STROKE TRAINING FOR

EMS PROFESSIONALS
May 2022
Course Objectives
About Stroke

Stroke Policy Recommendations

Stroke Protocols & Hospital Care

Stroke Assessment & Severity Tools

Pre-Notification

Stroke Treatment
2
ABOUT STROKE
Why Should We Care?
• Despite new treatment and prevention
advances, stroke is not going away

• Stroke treatments are available and are

effective if:
o Available at the receiving hospital
o Administered quickly

• EMS personnel play a critical role

in helping ensure stroke patients have
access to these therapies
Stroke Facts
• A stroke is a medical emergency! Stroke occurs when blood flow is either cut
off or is reduced, depriving the brain of blood and oxygen.1
• About 795,000 strokes occur in the U.S. each year – roughly the same as
number of heart attacks (805,000) that occur each year.1
• Stroke is the fifth leading cause of death in the U.S.1
• Stroke is a leading cause of adult disability.1
• On average, every 40 seconds, someone in the United States has a stroke.1
• About 1.9 million brain cells die on average for each minute that a large
vessel stroke goes untreated.2
• About 7.6 million stroke survivors living in the U.S.1
• The indirect and direct cost of stroke is $52.8 billion annually (2017-18).1
• Stroke crosses all ages, racial/ethnic and socioeconomic groups.1

1. Tsao CW, et al. Heart Disease and Stroke Statistics. (2022) Circulation.
2. Saver JL. Time Is Brain—Quantified. (2006) Stroke.
Different Types of Stroke
Ischemic Stroke
• It’s caused by a blockage in an artery stopping normal
blood and oxygen flow to the brain
• About 87% of strokes are ischemic
• There are two types of ischemic strokes:
o Embolism: Blood clot or plaque fragment from elsewhere
in the body gets lodged in the brain
o Thrombosis: Blood clot is formed in an artery that
provides blood to the brain
• A stroke caused by a large vessel occlusion (LVO)
is a severe type of ischemic stroke that may need
more advanced care.

Tsao CW, et al. Heart Disease and Stroke Statistics. (2022) Circulation.
Different Types of Stroke
Hemorrhagic Stroke
• About 13% of strokes are caused by a hemorrhage
o Caused by a breakage in a blood vessel within the brain
• Can be the result of a ruptured aneurysm
• Two types of hemorrhagic stroke:
o Intracerebral Hemorrhage (within the brain tissue,
sometimes referred to as intraparenchymal): A blood
vessel bursts leaking blood into the brain tissue
o Subarachnoid Hemorrhage: Occurs when a blood
vessel bursts near the surface of the brain and blood
pours into the area outside of the brain, between
the brain and the skull

Tsao CW, et al. Heart Disease and Stroke Statistics. (2022) Circulation.
Different Types of Stroke
Transient Ischemic Attack (TIA)
• A TIA or Transient Ischemic Attack produces stroke-like symptoms
• TIA is caused by a blockage, but unlike a stroke, the blockage is temporary
and usually causes no permanent damage to the brain
• About 7% of TIA patients have a stroke within 90 days. Even though
these patients may not receive thrombolysis (clot-busting medications),
it’s important for them to be evaluated quickly in the emergency
department. TIA is a medical emergency!

Tsao CW, et al. Heart Disease and Stroke Statistics. (2022) Circulation.
Common Stroke Symptoms*
Right-Sided (Hemisphere) Stroke Brainstem Stroke
• Slurred speech - dysarthria • Nausea, vomiting or vertigo
• Weakness or numbness of the left side • Speech problems
of face, arm or leg • Swallowing problems
• Left-sided neglect • Abnormal eye movements
• Right gaze preference • Decreased consciousness
• Crossed findings (both sides
Left-Sided (Hemisphere) Stroke of the body)
• Speech problems – what is being said or
inability to get words out * Symptoms may occur alone or in
• Problems with comprehension combination with each other.
• Weakness or numbness of the right side
of face, arm, or leg
• Left gaze preference

Tsao CW, et al. Heart Disease and Stroke Statistics. (2022) Circulation.
Common Stroke Symptoms
Hemorrhagic Stroke
Intracerebral Hemorrhage
• Nausea and vomiting
• Headache
• One-sided weakness
• Decreased consciousness

Subarachnoid Hemorrhage
• Worst headache of life
• Intolerance to light
• Neck stiffness or pain

Tsao CW, et al. Heart Disease and Stroke Statistics. (2022) Circulation.
Common Stroke Mimics
STROKE MIMICS
Alcohol Intoxication
Cerebral Infections
Drug Overdose/Toxicity
Epidural Hematoma
Hypoglycemia
Metabolic Disorders
Migraines
Neuropathies (Bell’s Palsy)
Seizure and Post Seizure (Todd’s Paralysis)
Brain Tumors
Hypertensive Encephalopathy
STROKE TREATMENT
Ischemic Stroke
Treatment Protocols

* Thrombolysis with IV Alteplase (tPA) is also

recommended for selected patients who
can be treated within 3 to 4.5 hours of
symptom onset or last known well time.
Ischemic Stroke
Treatment Protocols
• IV thrombolysis (a.k.a. tPA or Alteplase) is the clot busting drug used
with stroke patients.
Medical • Patients must be within the time window of 0–3 hours (or 3–4.5-hour
Management window in certain eligible patients) from symptom onset.
• There are other contraindications associated with the use of
the drug. clot busting drug

• Mechanical thrombectomy (MT) is an endovascular therapy that

uses a stent retriever device to remove the clot in patients with
LVO stroke.
• The time window for MT is up to 24 hours from symptom onset.
Mechanical • Quicker treatment results in better outcomes, so the up to
Thrombectomy 24-hour time window facilitates MT for more patients but
shouldn’t be seen as allowing more time for decision-making or
transport delays.
• If the patient is eligible for IV thrombolysis, that should be
administered first. stent retriever device
Patient Outcomes in Research Trials
Thrombolytics1 Mechanical Thrombectomy2
• Ischemic stroke patients who • In a meta-analysis of major MT
receive thrombolysis are at least trials, 40% of patients treated
30 percent more likely to have had reduced disability as a result
minimal or no disability at three of thrombectomy, including 23%
months, compared to patients of patients achieving an
who do not receive this therapy. independent outcome.

1. NINDS rt-PA Study Group Investigators. Tissue Plasminogen Activator for Acute IschemicStroke. The New England Journal of Medicine, 333:24, 1995.
2. Campbell BC et al. Safety and Efficacy of Solitaire Stent Thrombectomy: Individual Patient Data Meta-Analysis of Randomized Trials. Stroke. 2016.
Contraindications to Thrombolysis

• Severe recent or acute head trauma

• Recent intracranial/intraspinal surgery
• History of intracranial hemorrhage EMS identification of current
medications, especially
• Recent GI malignancy or bleeding anticoagulants, & obtaining
• Blood clotting impairment patient history including co-
• Recent treatment with heparin morbid conditions (e.g. recent
surgery, procedures or stroke)
• Taking anticoagulant
& family contact information is
• Known or suspected aortic arch dissection critical because it may impact
• To see a list of more contraindications treatment decisions.
to thrombolysis, please see the AHA/ASA
2019 Acute Ischemic Stroke Guidelines

Powers WJ, et al. 2019 Update to 2018 Guidelines for Early Management of Acute Ischemic Stroke. (2019) Stroke.
STROKE PROTOCOLS &
HOSPITAL CARE
Stroke Care
The goal of stroke care is to minimize brain injury
and maximize the patient’s recovery

The Stroke Chain of Survival links actions to be taken by patients, family members, and
healthcare professionals to maximize stroke recovery. The links include:
• Family member, friend or bystander recognizes stroke warning signs and rapidly calls 9-1-1
• EMS rapidly arrives at scene and performs stroke assessment
• EMS rapidly notifies receiving hospital that patient will be arriving and EMS transports
patient to the receiving hospital
• Hospital rapidly diagnoses and treats patient
Hospital Levels of Care

Acute Stroke Ready Hospital (ASRH) ASRH Acute Stroke Ready Hospital
• Stabilize the patient & provide IV thrombolysis if appropriate PSC Primary Stroke Center
• Transfer most patients to a CSC, TSC or PSC CSC Comprehensive Stroke Center

• Frequently rely on telestroke for neurology expertise TSC Thrombectomy-Capable Stroke Center

Primary Stroke Center (PSC) To find certified stroke centers in your area,
check out the American Heart Association map
• Stabilize patient and provide IV thrombolysis if appropriate here: heart.org/en/professional/quality-
improvement/hospital-maps
• Either admit or transfer to a CSC
• Most common type of stroke center

1. ASA Mission:Lifeline Stroke Committee. Emergency Medical Services Acute Stroke Triage and Routing. (2020)
2. Jauch EC, et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities. (2021) Stroke
Hospital Levels of Care
Thrombectomy-capable Stroke Center (TSC)
• Meet all criteria of a PSC, including administering
IV thrombolysis if appropriate
ASRH Acute Stroke Ready Hospital
• Also provide mechanical thrombectomy (MT) for stroke PSC Primary Stroke Center
patients with large vessel occlusion (LVO)
CSC Comprehensive Stroke Center
TSC Thrombectomy-Capable Stroke Center
Comprehensive Stroke Center (CSC)
• Have the capability to support all needed levels of care to
To find certified stroke centers in your area,
all types of stroke patients, including hemorrhagic stroke: check out the American Heart Association map
o Provide IV thrombolysis and/or MT for ischemic stroke here: heart.org/en/professional/quality-
patients when appropriate improvement/hospital-maps

o Full complement of stroke neurology, critical care, &

neurosurgical personnel & infrastructure
o Special interventions
o Highly technical procedures

Jauch EC, et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities. (2021) Stroke
Levels & Capabilities of Hospital
Stroke Certifications
Characteristics ASRH PSC TSC CSC
Often urban / Often urban /
Location Typically rural Typically urban
suburban suburban
Stroke team accessible/available 24/7 Yes Yes Yes Yes
Non-contrast CT available 24/7 Yes Yes Yes Yes
Advanced imaging available 24/7
(e.g., CTA/CTP/MRI/MRA/MRP) Typically No Possibly Yes Yes

Intravenous thrombolysis capable 24/7 Yes Yes Yes Yes

Thrombectomy capable 24/7 No Typically No Yes Yes
Diagnose stroke etiology and manage post-stroke Yes, Yes,
Unlikely Yes, Routine
complications Complex Complex
Admit hemorrhagic stroke No Possibly Possibly Yes
Clip/coil ruptured intracranial aneurysms No Unlikely Possibly Yes
Dedicated stroke unit No Yes Yes Yes
Neurocritical care unit and expertise No Possibly Possibly* Yes
Clinical stroke research performed Unlikely Possibly Possibly Yes
*Access to neurocritical care expertise required and may be provided by telemedicine.

Modified from Jauch EC, et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities. (2021) Stroke
STROKE POLICY
RECOMMENDATIONS
EMS Assessment & Management
• Support ABCs: airway, breathing, circulation. Give oxygen if needed.
• Perform prehospital stroke assessment using a prehospital stroke screening tool.
• Establish time when patient was last normal; interview family members or
witnesses, if needed.
• Identify if patient has significant pre-stroke disability.
• Identify current medications, especially anticoagulants, and obtain patient
history including co-morbid conditions (e.g. recent surgery, procedures or stroke)
that may impact treatment decisions.
• Provide advance notification to receiving hospital as soon as possible of potential stroke
patient “CODE STROKE.”
• Check glucose level if possible.

1. Powers WJ, et al. 2019 Update to 2018 Guidelines for Early Management of Acute Ischemic Stroke. (2019) Stroke.
2. ASA Mission:Lifeline Stroke Committee. Emergency Medical Services Acute Stroke Triage and Routing. (2020)
EMS System Recommendations

• EMS leaders, in coordination with local,

regional, & state agencies & in consultation
with medical authorities & local experts,
should develop triage paradigms & protocols
to ensure that patients with known or
suspected stroke are rapidly identified &
assessed by use of a validated, standardized
tool for stroke screening.1,2

1. Powers WJ, et al. 2019 Update to 2018 Guidelines for Early Management of Acute Ischemic Stroke. (2019) Stroke.
2. Adeoye O, et al. Recommendations for the Establishment of Stroke Systems of Care. (2019) Stroke.
EMS System Recommendations

• In prehospital patients who screen positive

for suspected stroke, a standard prehospital
stroke severity assessment tool should be
used to facilitate triage.1
• Patients with a positive stroke screen or who
are strongly suspected to have a stroke
should be transported rapidly to the closest
healthcare facility that is able to administer
IV thrombolysis.2

1. Adeoye O, et al. Recommendations for the Establishment of Stroke Systems of Care. (2019) Stroke.
2. Powers WJ, et al. 2019 Update to 2018 Guidelines for Early Management of Acute Ischemic Stroke. (2019) Stroke.
EMS System Recommendations

• Effective prehospital procedures to

identify patients who are ineligible for
IV thrombolysis and have a strong
probability of LVO stroke should be
developed to facilitate rapid transport of
patients potentially eligible for
thrombectomy to the closest healthcare
facilities that are able to perform MT.1

1. Powers WJ, et al. 2019 Update to 2018 Guidelines for Early Management of Acute Ischemic Stroke. (2019) Stroke.
Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the
American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS
Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society | Stroke (ahajournals.org) 27
Overarching Principles
Destination Plans
Ideal destination plans are complex, nuanced, & factor in
all available data sources including:
• traffic patterns
• site-specific performance data on the frequency of
use, and
• timeliness of IV thrombolytics and endovascular
therapy, and their associated clinical outcomes

Regional destination plans should consider general

eligibility for IV thrombolytics and for those patients with
suspected large vessel stroke within 24 hours of last known
well time, should prioritize a nearby Comprehensive
Stroke Center over other centers of lower capability when
available within acceptable transport times.

More information available at: stroke.org/StrokeTransportPlans

Jauch EC et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban
Communities From the Prehospital Stroke System of Care Consensus Conference. (2021) Stroke.
Overarching Principles
Rapid Access to Appropriate Level of Care
The regional stroke system of care should ensure
rapid access to the appropriate level of care,
during both the prehospital and hospital phases of
care. In general, when more than one stroke center
is within close proximity from the scene, transport
to the highest level of care is preferable.

Coordinated Quality Improvement

All participating EMS agencies should engage in
quality improvement programs coordinated with
the stroke system of care as a whole, with
emphasis on dispatch, response, field triage, and
transitions of care.

More information available at: stroke.org/StrokeTransportPlans

Rural Transport Recommendations

Jauch EC et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities
From the Prehospital Stroke System of Care Consensus Conference. (2021) Stroke.
Suburban Transport Recommendations

Jauch EC et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities
From the Prehospital Stroke System of Care Consensus Conference. (2021) Stroke.
Urban Transport Recommendations

Jauch EC et al. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities
From the Prehospital Stroke System of Care Consensus Conference. (2021) Stroke.
STROKE ASSESSMENT
& SEVERITY TOOLS
Stroke Assessment &
Triage
Stroke Assessment Tools

• Stroke assessment tools help EMS identify

a stroke quickly and transport the individual
to the appropriate center.
EMS Stroke Identification*
• A simple screening that generates
a binary result of positive (stroke 100

% of Stroke Identification Sensitivity

suspected) or negative (stroke unlikely)1.
80
• Prehospital stroke assessment training raises No Training in Use of
the accuracy of stroke identification2. Stroke Assessment Tool
60
• Paramedics demonstrated a sensitivity of
61-66% without stroke assessment training 40 Training in Use of
and 86-97% with training2. Stroke Assessment
Tool
20

0
Stroke Assessment
Tool Training

1. ASA Mission:Lifeline Stroke Committee. Emergency Medical Services Acute Stroke Triage and Routing. (2020).
2. Maggiore, W. A. (2012). 'Time is Brain' in Prehospital Stroke Treatment . Journal of Emergency Medical Services , 1-9.
http://www.jems.com/article/patient-care/time-brain-prehospital-stroke-treatment
 Field Assessment of Stroke

Multiple tools are available to screen for stroke.

• Current AHA/ASA guidance does not recommend
one tool over another. Jurisdictions should choose a
single validated and standardized screening tool
for use across the region, if possible.
• Cincinnati Prehospital Stroke Scale is most
widely used.
• Other validated stroke screening tools include:
o Los Angeles Prehospital Stroke Screen (LAPSS)
o FAST (Face, Arm, Speech, Time)
o Miami Emergency Neurological Deficit Scale (MENDS)

Adeoye O, et al. Recommendations for the Establishment of Stroke Systems of Care. (2019) Stroke.
 Field Assessment of Stroke
Cincinnati Prehospital Stroke Scale
Facial Droop
Have patient look up at you,
Normal: Left and right side of face move equally
smile and show their teeth.
Abnormal: One side of face does not move at all

Have patient lift arms up Arm Drift

and hold them out with eyes Normal: Both left and right arm move together or not at all
closed for 10 seconds. Abnormal: One arm does not move equally with the other

Speech
Have patient say a simple
Normal: Patient uses correct words with no slurring
sentence, i.e. “You can’t teach
an old dog new tricks.” Abnormal: Patient has slurred speech, uses inappropriate
words or cannot speak

If any 1 of these 3 signs is abnormal, probability of stroke is 72%.

If all 3 findings are present, probability of acute stroke is >85%.

Adapted from: Kothari RU, Pancioli A, Liu T., Brott T., Broderick J. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.”
Ann Emerg Med. 1999 Apr;33(4):373-8, permission foruse.
 Layperson Stroke Recognition

Face Drooping – Ask the person to smile. Does one

side of the face droop or is it numb?

Arm Weakness – Ask the person to raise both arms. Is

one arm weak or numb? Does one arm drift downward?

Speech Difficulty – Ask the person to repeat a simple

sentence, such as “the sky is blue.” Is the sentence
repeated correctly? Are they unable to speak, or are
they hard to understand?

Time to call 9-1-1 – If the person shows any of these

symptoms, even if the symptoms go away, call 911 and
get them to the hospital immediately.

stroke.org/WarningSigns
Stroke Severity Scales

• A scale to quantify neurologic deficits to identify

patients with severe symptoms likely due to LVO or
hemorrhagic stroke
• At least 6 different scales have been published.
• Each EMS region should choose a single severity scale
and monitor adherence to usage as well as accuracy.
• Examples include:
o Cincinnati Stroke Triage Assessment Tool (C-STAT)
o Facial palsy, Arm weakness, Speech changes, Time,
Eye deviation, Denial / neglect (FAST-ED)
o Rapid Arterial Occlusion Evaluation Scale (RACE)
o Los Angeles Motor Scale (LAMS)
o Vision, Aphasia, Neglect (VAN)
PRE-NOTIFICATION
 Pre-Notification Systems

• EMS professionals should notify hospital staff that a stroke patient is being sent to the
hospital prior to their arriving at the hospital.
• Pre-notification systems help improve rapid triage, evaluation, and treatment of patients
with acute ischemic stroke.
• The sooner the patient gets medical treatment, the greater potential for a better outcome.

EMS Pre-Notification Systems

The study cited There was an When a pre- Overall, pre-

below by Lin, et al. increase in the notification system notification resulted
observed shorter percentage of was used there were in more rapid triage,
symptom onset to patients with door- lower onset to door evaluation, &
hospital arrival when to-imaging times times observed treatment of
a pre-notification within 25 minutes. (113 minutes versus patients with acute
system was used. 150 minutes). ischemic stroke.

Lin, C. B., Peterson, et al. Emergency Medical Service Hospital Pre-Notification is Associated with Improved Evaluation and
Treatment of Acute Ischemic Stroke. (2012). Journal of the American Heart Association.
Conclusions

• Stroke is treatable.

• Time lost is brain lost!

• Use a stroke screening tool & severity scale to determine

whether suspected stroke & likelihood of LVO.

• Follow stroke transport protocol for your area to

determine destination.

• Give advance notification to receiving hospital.

Thank You.

43