Stroke Assessment for Paramedics
Time is brain. Learn FAST, MEND, stroke mimics, and the UK prehospital stroke pathway — so every second you save translates directly into better outcomes.
Start Free TodayWhy Stroke is a Time-Critical Emergency
In ischaemic stroke, approximately 1.9 million neurons die every minute that a stroke goes untreated. The window for thrombolysis (clot-busting treatment) is 4.5 hours from onset. Every minute a paramedic saves through rapid recognition and pre-alert translates directly to better patient outcomes.
The paramedic's role is not to diagnose stroke definitively — it is to recognise it rapidly, exclude treatable mimics, document time of onset accurately, and deliver the patient to the right place in the shortest time.
Last Known Well Time
Always establish and document the exact time the patient was last seen or known to be without symptoms — not when symptoms were discovered. If a patient wakes with symptoms, their last known well time is when they went to sleep. This is critical for thrombolysis eligibility.
Stroke Assessment Tools Used in UK Prehospital Practice
FAST
Face — ask the patient to smile. Is there any drooping or asymmetry? Arms — ask them to raise both arms. Does one drift downward? Speech — is speech slurred, confused, or absent? Can they understand what you say? Time — note the exact time symptoms were first observed, or when the patient was last known to be well.
FAST is the primary stroke recognition tool used across UK ambulance services. A positive FAST screen should trigger immediate action — treat as a stroke until proven otherwise.
MEND
MEND provides a more structured prehospital neurological assessment used by UK ambulance services alongside FAST:
Mouth — ask the patient to show their teeth or smile. Look for facial asymmetry or droop. Eyes — check for visual disturbance, gaze deviation, or field defects. New symptoms — are these symptoms new and sudden in onset? Stroke symptoms are characteristically sudden. Deficit — assess for focal neurological deficit: arm or leg weakness, sensory loss, coordination problems, dysphasia. Time — establish and document the exact time of onset or last known well time.
Know Your Local Protocol
Assessment tools and stroke pathway criteria vary between ambulance trusts. Always follow your trust's current guidelines — FAST and MEND provide the clinical framework, but local protocols determine destination decisions and pre-alert criteria.
Stroke Mimics — Don't Miss These
🩸 Hypoglycaemia
Always check BM. Most important and immediately treatable mimic. Can present with focal neurological signs.
⚡ Todd's Paresis
Focal weakness after a seizure. Resolves within hours. History of seizure activity is key.
🧠 Complex Migraine
Can cause focal neurology. Typically younger patients with migraine history. Aura precedes headache.
💊 Toxic/Metabolic
Alcohol, drug toxicity, severe electrolyte disturbance, hepatic encephalopathy.
🦠 Encephalitis
Infection causing brain inflammation. Fever, confusion, focal signs. Often slower onset.
🎭 Functional
Functional neurological disorder. Signs may be inconsistent or variable. Diagnosis of exclusion.
Prehospital Stroke Management
On Scene
ABCDE assessment. Check blood glucose — treat hypoglycaemia if present (BM <4mmol/L). Position at 30–45 degrees head-up if conscious and tolerating. Avoid routine high-flow oxygen unless SpO2 <94%. Obtain accurate last-known-well time.
Haemorrhagic vs Ischaemic Stroke
Paramedics cannot differentiate haemorrhagic from ischaemic stroke without a CT scan. Avoid aggressive BP treatment prehospital unless there is specific clinical direction — rapid transport to CT is the priority.
Pre-Alert
Pre-alerting the stroke unit or receiving hospital activates the stroke pathway before arrival, reducing door-to-needle time for thrombolysis. Include: suspected stroke, FAST positive, last known well time, BM, and current clinical status.
Practise Stroke Assessment
AI Patient Scenarios Pro
Practise stroke presentations — including stroke mimics — and rehearse your assessment, time documentation, and pre-alert communication.
Chat with Hollie Free
Ask Hollie to explain FAST and MEND, quiz you on stroke mimics, or walk through the pathophysiology of ischaemic vs haemorrhagic stroke.
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Frequently Asked Questions
What stroke assessment tools do UK paramedics use?
UK paramedics primarily use FAST (Face, Arms, Speech, Time) for rapid stroke recognition, and MEND (Mouth, Eyes, New symptoms, Deficit, Time) as a structured prehospital neurological assessment. Tools and pathways vary between ambulance trusts — always follow your local protocol.
What is the prehospital management of a suspected stroke?
Prehospital stroke management focuses on rapid recognition, accurate time of onset documentation, blood glucose measurement (to exclude hypoglycaemia as a mimic), appropriate positioning (30-45 degree head-up if tolerated), and pre-alerting the stroke unit. The time window for thrombolysis is 4.5 hours from onset — paramedic pre-alert and rapid transport is critical.
What are common stroke mimics?
Common stroke mimics include hypoglycaemia (always check BM), postictal Todd's paresis after a seizure, complicated migraine, tumour, encephalitis, and functional neurological disorder. Hypoglycaemia is the most important to exclude as it is immediately treatable.