How to Treat Strokes

Learn How EMTs & Paramedics Identify, Treat, and Care for Patients who Suffer a Stroke

Stroke is one of the top 15 most common emergencies that EMS professionals respond to, accounting for 2% of all EMS calls.

(Click here for our list of the most common EMS Emergencies for EMTs and Paramedics).

Stroke is a medical condition in which poor blood flow to the brain causes cell death and improper brain function. There are two main types of stroke: Ischemic stroke and Hemorrhagic stroke.

The signs and symptoms of a stroke may include an inability to move or feel on one side of the body, problems understanding or speaking, dizziness, or loss of vision to one side.

Symptoms often appear soon after the stroke has occurred. If symptoms last less than one or two hours, the stroke is a transient ischemic attack (also known as a min-stroke).

A hemorrhagic stroke may also be associated with a severe headache. The symptoms of a stroke can be permanent. Long-term complications may include pneumonia and loss of bladder control.

The main risk factor for stroke is high blood pressure. Other risk factors include tobacco smoking, obesity, high blood cholesterol, diabetes mellitus, a previous TIA, end-stage kidney disease, and atrial fibrillation.

Facts About Strokes

• Every year, more than 795,000 people in the United States have a stroke
• Stroke is the number 5 cause of death in the United States, resulting in more than 137,000 deaths per year (or about 1 of every 18 deaths)
• In the United States, someone has a stroke every 40 seconds. Every 4 minutes, someone dies of a stroke
• Stroke is a leading cause of serious long-term disability.
• Stroke reduces mobility in more than half of stroke survivors age 65 and over
• In 2018, one in every six deaths from cardiovascular disease was due to stroke
• About 1 in 4 strokes are in people who have had a previous stroke
• About 87% of all strokes are ischemic

Stroke Definition

What is a Stroke?

A stroke is a medical condition in which poor blood flow to the brain causes cell death and improper brain function. There are two main types of stroke: Ischemic and Hemorrhagic.

An ischemic stroke is typically caused by blockage of a blood vessel, though there are also less common causes.

A hemorrhagic stroke is caused by either bleeding directly into the brain or space between the brain’s membranes.

A cryptogenic stroke is a stroke without an obvious explanation. The term cryptogenic means “of unknown origin.” Approximately 30% to 40% of ischemic strokes are cryptogenic.

What is an Ischemic Stroke?

In an ischemic stroke, the blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four possible causes:

1. Thrombosis: Obstruction of a blood vessel by a blood clot forming locally
2. Embolism: Obstruction of a blood vessel by an embolus. An embolus is an unattached mass that travels through the bloodstream and is capable of blocking the flow of blood. Possible causes of embolism include blood clots, cholesterol plaque or crystals, fat globules, gas bubbles, and foreign bodies.
3. Systemic hypoperfusion: A general decrease in blood supply, e.g., in shock)
4. Cerebral venous sinus thrombosis: Presence of a blood clot in the dural venous sinuses, which drains blood from the brain.

What is a Hemorrhagic Stroke?

Hemorrhagic stroke is due to bleeding. There are two main types of hemorrhagic stroke:

1. Intracerebral hemorrhage: Bleeding within the brain itself. This occurs when an artery in the brain bursts and floods the surrounding tissue with blood.
2. Subarachnoid hemorrhage: Bleeding that occurs outside of the brain but still within the skull, in the delicate innermost layer of the meninges, which are three membranes that surround the brain and spinal cord.

How are Strokes Diagnosed?

Diagnosis is typically based on a physical exam and supported by medical imaging such as a CT scan or MRI scan. A CT scan can rule out bleeding but may not necessarily rule out ischemia, which early on typically does not show up on a CT scan. Other tests such as an electrocardiogram (ECG) and blood tests determine risk factors and rule out other possible causes.

Low blood sugar may cause symptoms similar to a stroke.

How to Prevent a Stroke

Prevention includes decreasing risk factors, surgery to open up the arteries to the brain in those with problematic carotid narrowing, and warfarin in people with atrial fibrillation. Physicians may recommend aspirin or statins to prevent strokes. A stroke or TIA often requires emergency care. If detected within three to four and half hours, an ischemic stroke may be treatable with a medication that can break down the clot.

Some hemorrhagic strokes benefit from surgery. Stroke rehabilitation can be used to attempt recovery of lost function and ideally takes place in a stroke unit; however, these are not available in much of the world.

Signs and Symptoms of Stroke

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

Face Drooping: Does one side of the person’s face droop, or is it numb? Ask the person to smile. If their smile is uneven or lopsided, call 911.

Arm Weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? If so, call 911.

Speech: Is the person’s speech slurred or hard to understand? Is the person unable to speak? Ask the person to repeat a simple sentence. If they have trouble speaking, call 911.

Time to Call 911:  If the person shows any of the symptoms above, even if the symptoms go away or seem mild, call 911 immediately.

Additional Symptoms of a Stroke

• Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

When to Call 911

Call 911 immediately if any of the following major stroke warning signs occur:

• Sudden weakness or numbness that occurs in the face, arm, or leg, particularly on one side of the body
• Sudden difficulty seeing on one or both eyes
• Sudden confusion, difficulty speaking, or difficulty understanding. May have either slurred speech or confused speech
• Sudden problems with walking, severe dizziness; or loss of balance or coordination
• Sudden, severe headache, for no reason
• Difficulty swallowing

How to Treat a Stroke

While waiting for an EMT or paramedic to arrive, have the suspected stroke victim lie down. Watch the person and lift their chin to open the airway. Check for breathing and pulse. If necessary, perform cardiopulmonary resuscitation (CPR).

If the person is breathing but unconscious, roll them onto their side. (Do not move the person if you suspect a head, neck, or back injury.)

If the person is conscious, try to reassure and comfort them. Loosen constricting clothing or jewelry. If the person is having difficulty swallowing, try to turn them onto their side. Do not give the person anything to eat or drink.

How Do EMTs & Paramedics Treat Stroke Victims?

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.

Treatment Guidelines & Resources for Medical First Responders

The National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO) provides treatment guidelines for stroke and transient ischemic attack on page 43. These guidelines are maintained by NASEMSO to facilitate the creation of state and local EMS system clinical guidelines, protocols, and operating procedures. These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include the following patient assessment for suspected stroke and transient ischemic attack:

Assessment

1. Use a validated prehospital stroke scale that may include, but is not limited to:
   • Facial smile/grimace – ask patient to smile
   • Arm drift – close eyes and hold out arms for a count of 10 seconds
   • Speech – “You can’t teach an old dog new tricks”
2. Pertinent historical data includes:
   • History – “last known well” and source of that information
   • Neurologic status assessment [see Appendix VII]
   • Patient is taking warfarin or any anticoagulant medication
3. Evaluate for the presence of stroke mimics, including:
   • Hypoglycemia
   • Seizure
   • Sepsis
   • Migraine
   • Intoxication

Treatment and Interventions

1. Determine “last known well” time
2. Administer oxygen as appropriate with a target of achieving 94-98% saturation
3. If seizure activity present, treat per Seizures guideline
4. Check blood glucose level
   Treat only if glucose less than 60 mg/dL
5. Acquire 12-lead EKG, if possible
6. Hospital notification per local stroke plan

EMS Protocol for Stroke Emergencies

Protocols for prehospital treatment of seizures vary by EMS provider and can also depend on the patient’s symptoms or medical history. Below are typical guidelines for the management of patients with suspected stroke.

• Manage CABs (chest compression-airway-breathing); provide oxygen if needed
• Perform prehospital stroke assessment
• Establish and record exact time patient was last seen normal
• If possible, bring a witness to the hospital; alternatively, record the name and phone number (preferably cell phone number) of the witness
• Medical history:
  • Identify current medications taken by the patient, especially any anticoagulants (aspirin, warfarin, etc.)
  • Record recent illnesses, surgery, or trauma and any history of stroke, drug abuse, migraine, infection, and pregnancy
• Formal stroke assessment tools can increase paramedic sensitivity to stroke identification to 90% or higher
• Frequently used screening tools include
  • Cincinnati Prehospital Stroke Severity Scale
  • Los Angeles Prehospital Stroke Screen (LAPSS)

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