For all patients:

If the patient looks unwell OR presents with acute problem:

• Life support - DRS ABC
• Person on back OR partly sitting up
• Calculate REWS
• Give oxygen if O2 sats less than 94%

Further advice can only be given with a full set of vitals.

Based on the REWS Scale selected and score calculated:

This patient is "low risk" - see protocol indicated by symptoms Medical Consult Advised URGENT Medical Consult Advised THEN:

• Vitals at least every 15 minutes
• Put in IV cannula - 18G
• Take blood for Point Of Care (POC) test:
• Glucose
• Electrolytes
• Venous Gas
• Troponin
• ECG
• Urinalysis
• Measure weight

AND CONSIDER:

• IV antibiotics
• IV fluid bolus for low BP

Further Risk Assessment Advised FIRST:

• Vitals at least every 15 minutes
• Put in IV cannula - 18G
• Take blood for Point Of Care (POC) test:
• Glucose
• Electrolytes
• Venous Gas
• Troponin
• ECG
• Urinalysis
• Measure weight

ASSESS for HIGH RISK features:

• ECG for ST elevation
• Point Of Care (POC) tests for:
• Lactate - 2 mmol/L or more
• Sodium:
• 125 mmol/L or less OR
• 150 mmol/L or more
• Potassium:
• 3 mmol/L or less OR
• 7 mmol/L or more

Are there any HIGH RISK features?

Yes

No

Medical Consult Advised AND:

• Observations at least every 30 minutes

URGENT Medical Consult Advised AND:

• Vitals at least every 15 minutes

AND CONSIDER:

• IV antibiotics
• IV fluid bolus for low BP