One-Pager
Prehospital Stroke and STEMI
Stroke and LVO screens, last known well, destination, 12-lead, STEMI times, and aspirin and nitro cautions for EMT and paramedic
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Stroke: screen and time it
| Tool | Checks | Positive |
|---|---|---|
| Cincinnati (CPSS) | Face droop, arm drift, speech | Any 1 abnormal |
| BE-FAST | FAST plus balance and eyes (vision) | Any new deficit |
| LAMS (0-5) | Face 0-1, arm drift 0-2, grip 0-2 | ≥4: LVO likely |
| RACE (0-9) | Face, arm, leg, gaze, aphasia or agnosia | ≥5: LVO likely |
- LVO clues: gaze deviation, aphasia, neglect, dense one-sided weakness
- Bleed clues (none specific): severe headache, vomiting, falling LOC, very high BP
- Last known well (LKW): last time seen normal (and by whom), not when found or woke up
- Glucose on every suspected stroke; treat if <60 mg/dL, then rescreen
- Mimics: hypoglycemia, seizure with postictal weakness, sepsis, migraine, intoxication
- Ask: anticoagulants, recent trauma, surgery, bleeding, seizure
Stroke: destination and field care
| From LKW | Treatment | EMS destination |
|---|---|---|
| ≤4.5 h, no LVO signs | IV thrombolysis | Closest stroke-capable hospital |
| ≤24 h, LVO likely | Thrombectomy, plus lytic if eligible | Thrombectomy-capable center (TSC or CSC) |
- LVO signs: direct to a TSC per plan, if the extra time will not cost lytic eligibility
- Going to a distant (45-60 min) TSC did not beat a well-run local stroke center
- Stroke alert early: LKW, scale and score, glucose, anticoagulants, ETA
- Scene time ≤15 min; IV line, but avoid multiple attempts
- Oxygen only if hypoxemic (SpO₂ 94-98%); NPO until a swallow screen
- Head of stretcher 15-30° if SBP >100, neck neutral; protect weak limbs
- Cardiac monitor; 12-lead if it does not delay transport
STEMI: 12-lead and destination
- 12-lead within 10 min of first medical contact (FMC); transmit or read it
- Nondiagnostic with ongoing symptoms: repeat 12-leads (some occlusions lack ST elevation)
- STEMI: new J-point ST elevation in 2 contiguous leads, ≥1 mm (V2-V3: ≥2 mm men 40+, ≥2.5 mm men <40, ≥1.5 mm women), without LBBB or LVH
- Inferior STEMI: add right-sided leads (V4R) to look for RV infarct
- ST depression in V1-V3: think posterior MI; check V7-V9 for ST elevation
- Early STEMI alert, short scene time, pads on high-risk patients
| Situation | Goal (ACC/AHA 2025) |
|---|---|
| Direct to PCI center | FMC to device ≤90 min |
| Transfer for PCI | FMC to device ≤120 min |
| PCI not possible within 120 min, onset <12 h | Lytic within 30 min of arrival if no contraindication, then transfer |
| Cardiogenic shock | Emergency PCI or CABG, any time from onset |
Aspirin, nitro and oxygen
Typical adult doses for exam study. Follow your agency's protocols.
| Drug | Typical dose | Hold if |
|---|---|---|
| Aspirin | 162-325 mg chewed, not enteric-coated | True allergy, active bleeding, possible stroke |
| Nitroglycerin | 0.4 mg SL every 5 min, up to 3 | SBP <90-100, PDE5 inhibitor, possible stroke, RV infarct (per protocol) |
| Oxygen | If SpO₂ <90%, dyspnea or heart failure | Not routine if SpO₂ ≥90% |
EMT vs paramedic
| Task | EMT | Paramedic |
|---|---|---|
| Stroke scale, LKW, glucose | Yes | Yes |
| Low glucose | Oral glucose if alert and can swallow | IV dextrose |
| 12-lead | Acquire and transmit | Also interpret |
| Aspirin | Yes | Yes |
| Nitroglycerin | Assist with patient's own | Give SL per protocol |
| IV access, opioid analgesia | No | Yes |
| Fibrinolytics | No | Only where the medical director approves |
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Sources
- Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2026;57(8):e316-e436 (epub Jan 26, 2026). doi:10.1161/STR.0000000000000513. Correction: Stroke. 2026;57(8):e461-e467. Link
- Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Circulation. 2025;151(13):e771-e862 (epub Feb 27, 2025). doi:10.1161/CIR.0000000000001309. Link
- National Association of State EMS Officials. National Model EMS Clinical Guidelines, Version 3.0. March 2022 (Suspected Stroke/TIA; Chest Pain/ACS/STEMI; Appendix medication formulary: Nitroglycerin). Link
- National Association of State EMS Officials. National EMS Scope of Practice Model 2019: Including Change Notices 1.0 and 2.0 (Report No. DOT HS 813 151). NHTSA; August 2021. Link
- Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33(4):373-378. Link
- Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke. 2017;48(2):479-481. Link
- Nazliel B, Starkman S, Liebeskind DS, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke. 2008;39:2264-2267. Link
- Pérez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014;45(1):87-91. Link
- Mills NL, Newby LK, Zaman S, et al. Fifth Universal Definition of Myocardial Infarction (2026). Glob Heart. 2026;21(1):64. doi:10.5334/gh.1578. Link
- Nitrostat (nitroglycerin sublingual tablets) prescribing information. Viatris Specialty LLC; DailyMed set ID 9a52da75-d0af-4237-96c0-0b12adfa8636 (label version 2/2023). Link
- Cialis (tadalafil) prescribing information. Eli Lilly and Company; revised 3/2026 (DailyMed update June 2026), DailyMed set ID bcd8f8ab-81a2-4891-83db-24a0b0e25895. Link
- Viagra (sildenafil) prescribing information. Viatris Specialty LLC; DailyMed set ID d905dc8d-917f-4ea3-a4ee-a1ecf6967d4e (label version 11/2023). Link
- Stendra (avanafil) tablets prescribing information. Revised 10/2022; DailyMed set ID fa7d93e3-b69b-4e02-8146-89760cd8e9d6. Link
- Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108-2129. Link