Stroke: Time Is Brain
Stroke is the fifth leading cause of death in the United States and a leading cause of long-term disability. For every minute a large vessel stroke goes untreated, approximately 1.9 million neurons die. The EMT's role in rapid recognition, assessment, and transport directly impacts patient outcomes.
Types of Stroke
Ischemic stroke (87% of cases): Caused by a blood clot blocking an artery in the brain. Treatment includes clot-dissolving medications (tPA/alteplase) within 4.5 hours of symptom onset or mechanical thrombectomy within 24 hours for large vessel occlusions.
Hemorrhagic stroke (13% of cases): Caused by bleeding in the brain from a ruptured blood vessel. Treatment involves blood pressure management and possibly surgical intervention. tPA is contraindicated in hemorrhagic stroke, which is why hospital imaging (CT scan) is performed before treatment.
Cincinnati Prehospital Stroke Scale
The Cincinnati Stroke Scale is a rapid assessment tool that takes less than one minute to perform:
- Facial Droop: Ask the patient to show their teeth or smile. Normal: both sides move equally. Abnormal: one side does not move as well or at all.
- Arm Drift: Ask the patient to close their eyes and hold both arms out straight for 10 seconds. Normal: both arms move equally or not at all. Abnormal: one arm drifts downward or does not move.
- Speech: Ask the patient to repeat "You can't teach an old dog new tricks." Normal: clear speech without slurring. Abnormal: slurred speech, wrong words, or inability to speak.
One abnormal finding on the Cincinnati Stroke Scale gives a 72% probability of stroke. Three abnormal findings give an 85% probability.
Critical Time Points
Document the last known well time (the last time the patient was seen or known to be normal). This is the most critical piece of information for hospital decision-making. If the patient woke up with symptoms, the last known well time is when they went to sleep.
The goal is emergency department arrival within 60 minutes of symptom onset. Communicate a stroke alert to the receiving facility en route so the stroke team can be assembled before arrival.
Stroke Mimics
Several conditions can mimic stroke symptoms: hypoglycemia, seizure with postictal state, migraine with aura, Bell's palsy, drug toxicity. Check blood glucose on every patient with stroke-like symptoms. However, do not delay transport to rule out mimics. Treat every potential stroke as a stroke until proven otherwise at the hospital.
EMT Management
- Maintain airway and assess breathing
- Check blood glucose and treat hypoglycemia if present
- Position with head elevated 30 degrees if tolerated
- Do not give anything by mouth (aspiration risk)
- Monitor for seizures and vomiting
- Establish and document last known well time
- Transport to the closest appropriate stroke center
- Provide early hospital notification for stroke team activation