COMPREHENSIVE ADVANCED LIFE SUPPORT CALS PROVIDER MANUAL THE FIRST 30 MINUTES EDITION 15 2019 DIRECTOR: DARRELL CARTER, MD EDUCATION MANAGER: Ann Gihl, RN Comprehensive Advanced Life Support © January 2019 All Rights Reserved www.calsprogram.org NOTE TO USERS The CALS course was developed for rural and other healthcare providers who work in an environment with limited resources, but who are also responsible for the emergency care in their often geographically isolated communities. Based on needs assessment and ongoing provider participant feedback, the CALS course endorses practical evaluation and treatment recommendations that reflect broad consensus and time-tested approaches. The organization of the CALS Provider Manual reflects the CALS Universal Approach. The FIRST THIRTY MINUTES (previously known as Volume 1) of patient care. ACUTE CARE ALGORITHMS/ TREATMENT PLANS/AND ACRONYMS provide critical care tools and are designed for quick access. The STEPS describe a system to diagnose and treat emergent patients. The FOCUSED CLINICAL PATHWAYS provide a brief review of most conditions encountered in the emergency setting. Supplement to the First Thirty Minutes (previously known as Volume 2) is composed of RESUSCITATION PROCEDURES divided into appropriate areas of clinical expertise, which illustrate hands-on techniques. Reference material for the First thirty Minutes (previously known as Volume 3) is composed of DIAGNOSIS, TREATMENT, AND TRANSITION TO DEFINITIVE CARE PORTALS, is also divided into appropriate areas of clinical expertise. In conjunction with the FOCUSED CLINICAL PATHWAYS, these detail further specialized guidelines on many conditions. Recommendations in the CALS course manual are aligned with those from organizations such as the American Heart Association, American College of Surgeons, American Academy of Family Physicians, American College of Emergency Physicians, American Academy of Neurology, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, National Institutes of Health, and Centers for Disease Control. The CALS Program has selected and modified some recommendations to meet the specific needs and constraints of our rural and remote participants. CALS teaches basic sound management principles and intentionally refrains from making definitive statements advocating or condemning rational alternatives for achieving a desired clinical result. The CALS position is to present reasonable options unless the evidence base clearly supports one choice over another. CALS PROVIDER MANUAL EDITION 15- 2019 OVERVIEW OF CHANGES—UPDATE 2019 (page iii that follows) provides an overview of the new material. The CALS Provider Manual is available in a variety of formats including online. January 2019 i DISCLAIMER The information presented through the Comprehensive Advanced Life Support Program (including the CALS Manual, Provider Course and Benchmark Skills Lab—“CALS Program” or “Program”) is made available for educational purposes through a collaborative effort. The effort has involved a multidisciplinary group of individuals and organizations. The information is not intended to represent the only—nor necessarily in every circumstance the best—methods or procedures appropriate for the medical situations discussed. Rather, the information is intended to present an approach, view, statement, or opinion of the persons involved in the development of the Program, which may be helpful to others who face similar situations. Best efforts have been made to assure the accuracy of the information presented through the Program. Nevertheless, medicine is constantly changing, and not all therapies are clearly established. In addition, human error is always possible. Therefore, physicians and other members of the health care team must confirm the accuracy of the material presented in the CALS Program. They may wish to check current information regarding specific details, such as drug doses, indications and contraindications, drug interactions, and other information in appropriate, current standard sources (such as package inserts or standard medical reference textbooks) prior to clinical application. CALS, for itself and for the persons and other organizations participating in the development and distribution of the Program, disclaims any and all liability for injury, or any other damages, resulting to any individual participating in the Program and for all claims that may arise out of the use of the information written or presented or techniques demonstrated or discussed therein by such individuals, whether such claims may be asserted by an individual who participated in the Program or by any other person. • Much of the information in the Obstetrics portals was obtained from the Advanced Life Support in Obstetrics (ALSO) Syllabus. The ALSO Program and its copyright are owned by the American Academy of Family Physicians. The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association. Any fees charged for such a course, except for a portion of fees needed for AHA course material, do not represent income to the Association. January 2019 ii CONTRIBUTORS The CALS Program gratefully acknowledges the generosity of many volunteer authors, reviewers, and instructors who have selflessly donated hundreds of hours of time. These individuals have shared in the creation of this CALS Provider Manual. Great appreciation is also extended to the many organizations* that have made it possible for CALS to grow from a fledgling, grassroots volunteer group into a flourishing, self-supporting organization. The Minnesota Academy of Family Physicians (MAFP), Minnesota American College of Emergency Physicians (MNACEP), and Department of Emergency Medicine at the University of Minnesota Medical School provided the support, framework, and organizational structure for the development of CALS. These three organizations continue to promote CALS within their own organizations and beyond, which has led to broad acceptance of CALS in the fields of family medicine, emergency medicine, and trauma. MNACEP provided invaluable assistance, which led to the financial sustainability of the CALS Program. The Emergency Medical Services Regulatory Board and the Office of Rural Health and Primary Care, Minnesota Department of Health have provided broad institutional support. The following organizations have also collaborated with and offered support in a variety of ways: Emergency Medical Services for Children Hennepin County Medical Center Hennepin County Medical Center Trauma Services Hennepin County Medical Center Traumatic Brain Injury Center Methodist Hospital Minneapolis Medical Research Foundation Minnesota Poison Control System National Highway Traffic and Safety Administration Regions Medical Center U Care Foundation University of Minnesota Medical School We acknowledge the CALS instructors and staff whose hard work and dedication make the CALS program viable. January 2018 * All organizations are in Minneapolis-St. Paul (Minnesota). v PREFACE: CALS CONCEPTS, GOALS, AND OBJECTIVES The Comprehensive Advanced Life Support (CALS) Program was conceived and developed from the understanding that success in improving rural emergency and critical care depends on providing existing teams of rural physicians and other team members with the tools to better care for critically ill/injured patients. The CALS curriculum is designed as an effective approach (1) to diagnose and treat the majority of emergency/critical care patients as well as (2) to help rural health care providers become skilled in treating undifferentiated emergencies. Mission of CALS: CALS improves patient care by providing advanced life support education to rural healthcare providers. The focus of the CALS Program is to train medical personnel in a team approach to anticipate, recognize, and treat life or organ-threatening illness or injury. The CALS Program is designed for physicians, physician assistants, nurse practitioners, RNs, LPNs, paramedics and other allied health care professionals (eg, nurse anesthetists and respiratory therapists) who work in rural or remote settings with limited medical resources. In these settings, a broad range of medical emergencies must be addressed, but there is a lack of or limited access to subspecialty health care providers, organized and knowledgeable emergency teams, and/or technologically advanced diagnostic and treatment equipment. CALS has been specifically designed to help minimize the adverse effects of these limitations, which are common to many rural and remote settings. The CALS curriculum, conducted in a collaborative environment, consists of four components: Home Review of the CALS Provider Manual, the CALS Provider Course classroom sessions, CALS Benchmark Skills Lab, and CALS Trauma Module. Home Review involves studying the CALS Provider Manual in preparation for the interactive components. The two-day CALS Provider Course is comprised of interactive presentations and real-world, scenario-based skill stations in cardiac, trauma, pediatric, obstetric, neonatal, and medical advanced life support as well as difficult airway management. The one-day CALS Benchmark Skills Lab includes skills needed for resuscitation, stabilization, and management of critically ill or injured patients. The Benchmark Skills Lab targets both skills