Goal of Emergency Stroke Care: Save the Penumbra

ASLS Penumbra

Penumbra is zone of reversible ischemia around core of irreversible infarction - salvageable in first few hours after ischemic stroke onset.

Every 40 seconds, someone in the United States has a stroke; the stroke results in a death every 4 minutes. Globally, stroke is a leading cause of death and the leading cause of disability. Emergency treatments to limit the risk of disability are available but must be administered within a brief window of time. Thus, it is vital that emergency medical services (EMS) personnel recognize, stabilize, and transport a stroke patient with a new sense of urgency and medical centers handle these patients on an emergency basis that includes developing acute stroke teams and forming networks with other medical centers to enable rapid evaluation and treatment 24 hours a day, 7 days a week.

Advanced Stroke Life Support ® is a practical, hands-on, 8-hour course that:

  • Was developed by experts in stroke, emergency medicine, prehospital care, and nursing education
  • Is updated and improved continuously
  • Has been used to train thousands of EMS personnel, nurses, and physicians from hundreds of institutions across the U.S. and throughout the world
  • Provides a unique neurologic assessment tool-the MEND exam-ideal for both prehospital and hospital use
  • Designed to meet the education requirements for Joint Commission certified stroke centers


ASLS examination

As first released in 1998, the ASLS® curriculum was designed for EMS responders, and a prehospital-only version remains available. Early in its development, however, at the urging of neuroscience nurses and neurologists, the curriculum was expanded to add hospital-based content. The version that includes in-hospital care in the emergency department and stroke unit, ASLS® for Hospital and Prehospital Providers, is suitable for all audiences. From the onset, ASLS® was intended for widespread dissemination using a train-the-trainer strategy, i.e., preparing others to teach the curriculum with ready-made course materials available for purchase.

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Course Overview

ASLS Course chart

A key feature of the ASLS ® curriculum is hands-on skills training, during which instructors simulate stroke syndromes, and learners perform the MEND Examination, a unique neurologic assessment tool developed with the course. Computer-based multimedia skills training, interactive discussions, and didactic sessions are also components of the curriculum.

The major learning goals for all audiences are to:

  • Describe why early treatment may result in a marked reduction in risk of disability
  • Identify the five main stroke syndromes and relate them to pathophysiology and clinical signs
  • Perform focused evaluation to identify stroke, its location and severity, and t-PA contraindications.

These are included, with learning objectives specific to the audience, in the ASLS ® Course Description. Concurrent breakout sessions facilitate teaching both prehospital and in-hospital audiences together (see ASLS ® Course Agendas).

The curriculum incorporates videos to visually demonstrate the neurologic exam on a normal patient and on a patient exhibiting signs that mimic a stroke, as well as characteristics associated with the various stroke syndromes. Teaching points are also enhanced through the use of diagnostic test scans and x-rays, illustrations, and animation.

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Efficacy and Outcomes

Pre and Post Course Assessments: Results

ASLS Course chart

The efficacy of the ASLS ® course is continuously assessed through written examinations of cognitive skills and course evaluations. A psychomotor skills study with paramedic learners showed:

  • Paramedics improve their stroke knowledge significantly after taking the ASLS® course
  • Paramedics improve their patient skills significantly after taking the course
  • 73 randomly selected paramedics participated in pre- & postcourse "patient" scenarios
  • Skills checklist scores for CPSS, MEND Exam, and ED reporting improved significantly.

In Use

The ASLS® curriculum is widely used by hundreds of hospitals, fire rescue, ambulance and EMS systems, and educational institutions throughout the United States. Region and statewide implementation has frequently been facilitated by state departments of health, stroke registries, clinical and educational consortia, and professional associations. ASLS® is also taught in Hong Kong and Mexico.

Training centers using ASLS

ASLS and MEND Published Studies, Abstracts, and Poster Presentations:

Click to access PDF
ISC 2019 AHA Best Practice Presentation - MEND Exam by Nurses - Salinas Valley
ASLS Course Effectiveness Published Abstract ISC 2018
ASLS Course Effectiveness Poster Presented at ISC 2018
MEND Exam Validation Published Abstract ISC 2018
MEND Exam Validation Poster Presented at ISC 2018
MEND Exam LVO Predictability Published Abstract ISC 2018
MEND Exam LVO Predictability Poster Presented at ISC 2018
EMS Quarterback Role Improves Stroke Alert Time Targets Published Abstract ISC 2018
A Collaborative Approach to Emergency Medical Service Stroke Training Published Abstract ISC 2018
Impact of EMS Field-Telestroke With Hand-held iPads on IV-TPA Therapy for Stroke Published Abstract ISC 2018
ASLS for Greater Prehospital Recognition of Acute Stroke - Am J Emerg Med May 2017
Monroe County Telemedicine Published Abstract ISC 2016
Monroe County Telemedicine Poster Presented at ISC 2016
Pre-hospital Stroke Evaluation Using Expanded Stroke Screening Tools
ASLS-Making a Difference in Stroke Care Published Abstract ISC 2015
The Neurological Emergency Room and Prehospital Stroke Alert 2013
MEND-NIHSS Correlation Published Abstract ISC 2012
MEND Monroe ISC 2012 - Abstract and Poster
MRC ASLS Abstract for ISC 2012
ASLS Hong Kong ISC 2011 - Abstract and Poster
Striking out at Stroke- US-UK Perspective 2010
ASLS and MEND Research Presentations at the International Stroke Conference 2010-2015
Implementation Strategies for Emergency Medical Services within Stroke Systems of Care
Med Teach 2005- Stroke training and prehospital providers
Improvement in Paramedic Examination Skills Following a Stroke Course - ISC Published Abstract 2001
Stroke on the MEND JEMS article Oct 2000
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