Stroke Basics


Staci Neher

NR-P, Adjunct EMS Instructor


A lot of new medics tend to get freaked out by strokes. I know I did!  The thought process that was going through my mind is the same as a heart attack…time is muscle.  Except with the stroke…time is brain.  Strokes if not treated in a timely manner have long term affects that can alter an individual’s life forever.  So yeah, we freak out.  


We know there are two types of strokes – ischemic and hemorrhagic; with ischemic being way more common than hemorrhagic.


  1. Ischemic strokes occur when a thrombus or embolus obstructs a vessel in the brain thereby diminishing the blood flow. 

  2. Hemorrhagic strokes occur when the damaged vessel ruptures

The standard for many, many years in EMS of determining a stroke in the field was the Cincinnati Stroke Scale.

With the Cincinnati if you had an abnormal finding you called it a stroke.


So, what if you have a tool in your handy dandy paramedic tool box that could help you determine the type and severity of the stroke.  Would you want to use it?  Of course!


The newest scale to gain popularity with neurologist and EMS alike is the Rapid Arterial Occlusion Evaluation Scale (RACE).  It is a modified NHISS and it takes a little more time to perform.  Most providers will go with the Cincinnati first and then the RACE after getting things like vital signs, cardiac monitor, and IVs started.  With the RACE score you can identify the severity of the stroke and assist the neurologist with localizing the area of the brain it is occurring in.

Rapid Arterial Occlusion Evaluation Stroke Scale (RACE)

Anything with a score above one is considered a stroke.  Anything with a score above 4 is considered an Emergent Large Vessel Occlusion (ELVO).  These types of strokes have the highest rates of mortality and morbidity.


Lastly, we have the NIHSS stroke scale used by neurologist to measure the quality of the stroke and impairments it may cause.  The higher the score, the more severe the stroke.  As you can see; there are eleven items to be assessed and scored, which is time consuming and somewhat impractical for EMS providers. 

National Institues of Health Stroke Scale (NIHSS)

The moral of the story is: don’t freak out with strokes!  Yes, it is a time critical diagnosis.  So, your goal is to get the patient to a comprehensive stroke center as quickly as possible.  Of course, you want to obtain a glucose level and run a 12 lead with these patients due to stroke mimics.  Be kind to the emergency room team and start a large bore IV in the antecubital space to facilitate rapid CT scan upon arrival to the hospital.