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AMLS Patient Contiguous Common Selected

Assessment Leads Laboratory Common
Pathway Values Toxidromes
 AMLS Patient Assessment Pathway

INITIAL OBSERVATIONS

Scene/Situation Patient
Safety threats Cardinal presentation/Chief complaint
Situational clues Primary survey

FIRST IMPRESSION

Identify and treat life threats immediately

Sick/Not sick?
Generate initial differential diagnosis

DETAILED ASSESSMENT
Continually
reassess History Secondary survey Diagnostics
OPQRST, SAMPLER Vital signs, full-body or Glucose, ECG, O2 saturation,
focused physical exam ETCO2

REFINE THE DIFFERENTIAL DIAGNOSIS

(BASED ON ASSESSMENT AND CLINICAL REASONING)

Life threatening Critical Nonemergent

ONGOING MANAGEMENT

Reassess, further refine the diagnosis, Patient disposition

modify treatment
Contiguous Leads

I Lateral aVR V1 Septal V4 Anterior

II Inferior aVL Lateral V2 Septal V5 Lateral

III Inferior aVF Inferior V3 Anterior V6 Lateral

Common Laboratory Values
Lab Values Normal Range SI Units Causes of Decreased Causes of Increased
Levels Levels

Anion Gap 12 ± 4 mEq/L 12 ± 4 mmol/L Alkali ingestion Diabetic ketoacidosis

Chronic vomiting Renal failure
Chronic gastric GI bicarbonate loss
suctioning (diarrhea)
Multiple myeloma Sepsis

Bicarbonate (HCO3) 21–28 mEq/L 21–28 mmol/L Chronic diarrhea Chronic vomiting
Critical: ↑ 40 mEq/L Starvation COPD
↓ 15 mEq/L Diabetic ketoacidosis Mercurial diuretics
Acute renal failure Chronic gastric suctioning

Blood Glucose 70–110 mg/dL 3.8–6.1 mmol/L Adrenal insufficiency Diabetic mellitus
*(P-Glucose) Critical: ↑ 400 mg/dL Cirrhosis Cushing disease
↓ 50 mg/dL Starvation Corticosteroids
Insulin overdose Renal failure

Blood (or Serum) Urea 10–20 mg/dL 3.6–7.1 mmol/L Liver failure Dehydration, GI bleed
Nitrogen (BUN) Critical: ↑ 100 mg/dL Overhydration CHF
Malnutrition Acute myocardial
Malabsorption infarction
Sepsis
Renal Failure

Chloride (CL−) 98–106 mEq/L 98–106 mmol/L Overhydration Dehydration

Critical: ↑ 115 mEq/L Respiratory acidosis, Eclampsia
↓ 80 mEq/L metabolic alkalosis Respiratory acidosis,
CHF metabolic alkalosis
Hypokalemia Kidney disease

Creatinine (Cr) W: 0.5–1.1 mg/dL W: 45–90 mmol/L Debilitation Renal failure

M: 0.6–1.2 mg/dL M: 60–105 mmol/L ↓ Muscle mass
Critical: ↑ 4 mg/dL (muscular dystrophy,
myasthenia gravis)

Hemoglobin (Hb, Hgb) 12–18 g/dL 7.4–11.2 mmol/L Anemia CHF

Critical: ↑ 20 g/dL Kidney disease COPD
↓ 8.0 g/dL Lymphoma High altitudes
Hemorrhage Severe burns,
dehydration

Hematocrit (Hct) 37–52% 0.37–0.52 volume Anemia COPD

Critical: ↑ 60% fraction Pregnancy Severe dehydration
↓ 15% Cirrhosis Eclampsia
Hemorrhage Burns

Magnesium (Mg) 1.3–2.1 mEq/L 0.65–1.05 mmol/L Malnutrition Addison disease

Critical: ↑ 3 mEq/L Malabsorption Hypothyroidism
↓ 0.5 mEq/L Alcoholism Antacid ingestion
Hypokalemia Uncontrolled diabetes
Renal failure

pH 7.34–7.45 7.35–7.45 Acidosis: respiratory Alkalosis: CHF

failure Pulmonary emboli
Severe diarrhea Carbon dioxide
Renal failure poisoning
Ketoacidosis Chronic vomiting
Sepsis Gastric suctioning
Mercurial diuretics

Continued…
Common Laboratory Values (continued)

Lab Values Normal Range SI Units Causes of Decreased Causes of Increased

Levels Levels

Partial Pressure of 35–45 mmHg 4,5–6,1 kPa Pulmonary emboli COPD

Carbon Dioxide (PCO2) Critical: ↑ 60 mm Hg Anxiety, pain Oversedation
↓ 20 mm Hg Pregnancy Pickwickian syndrome
Hypoxemia Respiratory failure

Partial Pressure of 80–100 mm Hg 10,0–13,0 kPa Acute respiratory Hyperventilation

Oxygen (PO2) Critical: ↓ 40 mm Hg distress syndrome Increased inspired
Pneumonia oxygen
Pneumothorax
Pulmonary edema
Restrictive lung disease
COPD

Platelet Count (P) 150,000– 400,000/mm3 *W: 165–390 Hemorrhage Malignant disorder
Critical: ↑ 1 million/mm3 *M: 145–350 Thrombocytopenia Rheumatoid arthritis
↓ 50,000/mm3 Disseminated Polycythemia
intravascular Iron deficiency anemia
coagulation
Pernicious anemia

Potassium (K+) 3.5–5.0 mEq/L 3.5–5.0 mmol/L Infection Dehydration

Critical: ↑ 6.5 mEq/L Cirrhosis
↓ 2.5 mEq/L Malnutrition, protein
loss
Overhydration

Sodium (Na+) 135–145 mEq/L 135–145 mmol/L Burns that affect a large Uncontrolled diabetes
Critical: ↑ >160 mEq/L↓ Critical: ↑ >160 mmol/ area of the body Underlying polyuria
<120 mEq/L L↓ <120 mmol/L Diarrhea disorders
Diuretics Diuretics
Heart failure Tube feeding
Kidney diseases Hypertonic infusions
Liver cirrhosis Osmotic diuresis
Syndrome of Lactulose
inappropriate Mechanical ventilation
antidiuretic hormone
secretion (SIADH)
Sweating
Vomiting

Albumin 3.5–5.0 g/dL 35–50 g/L Infection Dehydration

Cirrhosis
Malnutrition, protein
loss
Overhydration

*Designates International Value/Identification

CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; GI = gastrointestinal;
M = man; W = woman.
Data from Pagana KD, Pagana TJ. 2009. Mosby’s Diagnostic and Laboratory Test Reference. 9th ed. St: Elsevier.
Selected Common Toxidromes
Findings Examples of Responsible Agents Prehospital Treatment Strategies

Sympathomimetic Tachycardia Cocaine Benzodiazepines

Hypertension Amphetamine/methamphetamine IV fluids
Mydriasis Ephedrine
Diaphoresis Monoamine oxidase inhibitors (MAOIs)
Agitation Withdrawal (eg, ethyl alcohol,
Tremor benzodiazepines)
Delirium

Anticholinergic Tachycardia Antihistamines Benzodiazepines

Mydriasis Tricyclic antidepressants IV fluids
Agitation GI antispasmodics
Delirium Over-the-counter sleep aids
Mumbling speech Some muscle relaxants (eg, Flexeril)
Dry axillae/membranes

Cholinergic DUMBELS Organophosphates Atropine

Diarrhea Carbamates Airway management
Urination Nicotine
Miosis Pilocarpine
Bronchorrhea/bradycardia Mestinon (pyridostigmine)
Emesis
Lacrimation
Salivation/seizures

Opioid CPR Heroin Supplemental oxygen

Coma Hydromorphone (Dilaudid) Naloxone (0.4 mg IV/IM per dose)
Pinpoint pupils Fentanyl
Respiratory depression Oxycodone
Hydrocodone
Diphenoxylate/atropine (Lomotil)
Tramadol

Sedative-Hypnotic Depressed mental status Benzodiazepines Elevation of head of bed

Normal vitals Barbiturates Nasal or oral airway
Alcohols Supplemental oxygen
Some muscle relaxants (eg, carisoprodol
[Soma])
Gamma hydroxybutyrate (GHB)

GI = gastrointestinal; IM = intramuscular; IV = intravenous.