Although our ability to manage strokes in the field is minimal, EMS serves a critical role in obtaining a history of the illness - specifically a patient’s last known normal.
What changes in the AHA/ASA 2018 guidelines for stroke care are important to EMS providers?
Many of the changes made to the stroke management guidelines for 2018 are applicable only to the in-hospital setting. However, there are a few changes that have been made in regards to EMS identification and management of stroke patients in the pre-hospital setting.
The key changes to the guidelines have to do primarily with early identification of strokes using some tested stroke identification tool or scale (i.e. FAST (face, arms, speech, time), LAPS (Los Angeles Prehospital Stroke Screen), and the Cincinnati Prehospital Stroke Scale (CPS)) (1). By identifying stroke symptoms early, EMS can alert the receiving hospital with enough time to allow a stroke team to assemble, and prepare all necessary equipment quickly in order to begin rapid assessment and treatment of the patient. As mentioned earlier, EMS also plays a crucial role history gathering, which serves to provide physicians and nurses with the patient’s “last known normal” in order to determine which types of treatment are most appropriate for the patient (1,2,3). Additionally, this history gathering aids in EMS personnel’s determination of where a patient should be transferred. For example, patients who qualify for IV thrombolytic treatment (like tPA) - meaning they fall in the range of a last known normal of 3-4.5 hours prior - may be transported to a closer facility to initiate treatment (although they later may be transported to a facility with mechanical thrombectomy treatment capabilities), while those who fall outside this window are disqualified from IV tPA, and therefore direct transfer to a facility with mechanical thrombectomy capabilities is necessary (the current time limit on thrombectomy ranges from 6-24 hours (4) with much more research needed on the subject). Many of these protocols will still be determined on an agency-specific level - therefore providers should research local protocols with regards to the care and transport of stroke patients.
Aside from early identification and rapid transport of stroke patients, it is important that EMS providers understand the value of obtaining both a blood glucose and temperature reading for patients experiencing stroke-like symptoms. While EMS providers cannot truly diagnose a stroke in the field (only initiate a stroke alert based on the presented symptoms and vitals), they can take steps in correcting other ailments that may either mislead a provider into thinking a patient is experiencing a stroke, or treat symptoms of a true stroke that may prevent excessive damage to the patient. Two examples of these are hypoglycemia and hyperthermia. Again, it is important to note that specific treatment is based on local protocols and medical direction, however, knowing that hypoglycemia (defined as blood glucose <60 mg/dL (1)) can either present with symptoms that mimic a stroke (and therefore correction of hypoglycemia can prevent undue stress to the patient and the hospital system), or exacerbate disability from stroke, is key, as we are able to correct this in the field. Also, understanding that hyperthermia (which is anything greater than 38 degrees Celsius, according to the 2018 guidelines (1)) can exacerbate damage done by stroke, and therefore cooling protocols may be in place (ice packs, antipyretic medications, etc.) is important in EMS provider’s education.
Lastly, EMS can play a role in public education on self-identification of stroke. Research has found that “Blacks and Hispanics particularly have lower stroke awareness than the general population and are at increased risk of prehospital delays in seeking care” (1). We, as EMS providers, can, therefore, educate individuals we come in contact with on the signs and symptoms of stroke, as well as the importance of rapid EMS notification.
Ultimately, the goal of EMS in stroke care is early identification and rapid transport to an appropriate hospital. However, having the ability to recognize and treat stroke symptoms, as well as educate the public, may improve the overall outcome and limit disability of patients.