Universal Care Guideline

Table of Contents

Aliases

Patient assessment, patient history, physical assessment, primary survey, secondary survey

Patient Care Goals

Facilitate appropriate initial assessment and management of any EMS patient as required by EMTALA and link to appropriate specific guidelines as dictated by the findings within the Universal Care guideline.

Patient Presentation

Inclusion Criteria

All patient encounters with and care delivery by EMS personnel when there is a concern for an emergency medical/trauma condition.

Exclusion Criteria

Models of healthcare not covered by EMTALA such as Mobile-Integrated Healthcare or Health Fairs.

Patient Management

Assessment

  1. Assess scene safety
    1. Evaluate for hazards to EMS personnel, patient, bystanders
    2. Determine number of patients
    3. Determine mechanism of injury
    4. Request additional resources if needed and weigh the benefits of waiting for additional resources against rapid transport to definitive care
    5. Consider declaration of mass casualty incident if needed
  2. Use appropriate personal protective equipment (PPE) for body substance isolation. If available and warranted by scene factors, use ballistic protection.
  3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g. operations at night or in darkness, on or near roadways)
  4. Consider cervical spine stabilization and/or spinal care if trauma
  5. Primary survey (Airway, Breathing, Circulation is cited below; although there are specific circumstances where Circulation, Airway, Breathing may be indicated such as cardiac arrest or major arterial bleeding)
    1. Airway (assess for patency and open the airway as indicated)
      1. Patient is unable to maintain airway patency—open airway
      2. Head tilt chin lift
      3. Jaw thrust
      4. Suction
      5. Consider use of the appropriate airway management adjuncts and devices: oral airway, nasal airway, blind insertion, or extraglottic airway device, endotracheal tube
      6. For patients with laryngectomies or tracheostomies, remove all objects or clothing that may obstruct the opening of these devices, maintain the flow of prescribed oxygen, and reposition the head and/or neck
      7. Obstructed airway, laryngectomy, or tracheostomy – go to Airway Management guideline
    2. Breathing
      1. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning
      2. Administer oxygen as appropriate with a target of achieving 94-98% saturation for most acutely ill patients
      3. Apnea (not breathing) – go to Airway Management guideline
    3. Circulation
      1. Control any major external bleeding [see Extremity Trauma/External Hemorrhage Management guideline]
      2. Assess pulse
        1. If none – go to Cardiac Arrest guideline
        2. Assess rate and quality of carotid and radial pulses
        3. Evaluate perfusion by assessing skin color and temperature
        4. Evaluate capillary refill
    4.  Disability
      1. Evaluate patient responsiveness: AVPU scale (Alert, Verbal, Pain, Unresponsive)
      2. Evaluate gross motor and sensory function in all extremities
      3. Check blood glucose in patients with altered mental status
      4. If acute stroke suspected – go to Suspected Stroke/Transient Ischemic Attack guideline
    5. Expose patient as appropriate to complaint
      1. Be considerate of patient modesty
      2. Keep patient warm
  6. Secondary survey The performance of the secondary survey should not delay transport in critical patients. See also secondary survey specific to individual complaints in other protocols. Secondary surveys should be tailored to patient presentation and chief complaint. The following are suggested considerations for secondary survey assessment:
    1.  Head
      1. Pupils
      2. Naso-oropharynx
      3. Skull and scalp
    2.  Neck
      1. Jugular venous distension
      2. Tracheal position
      3. Spinal tenderness
    3.  Chest
      1. Retractions
      2. Breath sounds
      3. Chest wall deformity
    4.  Abdomen/Back
      1. Flank/abdominal tenderness or bruising
      2. Abdominal distension
    5.  Extremities
      1. Edema
      2. Pulses
      3. Deformity
    6. Neurologic
      1. Mental status/orientation
      2. Motor/sensory
  7. Obtain Baseline Vital Signs (An initial full set of vital signs is required: pulse, blood pressure, respiratory rate, and neurologic status assessment)
    1. Neurologic status assessment [see Appendix VII] involves establishing a baseline and then trending any change in patient neurologic status
      1. Glasgow Coma Score (GCS) is required by the State of Missouri
    2. Patients with cardiac or respiratory complaints
      1. Pulse oximetry
      2. 12-lead EKG should be obtained early in patients with cardiac or suspected cardiac complaints
      3. Continuous cardiac monitoring, if available
      4. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry
    3. Patient with altered mental status
      1. Check blood glucose
      2. Consider waveform capnography (essential for patients who require invasive airway management) or digital capnometry
    4. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should be taken shortly before arrival at receiving facility
    5. Critical patients should have pertinent vital signs frequently monitored
  8. Obtain OPQRST history:
    1. Onset of symptoms
    2. Provocation – location; any exacerbating or alleviating factors
    3. Quality of pain
    4. Radiation of pain
    5. Severity of symptoms – pain scale
    6. Time of onset and circumstances around onset
  9. Obtain SAMPLE history:
    1. Symptoms
    2. Allergies – medication, environmental, and foods
    3. Medications – prescription and over-the-counter; bring containers to ED if possible
    4. Past medical history
      1. look for medical alert tags, portable medical records, advance directives
      2. look for medical devices/implants (some common ones may be dialysis shunt, insulin pump, pacemaker, central venous access port, gastric tubes, urinary catheter)
    5. Last oral intake
    6. Events leading up to the 911 call
      1. In patients with syncope, seizure, altered mental status, or acute stroke, consider bringing the witness to the hospital or obtain their contact phone number to provide to ED care team

Treatment and Interventions

  1. Administer oxygen as appropriate with a target of achieving 94-98% saturation
  2. Place appropriate monitoring equipment as dictated by assessment – these may include:
    1. Continuous pulse oximetry
    2. Cardiac rhythm monitoring
    3. Waveform capnography or digital capnometry
    4. Carbon monoxide assessment
  3. Establish vascular access if indicated or in patients who are at risk for clinical deterioration.
    1. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine (20 mg/mL) with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO medication administration
  4. Monitor pain scale if appropriate
  5. Reassess patient

Notes – Universal Care Guideline