1
Scene Size-Up & Safety ▼
- BSI: Gloves (fall risk — possible blood)
- Fall hazard assessment: Patient on floor? C-spine consideration?
- Note environment: alone, altered — how long down?
- Gather medications — anticoagulants (Warfarin, Eliquis, Xarelto, Plavix)?
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2
ABCs + IMMEDIATE Glucose Check
- Airway: Protect — altered patients at risk for aspiration. Recovery position if unconscious.
- Breathing: Rate, depth, SpO2. O2 if SpO2 < 94% only — avoid hyperoxia.
- Circulation: Pulse, BP (both arms). Note: hypertension is common and expected — do NOT aggressively treat in field unless directed.
📉
GLUCOSE — CHECK IMMEDIATELY
Hypoglycemia mimics stroke. BGL < 60 mg/dL → treat NOW before continuing. Oral glucose if conscious, ALS for D50/D10 IV if altered.
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🎯 Step 3 — Cincinnati Stroke Scale
0 / 3
Cincinnati Score — Tap items below to assess
1. Facial Droop
1
Ask patient to show teeth or smile. Observe both sides of face.
2. Arm Drift
2
Ask patient to close eyes, hold both arms out (palms up) for 10 seconds. Observe for drift.
3. Abnormal Speech
3
Ask patient to repeat: "The sky is blue in Cincinnati"
🆙 Step 4 — BE-FAST Reference
B
Balance
Sudden loss, ataxia
E
Eyes
Sudden vision change
F
Face
Droop, asymmetry
A
Arms
Drift, weakness
S
Speech
Slur, confusion
T
Time
CALL 911 NOW
⏱ Step 5 — Last Known Well Time
tPA Window Calculator
tPA eligibility window: < 3–4.5 hours from last known well. Earlier = better outcomes.
Last Known Well Time
6
SAMPLE History ▼
- Anticoagulants? — Warfarin, Eliquis, Xarelto, Pradaxa, Plavix (affects tPA eligibility)
- Prior stroke or TIA? — when, residual deficits
- Atrial fibrillation? — major embolic stroke risk
- Hypertension, diabetes?
- BP medications: Don't aggressively lower BP in field (neuroprotective hypertension)
- Recent surgery? (within 14 days — tPA contraindication)
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🧩 Step 7 — Stroke Mimics Checklist
Hypoglycemia ✓ Checked
BGL < 60 → treat first. Most important mimic to rule out.
Todd's Paralysis
Post-seizure focal weakness; witness seizure activity. Resolves in hours.
Bell's Palsy
Peripheral facial droop (entire face including forehead). Arm/speech normal.
Complex Migraine
Hemiplegic migraine with focal deficits. Severe headache history.
Intoxication / Overdose
Slurred speech, confusion. ETOH breath, drug paraphernalia, pupils.
🚨 Step 8 — STROKE ALERT Management
NOTIFY RECEIVING HOSPITAL: Code Stroke notification en route. Target certified stroke center (nearest, not closest). Give Cincinnati score, LKW time, current time.
Management Checklist
BLS O2 only if SpO2 < 94%. Avoid hyperoxia — excess O2 may worsen outcomes in stroke. NC 2-4L only as needed.
BLS Position: HOB 30° (head of bed/stretcher). Airway management — recovery position if unresponsive to protect airway.
BLS NPO — Nothing by mouth. Dysphagia risk. High aspiration risk in stroke.
BLS Glucose management: BGL < 60 → oral glucose if conscious and can protect airway. BGL > 200 → note but do not treat pre-hospital.
ALS IV access: Large bore × 2 en route. D50 or D10 for hypoglycemia if altered. Saline lock only (no dextrose drips).
ALS Monitor: 12-lead ECG (AF identification). Cardiac monitoring. Vitals every 5 min. BP: do NOT lower aggressively unless directed by medical control.
BLS TRANSPORT: Load & Go. Do not delay for IV attempts. Minimize on-scene time. Document all times (dispatch, arrival, LKW, departure).