Initial Medical Assessment and Care

Section 2 - PRIMARY CARE

2.01 INITIAL MEDICAL ASSESSMENT AND CARE

INITIAL ASSESSMENT:

GENERAL IMPRESSION

Level of Consciousness

A - Alert

V - Responds to Verbal stimuli

P - Responds to Painful stimuli

U - Unresponsive

ORIENTATION x 4/4

4/4 - Person, place, time, incident

3/4 - One faculty absent

2/4 - Two faculties absent

1/4 - Three faculties absent

Altered Mental Status (AMS) is defined as an alteration in either the patient’s LOC or Orientation.

AIRWAY	Establish and maintain airway. Utilize cervical spine precautions when indicated.
BREATHING	Provide oxygen or assist ventilations as indicated.
CIRCULATION	Check pulses, skin & control any external hemorrhage.

FOCUSED AND DETAILED HISTORY AND PHYSICAL EXAM:

• Obtain history of present illness and past medical history.
• Record allergies and medications. Record name, dosage & frequency of medications.
• Systematic head-to-toe and neurological assessment.
• Establish a baseline set of vitals signs. Initial set of vitals must be obtained manually. A baseline set of vital signs includes blood pressure (palpable systolic is acceptable), pulse, respiratory rate and effort, GCS, AVPU, pain score and scale, and SaO2.

PERFORM INITIAL MEDICAL CARE SIMULTANEOUSLY WITH THERAPIES:

• Loosen tight clothing and reassure patient.
• Place patient in position of comfort if not contraindicated.
• OXYGEN: Nasal cannula, NRB mask, or BVM as appropriate for patient condition:
  • Provide supplemental OXYGEN, assist ventilations, intubate and suction as indicated by inadequate breathing / impaired gas exchange.
• Once a medication route has been established, administer medication as indicated per Practice Parameters, (i.e., IV, IO, IN).
• CARDIAC MONITOR LD II, MCL I, or 12 LEAD ASSESSMENT if available. Record strips at least every 5-10 minutes, AND before and after pharmacological or electrical intervention.
• Establish IV or IO of 9% NaCl at KVO, or IV Lock system as indicated by patient condition.
  • Attempt X 2 unless situation demands further repeated attempts. Failure to obtain IV access does not preclude the intervention of other definitive therapy.
• Apply pulse oximeter, if available, to all patients with potential cardiac or respiratory emergencies.
• Apply EtCO2 monitor device to patients with potential cardiac or respiratory emergencies.
• Assess blood glucose with glucometer as indicated per Practice Parameters.
• Repeat vital signs and assess patient EVERY 10 MINUTES (STABLE) or 5 MINUTES (UNSTABLE) until patient care is transferred.
• Document each ALS INTERVENTION and their corresponding times.

Document the patient's condition or behaviors which result in a variance to Practice Parameters. If no response to Practice Parameters, contact Medical Control for consult.