Pre-hospital management

Public awareness - How can we do better?

  • Population-based studies demonstrate a lack of knowledge of stroke symptoms and warning signs which may impede pre-hospital management, treatment and preventive efforts.
  • Public education campaigns are increasingly used to raise stroke awareness and aim to educate about the need to immediately call emergency services at the onset of suspected stroke.1
  • Stroke awareness campaigns target people who might experience stroke symptoms, those who might witness stroke and often also primary care clinicians to optimise recognition and intervention for stroke.1
  • In order to change response behaviours, public awareness campaigns should:
    • Target the general public as stroke witnesses
    • Raise symptom-awareness and awareness to take action
    • Keep the message simple
  • The ultimate aim is to keep the time to treatment as short as possible
  • Public awareness campaigns can increase ambulance dispatches for stroke

Stroke chain of survival

  • Early recognition of stroke warning signs may reduce treatment delays and, in the best case, decrease long-term disabilities.
  • To support patients, family members, pre-hospital and emergency room personnel, the American Heart Association developed the Stroke Chain of Survival involving eight steps to be taken if someone is suffering a stroke.2

The 8 D’s of stroke care

The 8 D’s of stroke care


  • Effective EMS systems can minimise delays in pre-hospital dispatch, assessment, and transport, and ultimately increase the number of stroke patients reaching the hospital and being prepared for thrombolytic therapy within the approved time window.3,4

Cincinnati Pre-hospital Stroke Scale

The Cincinnati Pre-hospital Stroke Scale (CPSS) is a 3-item scale used to diagnose a potential stroke in a pre-hospital setting. It tests abnormalities in facial droop, arm drift and speech, which can be important indicators of a stroke.5

3 Question Checklist 3 Question Checklist Score

Hospital arrival times and thrombolysis rates in AIS patients according to mode of transport

The mode of transport to the emergency department has a huge impact on triage, diagnosis, and treatment of patients with stroke.6

transport mode diagram

The shortest pre-hospital time delays and highest thrombolysis rates were seen in ischaemic stroke patients transported by helicopter.6

Pre-admission notification by EMS: the best way to shorten door-to-needle time (DNT)

Pre-hospital notification by EMS may enable rapid dispatch and reduce intra-hospital processing times in cases of acute ischaemic stroke.7

Ischaemic strokes

  1. Saver JL. Time is brain--quantified. Stroke 2006;37:263–-66.
  2. González RG. Imaging-guided acute ischemic stroke therapy: From ‘time is brain’ to ‘physiology is brain’. AJNR Am J Neuroradiol 2006;27:728-735.
  3. Donnan GA, et al. Neuroimaging, the ischaemic penumbra, and selection of patients for acute stroke therapy. Lancet Neurol 2002;1:417–-25.
  4. Kaste M. et al. Organization of stroke care: education, stroke units and rehabilitation. European Stroke Initiative (EUSI). Cerebrovasc Dis Basel Switz 2000;10 Suppl 3:1-11.
  5. Kothari R. et al. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke 1995;26:937-941.
  6. Kothari RU., et al. Emergency physicians. Accuracy in the diagnosis of stroke. Stroke 1995;26:2238–2241.
  7. Act FAST. 2014. Available at: Accessed April 16, 2018.
  8. Fonarow GC. et al. Improving door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association’s Target: Stroke initiative. Stroke 2011;42:2983-2989.
  9. NINDS NIH website. Stroke proceedings. Latest update 2008.
  10. Personal communication, Peter Schellinger, Jan 2011.