EMT · Patient Treatment and Transport · 8 min read
Stroke, Seizures and Altered Mental Status
- Differentiate the presentations of ischemic stroke, hemorrhagic stroke, and transient ischemic attack, and apply the Cincinnati Prehospital Stroke Scale correctly during assessment.
- Describe the emergency basic life support management priorities for patients experiencing active seizures, status epilepticus, and postictal phases.
- Identify common causes of altered mental status and apply systematic assessment methods, airway interventions, and transport protocols within the basic life support scope.
Stroke Pathophysiology and Prehospital Assessment
A stroke occurs when a blood vessel supplying the brain is blocked or ruptures, causing brain injury. These vascular events deprive delicate brain tissue of vital perfusion, leading rapidly to cellular dysfunction. Understanding the underlying mechanism of a stroke helps emergency medical technicians appreciate why prompt identification and rapid emergency transport are so critical in the prehospital setting. Ischemic strokes account for the majority of strokes and occur when blood flow to part of the brain is blocked, commonly by a clot. Conversely, hemorrhagic strokes result from bleeding within or around the brain and may present with a sudden, severe headache. A related condition, the transient ischemic attack, produces temporary stroke-like neurological symptoms that resolve completely without permanent infarction, serving as a warning sign of potential future vascular compromise.
To quickly identify stroke signs in the field, emergency medical technicians utilize standardized screening assessments. The Cincinnati Prehospital Stroke Scale evaluates three specific signs: facial droop, arm drift, and abnormal speech. To assess for facial droop, the EMT instructs the patient to smile or show their teeth to observe facial symmetry, looking for an uneven smile where one side of the face does not move as well as the other. To assess for arm drift, the patient closes their eyes and extends both arms forward with palms facing upward for ten seconds, allowing the provider to see if one arm drops down or turns inward compared to the other. To assess speech during a stroke screen, the EMT asks the patient to repeat a simple standard phrase to listen for slurred words, inappropriate phrasing, or an inability to speak.
An abnormal finding on any component of the Cincinnati Prehospital Stroke Scale suggests a possible stroke and warrants urgent evaluation; the scale does not establish a diagnosis. When performing this screening, the emergency medical technician must recognize that even subtle deficits require decisive action and immediate communication with medical facilities. Stroke screening tools help identify possible stroke quickly, but a normal Cincinnati Prehospital Stroke Scale result does not rule out stroke, particularly a posterior-circulation stroke.
| Condition | Underlying Mechanism | Key Clinical Features |
|---|---|---|
| Ischemic Stroke | Blood flow to part of the brain is blocked, commonly by a clot | Accounts for the majority of all strokes; produces acute focal neurological deficits |
| Hemorrhagic Stroke | Bleeding occurs within or around the brain | Brain injury that may present with a sudden, severe headache |
| Transient Ischemic Attack | Temporary reduction in cerebral blood flow | Produces temporary stroke-like neurological symptoms that resolve completely without permanent infarction |
Common mistakes
- Administering oral glucose to an altered patient who cannot swallow or follow commands, creating a severe airway compromise and aspiration risk.
- Attempting to force an oral airway, bite stick, or other object into the mouth of a patient experiencing an active convulsive seizure.
- Delaying rapid transport of a suspected stroke patient to perform non-essential assessments rather than identifying the exact time last known well and expediting delivery to a stroke-designated facility.
- Administering routine high-concentration oxygen to a non-hypoxic stroke patient instead of titrating oxygen strictly as needed to maintain saturation at or above 94 percent.
Key points
- An ischemic stroke results from blocked blood flow to part of the brain, while a hemorrhagic stroke results from bleeding within or around the brain; a transient ischemic attack causes temporary stroke-like symptoms without permanent infarction.
- The Cincinnati Prehospital Stroke Scale assesses facial droop, arm drift, and abnormal speech; an abnormal finding on any component warrants urgent prehospital stroke care and rapid hospital transport.
- Key BLS stroke priorities include establishing the time last known well, providing early facility notification, maintaining oxygen saturation at or above 94 percent per protocol without routine hyperoxia, and padding paralyzed extremities.
- During active seizures, protect the patient by moving nearby hazards; never restrain the patient or insert objects into the mouth.
- Convulsive status epilepticus is a seizure lasting five minutes or more or repeated seizures without recovery between them, representing a life-threatening emergency that risks hypoxia, hyperthermia, and permanent brain damage.
- In the postictal phase or with general altered mental status, manage the airway by clearing secretions, using the recovery position if breathing is adequate and trauma is absent, and assisting ventilations with a BVM if respiration is inadequate.
- Altered mental status requires evaluating baseline function, assessing AVPU or Glasgow Coma Scale, ruling out hypoglycemia, considering sepsis in older adults, and administering intranasal naloxone per protocol for suspected opioid overdose with hypoventilation.
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