Standing Orders CONTENTS

Transcription

1 STANDING 2013 ORDERS The Council Risk Management Committee annually updates standing orders for medical situations, a unified health care plan, and standard operating procedures for all of our camps, programs, and activities.

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3 CONTENTS preface... 0 Contents... 2 Reference to specifc brands of medication... 5 AEDs: (Automated External Defibrillators)... 5 Abrasions... 5 Minor... 5 Severe... 5 Animal Bites... 5 Antibiotics... 6 Anaphylactic Shock... 6 Angioedema... 6 Asthmatic Attack... 7 Emergency Treatment of acute shortness of breath with a history of asthma or bronchitis... 7 Proventil HFA:... 7 Asmanex:... 7 Blisters... 7 Burns... 7 Heat or Chemical First Degree... 7 Sunburn First Degree... 8 All Second and Third Degree... 8 Cough... 8 Ear Ache... 8 Emergency Hypersensitivity Reaction Intervention Procedure... 8 Page 2

4 Emergency intervention procedure (For MD, RN, PA, or NP only)... 8 All Patients:... 8 Adult or Large Child... 9 Child... 9 Eye... 9 Foreign body in eye... 9 All other problems... 9 Flu Syndrome... 9 Fever... 9 Nausea... 9 Diarrhea Head Injuries Heat Stroke/Exhaustion Stroke Exhaustion Hives Insect Bites or Severe Allergic Reactions to Foods, e.g. Nuts Severe Bee, Wasp or Yellow Jacket Minor Lacerations Minor - Less than 1cm with no fat protruding Major Greater than 1 cm with fat protruding Extensive and deep Nettles, Poison Oak or Poison Ivy Nose Epistataxis Oxygen Use Pain Mild Back pain Page 3

5 Puncture Wounds Snake Poisonous Non Poisonous Sore Throat Spider Sprain/Fracture Sprain Closed Fracture Open Fracture Universal Precautions Upper Respiratory APPENDIX: Suggested Revisions UNDER REVIEW Epinephrine auto injector (Lucas) Subcutaneous administration of epinephrine (adrenalin) (Lucas) Page 4

6 Reference to specifc brands of medication Throughout the document, brand names for medication may be included for better understanding of the medication but not as a directive to only use that brand and not a generic or other medicine that is of the same pharmaceutical compound. AEDS: (AUTOMATED EXTERNAL DEFIBRILLATORS) There are AEDs present at Chesebrough, Hi-Sierra, and council activities. They will be kept in the Health Lodge. They should be accessible to all camp staff as well as adult leaders and Scouts trained in their use. The protocol and testing should be performed by the Health Lodge medical officer. All camp staff who are CPR/AED certified should be familiar with the use of this unit. In an emergency, CPR protocols should be followed including the initiation of EMS (Emergency Medical System or 911). The AED should be brought to the scene of resuscitation as soon as possible. Many cardiac arrests, particularly in adults, may have shockable rhythms, and the AED should be employed as soon as possible even if it means delaying CPR for a brief time. The AEDs can be shown to all Scouters during camp experiences by an AED trained individual. This demonstration may be the motivation for everyone, at all ages, to become CPR certified with training in their usage. ABRASIONS Minor Clean thoroughly with soap and water. Apply antiseptic or antibiotic ointment (check for allergies) If bleeding or open apply dry sterile dressing. Question date of last tetanus booster. Return following day if signs of infections. Severe Gently scrub abrasion with soap and warm water, removing all particles. Follow minor abrasion process. ANIMAL BITES Wash area with soap and water. Apply Neosporin ointment with small dressing. Check Tetanus date. Page 5

7 ANTIBIOTICS Antibiotics are not to be given. ANAPHYLACTIC SHOCK (Which may be secondary to sting, bite or ingestion of allergic foods) Symptoms: Allergic Reaction Rapid pulse Clammy Typical Shock Symptoms Shortness of breath Respiratory distress. Bring patient to Health Officer immediately. Shock treatment (blanket, oxygen, head lowered and feet elevated, etc.). Contact EMS if P>140 or systolic <80. Monitor breathing until help arrives. Administer epinephrine from camper s kit, if applicable. ANGIOEDEMA Angioedema is the rapid swelling (edema) of the dermis, subcutaneous issue, mucosa and sub mucosal tissues. It is very similar to urticaria, but urticaria, commonly known as hives, occurs in the upper dermis. Signs and Symptoms: The skin of the face, normally around the mouth, and the mucosa of the mouth and/or throat, as well as the tongue, swell up over the period of minutes to several hours. The swelling can also occur elsewhere, typically in the hands. The swelling can be itchy or painful. There may also be slightly decreased sensation in the affected areas due to compression of the nerves. Urticaria (hives) may develop simultaneously. In severe cases, stridor of the airway occurs, with gasping or wheezy inspiratory breath sounds and decreasing oxygen levels. Tracheal intubation is required in these situations to prevent respiratory arrest and risk of death. Sometimes, there has been recent exposure to an allergen (e.g. peanuts), but more often the cause is either idiopathic (unknown) or only weakly correlated to allergen exposure. As to our treatment regimen, I would add give oxygen at 4 liters/minute and note that I have never seen a patient who could tolerate a position other than sitting up due to the airway involvement. Elevating the legs may be contraindicated due to the venous return and consequent increased venous congestion that occurs most especially in the head and neck region. Keeping the patient cool is helpful (Ice helps slow edema - Ice chips to mouth, ice bag around neck, in armpits and/or groin) Treatment: If available, the administration of an inhaled corticosteroid after the albuterol should be considered. I would increase the dose of Ranitidine to 150 mg or Famotidine to 40mg as it is more effective and is the usual recommended prescription dose. Also, the dosing Page 6

8 of Diphenhydramine, a 50mg loading dose is great (it's probably safe even in those under 100 lbs., just highly sedating) but is probably the only dose we will be giving so a discussion about later dosing is perhaps unnecessary. ASTHMATIC ATTACK Bring patient to Health Lodge. Determine if patient has their own asthmatic medication; let them administer dosage to themselves. If severe, contact Emergency Services; provide oxygen until help arrives. Emergency Treatment of acute shortness of breath with a history of asthma or bronchitis Many campers who have been stable with their breathing disorder do not bring their inhalers to camp. Camp is an environment full of respiratory triggers to which these individuals are not normally exposed and their symptoms often return while at camp. In view of this experience and in a desire to stabilize these individuals so that they may arrive at the emergency facility in a recoverable state, the following protocol is approved: BLISTERS Proventil HFA: Shake the canister and activate inhaler by pressing down on the bottom of the canister. Have the patient exhale and then while inhaling place the inhaler mouth at the patient s mouth and have the patient press down on the canister, inhaling the medication deeply and then hold their breath for up to ten seconds. If the patient s shortness of breath does not resolve the distress, repeat the procedure. Provide oxygen if required. Contact EMS and have the patient transported to an emergency care facility if necessary. Asmanex: After the application of Proventil HFA, shake the Asmanex container and give one puff of the Asmanex in the same manner as the Proventil HFA. One minute later, give another puff. Patient should be seen at an emergency care facility. Avoid breaking eliminate cause. If opened triple antibiotic and dressing Have patient return next day for redressing. BURNS Heat or Chemical First Degree Cool water immediately loose, dry dressing. Page 7

9 Return following day for redressing Sunburn First Degree Apply Over the counter sunburn product. All Second and Third Degree Take to hospital. COUGH Check temperature, if elevated isolate from other campers. If persistent or causing distress take to hospital. EAR ACHE Check temperature, if elevated and ear ache is persistent take to hospital. No swimming. EMERGENCY HYPERSENSITIVITY REACTION INTERVENTION PROCEDURE Recognizing early signs and symptoms is crucial in the management of hypersensitivity reactions. The most common symptoms seen in anaphylaxis are hives (reddened wheals on the skin) and angioedema (giant wheals that may include face, lips, hands, feet or larynx) in about 88% of patients while respiratory tract involvement (difficulty breathing, shortness of breath, cough) occurs in approximately 50% of patients. 1. Call for assistance (911/Camp Director) 2. Assist patient to position of comfort (lying down if comfortable) 3. Treat for shock 4. Take vital signs every 5 minutes until advanced care arrives. EMERGENCY INTERVENTION PROCEDURE (FOR MD, RN, PA, OR NP ONLY) All Patients: Call for assistance (911 and Camp Director) Assist patient to recumbent position Treat for shock Loosen clothing Take vital signs every 5 minutes, then every 15 minutes when stable Page 8

10 Adult or Large Child Adrenaline Chloride 1:1000: Give.3cc subcutaneously. If it is an insect bite, give it as near the bite site as is clinically safe. May use Epipen if available. May repeat every 15 minutes if symptoms persist or return Albuterol (Proventil HFA) 2 puffs orally. May repeat in 15 minutes if there is shortness of breath Give Benadryl 50mg orally (or another antihistamine if Benadryl is not available) Give an HR2 inhibitor (i.e., Zantac 150mg (Ranitidine HCL) orally Child Adrenaline Chloride 1:1000: Give.15cc subcutaneously. If it is an insect bite, give it as near the bite site as is clinically safe. May use child Epipen if available. May repeat every 15 minutes if symptoms persist or return Albuterol (Proventil HFA) 1 puff orally. May repeat in 15 minutes if there is shortness of breath Give Benadryl 25mg orally (or another antihistamine if Benadryl is not available) Give an HR2 inhibitor (i.e., Zantac 75mg (Ranitidine HCL) orally EYE Foreign body in eye Remove with 4 x 4 gauze if not embedded. Rinse with tepid water. If embedded, cover eye and take to hospital. All other problems Take to hospital. FLU SYNDROME Fever Monitor temperature check every two hours. If persistent or high, take to hospital. Nausea Monitor temperature check every two hours. If persistent more than 24 hours send patient home. Page 9

11 Diarrhea Determine source clear liquids only no solid food for 24 hours. No milk isolate patient send home if problem persists. HEAD INJURIES If any head injury is accompanied by an altered level of consciousness, dizziness, headache with vomiting, change in blood pressure or nose/ear bleeding: If intracranial hemorrhage or cervical spine injury is suspected, splint head and neck with sand bags, etc. and call paramedics. Monitor blood pressure until they arrive. HEAT STROKE/EXHAUSTION Stroke Symptoms: Headache Dry skin Rapid pulse Dizziness Nausea Elevated temperature. Move patient to cool location. Remove or loosen clothing. Contact Emergency Services. Exhaustion Symptoms: Tired Headache Nausea May be diaphoretic Pale Clammy. Normal temperature. Move to cool location. Treat cramps with warmth and massage. HIVES A welt-like raised rash that comes on suddenly and disappears rapidly maybe hives. The cause of the hives should be sought out if possible (an insect sting, a medication being taken, a known food allergy, etc.) Take vital signs and listen carefully to the lungs. Assess for any difficulty breathing or swallowing. If any signs of swelling of lips or airway or if the blood pressure is dropping, call 911 and state that the patient is having an ANAPYLACTIC reaction. Give an Epipen injection. This may be repeated in 20 if necessary. Keep the patient lying down, and feet up. Monitor blood pressure and pulse rate until the EMS arrives. INSECT BITES OR SEVERE ALLERGIC REACTIONS TO FOODS, E.G. NUTS Severe Bee, Wasp or Yellow Jacket Remove stinger if present with scraping motion. Page 10

12 Monitor for allergic reaction, if present determine if patient has an Epipen Kit. Allow patient to administer. Call paramedic if major. Minor Apply cold compress (ice). LACERATIONS Minor - Less than 1cm with no fat protruding. Clean thoroughly with soap and water. Tape securely with steri-strip and cover with sterile dressing. Verify last Tetanus, take to hospital if over 5 years. Monitor for infection and change dressing every 24 hours. Major Greater than 1 cm with fat protruding. Take to hospital for treatment Extensive and deep Apply direct pressure and elevate. Cover with dry sterile dressing. Contact EMS. NETTLES, POISON OAK OR POISON IVY Wash area with soap and water. Apply ice to decrease swelling. NOSE EPISTATAXIS Sit patient erect with head forward. Gently compress nostrils with thumb and forefinger against nasal septum. Hold for 5 to 20 minutes. Apply cool cloth on forehead and back of neck if patient is warm or hot. OXYGEN USE Oxygen is occasionally used in the camp setting. These guidelines will help you understand the policies the council has set up to better provide you with the use of oxygen in the camp setting. Oxygen is a treatment for hypoxemia (lack of oxygen in the blood), not breathlessness. (Oxygen has not been shown to have any effect on the sensation of breathlessness in non-hypoxemic Page 11

13 patients.) The essence of this guideline can be summarized simply as a requirement for oxygen to be prescribed according to a target saturation range and for those who administer oxygen therapy to monitor the patient and keep within the target saturation range. The guideline suggests aiming to achieve normal or near-normal oxygen saturation for all acutely ill patients apart from those at risk of hypercapnic (excessive amounts of carbon dioxide in the blood) respiratory failure or those receiving terminal palliative care. PAIN Mild Recommend Tylenol Monitor until gone. Back pain Apply heating pad. Rest. PUNCTURE WOUNDS All significant puncture wounds (other than slivers) of the head, chest, abdomen, or genital area, should be cleaned carefully, irrigated, and transported for physician evaluation. If there is a suspicion that a piece of foreign matter broke off inside the wound, (unless it is readily visible and easily removed with a sterile needle), a physician should evaluate the wounds. Minor wounds should be cleaned, possibly soaked in Beta dine or Hibiclens, and dressed. Even minor puncture wounds especially of the feet and hands have a large propensity to infection. These should be inspected daily for redness, swelling, or increased pain. SNAKE Identify the snake Poisonous Keep patient calm and transport immediately. Keep area lower than the heart and immobilize. Identify snake if possible. Do not use ice on bite area. Non Poisonous Clean and treat like any wound SORE THROAT Encourage fluids. Page 12

14 Monitor for temperature if elevated send home. Inspect throat for swelling or inflammation or redness. If so, transport to hospital. SPIDER Attempt to identify spider (if Black Widow or Brown Recluse, take to hospital). Ice pack for 30 minutes. Watch for signs of infection. If unable to stop bleeding, call paramedics. SPRAIN/FRACTURE Sprain Ice to prevent swelling (on 15 minutes off 15 minutes etc.). Elevate. Ace bandage. Provide crutches to keep weight off of it or sling if arm. Closed Fracture Splint to immobilize (joint to joint). Elevate if possible Transport to hospital. Open Fracture Cover with dry, sterile dressing. Contact Emergency Services. UNIVERSAL PRECAUTIONS Blood and body fluid precautions must be used with all campers/staff. Gloves are to be worn when touching blood, body fluids, mucus membranes and non-intact skin of all campers/staff If it is necessary to give CPR, a protective mask with a one-way valve is highly recommended. Gloves are to be worn with the cleaning of any items or surfaces contaminated with blood or body fluids Hands are to be washed after gloves are removed Page 13

15 Hands and other skin surfaces are to be washed with soap and water immediately after contact with blood or body fluids. If there is no water supply, use a waterless hand sanitizer. All blood and body fluid spills are to be cleaned up immediately with appropriate disinfectant and gloves are to be worn Clean-up materials are to be handled as hazardous waste and disposed of in special bags kept in the Health Lodge Sharps should be handled with care to avoid accidental cuts and disposed of in red sharps containers without recapping, bending or cutting Avoid overfilling sharps containers, empty when three-quarters full Seal the container prior to removal to prevent spillage with disposal Replace old sharps container immediately with new container Any material used in health care that has blood or body fluid contamination will be appropriately disposed UPPER RESPIRATORY A history of symptoms should include length and type of symptoms, fever, cough, wheezing, shortness of breath, sore throat, and associated allergies. Examination should include vital signs and temperature. Examine the throat and listen to lungs. If the patient has a low grade temperature (<101) has no sore throat a clear chest and the camper is not short of breath, then symptoms can be treated. Ibuprofen can help with achy feelings. If the nose is so congested that sleep is difficult, then a decongestant (Sudafed) can be used. If there is a cough then treatment can be with throat lozenges or Robitussin D. M. can be given. If the patient has significant other symptoms including high temperature, sore throat, and cough, then an examination by a physician would be indicated. If the camper has a history of asthma, allow the camper to carry his asthma medications (pills, inhalers) and use them as the camper has been directed by their physician. Hay fever with itchy eyes, nose, and throat with a dry cough (nonproductive) along with clear nasal drainage can be treated with an antihistamine/decongestant combination. If breathlessness, cough or wheeze do not respond, or if there is a lot of green or yellow mucus the camper should be referred to a higher level of care, so their parent(s) should be notified to transport those campers home. Page 14

16 APPENDIX: SUGGESTED REVISIONS UNDER REVIEW Epinephrine auto injector (Lucas) Intramuscular (IM) administration of epinephrine: auto injector (Epipen, Epipen Jr, Twinject, Anapen) May be performed by all staff trained in the use of epinephrine auto injectors 1. Administer one dose of epinephrine. May repeat every 5 to 15 minutes. Use the patient s epinephrine auto injector if available. a. IM administration into the middle third of the anterolateral aspect (middle outer side) of the thigh is preferred, through clothing if necessary. b. Administration into the buttocks should be avoided. 2. Albuterol (Proventil, Ventolin) 2 puffs orally. May repeat in (5-15) minutes if shortness of breath continues. Use patient s supply if available. a. Alternately levalbuterol (Xopenex) may be administered if patient uses instead of albuterol (use patient s own supply) 3. Administer diphenhydramine (Benadryl) 50mg (2 x 25mg capsules or oral liquid) 4. Give a dose of histamine-receptor 2 antagonist (HR2) such as ranitidine (Zantac) 75mg or famotidine 20mg (Pepcid) 5. Transport via advanced medical care to the nearest medical facility. Ensure advanced medical care is fully informed of medications given and vital signs. 6. If camper returns to camp, ensure that scheduled antihistamine doses are administered as prescribed. Drug Notes: There are no absolute contraindications to the use of injectable epinephrine in a life-threatening situation. Discussion points: Notes and References: World Health Organization (WHO) recommends the availability of one dose of epinephrine for every minutes of travel time to a medical emergency facility. More than 2 doses of epinephrine should only be administered under direct medical supervision (Lexi) The original procedure divided dosing into sections for adults and large children (15 years or greater, or 100 pounds and greater). Dosing in the medical literature and the package insert is as follows: EPINEPHRINE DOSING: 0.01mg/kg (max single dose 0.3mg) every 5 to 15 minutes (LexiComp, PI) Children kg (33 to 66 pounds), Children and adults > 30 kg (66 pounds) Alternate dose: (Sicherer 2007) Children 10-25kg (22-55 pounds) Page mg; may repeat every 5 15 minutes. 0.3mg; may repeat every 5-15 minutes 0.15mg

17 Children >25kg (55 pounds) Page mg If the original procedure is followed the pediatric Epipen must be supplied stocked in the health lodges as well as the Epipen or we would be unable to treat campers who weigh less than 100 pounds. If the pediatric dose is not supplied at camp, the Health Officer should note any campers under the procedure weight (especially those with severe allergies - although allergies to insect bites such as bee stings can escalate at any time) and plan alternative measures in case of an incident. Recommend following dosing in the literature and package insert using 0.3mg (standard Epipen) for all campers. DIPHENHYDRAMINE DOSING: 5mg/kg/24 hours divided in 4 to 6 doses, maximum dose of 300mg per day (PI) In the original document it is suggested that you may give another antihistamine if diphenhydramine is not available. Caution: onset of action for most antihistamines other than diphenhydramine is 1 3 hours. It would be better than nothing but could delay onset of effective antihistamine coverage. Original document recommended dose of 25mg of diphenhydramine for patients under the age of 15 or under 100 pounds. A patient of 30kg would be allowed 150mg of diphenhydramine in 24 hours. Recommend an initial dose of 50mg for patients over 30kg (66 pounds). Repeat doses of 25mg would allow 4 additional doses to be given in 24 hours. ALBUTEROL DOSING: dose for adults and children 12 years of age and older is 2 puffs every 4 hours as needed (PI). Original document recommended 1 puff for children under the age of 15 or under 100 pounds. Recommend a dose of 2 puffs for all campers. There are instructions in the original document to give the injection as near the bite site as clinically safe for an insect bite. This might be effective for subcutaneous injections, but the Epipen should be given intramuscularly into the thigh if possible. Subcutaneous administration of epinephrine (adrenalin) (Lucas) MD, RN, PA or NP only Subcutaneous administration results in a slower absorption and is less reliable than intramuscular (IM) administration. IM administration is preferred in the setting of anaphylaxis. Kathi Lucas commentary: Feel that this section is not necessary, as epinephrine ampoules, needles, syringes, and adequate level of training are not consistently available at camps at all times and route is not recommended as first line for anaphylaxis.