CALS Universal Approach To Emergency Advanced Life Support
The CALS universal approach emphasizes team action. A team of emergency care providers can be much more efficient than a single provider. The team leader directly attends to the patient and sets treatment priorities. Team members anticipate needs and are skilled in performing their roles. They respect the team leader's overall control. The team leader appreciates and respects the preparedness of the team and considers their suggestions when something seems amiss.
The First 30 Minutes of Stabilization
Step 1: Activate the Team
As soon as it is known that a critically ill or injured patient is coming to the emergency facility, summon all needed personnel. Critical care transport may be activated.
Step 2: Obtain Immediate Control and Immobilization
Position the patient so that he or she can be cared for safely. In blunt trauma, spine immobilization is needed. Agitated patients must be restrained. The patient is placed on a work surface stationed in a suitable space to give the team members access. After this is accomplished, the team leader is given “10 seconds of silence" by the team to mentally take in the scene while making direct contact with the patient.
Step 3: Perform the Initial (Primary) Survey for All Patients—Identify and Treat Life Threats and Obtain the SAMPLE History
While the team works, the team leader performs a rapid search for immediate life threats and corrects them if they are found. For example, if exsanguinating external bleeding is found, the team leader directs a team member to apply pressure to the site. The leader looks for airway, breathing, and circulatory problems (the ABCs). Life-threatening neurologic problems are addressed. As this step is finished, the leader obtains a SAMPLE history.
Whenever possible, obtain a SAMPLE history before sedating the patient
| S | Signs and symptoms | P | Past history, pregnancy |
| A | Allergies | L | Last meal |
| M | Medications | E | Events, environment |
Step 3: The Team Acts Simultaneously with the Initial (Primary) Survey
Immediately after the 10 seconds of silence, the team members work rapidly to obtain exposure, measure vital signs, obtain venous access, and draw blood. They apply monitor leads. They begin fluid resuscitation as directed by the leader.
Step 4: Form a Preliminary Clinical Impression
The team leader develops a preliminary impression of the patient's condition by using the historical and clinical data obtained thus far. This impression causes the leader to select a pathway of action that will address the patient's problem. It may be as simple as recognizing the need for neonatal resuscitation or as complex as recognizing that the patient is obtunded with no clear cause. The team leader must remain flexible and remain willing to start over again. Perform a focused evaluation (secondary survey) in order to assist in formulating a working diagnosis.
Step 5: Form a Working Diagnosis and Arrange a Disposition
By this time, the team leader has enough information from clinical observations and initial laboratory results to form a working diagnosis. The leader continues to keep an open mind. Once the working diagnosis is clear, the portals in Volume III assist when additional information is needed. Patient disposition is arranged. The team makes sure that transfer information is complete and checks to be sure that the patient's medical safety has been provided for as much as possible.
Step 6: Team Process Review and Debriefing
It is important for the team (including the team leader) to review the emergency experience, including what went right, what went wrong, whether needed supplies were easily available, and whether communications were optimal. After a difficult case, team members may need emotional support.