How to Treat Strokes

A guide for EMTs and Paramedics in identifying and managing stroke cases in the field.

According to guidelines published by the American Heart Association and American Stroke Association, before 2008, public education campaigns used the “5 Suddens” (sudden weakness, speech difficulty, vision loss, dizziness, severe headache) to help identify a stroke. More recently, the FAST campaign (Face, Arm, Speech, Time) has been reintroduced, as 88% of strokes and Transient ischemic attacks (TIAs) present with at least one of these symptoms.

Transient ischemic attacks (TIAs), often called “mini-strokes,” present similar symptoms that resolve within hours but serve as a warning for future strokes. Without prompt treatment, strokes can lead to permanent complications, including cognitive deficits, motor impairments, and secondary conditions like pneumonia or bladder control issues. In addition, nearly all individuals recall key FAST signs months after education. Regardless of the approach, repetition is essential for lasting public awareness and early intervention is essential to reduce the risk of severe complications and improve patient outcomes.

Major risk factors for stroke include high blood pressure, tobacco use, obesity, diabetes, and atrial fibrillation. EMS professionals play a crucial role in identifying strokes in the field, using tools like the FAST acronym (Face drooping, Arm weakness, Speech difficulties, Time to call 911) and coordinating care with hospital stroke teams. Learn more about the most common EMS Emergencies for EMTs and Paramedics.

Facts Summary About Strokes

The following statistics from the CDC provide a comprehensive overview of stroke incidence and impact in the United States as of October 2024:

• Annual Incidence: More than 795,000 people experience a stroke each year.
• Frequency: In the U.S., someone has a stroke every 40 seconds, and every 3 minutes and 11 seconds, someone dies from a stroke.
• Disability: Stroke is a leading cause of serious long-term disability.
• Mobility Impact: Stroke reduces mobility in more than half of survivors aged 65 and older.
• Cardiovascular Disease: In 2022, 1 in 6 deaths (17.5%) from cardiovascular disease was due to stroke.
• Recurrent Strokes: Nearly 1 in 4 strokes occur in individuals who have had a previous stroke.
• Ischemic Strokes: About 87% of all strokes are ischemic, involving blocked blood flow to the brain.

According to the American Heart Association’s 2024 Heart Disease and Stroke Statistics Update Fact Sheet, coronary heart disease (CHD) was the leading cause of death, followed by stroke at 17.5%. Stroke accounted for approximately 1 in every 21 deaths in the United States.

Stroke Definition

What is a Stroke?

A stroke, also known as a cerebrovascular accident (CVA), is a medical emergency that occurs when blood flow to a part of the brain is disrupted, leading to brain cell death and potential loss of neurological function. This interruption can result from two primary causes:

• Ischemic Stroke: The most common type, accounting for approximately 87% of all strokes, occurs when a blood clot or other obstruction blocks blood flow in an artery supplying the brain. This is often caused by atherosclerosis (narrowing of arteries due to plaque buildup).
• Hemorrhagic Stroke: Caused by the rupture of a blood vessel in or around the brain, leading to bleeding (hemorrhage). This can result from high blood pressure, trauma, aneurysms, or other vascular abnormalities.

Both types of strokes deprive brain tissue of oxygen and nutrients, causing brain cells to begin dying within minutes. The extent and location of the damage determine the severity and type of symptoms, which may include weakness or paralysis on one side of the body, difficulty speaking or understanding language, loss of vision, dizziness, or severe headache (common in hemorrhagic strokes).

Strokes can have long-lasting effects, including physical disability, cognitive impairment, and emotional challenges. They are a leading cause of death and long-term disability worldwide, but early intervention, such as the use of thrombolytic therapy in ischemic strokes or surgical interventions in hemorrhagic strokes, can significantly improve outcomes.

What is an Ischemic Stroke?

An ischemic stroke occurs when the blood supply to a part of the brain is reduced or completely blocked, leading to dysfunction or damage to the affected brain tissue. This type of stroke is the most common, accounting for nearly 87% of all strokes. The disruption in blood flow can result from four primary causes:

1. Thrombosis: A blood clot forms locally within a blood vessel, obstructing blood flow to the brain.
2. Embolism: A traveling embolus—an unattached mass such as a blood clot, cholesterol plaque, fat globule, gas bubble, or foreign body—blocks a blood vessel, cutting off circulation.
3. Systemic Hypoperfusion: A general decrease in blood supply due to conditions like shock, which reduces overall blood flow to the brain and other organs.
4. Cerebral Venous Sinus Thrombosis (CVST): A blood clot forms in the dural venous sinuses, the vessels responsible for draining blood from the brain, leading to impaired drainage and increased pressure.

Each of these causes can critically disrupt oxygen and nutrient delivery to the brain, emphasizing the importance of rapid diagnosis and treatment to minimize damage and improve outcomes.

What is a Hemorrhagic Stroke?

A hemorrhagic stroke occurs when a blood vessel in or around the brain ruptures, leading to bleeding that damages surrounding brain tissue. This type of stroke is less common than ischemic strokes but is often more severe. There are two primary types of hemorrhagic stroke:

1. Intracerebral Hemorrhage: Bleeding occurs directly within the brain tissue when an artery bursts, flooding the surrounding area with blood. This can increase pressure inside the skull and disrupt normal brain function.
2. Subarachnoid Hemorrhage: Bleeding occurs in the space between the brain and the thin, delicate membranes (meninges) that cover it, specifically in the subarachnoid space. This type of stroke is often caused by the rupture of an aneurysm or head trauma.

Both forms of hemorrhagic stroke require immediate medical attention, as they can lead to elevated intracranial pressure, brain swelling, and significant neurological deficits if not promptly treated.

How are Strokes Diagnosed?

Strokes are diagnosed through a combination of physical examinations, imaging tests, and laboratory evaluations to confirm the type of stroke, its severity, and the underlying cause. Rapid diagnosis is critical to ensure appropriate and timely treatment, as the outcomes depend heavily on early intervention.

1. Physical Examination: Healthcare providers assess symptoms such as facial drooping, arm weakness, speech difficulties, and balance or coordination issues. They may also check vital signs, including blood pressure, and use tools like the FAST acronym (Face, Arms, Speech, Time) to quickly identify potential strokes. A neurological exam evaluates reflexes, sensory responses, and cognitive function.

2. Imaging Tests:

• Computed Tomography (CT) Scan: A non-invasive imaging technique used to identify hemorrhagic strokes or rule out other conditions, such as tumors. A CT angiography may be performed to evaluate blood vessels.
• Magnetic Resonance Imaging (MRI): Provides detailed images of the brain to detect ischemic strokes and assess damage to brain tissue. MR angiography can also evaluate blood flow in the brain’s vessels.
• Carotid Ultrasound: Assesses blood flow in the carotid arteries, which supply blood to the brain, to check for blockages or narrowing.

3. Laboratory and Other Diagnostic Tests:

• Blood Tests: Measure glucose levels, clotting function, and cholesterol to identify stroke risk factors or other underlying conditions.
• Electrocardiogram (ECG): Detects irregular heart rhythms, such as atrial fibrillation, which can contribute to embolic strokes.
• Echocardiography: Examines the heart for clots or structural abnormalities that may lead to embolic strokes.

These diagnostic methods allow healthcare teams to differentiate between ischemic and hemorrhagic strokes and tailor treatment accordingly, whether through clot-dissolving medications, surgical interventions, or other therapies.

How Do You Prevent a Stroke?

Preventing a stroke involves managing risk factors, adopting a healthy lifestyle, and addressing underlying medical conditions. While not all strokes can be prevented, taking proactive steps significantly reduces the likelihood of an event.

1. Manage Medical Conditions:

1. • Control High Blood Pressure: Hypertension is the leading cause of strokes. Regular monitoring and prescribed medications, combined with dietary and lifestyle changes, are essential.
   • Treat Atrial Fibrillation: Irregular heartbeats increase the risk of embolic strokes. Anticoagulants or other medications can help manage this condition.
   • Manage Diabetes: Keeping blood sugar levels within the target range prevents damage to blood vessels.
   • Lower Cholesterol: A diet low in saturated fats and the use of cholesterol-lowering medications (e.g., statins) can reduce plaque buildup in arteries.

2. Adopt a Healthy Lifestyle:

1. • Eat a Balanced Diet: A diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats promotes vascular health. The DASH or Mediterranean diets are particularly effective.
   • Exercise Regularly: Aim for at least 150 minutes of moderate-intensity aerobic activity per week to improve cardiovascular health.
   • Quit Smoking: Smoking damages blood vessels and accelerates atherosclerosis, significantly increasing stroke risk.
   • Limit Alcohol Consumption: Excessive alcohol intake can raise blood pressure and increase stroke risk. Moderate consumption—up to one drink per day for women and two for men—is advised.

3. Preventive Medications and Monitoring:

1. • Aspirin Therapy: In certain cases, low-dose aspirin may be prescribed to prevent clot formation, especially for individuals with a history of transient ischemic attacks (TIAs).
   • Regular Health Checkups: Routine screening for blood pressure, cholesterol, and other risk factors allows early detection and intervention.

By combining medical management, lifestyle changes, and routine monitoring, individuals can significantly reduce their risk of both ischemic and hemorrhagic strokes.

Signs and Symptoms of Stroke

Use the Letters F.A.S.T. to Identify a Stroke

Recognizing the signs of a stroke quickly can save a life. The acronym F.A.S.T. makes it easy to remember the key symptoms and the urgency of action:

• Face Drooping: Check if one side of the person’s face is drooping or feels numb. Ask them to smile. If their smile is uneven or appears lopsided, it’s a warning sign.
• Arm Weakness: Determine if one arm is weak or numb. Ask the person to raise both arms. If one arm drifts downward or cannot be lifted, it could indicate a stroke.
• Speech Difficulty: Listen for slurred or hard-to-understand speech, or an inability to speak altogether. Ask the person to repeat a simple sentence. Difficulty speaking clearly is a red flag.
• Time to Call 911: If any of these symptoms are present—even if they go away or seem minor—call 911 immediately. Acting quickly is critical to minimize damage and improve outcomes.

Remember, every second counts during a stroke. F.A.S.T. can help you take swift and potentially life-saving action. These signs may appear suddenly and without warning, and  immediate action is essential to reduce brain damage and increase the chances of recovery. Time is critical, and the sooner you call 911, the better the chances of successful treatment.

How Do You Treat a Stroke?

When someone is experiencing a stroke, immediate action is crucial, and the first few minutes can significantly impact their recovery. While bystanders can play an important role in recognizing symptoms and providing basic assistance, emergency medical technicians (EMTs) have specialized training and equipment to provide advanced care. Understanding the difference between what a non-professional can do in an emergency and what an EMT can do once they arrive helps clarify the steps to take in these critical moments.

Non-professional treatment of a stroke

If you suspect someone is having a stroke, it’s important to act quickly and calmly while waiting for emergency medical professionals to arrive. Here are the key steps you should take:

1. Call 911 Immediately: Time is critical in stroke treatment, so contact emergency services as soon as you notice any signs of a stroke. Provide clear and concise information about the person’s symptoms, the time they started, and their current condition.
2. Stay Calm and Keep the Person Comfortable: Help the person stay calm and try to make them as comfortable as possible. Encourage them to remain still and avoid any physical activity, as moving around could worsen their condition.
3. Note the Time of Symptom Onset: If possible, try to note when the symptoms began. This information will be crucial for medical professionals, as the effectiveness of certain treatments (e.g., clot-busting drugs for ischemic strokes) depends on how soon they are administered after the onset of symptoms.
4. Monitor Breathing and Vital Signs: Keep an eye on their breathing. If the person stops breathing or becomes unconscious, you may need to perform CPR (cardiopulmonary resuscitation). However, do not try to force the person to eat, drink, or take any medication, as this could lead to choking or other complications.
5. Position the Person Safely: If the person is conscious and alert, have them sit or lie down with their head elevated to help reduce the risk of aspiration or choking. If they are unconscious, place them on their side to help prevent choking, especially if they begin to vomit.
6. Do Not Give Food or Drink: Do not offer the person anything to eat or drink, as swallowing may be impaired during a stroke, increasing the risk of choking.
7. Reassure the Person: If the person is alert, reassure them that help is on the way. Keep them calm and avoid arguing with them if they appear confused or have difficulty understanding what is happening.
8. Prepare for EMT Arrival: Clear the area to make it easier for EMTs or paramedics to access the person. Have information ready, such as the person’s medical history, medications, allergies, and any relevant details about their stroke symptoms.

Prompt action and the right steps while waiting for professional help can significantly impact the outcome of a stroke. Every minute counts, so stay focused and do everything you can to support the person in need of urgent care.

Professional EMT treatment of a stroke

In the event of a stroke emergency, an EMT or paramedic will likely be the first healthcare provider to assess and treat your condition. EMTs have a clear set of protocols and procedures for most of the 911 emergencies they encounter, including stroke symptoms. For all suspected strokes, the first step is a rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.

ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure. The ABCDE approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment. It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units. The treatment for a stroke depends on the type (ischemic or hemorrhagic), its severity, and how quickly treatment is initiated. Rapid intervention is essential to minimize brain damage and improve outcomes. Treatment typically involves medications, surgical procedures, and supportive care.

1. Ischemic Stroke Treatment:

1. • Thrombolytics (Clot-busting Drugs): For ischemic strokes, the primary treatment is the administration of tissue plasminogen activator (tPA), which dissolves blood clots and restores blood flow to the brain. tPA must be given within 3 to 4.5 hours of symptom onset to be most effective.
   • Mechanical Thrombectomy: For some patients, a minimally invasive procedure may be used to remove the clot physically. This is typically performed if the clot is large or in a major artery and is often done within 6 to 24 hours of symptom onset.
   • Antiplatelet Drugs: Following the acute phase, medications like aspirin may be prescribed to prevent further clotting.

2. Hemorrhagic Stroke Treatment:

1. • Surgical Intervention: Hemorrhagic strokes may require surgery to repair the ruptured blood vessel or remove the blood accumulating in the brain. This can involve a craniotomy (removing part of the skull to access the brain) or the use of endovascular techniques to stop bleeding.
   • Blood Pressure Management: For hemorrhagic strokes, controlling high blood pressure is critical to prevent further bleeding. Medication may be used to lower blood pressure or control brain swelling.
   • Coagulation Factor Therapy: If the stroke is caused by a bleeding disorder (e.g., anticoagulant use), specific treatments to reverse the effects of blood thinners may be administered.

3. Supportive Care:

1. • Monitoring and Intensive Care: Patients are often closely monitored in a hospital’s intensive care unit (ICU) for signs of brain swelling, seizures, or changes in neurological function.
   • Rehabilitation: After stabilizing the patient, a comprehensive rehabilitation program involving physical therapy, occupational therapy, speech therapy, and psychological support is vital to help stroke survivors recover function and adapt to potential long-term disabilities.

4. Preventive Care Post-Stroke:

1. • Anticoagulants and Antiplatelet Drugs: To prevent further strokes, patients may be prescribed blood-thinning medications, such as aspirin or warfarin.
   • Lifestyle Modifications: After a stroke, patients are encouraged to adopt healthier habits, including a balanced diet, regular physical activity, and smoking cessation, to reduce stroke recurrence risk.

The treatment approach must be personalized based on the type of stroke, the severity, and the patient’s overall health, with the goal of minimizing damage, improving recovery, and reducing the likelihood of future strokes.

Treatment Guidelines and Resources for Medical First Responders

The National Model EMS Clinical Guidelines, developed by the National Association of State EMS Officials (NASEMSO), offer standardized protocols for stroke and transient ischemic attack (TIA) management. These guidelines are designed to assist in creating state and local EMS clinical protocols and are regularly updated to reflect the latest evidence-based practices. The most recent version, Version 3.0, was released in March 2022.

These guidelines provide a structured approach to patient assessment for suspected stroke and TIA, emphasizing the importance of early recognition and rapid intervention. Key components include:

• Assessment of Neurological Deficits: Utilizing validated stroke scales to evaluate the severity of symptoms.
• Determination of “Last Known Well” Time: Identifying the time when the patient was last known to be without symptoms, which is crucial for treatment decisions.
• Prehospital Care: Administering oxygen to maintain oxygen saturation levels between 94–98%, checking blood glucose levels, and performing a 12-lead electrocardiogram (EKG) when possible.
• Early Hospital Notification: Communicating with receiving hospitals to prepare for the patient’s arrival, especially if a large vessel occlusion (LVO) is suspected.
• Transport Decisions: Choosing the appropriate destination hospital based on the patient’s condition and available resources, which may include stroke-ready facilities, primary stroke centers, thrombectomy-capable stroke centers, or comprehensive stroke centers.
• Gather Patient History: Identify current medications, especially anticoagulants (e.g., aspirin, warfarin). Document recent illnesses, surgeries, or trauma, and any history of stroke, drug abuse, migraines, infections, or pregnancy.

These protocols are designed to facilitate rapid identification and treatment of stroke patients, improving outcomes through timely and appropriate care. It’s essential for EMS providers to be familiar with and adhere to their local and regional stroke protocols, as they may have specific variations based on available resources and regional guidelines.

Take the First Step toward a Rewarding and Impactful Career in EMS

Unitek EMT is proud to be one of the premier EMT schools in Arizona, dedicated to providing the highest standard of education and training to future emergency medical professionals. Our mission is clear: to cultivate skilled, confident, and compassionate EMTs who are prepared to excel in the fast-paced, high-pressure world of emergency medical services. To meet the diverse needs of our students, we offer a variety of flexible training options, including an accelerated EMT program, allowing you to become mission-ready and certified in a shorter time frame.

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As a Unitek EMT student, you will be part of a community that values excellence, empathy, and a commitment to making an impact in healthcare. We are here to support you at every step of your journey, whether you’re just starting out or looking to further your career. The training you receive here will empower you to step into the field with the skills and mindset of a true professional, ready to tackle any challenge and save lives when it matters most. Your future as a top-tier EMT starts now—let us help you take the first step toward a rewarding and impactful career in emergency medical services.