Stroke and TIA: EMT Guide

Stroke and Transient Ischaemic Attack: Emergency Recognition, Assessment and Management

Why this topic matters: Stroke is a time-critical emergency caused by interrupted cerebral blood flow or bleeding. Every minute of untreated ischaemia can worsen disability, but rapid recognition, organised prehospital triage, brain imaging and specialist treatment can change outcome. A transient ischaemic attack (TIA) has temporary neurological symptoms but is a warning of a possible completed stroke and still requires urgent assessment. This lesson is for EMT and emergency-medicine students; follow Uganda protocols, local stroke pathways and specialist direction for thrombolysis, thrombectomy, blood-pressure targets and anticoagulant reversal.

Learning objectives

Define ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage and TIA.
Recognise common and atypical stroke presentations using FAST and a structured neurological assessment.
Protect airway, breathing, circulation and brain perfusion while recording last-known-well time.
Explain emergency imaging, reperfusion eligibility, haemorrhage management and secondary prevention.
Plan nursing care, dysphagia precautions, monitoring, communication, transfer and rehabilitation referral.

What is a stroke?

An ischaemic stroke occurs when a cerebral artery is blocked by thrombus, embolus or severe stenosis, producing focal brain infarction. An intracerebral haemorrhage (ICH) is bleeding into brain tissue; subarachnoid haemorrhage (SAH) is bleeding into the subarachnoid space, often presenting with a sudden thunderclap headache. A TIA causes temporary focal neurological dysfunction without persistent infarction on imaging, but it is an emergency warning sign.

Stroke can affect movement, speech, vision, balance, sensation, swallowing, behaviour and consciousness. Posterior circulation strokes may cause dizziness, ataxia, diplopia, dysarthria or vomiting without obvious facial droop. Hypoglycaemia, seizure, migraine, sepsis, intoxication, Bell palsy and functional symptoms can mimic stroke, but a mimic must be considered alongside—not instead of—urgent stroke assessment.

FAST and red-flag recognition

Screen	Ask or look for	Emergency action
F – Face	New facial droop, asymmetry or numbness.	Note exact onset/last-known-well and activate stroke alert.
A – Arm	Sudden unilateral weakness, drift or loss of coordination.	Check both sides, glucose and time; keep patient safe from falls.
S – Speech	Slurring, word-finding difficulty, aphasia or inability to understand.	Record baseline language and arrange urgent imaging; do not give oral intake.
T – Time	When was the patient last known normal? Was the patient found on waking?	Time is treatment information: document witness details and call ahead.
Other red flags	Sudden severe headache, seizure, visual loss, diplopia, ataxia, collapse or reduced consciousness.	Consider posterior stroke, SAH or haemorrhage and transfer to resuscitation capability.

Prehospital and first-contact priorities

Recognise suspected stroke, note exact time last known well and perform a validated stroke screen.
Check airway, breathing, circulation, glucose, temperature and oxygen saturation. Treat hypoglycaemia promptly according to protocol.
Do not delay transport for unnecessary IV medicines, oral food/drink or a prolonged scene examination.
Keep the patient nil by mouth, position safely, protect weak limbs and bring medication/anticoagulant information.
Pre-alert a stroke-capable hospital with onset time, symptoms, glucose, anticoagulants, seizure/trauma history and estimated arrival.
Do not lower blood pressure in the field unless directed by a specific local protocol; cerebral perfusion may be pressure-dependent.

ABCDE and focused neurological examination

Step	Assessment	Actions
A – Airway	Gag/cough, secretions, vomiting, dysphagia and consciousness.	Position, suction, airway adjuncts and expert airway support if protective reflexes fail.
B – Breathing	Respiratory rate, work, SpO₂, aspiration and abnormal pattern.	Oxygen for hypoxaemia; ventilatory support if needed while protecting cerebral perfusion.
C – Circulation	Pulse, BP, ECG, perfusion, temperature and bleeding.	IV access, blood tests and cardiac monitoring; avoid hypotension and unnecessary rapid BP reduction.
D – Disability	GCS/AVPU, pupils, gaze, speech, facial movement, arm/leg power, sensation, neglect, ataxia and seizure.	Record a baseline stroke score where trained; repeat after any change or intervention.
E – Exposure	Trauma, rash, fever, neck stiffness, injection sites and medication patches.	Prevent hypothermia, identify infection/trauma and preserve privacy.

History that changes treatment

Last-known-well time, symptom discovery, wake-up stroke and progression.
Function and independence before the event, prior stroke/TIA and baseline deficits.
Anticoagulants, antiplatelets, recent surgery, bleeding, head trauma, pregnancy and known intracranial disease.
Seizure at onset, migraine history, hypoglycaemia, infection, drug exposure and malignancy.
Hypertension, diabetes, atrial fibrillation, sickle cell disease, HIV/TB, renal disease and smoking.
Witness contact, advance care plan, allergies and the patient’s communication needs.

Urgent investigations

Investigation	Purpose	Clinical point
Non-contrast CT brain	Exclude haemorrhage and identify early infarction.	All suspected acute strokes need urgent brain imaging before disease-specific therapy.
CT angiography/perfusion or MRI	Identify large-vessel occlusion, salvageable tissue or posterior circulation disease.	Use local availability and specialist selection; do not delay basic care awaiting advanced imaging.
Glucose and electrolytes	Detect stroke mimics and correct dangerous metabolic abnormalities.	Hypoglycaemia can mimic stroke; severe hyperglycaemia also worsens outcome.
FBC, coagulation, renal function and group/cross-match	Assess anaemia, platelets, anticoagulation, renal dosing and bleeding risk.	Draw promptly, but do not delay imaging or emergency transfer for routine results.
ECG and cardiac monitoring	Find AF, acute ischaemia or dangerous arrhythmia.	AF may be intermittent; monitoring informs secondary prevention.
Pregnancy testing and targeted tests	Guide imaging/medication decisions and investigate infection, toxicology or sickle complications.	Discuss risk-benefit urgently with the stroke team; pregnancy is not an automatic reason to delay lifesaving care.

Acute ischaemic stroke pathway

Activate the stroke team, record the treatment clock and obtain urgent brain imaging.
After haemorrhage is excluded, assess eligibility for intravenous thrombolysis using the current local protocol. Current international guidance supports rapid treatment in selected patients within a standard early window, with extended-window decisions based on advanced imaging and specialist criteria.
Assess for large-vessel occlusion and transfer or refer for endovascular thrombectomy when eligibility criteria and local capability are met.
Maintain oxygenation, normoglycaemia, normothermia and safe blood pressure; do not aggressively reduce BP unless indicated by the reperfusion or haemorrhage protocol.
Keep nil by mouth until a swallow screen is passed. Treat aspiration risk, fever, seizures and hypoglycaemia.
After acute therapy, begin antiplatelet/anticoagulant decisions only under the stroke team, considering infarct size, haemorrhage risk and AF.

Time principle: “Last known well” is a clinical variable. Document it in every handover. A patient who wakes with deficits may still be eligible for treatment after specialist imaging selection.

Intracerebral haemorrhage and subarachnoid haemorrhage

Suspect ICH with severe headache, vomiting, reduced consciousness, very high BP, focal deficit, seizure or anticoagulant use.
Suspect SAH with a sudden “worst-ever” thunderclap headache, neck stiffness, photophobia, collapse or brief loss of consciousness.
Protect airway and prevent aspiration; obtain urgent CT and call neurology/neurosurgery or a referral centre.
Manage BP according to the current haemorrhage protocol; avoid rapid uncontrolled reduction that worsens cerebral perfusion.
Reverse anticoagulation urgently with the prescribed agent and specialist guidance; do not give antithrombotics until haemorrhage is excluded.
Treat seizures, fever, hypoglycaemia, raised intracranial pressure and hydrocephalus with critical-care/neurosurgical support.
For SAH, monitor for rebleeding, vasospasm, hydrocephalus and electrolyte disturbance; early aneurysm treatment is specialist care.

Transient ischaemic attack

TIA symptoms resolve, but the risk of a completed stroke can be high, particularly soon after the event. Do not reassure the patient simply because speech or power has returned. Establish the exact symptoms and time, exclude hypoglycaemia and other mimics, arrange urgent brain/vascular assessment and start secondary prevention only after specialist evaluation.

Document focal symptoms witnessed by the patient or family, duration and complete resolution.
Check BP, glucose, ECG, medication adherence and vascular risk factors.
Escalate same day for high-risk features, recurrent episodes, carotid symptoms, AF or persistent uncertainty.
Provide clear return precautions for any recurrent FAST symptom, weakness, speech change, vision loss or severe headache.

Blood pressure, glucose and temperature

Measure BP correctly in both arms when appropriate and repeat manually if extreme or inconsistent.
In acute ischaemic stroke, BP treatment thresholds depend on whether reperfusion is planned and on other emergencies such as aortic dissection, ACS, heart failure or hypertensive encephalopathy.
In ICH, BP control follows the haemorrhage pathway and requires repeated measurements and neurological reassessment.
Correct hypoglycaemia immediately; avoid excessive glucose loading and monitor for recurrence.
Treat fever and investigate infection; maintain normothermia and avoid unnecessary sedatives that mask neurological deterioration.

Airway, dysphagia and aspiration prevention

Keep the patient nil by mouth until a trained swallow screen is passed, including tablets and water.
Position with head elevation when safe, suction secretions and provide oral care.
Refer for speech and language assessment; use prescribed texture modification, feeding assistance and aspiration precautions.
Escalate for declining consciousness, bulbar weakness, recurrent aspiration, hypoxia or inability to protect the airway.

Nursing care and monitoring

Perform scheduled neurological observations: GCS, pupils, limb power, speech, facial symmetry, gaze, glucose and vital signs.
Use pressure-area care, falls prevention, safe transfers and positioning of a weak shoulder/limb.
Monitor swallowing, nutrition, hydration, bladder/bowel function, fever, seizures and DVT risk.
Maintain IV access, check thrombolytic or anticoagulant safety and observe puncture sites for bleeding.
Use communication aids for aphasia, involve family and confirm understanding using teach-back.
Document door-to-imaging and door-to-treatment times, clinical changes, escalation and handover.

Complications in the first hours

Complication	Clues	Immediate response
Airway loss/aspiration	Wet voice, cough with fluids, falling SpO₂, vomiting or reduced consciousness.	Nil by mouth, suction, airway support, oxygen for hypoxaemia and urgent review.
Neurological worsening	New weakness, falling GCS, pupil change, seizure or severe headache.	Repeat ABCDE/glucose, urgent imaging and stroke/neurosurgical escalation.
Post-thrombolysis bleeding	Headache, vomiting, hypertension, worsening deficit, gum/urine/GI bleeding.	Stop infusion if running, urgent CT and follow the bleeding protocol.
Raised intracranial pressure	Reduced consciousness, vomiting, bradycardia with hypertension, irregular breathing or pupil changes.	Airway/ventilation support, head positioning and neurocritical-care consultation.
Seizure	Convulsions, eye deviation or unexplained altered mental state.	Protect airway, check glucose, treat seizure and search for cause.
DVT/PE and immobility complications	Leg swelling, pain, hypoxia or sudden tachycardia.	Prevention plan, mobilisation/physio and investigation if suspected.

Secondary prevention and rehabilitation

Determine the mechanism: AF, carotid disease, small-vessel disease, hypertension, diabetes, dyslipidaemia, sickle cell disease or other causes.
Use antiplatelet or anticoagulant therapy only as prescribed after haemorrhage risk is assessed.
Control BP, diabetes and lipids; support smoking cessation, healthy diet, activity and medication adherence.
Refer for physiotherapy, occupational therapy, speech/swallow therapy, psychology, social work and rehabilitation.
Screen for depression, cognitive impairment, neglect, falls, pressure injury, malnutrition and caregiver strain.
Provide a written emergency plan and teach family FAST recognition and when to call emergency services.

Clinical scenarios

Scenario 1 – Wake-up stroke: A person wakes with aphasia and right-sided weakness. Record the last time they were normal before sleep, check glucose/ABCDE, activate stroke alert, obtain urgent imaging and do not exclude reperfusion solely because onset was unwitnessed.

Scenario 2 – Suspected ICH: A patient with severe headache, vomiting, BP 230/120 and declining consciousness is brought by family. Protect the airway, monitor, check glucose, obtain urgent CT, call neurosurgery and follow the haemorrhage BP/reversal pathway.

Scenario 3 – Resolved TIA: A patient had 15 minutes of unilateral weakness that has resolved. Do not discharge without risk assessment. Document symptoms/time, ECG and glucose, arrange urgent specialist evaluation and provide FAST return precautions.

Common errors to avoid

Failing to record last-known-well time or treating arrival time as onset time.
Giving food, drink or tablets before a swallow assessment.
Lowering BP aggressively without considering stroke type, reperfusion eligibility and cerebral perfusion.
Assuming a normal early CT excludes ischaemic stroke.
Ignoring posterior circulation signs, hypoglycaemia, seizure or anticoagulant use.
Delaying transfer for nonessential tests or waiting for every laboratory result before imaging.
Calling a resolved event “just a TIA” and failing to arrange urgent follow-up.

STROKE TIME: S – Secure airway and glucose; T – Time last known well; R – Rapid stroke screen; O – Oxygen only if hypoxaemic; K – Keep nil by mouth; E – Escalate and image. TIME – Treat urgently, Investigate brain, Monitor neurology, Evaluate prevention.

Revision questions

Differentiate ischaemic stroke, ICH, SAH and TIA.
Why is last-known-well time more useful than the time a patient was found?
List the ABCDE priorities for a patient with suspected stroke.
Why must swallowing be assessed before oral intake?
What clinical features suggest posterior circulation stroke or SAH?
When should a patient be considered for thrombolysis or thrombectomy?
What warning signs require urgent repeat imaging after acute stroke treatment?

Key takeaways

Stroke and TIA are emergencies; rapid recognition and pre-alert improve access to treatment.
Record last-known-well time, glucose, anticoagulants and baseline function.
Urgent brain imaging distinguishes haemorrhage from ischaemia and guides therapy.
Protect airway, prevent aspiration, maintain oxygenation and avoid harmful BP or glucose extremes.
Reperfusion and haemorrhage treatments require specialist protocols and close monitoring.
Secondary prevention and rehabilitation begin during the acute admission.