How does emergency response to stroke differ between Canada and the USA?

Emergency Response to Stroke: Differences Between Canada and USA

The Canadian and American emergency response systems for stroke differ primarily in their organizational structures, with Canada emphasizing centralized provincial coordination while the US system varies by state and county, though both countries share similar clinical protocols and time-sensitive approaches to stroke management.

Public Awareness and Initial Response

Both countries emphasize public education about stroke recognition using the FAST (Face, Arms, Speech, Time) acronym 1, 2:

• Canada: The Canadian Stroke Best Practice Recommendations emphasize nationwide public education campaigns focused on FAST, with approximately 40% of Canadians unable to recognize any stroke symptoms 1
• USA: The American College of Cardiology similarly recommends FAST for stroke recognition and immediate EMS activation 2

Key differences:

• Canada has a more centralized approach to public education campaigns
• Both countries struggle with public recognition of stroke symptoms, with studies showing that the word "stroke" is used unprompted by only about 51% of callers to emergency services 3

EMS Response and Pre-hospital Care

Dispatch Systems:

• Canada: Provincial coordination with standardized protocols for stroke recognition
• USA: More variable by state and county with less centralized coordination

Transport Protocols:

• Canada: Emphasis on direct transport to designated stroke centers with "code stroke" pre-notification 1
• USA: Similar approach with priority transport to nearest stroke-capable center, but with specific time parameters (transport time difference <30-45 minutes) for comprehensive stroke centers 2

Studies show that EMS dispatchers recognize stroke with varying sensitivity - one study reported 66.2% sensitivity in identifying stroke during emergency calls 4, while another found only 31% of stroke calls were correctly coded by dispatchers 3.

Hospital Systems and Acute Care

Initial Assessment:

• Both countries recommend:
  • Immediate neurological assessment using standardized scales
  • Non-contrast CT brain imaging within 20 minutes of arrival
  • CT angiography to identify large vessel occlusion

Reperfusion Therapy:

• Canada: Intravenous thrombolysis within 4.5 hours and endovascular thrombectomy up to 24 hours with appropriate imaging 1
• USA: Same time windows with similar protocols for thrombolysis and thrombectomy 2

Antiplatelet Therapy:

• Canada: Recommends 160mg ASA loading dose for non-thrombolysis patients after excluding hemorrhage 1
• USA: Recommends 160-325mg aspirin within 24-48 hours of onset if no thrombolysis 2

Stroke Systems of Care

Organizational Structure:

• Canada: More centralized provincial coordination with standardized protocols across regions
• USA: More variability between states and regions with greater emphasis on local protocols

Quality Improvement:

• Both countries emphasize data-driven performance feedback
• USA: More emphasis on Joint Commission certification and standardized metrics 2

Implementation Challenges

Common challenges in both countries:

• Delays in seeking medical attention after symptom onset
• Variability in EMS recognition of stroke symptoms
• Rural and remote access to specialized stroke care

Practical Algorithm for Emergency Stroke Response

1. Symptom Recognition

   • Use FAST assessment
   • Call emergency services immediately (9-1-1)
   • Note exact time of symptom onset

2. EMS Response

   • Dispatcher stroke recognition protocols
   • Pre-notification to receiving hospital
   • Direct transport to appropriate stroke center

3. Emergency Department

   • Immediate neurological assessment
   • CT imaging within 20 minutes
   • Decision for reperfusion therapy based on time windows:
     • IV thrombolysis: ≤4.5 hours
     • Endovascular thrombectomy: ≤24 hours with appropriate imaging

4. Post-Acute Care

   • Admission to specialized stroke unit
   • Regular monitoring of vital signs and neurological status
   • Early rehabilitation assessment within 48 hours

Pitfalls to Avoid

• Failing to recognize stroke symptoms in younger patients
• Delaying transport for additional on-scene assessments
• Not considering extended time windows for thrombectomy with appropriate imaging
• Administering antiplatelet therapy before excluding hemorrhage
• Neglecting blood pressure management after reperfusion therapy

While both Canadian and American systems have similar clinical protocols, the organizational structures and implementation approaches differ, with Canada having more centralized provincial coordination compared to the more variable state and county-based systems in the USA.