Comprehensive Advanced Life Support

Aka: Comprehensive Advanced Life Support, CALS, CALS Universal Approach

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II. Precautions

  1. These notes are NOT an official CALS program reference
  2. Goals of these notes was to ensure I was preparing adequately for course taken in 2017
    1. CALS study materials are expansive (3 volumes) and only loosely organized
    2. Outline below roughly covers similar material to CALS, but links are to my own colated notes from various sources
      1. Linked topics, despite being up-to-date, are likely to vary from CALS guidelines
      2. Sources include primary emergency medicine literature, as well as CALS, PALS, NRP, ALSO, ATLS

III. Definition

  1. Comprehensive Advanced Life Support (CALS)
    1. Resuscitation course targeted at rural medical providers and combines aspects of ACLS, PALS, NRP, ALSO and ATLS
    2. Focus on emergency skills, knowledge and equipment, effective teams and patient focused care

IV. Protocol: Universal Approach

  1. General Approach
    1. Emergency Decision Cycle (OODA Loop, AAADA Model)
    2. Advanced Directives in the Emergency Department
  2. Step 1: Ready for patient arrival
    1. Activate team and assign roles
    2. Apply applicable protocols
    3. Review patient record in EMR if available
  3. Step 2: Patient arrival and situation control
    1. Everyone quiet while EMS gives report
    2. Restrain or immobilize patient as needed (e.g. Sedation in Excited Delirium)
  4. Step 3: Primary Survey (lead by Team Leader)
    1. ABC Management
      1. Includes Adult Resuscitation, Pediatric Resuscitation, Cardiac Arrest and CPR
      2. Includes Trauma Primary Survey (includes Exsanguination management)
      3. Emergency Airway Management
      4. Emergency Breathing Management
      5. Emergency Circulation Management
      6. Emergency Disability Management (AVPU, GCS)
      7. Emergency Exposure Management
    2. Initial Measures
      1. IV-O2-Monitor
      2. Vital Signs
      3. EKG
    3. Immediate interventions
      1. DONT Mnemonic (Dextrose, Oxygen, Naloxone, Thiamine) for Altered Level of Consciousness
      2. Consider Reversible Causes of Cardiopulmonary Arrest
    4. SAMPLE History (Signs/Symptoms, Allergies, Meds, PMH, Last Meal, Events)
      1. Obtained as able from EMS, family or patient
  5. Step 4: Secondary Survey and Focused Evaluations
    1. Trauma Secondary Survey
    2. See System Specific Protocols as described below
    3. Evaluate with serial exams, labs, imaging, diagnostics
  6. Step 5: Working Diagnosis, Stabilization and Disposition
    1. Return to Step 3 if patient decompensates or fails to improve
    2. Induced Therapeutic Hypothermia (e.g. Post-Cardiac Arrest Care)
    3. Emergency Transport (to higher level of care)
      1. See Transfer of the Critically Ill Patient
  7. Step 6: Team Process Review
    1. Debriefing as needed

V. Protocol: Cohort Specific

  1. Pediatric specific management
    1. Pediatric Emergency Care
    2. Emergency Pediatric Dosing (Broselow Tape)
    3. Pediatric Assessment Triangle
    4. Newborn Resuscitation
    5. Newborn Distress
    6. Dehydration Management in Children
  2. Obstetric specific management
    1. Obstetric Emergency (Obstetrical Resuscitation)
    2. Obstetrical Trauma
    3. Placental Abruption
    4. Placenta Previa
    5. Postpartum Hemorrhage
    6. Shoulder Dystocia
    7. Assisted Delivery
    8. Cesarean Section
    9. Perimortem Cesarean Section
  3. Other patient specific guidelines
    1. Obesity and Emergency Stabilization

VI. Protocol: System Specific

  1. Cardiovascular Emergencies
    1. Ventricular Fibrillation or Pulseless Ventricular Tachycardia
    2. Asystole or Pulseless Electrical Activity (PEA)
    3. Unstable Bradycardia
    4. Unstable Tachycardia
    5. Atrial Fibrillation Acute Management
    6. Acute Coronary Syndrome
    7. Aortic Dissection
    8. Cardiac Tamponade
    9. Cardiogenic Shock (Acute Pulmonary Edema)
    10. Hypertensive Emergency
  2. Eye Emergencies
    1. Eye Trauma
    2. Blunt Eye Injury
    3. Central Retinal Artery Occlusion
    4. Chemical Eye Injury
    5. Globe Perforation
    6. Retrobulbar Hematoma
  3. Respiratory Emergencies
    1. Pulmonary Embolism
    2. Foreign Body Aspiration
    3. Tension Pneumothorax
    4. Pulmonary Contusion
    5. Status Asthmaticus
    6. Flail Chest (or multiple Rib Fractures)
  4. Hematologic and Oncologic Emergencies
    1. Oncologic Emergency
    2. Neutropenic Fever
    3. Anticoagulant Reversal
  5. Neurologic Emergencies
    1. Emergency Neurologic Exam
    2. Seizure Emergency Management (Status Epilepticus)
    3. Altered Level of Consciousness
    4. Closed Head Injury
    5. Brainstem Herniation
    6. Cerebrovascular Accident
    7. Penetrating Neck Trauma
  6. Psychiatric Emergencies
    1. Psychiatric Exam in the Emergency Department
    2. Excited Delirium
    3. Sedation in Excited Delirium
  7. Fluids, Electrolytes and Nutrition Emergencies (as well as renal emergencies)
    1. Hemorrhagic Shock
    2. Hemodialysis Emergency
    3. Metabolic Acidosis
  8. Infectious Emergencies
    1. Septic Shock
    2. Community Acquired Pneumonia
    3. Healthcare Associated Pneumonia (HCAP, Nosocomial Pneumonia)
    4. Meningitis
    5. Encephalitis
  9. Abdominal Emergencies
    1. Abdominal Aortic Aneurysm
  10. Orthopedic Injury
    1. Skeletal Immobilization (Cervical Collar, Spine Board, Four-Person Log Roll)
    2. Cervical Spine Injury
    3. Thoracolumbar Injury
    4. Pelvic Fracture
    5. Femur Fracture
  11. Trauma and Environmental Injuries
    1. Heat Related Illness
    2. Burn Injury
    3. Hypothermia Management
    4. Frostbite
    5. Unknown Ingestion
    6. Biological Weapon
    7. Chemical Weapon
    8. Mass Casualty Incident
    9. Blast Injury
    10. Gunshot Wound
    11. Knife Wound

VII. Protocol: Skills

  1. See Emergency Procedure Skills
  2. Airway
    1. Nasopharyngeal Airway and Oropharyngeal Airway
    2. Rapid Sequence Induction
    3. Advanced Airway
    4. Endotracheal Intubation
    5. Cricothyrotomy
  3. Breathing
    1. Chest Tube
    2. Needle Decompression of Thorax
    3. Non-Invasive Positive Pressure Ventilation (NIPPV, BiPap, CPap)
    4. Mechanical Ventilation
  4. Circulation
    1. Defibrillation
    2. Synchronized Cardioversion
    3. Emergency Transvenous Pacing
    4. Emergency Pericardiocentesis
    5. Emergency Thoracotomy
    6. Arterial Cannulation (Arterial Line)
    7. Central IV Access
    8. Umbilical Vein Catheter
    9. Intraosseous Access
  5. Disability
    1. Skull Trephination
  6. Trauma
    1. Hemorrhage Management
    2. Pelvic Binder
  7. Imaging
    1. Bedside Ultrasound
    2. FAST Exam
    3. Emergency Echocardiography
  8. Medications
    1. Procedural Sedation and Analgesia
    2. Sedation in Excited Delirium
  9. Miscellaneous
    1. Orogastric Tube
    2. Nasogastric Tube
    3. Suprapubic Catheterization

VIII. Protocol: Safety

  1. Emergency Department Violence
  2. Emergency Exposure Management

IX. Protocol: Medications

  1. Procedural Sedation and Analgesia
  2. Sedation in Excited Delirium

X. Protocol: Miscellaneous (not yet covered)

  1. Emergency Preparedness
  2. Universal Approach

XI. References

  1. (2016 ) CALS, 14th Ed

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