• Unilateral motor weakness or paralysis to the face, limb, or side of the body, including facial droop.
• Unilateral numbness
• Dizziness/vertigo
• Acute visual disturbance, loss of vision in one eye or one side of vision
• Difficulty with balance or uncoordinated movements of a limb, gait disturbance
• Difficulty with speech understanding or production (slurred or inappropriate use of words)
• Severe headache for no obvious reason
• Altered mental state.

EMT Standing Order

• Routine Patient Care.
• Complete the Prehospital Stroke Screening Tool
  • If Prehospital Stroke screen is positive, complete stroke severity score (e.g., FAST-ED or Cincinnati) to determine probability of a large vessel occlusion (LVO). May use paper form or approved app.
• Establish Stroke Alert Criteria and notify receiving hospital of “Stroke Alert” with findings from the screening tools, thrombolytic checklist and time last known well Time Last Known Well (TLKW).
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Parmedic in patient care.

For symptomatic:

Administer oxygen as appropriate with a target of achieving 94 - 98% saturation.

• Elevate head of stretcher to 30° (unless patient requires spinal motion restriction);
• Minimize on-scene time; do not delay for ALS intercept;
• Acquire and transmit 12-lead ECG, if available;
• Correct glucose if < 60 mg/dL. See Diabetic Emergencies Hypoglycemia Adult.
• Rapid transport to the most appropriate facility based on the destination guidance utilizing your local stroke plan.

AEMT/Paramedic Standing Order

• Establish IV (18-gauge catheter & right AC preferred site) and administer 250 mL 0.9% NaCl bolus.
• In case of seizer or combative cases further dose of diazipam can be permitted

Prehospital Stroke Screening Tool

The stroke screen is positive if any abnormal finding in facial droop, arm drift or speech.

• Time last known well: (If patient awoke with symptoms, time last known to be at baseline)
• Witness: Best contact number for witness
• Prehospital Stroke Scale Examination: Please check: Normal / Abnormal
• Facial Droop: Have the patient smile and show teeth.
  • Normal: Both sides of the face move equally well
  • Abnormal: One side of the face does not move as well as the other.
• Arm Drift: Have the patient close their eyes and hold their arms extended for 10 seconds.
  • Normal: Both arms move the same, or both arms don’t move at all.
  • Abnormal: One arm doesn’t move, or one arm drifts down compared to the other.
• Speech: Ask the patient to repeat a phrase such as, “You can’t teach an old dog new tricks”
  • Normal: Patient says the correct words without slurring.
  • Abnormal: Patient slurs words, says the wrong word or is unable to speak.
• Blood Glucose: If the stroke screening scale is positive calculate the stroke severity score using FAST-ED

PEARLS for Anticoagulants:

• Patients may recognize anticoagulants as "blood thinners". Ask about anticoagulants including warfarin (Coumadin or Jantoven), Heparin (IV/IM - including Lovenox), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), betrixaban (Bevyxxa) or edoxaban (Savaysa) and immediately communicate to hospital staff.
• Please note, medication manufacturers are producing new anticoagulants frequently

PEARLS:

• Stroke requires time-sensitive interventions. Time = Brain
• Every minute of acute stroke = about 2 million neurons lost.
• Transport the witness, family or caregiver or obtain the witness's best phone number for hospital staff to verify the time of symptom onset or Time Last Known Well (TLKW).
• TLKW is the last time patient known to be at their neurological baseline. If the patient awakes with symptoms, TLKW is the time the patient was last known to be at their neurological baseline – Ask if the patient got up during the night and was at baseline!
• Consider stroke mimics including migraine, hypoglycemia, seizures, intoxication, sepsis, cerebral infectious process, toxic ingestion, neuropathies (Bell’s palsy), neoplasms, hypertensive encephalopathy or previous stroke.