Last updated: July 28, 2021 Show
Version control: Our ACLS, PALS & BLS courses follow 2020 American Heart Association Guidelines for CPR and ECC. American Heart Association guidelines are updated every five years. If you are reading this page after December 2025, please contact for an update. Version 2021.01.c To test for stroke probability, instruct the patient to show their teeth or smile. Evaluate for facial droop. It is abnormal if one side of the face does not move as well as the other. Next, evaluate arm drift. Instruct the patient to close their eyes and extend both arms straight out, with the palms up for 10 seconds. It is abnormal if one arm does not move or one arm drifts down compared with the other. Third, evaluate for abnormal speech. Have the patient say “you can’t teach an old dog new tricks.” It is abnormal if the patient slurs words, uses the wrong words, or is unable to speak. If any one of the 3 signs is abnormal, the probability of a stroke is 72%. PDF Version Print PDF Order the full set of printed crash cart cards Identify signs and symptoms of a possible stroke and activate the emergency response system. Pre-hospital interventions by EMS will focus on supporting ABCs and giving oxygen if indicated, performing a prehospital stroke assessment using an approved tool such as the Cincinnati Stroke Scale, checking glucose, establishing time of symptom onset (or last seen normal), triaging to a stroke center, and alerting the hospital to activate the stroke team. Within 10 minutes of ED arrival perform immediate general assessment within 10 minutes of patient arrival to the ED and stabilize ABCs if necessary. Provide oxygen therapy if hypoxic. Obtain IV access and perform laboratory assessments. Check glucose and treat if indicated. Obtain a 12-lead ECG and perform neurologic screening assessment. Do not delay CT, obtain CT without contrast within 20 minutes of patient arrival. A neurologic assessment by the stroke team or designee should be done within 20 minutes of patient arrival to the ED. Review patient history, establish the time of symptom onset or last known normal, and perform a neurological examination using a standardized tool such as the NIH Stroke Scan or Canadian Neurological Scale. If the CT scan shows hemorrhage, consult a neurologist or neurosurgeon and consider a transfer. Begin stroke or hemorrhage pathway. Admit to a stroke unit or intensive care. If the CT scan shows no hemorrhage, consider fibrinolytic therapy. Check the fibrinolytic exclusions, repeat the neurologic exam to determine if symptoms are improving or worsening. Candidates with the onset of symptoms within 3 hours or 4.5 hours in selected patients are eligible. If the patient is a candidate for rTPA review the risks and benefits with the patient and family. Begin fibrinolytic therapy within 60 minutes of patient arrival to the ED. Consider endovascular therapy for the onset of symptoms up to 24 hours and large vessel occlusion. Admit the patient to stroke care within 3 hours of arrival to the ED. Begin post-rTPA stroke care. Monitor blood pressure and neurological symptoms. Monitor for adverse reactions to fibrinolytic therapy. Please purchase the course before starting the lesson. Stroke is a condition in which normal blood flow to the brain is interrupted. Strokes can occur in two variations: ischemic and hemorrhagic. In ischemic stroke, a clot lodges in one of the brain’s blood vessels, blocking blood flow through the blood vessel. In hemorrhagic stroke, a
blood vessel in the brain ruptures, spilling blood into the brain tissue. Ischemic stroke and hemorrhagic stroke account for 87% and 13% of the total incidents, respectively. In general, the symptoms of ischemic and hemorrhagic strokes are similar. However, the treatments are very different. • Use four liters per minute nasal cannula; titrate as needed to keep oxygen saturation to 94-99 percent. • Check glucose; hypoglycemia can mimic acute stroke • Determine precise time of symptom onset from patient and witnesses • Determine patient deficits (gross motor, gross sensory, cranial nerves) • Institute seizure precautions
• At least two large gauge IVs in each antecubital fossa. • Take to stroke center if possible Clinical signs of stroke depend on the region of the brain affected by decreased or blocked blood flow. Signs and symptoms can include: weakness or numbness of the face, arm, or leg, difficulty walking, difficulty with balance, vision loss, slurred or absent speech, facial droop, headache, vomiting, and change in level of consciousness. Not all of these symptoms are present, and the exam findings depend on the cerebral artery affected. The Cincinnati Prehospital Stroke Scale (CPSS) is used to diagnose the presence of stroke in an individual if any of the following physical findings are seen: facial droop, arm drift, or abnormal speech. Individuals with one of these three findings as a new event have a 72% probability of an ischemic stroke. If all three findings are present, the probability of an acute stroke is more than 85%. Becoming familiar and proficient with the tool FAST utilized by the rescuers’ EMS system is recommended. Mock scenarios and practice will facilitate the use of these valuable screening tools. FAST: Face Drooping, Arm Weakness, Speech, and Time Symptoms Started Individuals with ischemic stroke who are not candidates for fibrinolytic therapy should receive aspirin unless contraindicated by true allergy to aspirin. All individuals with confirmed stroke should be admitted to Neurologic Intensive Care Unit if available. Stroke treatment includes blood pressure monitoring and regulation per protocol, seizure precautions, frequent neurological checks, airway support as needed, physical/occupational/speech therapy evaluation, body temperature checks, and blood glucose monitoring. Individuals who received fibrinolytic therapy should be followed for signs of bleeding or hemorrhage. Certain individuals (age 18 to 79 years with mild to moderate stroke) may be able to receive tPA (tissue plasminogen activator) up to 4.5 hours after symptom onset. Under certain circumstances, intra-arterial tPA is possible up to six hours after symptom onset. When the time of symptom onset is unknown, it is considered an automatic exclusion for tPA. If time of symptom onset is known, the National Institute of Neurological Disorders and Stroke (NINDS) has established the time goals below.
Emergency Department Staff
OxygenConfirm time of symptom onset Perform targeted neurological exam Complete fibrinolytic checklist Which test should be performed for a patient with suspected stroke?The 2 main types of scan used to assess the brain in people who have had a suspected stroke are: a CT scan. an MRI scan.
Which of these tests should be performed for a patient with suspected stroke within 20 minutes of hospital arrival?Obtain a 12-lead ECG and perform neurologic screening assessment. Do not delay CT, obtain CT without contrast within 20 minutes of patient arrival. A neurologic assessment by the stroke team or designee should be done within 20 minutes of patient arrival to the ED.
What additional assessment and stabilization activity should be completed within the first 10 minutes after the patient's arrival?Immediate general assessment and stabilization.
Once the patient has arrived at the emergency department, and within 10 minutes of arrival, assess the vitals, providing oxygen if the patient is hypoxemic.
Which best describes the length of time it should take to perform a pulse check during BLS assessment?Assess for breathing and pulse.
Simultaneously check the carotid pulse for a minimum of 5 seconds—but no more than 10 seconds—to determine if there is a pulse present. It's important to minimize delay in starting CPR, so take no more than 10 seconds to assess the patient.
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Which of these tests should be performed for a patient with suspected stroke within 25 minutes of hospital arrival?
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