Acute Stroke Management in Emergency Medical Services

Initial EMS Management

The American Heart Association recommends supplemental oxygen for hypoxemic stroke patients (oxygen saturation <94%) or those with unknown oxygen saturation 1, 2
Blood glucose should be checked in the field if possible, as hypoglycemia can mimic stroke symptoms 2
For patients with persistent chest pain, intravenous morphine may be considered, though caution is advised in unstable angina/NSTEMI due to association with increased mortality 1
EMS providers should establish IV access to prepare for potential hospital interventions, although this guideline is from Praxis Medical Insights, a more relevant guideline from the American College of Cardiology is not available 3

The American Heart Association recommends that unless the patient is hypotensive (systolic blood pressure <90 mm Hg), prehospital intervention for blood pressure is not recommended 1, 2
Blood pressure management is typically reserved for the hospital setting, particularly before thrombolytic therapy, as recommended by the American Stroke Association 4

The American Heart Association recommends intravenous alteplase (tPA) as the standard of care for eligible acute ischemic stroke patients within 4.5 hours of symptom onset 5, 6
Blood pressure must be <185/110 mmHg before tPA administration and maintained <180/105 mmHg for 24 hours after treatment, as recommended by the American Stroke Association 4

Time is critical - EMS providers should rapidly identify stroke symptoms, establish time of symptom onset, and provide pre-arrival notification to the receiving hospital, as recommended by the American Heart Association 2, 7
EMS should transport patients to the most appropriate stroke center when possible, as recommended by the American Stroke Association 6, 7
Stroke assessment scales should be used in the field to identify potential stroke patients, as recommended by the American Heart Association 2
Documentation of the last known normal time is essential for determining eligibility for time-sensitive interventions, as recommended by the American Heart Association 2

Delaying transport to administer medications in the field - rapid transport to a stroke center is the priority, as recommended by the American Stroke Association 7
Failing to notify the receiving hospital of a potential stroke patient, which can delay in-hospital treatment, as recommended by the American Heart Association 2
Administering antihypertensive medications in the field without specific indications, as recommended by the American Heart Association 1, 2
Missing the documentation of exact time of symptom onset or last known normal time, as recommended by the American Heart Association 2