Stroke Recognition & Last Known Well

Why This Is Hard

Stroke is a clock disease. Wrong last-known-well (LKW) times, missed posterior signs, and long scenes steal treatment windows. Paramedics win by recognition, glucose, rapid packaging, and clear hospital notification — not by running a full neurology exam in the living room.

Recognition Themes (Education)

• Face / Arm / Speech tools (Cincinnati-style) catch many anterior strokes.
• BEFAST-style additions: Balance, Eyes (vision), Face, Arms, Speech, Time — helps catch more presentations.
• Posterior clues: sudden severe dizziness/vertigo with neuro signs, diplopia, dysarthria, ataxia, sudden vision change — easy to call “just dizzy.”
• Mimics: hypo/hyperglycemia, seizure Todd’s paralysis, migraine, intoxication, sepsis AMS, syncope — still treat as stroke pathway if criteria met and protocol says so.

Last Known Well — Get It Right

• LKW is when the patient was last seen normal, not when discovered.
• Wake-up stroke: LKW is usually last seen normal before sleep unless better history exists.
• Write the clock time and the historian’s name/relationship.
• Anticoagulants, recent surgery, prior stroke, baseline deficits — gold for the ED.

EMS Priorities

1. ABCs; protect airway if vomiting/AMS.
2. Glucose per protocol (treat hypo if found).
3. Focused stroke scale your system uses; do not delay transport for extras.
4. Keep head elevated if protocol supports and no trauma concern requiring otherwise.
5. Early stroke alert / destination per local plan (PSC vs CSC).
6. Minimize scene time; parallel process history while packaging.

Field Pitfalls

• Documenting “onset when 911 called” instead of true LKW.
• Skipping glucose.
• Chasing a perfect exam while the clock runs.
• Missing posterior circulation signs.

Practice

Role-play a wake-up stroke history until your partner can state LKW in one sentence. Related: Altered Mental Status.

Sources & Further Study

• AHA stroke systems of care education; your stroke alert protocol.