To provide EMTs with the fundamental knowledge needed to recognize and manage potential stroke in the pre-hospital setting and make appropriate transport and hospital notification decisions based on the Stroke POE Plan.
dilation, bulging or ballooning out of part of the wall of a vein or artery in the brain.
Blood in the subarachnoid space may impair drainage of cerebrospinal fluid and cause a rise in intracranial pressure
Herniation of brain tissue may occur
Protrusion of brain tissue through the base of skull (shown as “e”) from pressure due to mass lesion
What can be done?
Rapid recognition and prompt transport to a Primary Stroke Service (PSS) provider
A Primary Stroke service provider is a DPH designated facility that offers emergency diagnostic and therapeutic services provided by a multidisciplinary team and available 24 hours per day, 7 days per week to patients presenting with symptoms of acute stroke.
Tissue plasminogen activator (tPA) and other thrombolytic (clot dissolving) agents used for heart attack, are also effective against certain ISCHEMIC strokes
A multi-center, randomized clinical trial conducted by The National Institute of Neurological Disorders and Stroke (NINDS) found that selected stroke patients who received t-PA within three hours of the onset of stroke symptoms were at least 30 percent more likely than placebo patients to recover from their stroke with little or no disability after three months.
Time Sensitive Treatment
Must receive treatment within three (3) hours of onset of symptoms
EMS must determine the exact time of onset as accurately as possible and also note the time the patient was last seen well
Transport to PSC within 2 hours of symptom onset if possible
Following the Mass EMS Pre-hospital Treatment Protocols for Acute Stroke (3.11), determine possibility of stroke based on BOSS scale (Protocols, Appendix Q) and assessment
Establish time of onset and last time seen at baseline
If stroke symptoms present & time from
onset of symptoms to hospital arrival will be
< 2 hours, transport patient to nearest appropriate DPH designated provider of Primary Stroke Service (PSS)
Notify receiving facility ASAP
GOAL: To transport patient to PSS within 2 hours of symptom onset.
Choose most appropriate mode of transport (ground, air) and destination to achieve this.
It may be more appropriate to transport to the nearest hospital for acute stabilization if:
Depressed level of consciousness
Documented or suspected severe hypoglycemia (diaphoretic & known diabetic)
If CT Scan capability is unavailable at the nearest PSS (e.g., “Cautionary Status”), the patient should be transported to the next nearest appropriate PSS
If the patient will arrive at the PSS more than 2 hours after symptom onset, transport to the nearest hospital.
These time guidelines may be revised as new therapies extend the stroke treatment time frame
Age, Sex, Race/Ethnicity
Onset time and last seen at baseline
Assessment and care provided (BLS/ALS)
Receiving Primary Stroke Service (PSS)
Trip times (dispatch, patient contact, hospital notified, hospital arrival)
Thrombolytic Checklist (include all information)
Remember to leave a copy of the Patient Care Report at the hospital per:
105 CMR 170.345 (C)(2)
The EMS patient care report is a CRITICAL part of the patient’s medical record and contains vital information pertinent to continuing care at the hospital and to providing follow-up information to EMS.
Two major categories of stroke
Common signs & symptoms of stroke
Risk factors for stroke
The importance of rapid stroke therapy
Pre-hospital assessment and care, the (BOSS) and thrombolytic checklist
Stroke POE plan
67 year old female at home
Chief complaint dizziness
History of NIDDM
Scenario 1 examined
There are many causes of dizziness that are not stroke-related. Review these together.
Older patients and those with Diabetes are at increased risk of ischemic stroke.
Discuss the other findings that might make you think this patient is experiencing a stroke.
54 year old male at minor MVA
Chief complaint sudden onset headache
History of hypertension
Scenario 2 examined
The MVA may have caused the headache, but maybe the headache caused the MVA. Remember to consider all the possibilities.
Patients with hypertension are at increased risk of ischemic stroke and intracerebral hemorrhage.
Headache is unusual in ischemic stroke, but is the hallmark of hemorrhagic stroke.
72 year old male at fast food restaurant
Wife reports patient “acting funny” and slurring words
History of TIA
Scenario 3 examined
Older patients and those with prior cerebrovascular disease are at increased risk of ischemic stroke.
“Acting funny” may indicate impaired language or cognitive function. Slurred speech may be aphasia or dysarthria.
Discuss what to do next to determine if this patient meets the POE criteria.
Ask your training officer
Consult your service Medical Director
Call your Regional office or visit their website
Contact OEMS at (617)753-7300 or visit http://www.mass.gov/dph/oems/oems.htm
Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology. In Brady, Essentials of Paramedic Care (pp. 1356-1361, 1827-1828). Upper Saddle River, NJ: Pearson Education, Inc.
Dambinova, S. (2004). Diagnostic Potential of New Brain Markers for TIA/Stroke Assessment. Business Briefing:Medical Device Manufacturing & Technology, 1-4.
Note: The Department of Public Health’s Office of Emergency Medical Services provides links to the referenced web sites as a public service. The Office of Emergency Medical Services does not exercise control over the content of these web sites. A link's presence here should not be construed as an endorsement of its contents by the Office of Emergency Medical Services.