Recognize & Stabilize
Complete routine patient care, identify immediate airway or breathing threats, obtain glucose, and perform a focused neurologic examination.
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Massachusetts EMS Clinical Course
Stroke Recognition & Prehospital Management
Protocol-focused education covering Last Known Well, FAST-ED, stroke mimics, Stroke Alert communication, oxygen use, destination considerations, and documentation.
Protocol
Massachusetts 2.18
Version
2026.2
Assessment
25 Questions • 80%
Section 01
Learning Objectives
By the end of this course, the learner should be able to:
Recognize common stroke presentations and high-risk stroke mimics.
Establish and document the patient’s exact Last Known Well.
Perform and score every FAST-ED component.
Apply Massachusetts Stroke Alert, oxygen, positioning, and transport guidance.
Deliver a concise prearrival report and document the neurologic assessment.
Section 02
Massachusetts Protocol Quick Reference
Review the supplied 2026.2 protocol and checklist before continuing.
Protocol Update Reminder
Always verify the current Massachusetts statewide protocols, regional point-of-entry plan, service policy, and medical-control requirements before using this material clinically.
Section 03
The Prehospital Mission
EMS does not determine the stroke subtype in the field.
Preserve Treatment Options
Establish the timeline, call the Stroke Alert early, choose the appropriate destination, and avoid unnecessary scene delay.
Section 04
Stroke Categories
Prehospital findings may suggest stroke but cannot reliably distinguish ischemia from hemorrhage.
Ischemic Stroke
An artery is obstructed by thrombus or embolus, reducing blood flow to brain tissue.
Hemorrhagic Stroke
Bleeding occurs within or around the brain and may produce headache, vomiting, hypertension, or rapid deterioration.
Transient Symptoms
Resolved focal deficits remain clinically important and require urgent evaluation.
Section 05
Last Known Well
The timeline is one of the most important pieces of information EMS provides.
Definition
Last Known Well is the last time the patient was observed at their neurologic baseline—not the time symptoms were discovered.
Wake-Up Stroke
For symptoms found on awakening, obtain the last time the patient was seen or heard normal before sleep and separately document discovery time.
- ✓Ask the patient, family, caregiver, coworker, or witness.
- ✓Document an exact clock time whenever possible.
- ✓Record the source of the information.
- ✓Explain why LKW is unknown when it cannot be established.
Section 06
Stroke Mimics
Several conditions can produce focal or stroke-like neurologic findings.
Hypoglycemia
Seizure with postictal paralysis
Migraine with aura
Bell’s palsy
Intoxication or medication effect
Sepsis, syncope, tumor, or metabolic disorder
Do Not Stop at the Mimic
A seizure can be caused by stroke, and persistent focal findings after glucose correction still require stroke evaluation.
Section 07
FAST-ED Stroke Scale
Score each domain separately and report both the total and the individual abnormal findings.
F
Facial Palsy
Ask the patient to smile or show their teeth. Compare both sides at rest and with movement.
Score
0–1
A
Arm Weakness
Have the patient hold both arms out. Score drift, effort against gravity, or no movement.
Score
0–2
S
Speech Changes
Assess naming, repetition, comprehension, aphasia, muteness, and dysarthria.
Score
0–2
E
Eye Deviation
Observe resting gaze and the patient’s ability to track without forcing the head or eyes.
Score
0–2
D
Denial / Neglect
Test simultaneous stimulation and awareness of both sides of the body and environment.
Score
0–2
Clinical Pearl
A low FAST-ED score does not completely exclude stroke, particularly posterior-circulation stroke.
Section 08
Posterior Circulation Stroke
Not every stroke presents with facial droop, arm weakness, or aphasia.
- ✓Sudden severe dizziness or inability to walk
- ✓Ataxia or loss of coordination
- ✓Diplopia or other acute visual disturbance
- ✓Dysarthria, vomiting, or altered consciousness
- ✓Headache or neck pain with a new neurologic deficit
Section 09
Stroke Alert & Treatment Priorities
Apply the supplied Massachusetts protocol and local implementation.
Stroke Alert
If any stroke-scale sign is abnormal and onset is less than 24 hours, notify the receiving hospital of a Stroke Alert, even when symptoms have resolved.
Transport
Do not delay transport for ALS intercept. Consider bringing a witness or caregiver who can verify symptom onset and baseline.
Oxygen
Avoid routine hyperoxygenation. Titrate to the patient’s condition and use oxygen for hypoxemia, dyspnea, or SpO₂ below 90% as directed by the supplied protocol.
Positioning
Elevate the head of the stretcher approximately 30 degrees when tolerated while protecting the airway and reassessing frequently.
Section 10
Destination & Notification
Early, complete communication helps the receiving stroke team prepare.
- ✓State “Stroke Alert” when criteria are met.
- ✓Patient age, sex, and baseline function.
- ✓Last Known Well and symptom-discovery time.
- ✓FAST-ED total and each abnormal component.
- ✓Blood glucose and key vital signs.
- ✓Anticoagulant or antiplatelet use.
- ✓Relevant trauma, seizure, surgery, or bleeding history.
- ✓Estimated time of arrival.
Example Radio Report
“Hospital, Medic 24 with a Stroke Alert. Seventy-two-year-old male, LKW 1410, sudden aphasia and right arm weakness. FAST-ED 5, glucose 112, takes apixaban, BP 188/96, SpO₂ 95% room air. ETA eight minutes.”
Section 11
Clinical Scenarios
Pause before revealing the discussion points.
Case: Wake-Up Aphasia
A 68-year-old is found aphasic at 0630. The spouse last spoke with the patient normally at 2230.
Discussion: LKW is 2230. Discovery time is 0630. Obtain glucose, complete FAST-ED, and report both times.
Case: Symptoms Resolved
The patient had 15 minutes of unilateral weakness and slurred speech that resolved before EMS arrival.
Discussion: Resolved symptoms do not eliminate stroke risk. Document the original deficits and activate a Stroke Alert when criteria are met.
Case: Low Glucose
The patient has facial droop and confusion with a glucose of 42 mg/dL.
Discussion: Treat hypoglycemia, repeat the neurologic examination and glucose, and continue stroke evaluation when focal findings persist.
Case: Dizziness & Ataxia
The patient has sudden vomiting, diplopia, and cannot stand, but has no arm drift.
Discussion: Consider posterior circulation stroke. A normal or low FAST-ED score does not eliminate the diagnosis.
Section 12
Documentation & Common Pitfalls
The PCR should preserve the timeline and the neurologic examination.
Document
- ✓Exact LKW and who supplied the time
- ✓Discovery time and symptom progression
- ✓FAST-ED components and total
- ✓Glucose, vital signs, oxygen indication, and reassessment
- ✓Stroke Alert time and destination rationale
Avoid
- ✓Using discovery time as LKW
- ✓Skipping glucose
- ✓Waiting until arrival to call the alert
- ✓Giving oxygen without an indication
- ✓Ignoring resolved or posterior-circulation symptoms
Course Review Complete
Ready for the final assessment?
The quiz contains 25 questions. A score of 80% or higher unlocks the completion certificate.
Begin Quiz