Last updated: July 28, 2021
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%.
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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.Symptoms of Stroke
• 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.
- General assessment by expert
- Order urgent CT scan without contrast
- Perform CT scan without contrast
- Neurological assessment
- Read CT scan within 45 minutes
- Evaluate criteria for use and administer fibrinolytic therapy (“clot buster”)
- Fibrinolytic therapy may be used within three hours of symptom onset (4.5 hours in some cases)
- Admission to stroke unit
- Before giving anything (medication or food) by mouth, you must perform a bedside swallow screening. All acute stroke individuals are considered NPO on admission.
- The goal of the stroke team, emergency physician, or other experts should be to assess the individual with suspected stroke within 10 minutes of arrival in the emergency department (ED).
- The CT scan should be completed within 10-25 minutes of the individual’s arrival in the ED and should be read within 45 minutes.
Emergency Department Staff
Complete EMS Care | Targeted Stroke Evaluation | Establish Symptom Onset Time | CT Scan of Brain Stat | Obtain 12-Lead ECG | Check Glucose and Lipids | Contact Stroke Team |
Oxygen
Confirm time of symptom onset
Perform targeted neurological exam
(NIH Stroke Scale)
Complete fibrinolytic checklist