clarify the misconceptions of stroke or as an introduction to identifying which signs are obvious or subtle.
- Explore scenarios that describe a variety of different situations or signs of stroke in detail. Ask learners how they would respond to each circumstance.
Learning connections
- Diabetic emergency can sometimes be mistaken for a stroke. If the person with suspected stroke has diabetes, help them to measure their blood glucose level.
- Assessment: While waiting for EMS to arrive or while in transit to medical care, first aid providers should draw from previous learning and recognise the importance of maintaining the person’s physical, mental and emotional safety.
- If the person becomes unresponsive, starts drooling or struggles to swallow, the first aid provider should place them on their side with their head tilted back. See Unresponsive and breathing normally.
- The first aid provider should monitor the person’s condition and provide reassurance until medical care arrives. A stroke can be an extremely frightening experience, and this is an excellent opportunity to reinforce empathy and build confidence in learners’ abilities to provide support to those affected.
Scientific foundation
Systematic reviews
Body position
In 2020, the Centre for Evidence-Based Practice (CEBaP) developed and evidence summary on whether the positioning of a person with a stroke affects a variety of outcomes. The 2019 NICE guideline “Stroke and transient ischaemic attack in over 16s: diagnosis and initial management” of 2019 was identified. No additional studies were searched. (CEBaP, 2020.)
There is limited evidence neither in favour of lying flat on the back nor sitting up. A statistically significant increase of a score of 0-2 on the modified Rankin Scale (mRS, a scale indicating the degree of disability) at 90 days, lying flat compared to sitting up, could not be demonstrated. A statistically significant decrease of mortality, recurrent stroke, pneumonia, length of hospital stay and neurological deterioration, lying flat compared to sitting up, could not be demonstrated. It was shown that lying flat resulted in a statistically significant decrease of mRS 0-2 (disability) and a statistically significant increase of general health score, compared to sitting up. However, the guideline developers did not consider these differences to be clinically relevant. Evidence is of low certainty and results cannot be considered precise due to limited sample size, low number of events, lack of data and large variability of results.
Stroke screening assessment systems
The International Liaison Committee on Resuscitation (ILCOR) performed a systematic review on the use of stroke assessment systems to aid with the recognition of stroke by first aid providers (Singletary 2020).
Time to treatment
For the critical outcome of time to treatment, they identified four observational studies evaluating four stroke scales:
- For the Kurashiki Prehospital Stroke Scale (KPSS), there is very low-certainty evidence from one observational study with 430 adults with suspected acute stroke. It reported an association between the use of the KPSS and an increase in the number of people with time from symptom onset to hospital arrival within three hours. Among people with emergency medical services use of the KPSS, 62.9% arrived within three hours compared with 52.3% who did not have the scale applied. This same study reported an association between the prehospital use of the KPSS and a shorter elapsed time from symptom onset to hospital admission.
- For the Los Angeles Prehospital Stroke Scale (LAPSS), there is very low-certainty evidence from one observational study with 1518 participants with a suspected acute stroke. It reported an association between the use of LAPSS and an increased time from symptom onset to emergency department arrival. This same study did not find a benefit associated with the use of LAPSS in a prehospital setting for the rate of people admitted within 120 minutes.
- For the Ontario Prehospital Stroke Scale (OPSS), there was very low-certainty evidence from one observational study in 861 participants suspected of acute stroke. It showed an association between the use of OPSS and an increase in the number of people with time from symptom onset to hospital arrival within three hours.
- For the Face, Arm, Speech, Time, Emergency Response Protocol (FASTER), there is very low-certainty evidence from one observational study with 115 participants. It showed an association between the use of FASTER and a shortened time from symptom onset to time of a specific tissue treatment. Among people receiving the specific treatment, no differences were associated with or without the use of the stroke screening tool and time from symptom onset to hospital.
Recognition of stroke
For the important outcome of recognition of stroke, with the outcome being a definitive stroke diagnosis or administration of thrombolytic therapy , they identified five observational studies evaluating five stroke scales:
- For FAST, there is low-certainty evidence from one observational study with 356 participants with suspected stroke. It showed an association between the use of FAST and an increase in the number of people with confirmed stroke or transient ischemic attack who were admitted within three hours of symptom onset.
- For KPSS, there is low-certainty evidence from one observational study with 430 participants with suspected stroke. It showed no association between the use of KPSS and receipt of thrombolytic therapy for people who were ultimately diagnosed with stroke.
- For LAPSS, there is moderate-certainty evidence from one observational study with 1518 adults. It showed an association between the bundle of changes including the use of LAPSS by paramedics and an increase in the number of correct initial diagnoses of stroke confirmed by a neurologist. The same study showed no association between the rate of treatment with intravenous tPA among people with confirmed stroke and the bundle of changes including the use of LAPSS.
- For OPSS, there is low-certainty evidence from one observational study with 861 participants suspected of stroke. It showed no association between the use of OPSS and the rate of recognition of ischemic stroke. This same study did show an association between the use of OPSS and an increase in the rate of thrombolytic therapy of all people with ischemic stroke, as well as an association between the use of OPSS and an increased rate of thrombolytic therapy for people with ischemic stroke arriving within three hours.
- For FASTER, there is very low-certainty evidence from one observational study including 181 participants with suspected acute stroke. It showed an association between the use of FASTER and the number of people who received thrombolytic therapy. Of patients who had the scale applied, 19.1% received thrombolytic therapy compared with 7.5% who did not have the scale applied.
When looking at studies investigating the correct stroke diagnosis, 19 observational studies enrolling a total of 8153 people and studying nine different stroke screening assessment systems. These studies were divided into subgroups based on whether the stroke scales included a glucose measurement or not.
Public recognition of stroke
Very low-certainty evidence was found on the important outcome of increased public recognition of stroke signs when using a stroke screening assessment system. One human study enrolling 72 members of the public measured the difference before training, immediately after, and three months after training. The study showed a benefit where 76.4 % of participants (55/72) were able to identify stroke signs before training on how to use a stroke screening assessment system compared with 94.4 % (68/72) immediately after training. Additionally, 96.9 % of participants (63/65) were able to identify stroke signs three months after training.
Supplementary oxygen
ILCOR conducted a systematic review about the use of supplementary oxygen for acute stroke and identified eight randomised controlled trials and one retrospective observational study (Singletary 2020).
For the outcome of survival at 1 week, 3 months, 6 months and 1 year, no benefit could be shown of giving supplemental oxygen (moderate-certainty evidence from three randomised controlled trials). Also, for neurological outcomes at 1 week, 3 months or 6 months, no benefit could be shown in six randomised controlled trials and an observational study (moderate- to very low-certainty evidence). However, one of these trials showed a higher chance of improvement for one of its outcomes (“improvement of NIHSS score of more than 4 at 1 week”) (moderate-certainty evidence), and a separate randomised controlled trial also showed benefit at seven months (low-certainty evidence).
For the outcome quality of life, no benefit of supplementary oxygen was shown in two randomised controlled trials, and one trial even showed a lower quality of life (low-certainty evidence).
For the imaging outcome “lesion volume change at 6 hours, at 24 hours, and at hospital discharge”, no difference could be shown in one randomised controlled trial (low-certainty evidence).
One observational study also looked at complications and could not show an association between supplementary oxygen on the one hand and pneumonia at hospital discharge, and pulmonary oedema and the use of non-invasive positive-pressure ventilation on the other hand, but showed a lower rate of hospital-acquired pneumonia and a higher rate of tracheal intubation and of respiratory complications (very low-certainty evidence).
Education reviews
Campaigns to improve public recognition of stroke and instigate fast action to get the person to a medical facility have had mixed results. In general, evidence identifies that campaigns based on FAST can increase people’s awareness of the need to act quickly and get the person to emergency medical care following the identification of one or more signs from the FAST mnemonic. (See Media.)
Wolters et al. (2015) retrospectively considered 668 consecutive patients with stroke between 2002–2008 and 2009–2013. In between these time intervals, a national television campaign on stroke recognition and how to act (based on FAST) ran. Results showed that patients were statistically more likely to seek medical care within three hours after seeing the campaign. The median time to get medical attention fell from 53 to 31 minutes, and arrival at the hospital fell from 185 to 119 minutes post-campaign.
Robinson et al. (2012) surveyed 1300 people in Leicester (UK) following a campaign on stroke recognition (FAST) and found that participants strongly remembered the campaign and the mnemonic elements. After surveying 356 adults in Birmingham (UK) following the same campaign, Beizk (2012) found that 64.9% were aware of the FAST campaign. Of this percentage however, 32.5% could not recall any letters, 9.5% remembered one, 13.0% two, 17.3% three, and 27.7% all four correctly.
Wall et al. (2008) identified low-quality evidence that training leads to an increase in the ability to identify signs of a stroke. After training, those able to identify the signs rose from 76.4% to 94.4%. Additionally, 96.9% of participants were able to identify the signs of stroke three months after training.
Caminiti et al. (2013) describe a study to develop a campaign aimed to increase stroke awareness and preparedness. They found that integrating theory with the information collected from target populations enabled them to create effective tools for that audience.
Bray et al. (2010) interviewed 100 stroke patients and 70 bystanders following two separate stroke awareness campaigns in Australia. 12% were aware of the campaign, and of these, 19% could recall stroke symptoms.
Flynn et al. (2014) conducted an interrupted time series to consider the impact of a UK stroke campaign completed in 2007–2011. They found a statistically significant increase in information-seeking behaviour and emergency admissions for stroke. They also noted a decrease in inappropriate care-seeking and thrombolysis activity which could be attributed to the campaign.
Additional information
Prevention
In analyses using data from the Global Burden of Disease Study, approximately 90% of stroke risk could be attributed to modifiable risk factors (such as high blood pressure, obesity, hyperglycaemia, hyperlipidaemia, and renal dysfunction), and 74% could be attributed to behavioural risk factors (such as smoking, sedentary lifestyle, and an unhealthy diet). Globally, 29% of the risk of stroke was attributable to air pollution. Although global age-adjusted mortality rates for ischemic and haemorrhagic stroke decreased between 1990 and 2015, the absolute number of people who have strokes annually, as well as related deaths and disability-adjusted life-years lost, increased. The majority of global stroke burden is in low-income and middle-income countries (Benjamin et al., 2019).
Recognition
The following content on recognition is from the 2016 Guidelines.
Studies demonstrated that training first aid providers to use stroke assessment systems enabled them to recognise stroke earlier. The faster response time led to a decrease in time between stroke onset and arrival at the hospital, as well as an improved outcome for the ill person. According to these studies, without training to use a stroke assessment system, 76.4% of lay people can recognise signs and symptoms of stroke. However, after such training, 94.4% are able to recognise stroke, and can do so three months after the training.
The American Red Cross Scientific Advisory Council focused on stroke scales that utilised validated and reliable items, including the Cincinnati Prehospital Stroke Scale (CPSS), the Los Angeles Prehospital Stroke Scale (LAPSS) and FAST. Simple stroke assessment systems (e.g. CPSS or FAST) are easy to use and have high sensitivity to recognise stroke. Although there are other stroke scales, these guidelines recommend using FAST. Specificity can be increased if the first aid provider can measure blood glucose levels (to exclude hypoglycaemia) and use a more advanced stroke assessment system.
Stroke-like symptoms that are mild and temporary may indicate a transient ischemic attack (TIA) or “mini stroke”, which is a warning that results in no lasting brain injury. The short duration of the symptoms and lack of permanent brain injury are the main differences between TIA and stroke. Nevertheless, recognising the possibility of a TIA is important because it allows early treatment to reduce the risk of a major stroke.
Access help
The following content on accessing help is from the 2016 Guidelines.
Early admission to a stroke centre greatly improves the prognosis for the person, highlighting the need for first aid providers and the lay public to be able to quickly recognise stroke symptoms and access EMS or initiate transport to a medical facility. The goal is for the ill person to receive definitive treatment in time to benefit from newer therapies. In most cases, this means receiving thrombolytic treatment (to dissolve a blood clot) within three to five hours of the onset of stroke symptoms. While the goal is to provide treatment within three hours, the sooner the better is the rule.
Early medical care
Oxygen supplementation does not significantly improve outcomes. In a randomised clinical trial in the UK between 2008 and 2015, patients with an acute stroke and normal oxygen saturations were randomised within 24 hours of admission to three days of continuous oxygen, nocturnal oxygen, or control. After three months, there was no significant difference in death and disability for the combined oxygen groups compared with control, or for the continuous oxygen group compared with the nocturnal oxygen group (Roffe et al., 2017).
References
Systematic reviews
Brandler, E.S., Sharma, M., Sinert, R.H., & Levine, S.R. (2014). Prehospital stroke scales in urban environments: a systematic review. Neurology, 82, 2241-2249.
Centre for Evidence-Based Practice. (2020). Evidence summary Stroke – Body position. Belgian Red Cross Flanders. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries
Rudd, M., Buck, D., Ford, G.A., & Price, C.I. (2016). A systematic review of stroke recognition instruments in hospital and prehospital settings. Emergency Medicine Journal, 33, 818-822.
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., … Woodin, J.A. (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation,142 (suppl 1):S284–S334. DOI https://doi.org/10.1161/CIR.0000000000000897
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., … Lee, C.C. (2020). International Consensus on First Aid Science With Treatment Recommendations. Resuscitation, Nov;156:A240-A282. DOI https://doi.org/10.1016/j.resuscitation.2020.09.016
Zhelev, Z., Walker, G., Henschke, N., Fridhandler, J., Yip, S. (2019). Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Systematic Review.
Non-systematic reviews
Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., … Virani, S. S. (2019). Heart Disease and Stroke Statistics—2019 Update: A Report from the American Heart Association. Circulation, 139(10). DOI
Johnson, W., Onuma, O., Owolabi, M., & Sachdev, S. (2016). Stroke: a global response is needed. Bulletin of the World Health Organization, 94(9), 634–634A. DOI https://doi.org/10.2471/blt.16.181636
Roffe, C., Nevatte, T., Sim, J., Bishop, J., Ives, N., Ferdinand, P., & Gray, R. (2017). Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke. JAMA, 318(12), 1125–1135. DOI https://doi.org/10.1001/jama.2017.11463
Education references
Becker, K. J., Fruin, M. S., Gooding, T. D., Tirschwell, D. L., Love, P. J., & Mankowski, T. M. (2001). Community Based Education Improves Stroke Knowledge. Cerebrovascular Diseases, 11(1), 34–43. DOI https://doi.org/10.1159/000047609
Bietzk, E., Davies, R., Floyd, A., Lindsay, A., Greenstone, H., Symonds, A., & Greenfield, S. (2012). FAST enough? The UK general public’s understanding of stroke. Clinical medicine, 12(5), 410.
Bray, J. E., O’Connell, B., Gilligan, A., Livingston, P. M., & Bladin, C. (2010). Is FAST stroke smart? Do the content and language used in awareness campaigns describe the experience of stroke symptoms?. International Journal of Stroke, 5(6), 440-446.
Caminiti, C., Schulz, P., Marcomini, B., Iezzi, E., Riva, S., Scoditti, U., Zini, A., Malferrari, G., Zedde, M. L., Guidetti, D., Montanari, E., Baratti, M., & Denti, L. (2017). Development of an education campaign to reduce delays in pre-hospital response to stroke. BMC Emergency Medicine, 17(1). DOI https://doi.org/10.1186/s12873-017-0130-9
Dombrowski, S. U., Mackintosh, J. E., Sniehotta, F. F., Araujo-Soares, V., Rodgers, H., Thomson, R. G., Murtagh, M. J., Ford, G. A., Eccles, M. P., & White, M. (2013). The impact of the UK ‘Act FAST’ stroke awareness campaign: content analysis of patients, witness and primary care clinicians’ perceptions. BMC Public Health, 13(1). DOI https://doi.org/10.1186/1471-2458-13-915
Flynn, D., Ford, G. A., Rodgers, H., Price, C., Steen, N., & Thomson, R. G. (2014). A time series evaluation of the FAST National Stroke Awareness Campaign in England. PloS one, 9(8), e104289.
Marx, J. J., Klawitter, B., Faldum, A., Eicke, B. M., Haertle, B., Dieterich, M., & Nedelmann, M. (2010). Gender specific differences in stroke knowledge, stroke risk perception and the effects of an educational multimedia campaign. Journal of Neurology, 257(3), 367–374. DOI https://doi.org/10.1007/s00415-009-5326-9
Maze, L. M., & Bakas, T. (2004). Factors Associated with Hospital Arrival Time for Stroke Patients. Journal of Neuroscience Nursing, 36(3), 139–144. DOI https://doi.org/10.1097/01376517-200406000-00005
Robinson, T. G., Reid, A., Haunton, V. J., Wilson, A., & Naylor, A. R. (2013). The face arm speech test: does it encourage rapid recognition of important stroke warning symptoms?. Emergency Medicine Journal, 30(6),467–471.
Wall, H. K., Beagan, B. M., O’Neill, H. J., Foell, K. M., & Boddie-Willis, C. L. (2008). Addressing stroke signs and symptoms through public education: the Stroke Heroes Act FAST campaign. Preventing chronic disease, 5(2).
Wolters, F. J., Paul, N. L., Li, L., & Rothwell, P. M. (2015). Sustained impact of UK FAST-test public education on response to stroke: a population-based time-series study. International Journal of Stroke, 10(7), 1108–1114.
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Published: 15 February 2021
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