PHILA TODAY · LIVE WELL · EAT WELL · MOVE WELL
STROKE SERIES · ARTICLE 2 OF 12 · THE MOST IMPORTANT ARTICLE
Spotting a stroke
F.A.S.T. and the golden hour.
This is the single most important article in the Phila Today Stroke Series. If you read only one Phila Today article ever, make it this one. The four-letter check it teaches takes about ten seconds. It is the difference between a stroke that costs an arm and a stroke that costs a life — or between a stroke that costs an arm and one that costs nothing at all.
If you have a parent, partner, sibling, or older friend, this article is more about them than it is about you. The person having a stroke is often the last person to recognise it. The friend, the family member, the stranger on the taxi — they are the ones who notice the face has drooped on one side. Knowing F.A.S.T. doesn’t just protect you. It protects everyone around you.
If you suspect a stroke right now
Do the F.A.S.T. check below. If any of the four signs is positive, call 10177 for an ambulance immediately. Note the exact time the symptoms started. Skip the rest of this article and read it later.
F.A.S.T. — the four-letter check
| | F | FACE | | | | | | Ask the person to smile. | | | | | | Does one side of the face droop? Is the smile crooked? | | | Does one eyelid hang lower than the other? |
A ARMS Ask the person to raise both arms above their head and hold them there. *Does one arm drift downwards? Does one arm fail to lift at all? Does one arm feel numb or heavy?* S
T TIME If any of the above is wrong, time is everything. *Call 10177 immediately. Note the exact time the symptoms started, or the last time the person was clearly well. Do not wait to see if it improves. Do not drive yourself — call the ambulance.* +-------+-------------------------------------------------------------+
Even one positive sign out of three is enough to call for help. You don’t need all three. The F.A.S.T. test was designed to catch the most common signs of the most common kind of stroke (ischaemic stroke affecting the anterior circulation). It is right about 70 – 80% of the time.
BE-FAST — the extended version
F.A.S.T. misses some strokes — particularly those affecting the back of the brain (the cerebellum and brainstem), which control balance, eye movements and coordination. To catch those, a slightly longer check called BE-FAST has been developed.
Letter What it stands for What to look for B Balance Sudden loss of balance, severe dizziness, inability to walk straight, falling to one side. E Eyes Sudden trouble seeing in one or both eyes. Double vision. A “curtain coming down” over part of the visual field. F Face Face droop on one side (as in F.A.S.T.). A Arms Weakness or drift on one side (as in F.A.S.T.). S Speech Slurred or strange speech (as in F.A.S.T.). T Time Call 10177. Note when symptoms started.
BE-FAST is right about 90% of the time. The two extra letters cover the strokes that F.A.S.T. misses — but F.A.S.T. is still good, and easier to remember if you’re in a hurry. Either is much better than no check at all.
Other signs to know about
Stroke can show up in many ways. F.A.S.T. and BE-FAST catch most cases, but a sudden onset of any of these — particularly if more than one is present — should make you think of stroke:
• A severe headache that comes on suddenly, without warning, like being hit on the back of the head — often called a “thunderclap” headache. This can be a haemorrhagic stroke or a burst aneurysm. Always serious.
• Sudden confusion or disorientation — not knowing where you are, who people are, what’s happening.
• Sudden numbness on one side of the body — face, arm or leg, often all on the same side.
• Sudden loss of vision — one eye, both eyes, or a patch of the visual field.
• Trouble swallowing that comes on suddenly.
• Loss of consciousness — uncommon as a first stroke sign but can happen, particularly in haemorrhagic strokes.
The single most important word in all of these is sudden. A stroke comes on quickly — usually over minutes — not over hours or days. If the symptoms came on slowly over a week, it is probably not a stroke. If it came on in the time it took to make a cup of tea, treat it as a stroke until proven otherwise.
The golden hour
Stroke researchers and emergency-medicine specialists talk about the “golden hour” — the first 60 minutes after a stroke begins. This is when treatment makes the biggest difference. Thrombolysis (clot-busting drugs) given inside the first 90 minutes prevents disability in roughly 1 in 4 patients treated. Given at the 4.5-hour mark, the same drug helps about 1 in 14. After 4.5 hours, thrombolysis isn’t given at all, except in very specific cases.
The single most useful piece of information for the ambulance
When did the symptoms start?
The hospital needs to know the exact time the stroke began, or — if the person woke up with the symptoms — the last time they were known to be clearly well. This determines whether clot-busting drugs can be used at all. If you can’t remember the exact time, the last reliable time the person was definitely fine is the next best information.
Examples: “She was talking normally to me at 14:00 when I left the room. I came back at 14:30 and her face was drooping.” Or: “He went to bed at 22:00 last night, feeling fine. I found him this morning at 06:00 unable to speak.” Don’t guess — give the bracket.
What to do in the first 5 minutes
If you suspect a stroke right now, in this order:
1. Do the F.A.S.T. check. 10 seconds. If any one is positive, treat it as a stroke.
2. Call 10177 for an ambulance. Say the word “stroke”. Give your address clearly. If you have private medical aid, you can also call ER24 (084 124), Netcare 911 (082 911), or your medical aid’s ambulance number — but if in doubt, 10177 will get there.
3. Note the exact time the symptoms started (or last known well time). Write it down so you don’t forget.
4. Lie the person down on their side, with the head slightly raised. If they are conscious and can sit comfortably, that’s fine too. The side position helps if they vomit or have trouble swallowing saliva.
5. Loosen tight clothing — collars, belts. Keep them comfortable.
6. Stay with them. Talk calmly. Reassure them. Watch for changes — if symptoms get worse, mention it when the ambulance arrives.
7. If they become unresponsive and stop breathing, start CPR immediately if you know how.
What NOT to do
Just as important as what to do:
• Do not give aspirin. Aspirin helps prevent ischaemic strokes — but if the stroke is the bleeding kind, aspirin makes it worse. Until the hospital does a CT scan, no aspirin.
• Do not give food or drink. Stroke often affects swallowing. Anything in the mouth can go down the wrong way and cause pneumonia.
• Do not give the person their usual medication. Especially their blood pressure tablets. The body sometimes raises BP after a stroke to push blood through the blocked area. Lowering it suddenly can make the stroke worse.
• Do not drive yourself or the person to hospital, unless the ambulance will genuinely take longer than 30 minutes. The ambulance team can start treatment on the way, and they will take the patient to the right kind of hospital — not necessarily the nearest. If you have no choice but to drive, go to a hospital with a CT scanner and ideally a stroke unit (most big public and private hospitals).
• Do not wait to see if the symptoms get better. If they do clear, it was a TIA — and that is still an emergency, just a different kind. See article 3.
• Do not assume it’s “just tiredness” or “low blood sugar”. Test the blood sugar if you have a meter handy (anything above 3.5 mmol/L is fine for the moment) — but otherwise, treat it as a stroke until proven otherwise at hospital.
Stroke mimics — things that look like stroke but aren’t
Some other conditions can look very like a stroke. The point isn’t for you to diagnose these at home — the point is to reassure you that even if you call an ambulance for a “stroke” and it turns out to be something else, you did the right thing. The hospital will sort it out.
Mimic How it differs from stroke Migraine with aura Often has a visual disturbance before the headache, but tends to evolve over 20 – 60 minutes rather than seconds. Recovers fully. Hypoglycaemia (low blood sugar) Confusion, slurred speech, occasionally weakness. Almost always in a known diabetic on insulin or a sulphonylurea. Recovers within minutes of sugar. Bell’s palsy Face droop, but affects the whole half of the face including the forehead — in stroke, the forehead is usually spared. Comes on over hours, not minutes. Seizure with post-ictal weakness The weakness comes after a seizure (Todd’s paralysis). Usually a known epileptic. Brain tumour Symptoms come on over weeks to months, not minutes. Severe anxiety / panic attack Numbness or tingling, sometimes weakness — usually on both sides equally rather than one-sided, and with chest tightness and rapid breathing.
About 1 in 5 patients who arrive at hospital with suspected stroke turn out to have something else. That is fine. The system is designed to investigate and sort out. It is much better to call an ambulance for a mimic than to ignore a real stroke.
If symptoms improve — TIA
Sometimes the F.A.S.T. signs appear and then go away on their own. The face droop resolves; the arm starts working again; the speech comes back. The whole episode lasts a few minutes to a few hours.
This is a transient ischaemic attack (TIA), sometimes called a “mini-stroke”. It is one of the most important warning signs in medicine. About 1 in 5 people who have a TIA will go on to have a full stroke within 3 months — and most of those second strokes are in the first 48 hours.
If you or someone you know has a TIA — even one that lasted only minutes — go to hospital the same day. The investigations and treatment that follow can prevent the full stroke that is otherwise likely to come. Article 3 covers TIA in more detail.
Teach two other people F.A.S.T.
F.A.S.T. is most useful when many people in a community know it. The person having a stroke is often the last to realise. The friend, the family member, the colleague, the neighbour, the security guard at the spaza — those are the people who notice and call for help.
If this article has been useful to you, send it to two other people. Or just teach them the four letters and what to do. Most people, once they know it, never forget.
F.A.S.T. — Face. Arms. Speech. Time. Call 10177.
The bigger picture
Of all the medical knowledge you will pick up in your life, F.A.S.T. is among the most cost-effective. Five minutes to learn. Ten seconds to use. Could save a life — yours or someone you love. Could prevent a lifetime of disability.
The reason we put this article second in the series — instead of leading with complications or risk factors as we did for BP and cholesterol — is that stroke is different. Spotting it changes the outcome more than understanding what causes it. You can leave the rest of the series for later. F.A.S.T. is the thing to take with you today.
The next article in the series covers the three kinds of stroke — ischaemic, haemorrhagic, and TIA. Understanding the difference helps you understand what the hospital will do, why the CT scan is so important, and why TIA is the warning sign we need to take so seriously.
Where to get more help
In an emergency — call 10177 for a state ambulance, or ER24 (084 124), Netcare 911 (082 911), or your medical aid’s emergency number.
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586 — has printable F.A.S.T. cards in several languages.
The Heart and Stroke Foundation Stroke Helpline — for information and patient support.
Print this article and put a copy on your fridge. Or save it to your phone. The seconds you save by being prepared could be the seconds that save a brain.
Phila Today Stroke Series — next: the three kinds of stroke — ischaemic, haemorrhagic and TIA.
Phila Today · Article 2 of 12 in the Stroke Series