Ischemic Stroke - Hennepin County Medical Center

EMS Perspectives
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Seventy-two percent of patients who have one abnormal finding
on these three exam points may be experiencing an acute stroke.
The patient is considered a possible CVA patient if any of the
tested signs/symptoms are abnormal.
The patient may be a candidate for thrombolysis (intravenous tPA)
if any of the tested signs/symptoms are abnormal and onset of
signs and symptoms began within 3 hours. Patients with ischemic
stroke who are outside of the 3-hour window may be candidates
for intra-arterial tPA or mechanical embolectomy, so timely hospital
care is essential.
Reference. Cincinnati Prehospital Stroke Scale (CPSS), Kothari, et al.,
Annals of Emergency Medicine, Volume 33, April 1999. Used with permission.
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Figure One. Cincinnati Prehospital Stroke Scale for EMS Providers
Transport. Even with the treatment window
being expanded up to 6-12 hours from symptom
onset, faster treatment is always better.
Nearly two million brain cells die during each
minute of a stroke. Rapid and safe transport to
the closest appropriate facility is a key element
of prehospital stroke care. Much like trauma
and cardiac centers, many major hospitals are
developing a “stroke center” model, which
allows for rapid, definitive care of the acute
stroke patient. When patients present with
stroke in areas where a “stroke center” is not
available, transport should be initiated to the
closest facility capable of initial assessment
and referral to a tertiary care center. In areas
where ground transport of an acute stroke
patient will not result in arrival at an appropriate
hospital within the treatment window,
aeromedical evacuation should be considered.
Notification. Like trauma, STEMI, and other
critical patients, it’s important to notify the
receiving facility of an inbound patient with
symptoms of acute stroke. This allows the
facility to notify staff, reserve the appropriate
procedure rooms, and prepare the computed
tomograph (CT) scanner (a head CT is
required prior to the administration of thrombolytics
to ensure that the patient does not
have a cerebral hemorrhage). Because “time
is brain,” early notification of the receiving hospital
allows the hospital-based team to prepare
to reduce the other transitions in care that are
necessary before treatment is started, such as
door-to-CT time, door-to-CT-interpretation
time, and CT-interpretation-to-treatment time.
Because of their critical role in stroke care,
EMS providers have an opportunity to provide
patients with some of the biggest possible
reductions in the time it takes for patients to
be treated. This can be most successful with
rapid response, early identification of acute
stroke, early rule-out or management of hypoglycemia,
and rapid transport to the closest
appropriate facility, along with early notification
to allow the hospital to mobilize resources.
EMS providers may not provide definitive
care, but they make definitive care effective
in acute stroke.
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* The treatments described summarize current practices in
emergency care and serve as a guideline for prehospital care.
EMS providers should defer to their agency’s medical director
and standing orders if there is a discrepancy between this
article and the agency’s current practice.
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16 | Approaches in Critical Care | December 2008