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SAMPLE OF PEDIATRIC OPERATING “GUIDELINES” FOR COMMON CONDITIONS AFFECTING SPECIAL NEEDS
INDIVIDUALS RELOCATED TO SHELTERS AND REFUGES OF LAST RESORT (RLR) - REGION 5/6 SOUTH
Glenda Grawe, MDBrent Kaziny, MD
Paul Sirbaugh, DOCarl Tapia, MD
Department of PediatricsBaylor College of Medicine
ACKNOWLEDGEMENTS:
The authors of this document would like to express their extreme gratitude to the State of Florida and to the many individuals who participated in the creation of the multifaceted Florida Special Needs Shelter Plan document1. As we began the process of creating our own region’s response to special needs shelters we realized very early on in the process that recreating the wheel with limited funds and time was not the right answer. Instead we searched for and found this publicly funded and tested plan that in our opinion is very well suited for application and/or adaptation in almost any area of the country, regardless of disaster type.
Special mention to our Florida Colleagues:
1) Deborah Ann Mulligan, MD FAAP FACEP, President, Florida Chapter AAP (2003 – 2005), Director, Institute for Child Health Policy, Professor Pediatrics, COMNova Southeastern University
2) Sandra A. Schoenfisch, R.N., Ph.D., Director, Florida State Office of Public Health Nursing
3) Carol Wright-Tanner, R.N., M.S.N., M.S., C.P.H.Q., L.H.R.M., Executive Community Health Nursing Director, Florida State Office of Public Health Nursing
4) Marianne Issa, R.N., B.S.N. Registered Nursing Consultant, Florida State Office of Public Health Nursing
5) John J. Lanza, MD, PhD, MPH, FAAP, County Health Department Director, Florida Department of Health, Escambia County Health Department, Chair, Florida Medical Association Public Health Council
We would also like to extend our special thanks to the following individuals without whom the sample guidelines and/or the pediatric training course would not have been possible:
1) Dr. Chris Souder, Associate Medical Director, City of Houston, EMS and the Houston Fire Department (HFD) for allowing us access and utilize several of the Houston Fire Department medical protocols
2) Dr. Emily Kidd, Assistant Medical Director, City of Houston, EMS for her invaluable input regarding overall disaster response
3) Dr. Brent Kaziny, Baylor College of Medicine Department of Pediatrics and Texas Children's Hospital (TCH) for his help with the creation and formatting of each of these guidelines.
4) Dr. Charles Macias, Associate Professor of Pediatrics, Chief of Academic Programs, Director of PEM Research Programs, Baylor College of Medicine for his academic oversight
5) Nicole Rosburg,MS, Certified Child Life Specialist II (CCLS), St Luke’s Community Medical Center – Wooldands, for her help in writing the guideline “Helping a Child with Special Needs”.
6) Leslie Johnson, Jamie Moreau and Elisa Oros, CCLS, from TCH’s Child Life Department for their presentation on caring for children in a special needs shelter.
7) Gail Parazynski, BSRN, Assistant Director of Nursing for the TCH Emergency Department for her presentation and guidance on caring for children with varying degrees of autism.
1 http://www.doh.state.fl.us/phnursing/spns/disasterguide.html
8) Tonia Nations and Elaine Hime with Texas Children's Hospital’s (TCH) Family Advisory Board for their personal support, education, experience and direction regarding Children with Special Health Care Needs (CSHCN).
9) Connie Smith, Research Administrative Coordinator, BCM for her assistance with organizing and coordinating the “Caring for CSHCN in a Sheltering Environment” conference
10) Robert Atcheson, Research Coordinator II, BCM, for his assistance with organizing the brochure for the “Caring for CSHCN in a Sheltering Environment” conference
CONSIDERATIONS:
The purpose of this document is to provide the pediatric medical team at a special needs shelter or refuge of last resort (RLR) with guidelines for managing some common conditions that they may encounter while caring for their pediatric shelter population. The purpose is not to provide the medical staff with hard and fast rules or protocols for managing every medical condition.
These guidelines are not intended to be used without review and modification to the specific needs of a given community and available resources of that community. Medical directors as well as nursing and other allied health care providers must be familiar with the scope of practice as regulated by the state of Texas in carrying out any protocols that are developed for use within the shelter setting.
Suggested online references for the State of Texas:
http://www.dshs.state.tx.us/plc/default.shtm: Professional Licensing and Certification Unit Home Page
http://www.bon.state.tx.us: Texas Board of Nursing
http://www.dshs.state.tx.us/emstraumasystems/ruladopt.shtm#EMS: Texas EMS Rules
TABLE OF CONTENTS
1. GENERAL OPERATIONS:____________________________________________51.01 HELPING A CHILD WITH SPECIAL NEEDS:______________________________5
1.02 DOCUMENTATION:_____________________________________________________7
1.03 GENERAL CARE:______________________________________________________8
1.04 BODY MECHANICS:____________________________________________________9
1.05 PERSONNEL - INJURY/ACCIDENTS:____________________________________10
1.06 INFECTION CONTROL/UNIVERSAL PRECAUTIONS:_____________________11
1.07 ISOLATION PRACTICES:______________________________________________13
1.08 RESTRAINTS:_________________________________________________________14
1.09 VIOLENT OUTBREAK:_________________________________________________15
2. GENERAL CARE:__________________________________________________162.01 GASTROSTOMY – FEEDING:___________________________________________16
2.02 GASTROSTOMY – ROUTINE CARE:____________________________________18
2.03 DISPLACED GASTROSTOMY TUBE:____________________________________19
2.04 GASTROSTOMY – BLOCKAGE:________________________________________20
2.05 OSTOMY CARE:______________________________________________________22
2.06 DISPLACED TRACHEOSTOMY TUBE:__________________________________24
2.07 DIAPER RASH:________________________________________________________26
2.08 DECUBITUS CARE____________________________________________________27
2.09 DRESSING CHANGE – CLEAN TECHNIQUE:____________________________28
2.10 DRESSING CHANGE – STERILE TECHNIQUE___________________________29
3. EMERGENCY CARE:_______________________________________________303.01 BASIC SKILLS AND ASSESSMENT:____________________________________30
3.02 BAG VALVE MASK VENTILATION:_____________________________________32
3.03 CARDIAC ARREST -- PEDIATRIC BLS:__________________________________33
3.04 CARDIAC ARREST -- PEDIATRIC ALS:__________________________________35
3.05 DIFFICULTY BREATHING:_____________________________________________37
3.06 AIRWAY OBSTRUCTION:______________________________________________39
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3.07 PEDIATRIC ASTHMA, BRONCHIOLITIS, REACTIVE AIRWAY DISEASE:___40
3.08 CROUP_______________________________________________________________41
3.09 ALLERGIC REACTION/ANAPHYLAXIS:_________________________________42
3.10 SEIZURES:___________________________________________________________44
3.11 HEAT STROKE, CRAMPS, AND EXHAUSTION:__________________________46
3.12 FAINTING:____________________________________________________________48
3.13 ALTERED MENTAL STATUS:______________________________________49
3.14 BLUNT TRAUMA:_____________________________________________________50
3.15 BURNS – CHEMICAL:_________________________________________________51
3.16 BURNS -- THERMAL:__________________________________________________52
3.17 BITES and STINGS:___________________________________________________55
3.18 BITES -- ANIMAL:_____________________________________________________57
3.19 BITES – HUMAN:______________________________________________________58
3.20 CUTS AND ABRASIONS:______________________________________________59
3.21 FRACTURES -- OPEN AND CLOSED:___________________________________61
3.22 JOINT DISLOCATIONS:________________________________________________63
3.23 SPRAINS AND STRAINS:______________________________________________64
3.24 SPLINTING -- FRACTURE OR DISLOCATION:___________________________65
3.25 INSULIN REACTIONS -- HYPOGLYCEMIA/HYPERGLYCEMIA:____________66
3.26 FEVER:_______________________________________________________________68
3.27 ABDOMINAL DISTRESS:_______________________________________________69
3.28 VOMITING:___________________________________________________________71
3.29 DIARRHEA:___________________________________________________________72
3.30 ACCIDENTAL INGESTION:_____________________________________________73
3.31 HEADACHE:__________________________________________________________74
3.32 CHEST PAIN:_________________________________________________________75
3.33 EYE INJURY/INFLAMMATION:_________________________________________76
3.34 EARACHE:___________________________________________________________78
3.35 NOSEBLEED (EPISTAXIS):_____________________________________________79
3.36 TETANUS PROPHYLAXIS:_____________________________________________80
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4. CONTAGIOUS CONDITIONS:________________________________________814.01 CHICKEN POX:_______________________________________________________81
4.02 INFLUENZA:_________________________________________________________82
4.03 MENINGITIS:__________________________________________________________84
4.04 GERMAN MEASLES (RUBELLA):_______________________________________86
4.05 IMPETIGO:____________________________________________________________87
4.06 LICE (PEDICULOSIS):_________________________________________________88
4.07 MEASLES (RUBEOLA):________________________________________________89
4.08 RINGWORM:__________________________________________________________90
4.09 SCABIES:____________________________________________________________91
4.10 SCARLET FEVER:_____________________________________________________92
4.11 ABSCESS:____________________________________________________________93
5. END OF LIFE:______________________________________________________945.01 DETERIORATION OF MEDICAL CONDITION:____________________________94
5.02 OUT OF HOSPITAL DNR ORDERS::____________________________________95
5.03 TERMINATION OF RESUSCITATION:___________________________________96
5.04 EXPIRATION:_________________________________________________________97
5.05 DEATH PROCEDURES:________________________________________________98
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1. GENERAL OPERATIONS:
Treat patients and families as if they are a member of your own family.Consider that if this was a member of your family; what care you would want for them if you were not present.
Provide compassion, caring, friendly demeanor and reassurance.If tension does develop, try to defuse them or find another staff member that can help.Remember this is a stressful situation for all involved.
1.01 HELPING A CHILD WITH SPECIAL NEEDS:
INITIAL APPROACH:1. Involve the primary caregiver in your interaction with the child: they can
provide information about the child’s developmental level and reactions to stress.
2. Choose a position that places you at eye level with the child.3. Use a low and even-toned vice when speaking.4. Maintain a pleasant expression but be aware that broad smiles can be
frightening.5. Assess how much “personal space” a child needs and respect that if
possible.6. Always tell a child what you are doing before you touch them.7. Allow children to sit with/on primary caregivers and have comfort items with
them during interactions if possible.
PREPARING CHILDREN FOR EVENTS:1. Allow a primary caregiver to be with the child if possible.2. Children are not small adults and do not understand things the way adults do.3. Use gentle, easy language and short phrases to speak with younger children
or children with developmental delay; be truthful.4. Do not use euphemisms or jargon to describe things to children; they are very
literal in their understanding.5. Use sensory descriptors to communicate: how long will it take?, what will it
feel like?, what equipment will be seen?, who will be there?, etc.6. Try to relate the situation to something a child already knows about.7. Have “adult” or potentially frightening conversations out of the child’s hearing.
PAIN AND FEAR:1. A young or special needs child may not be able to distinguish between pain
and fear.2. A special needs child may not react to pain or fear in the way you would
expect; some have extremely high tolerance to stress and pain while others may have extreme reactions or withdraw into self-stimulating behavior.
3. A special needs child may not recover as quickly from a frightening or painful event as a typically developing child.
4. If possible, recruit child life specialists from local hospitals to assist in reducing anxiety and increasing children’s understanding of events.
HELPING CHILDREN COPE:
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1. Children may experience behavior changes such as increased tantrums and anxiety, depression, nightmares, and regression; be patient.
2. Calm caregivers promote calmer children. Help primary caregivers meet their needs so they can focus on their children.
3. Turn off televisions and radios that repeat exposure to the disaster.4. Maintain schedules and routines as much as possible; this is often critical to
children with special needs.5. Validate children’s feelings and answer questions in developmentally
appropriate and non-threatening ways.6. Take a moment to engage a child in play or silliness. Even one moment of
fun can change a child’s mood.
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1. GENERAL OPERATIONS:1.02 DOCUMENTATION:
PURPOSE:To maintain records for optimal patient care and reference.
CONSIDERATIONS:Documentation is required for all cases in which any status change or patient intervention occurs.
PROCEDURE:S.O.A.P format charting in brief should be utilized:
1. S: Subjective data-Chief complaint, brief patient history, signs and symptoms
2. O: Objective data: What was seen and what was found, including any measurements such as vital signs.
3. A: Assessment: What the problem is and guideline used.
4. P: Plan: All interventions used or performed.
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1. GENERAL OPERATIONS:1.03 GENERAL CARE:
PURPOSE:To continue care of shelter patients to maintain current state of health
CONSIDERATIONS:Special needs children often have complicated medical problems and care needs. While in the shelter setting it is the goal to maintain, as close as possible the level of function these patients.
PROCEDURE:MEDICATIONS:
1. The nursing staff may administer prescription medications to clients or may assist them with self-administration of medication only under the orders of the private physician or Medical Director.
2. Unless there is some obvious contraindication, the medication orders issued by the client’s private physicians will be followed.
3. Clients will be permitted to take the medications that they bring with them to the shelter.
4. Should a client’s supply be completely consumed during the course of the disaster, the Medical Director may prescribe a new supply.
OXYGEN ADMINISTRATION:1. Clients may be permitted to follow their physician’s instructions about the
intermittent use of oxygen to relieve the symptoms of chronic obstructive lung disease or some related condition.
2. Those requiring 24-hour oxygen and/or who are electric dependent, should be evaluated for transfer to a skilled health care facility.
3. Use of the client’s own portable oxygen tanks is encouraged. 4. Clients utilizing oxygen concentrators are encouraged to bring their
equipment with them for use while electrical power is available. 5. Whenever possible, concentrator patients should have battery backup and
provide a small tank in case of power failure or switch to portable oxygen tanks for the duration of the shelter period.
6. Oxygen delivery will be requested by the Nurse Manager through the Supply Unit Leader to the Emergency Operation Center Logistics’ Officer after completing of triage in each of the Medical Special Needs Shelters (MSNS).
7. Instructions for the use of portable oxygen provided by the client’s own physician will be followed to the maximum extent possible.
8. Local oxygen suppliers have been advised by OEM of their responsibility to provide up to a seven day oxygen supply to their clients prior to an emergency.
9. If oxygen is not available locally, the local office of emergency management will request through the multi agency coordination center for through the appropriate Disaster District.
10. The preferable method of administering oxygen in a shelter environment is through the use of liquid oxygen, particularly those clients who are receiving oxygen 24-hours per day or are being administered a high volume of oxygen.
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1. GENERAL OPERATIONS: 1.04 BODY MECHANICS:
PURPOSE: Prevent undue strain and possible injury to one or more parts of the body during the required activities of a normal day.
CONSIDERATIONS: 1. Body mechanics is the coordinated use of body parts to produce motion and
maintain balance. Proper use prevents injury and makes the best use of strength. 2. Involves standing and sitting posture, bending and lifting, and prevention of
fatigue. 3. Factors which influence posture and body mechanics:
a. nutrition b. muscle tone c. body build - slender, medium frame, stocky d. properly fitting shoes, low-medium height heels e. properly fitting clothing, allowing freedom of motion.
4. A broad base of support will provide for better balance and control in lifting.
PROCEDURE: 1. Standing: head erect, chest upward and forward, abdomen, flat but not tense.
The feet parallel, at least 6-8 inches apart with one foot a half step ahead of the other. Maintain equal weight bearing with knees facing in the same direction. Never lock your knees.
2. Sitting: head erect, chest upward and forward, and abdomen flat but not tense. Hips flexed at right angles to the trunk, knees flexed, and feet resting flat and firmly on the floor. Arms and hands supported on arms of chair, or resting in lap.
3. Bending: one leg placed slightly in front of the other, feet 12 inches apart to widen the base of support, knees and hips flexed. This is especially important when lowering or preparing to lift a heavy object.
4. Lifting: same principle and position as in bending with increased hip and knee flexion. Have a wide base of support. Feet 12 inches apart. Keep the load close to your body. Bend hips and knees keeping your back straight. Do not twist your neck and back. Shift your feet to pivot. Never lift over your head. Lift with your thigh muscles.
5. Prevention of strain: a. Face in the direction of movement to avoid strain due to twisting. b. Take advantage of momentum. c. Push, pull or roll object when possible rather than lift. d. Keep object close to body and use thigh muscles rather than back when
lifting is e. unavoidable. If the patient or object appears too large or heavy, get help.
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1. GENERAL OPERATIONS: 1.05 PERSONNEL - INJURY/ACCIDENTS:
PURPOSE: Each agency participating in the shelter staffing has its own protocol for handling an employee incident. Each employee will follow the following procedure for a personal injury or accident while in the shelter.
CONSIDERATIONS:Maintain the health of the shelter staff.
EQUIPMENT/SUPPLIES: "Notice of Injury” form
PROCEDURE: 1. At the time of injury, evaluate and treat according to the injury. Determine if staff
person can continue in role of shelter staff. 2. Notify SHELTER DIRECTOR of injury, if not life threatening. If life threatening,
Activate EMS--Call 911, then notify SHELTER DIRECTOR. 3. Document injury on your agency's "NOTICE OF INJURY" form and the name of
the SHELTER DIRECTOR person who was notified of the incident. 4. After release from the shelter, deliver the "NOTICE OF INJURY" form to your
immediate supervisor, unless otherwise instructed.
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1. GENERAL OPERATIONS:1.06 INFECTION CONTROL/UNIVERSAL PRECAUTIONS:
PURPOSE: For the protection of the patient, caregiver, and provider.
CONSIDERATIONS: Assume that all blood and body fluids from all people are infectious.
EQUIPMENT/SUPPLIES: Gown/Apron Goggle/Face Shield Red Bags Bleach (1:10 dilution) Soap/Detergent Gloves Masks Waste Basket
PROCEDURE: 1. Wash hands. - Hands must be washed before and after contact with each
patient. 2. GLOVES must be worn when having direct contact with blood, body fluids,
mucous membranes or non-intact skin; when handling items soiled with blood, or when handling equipment contaminated with blood or body fluids. This includes, but is not limited to the following:
a. Injections b. Dressing changes c. The handling of soiled linens d. The collection and emptying of all foley catheter bags and drainage
devices e. Providing oral hygiene f. Cleaning a patient, emptying trash or changing linens.
3. Gloves must be changed after each patient contact and during care of single patient when moving from a contaminated area to a clean body site. When gloves are removed, thorough hand washing is required. Gloves do not take the place of hand washing.
4. GOGGLES or protective shields or glasses must be worn when there is a potential for a splash with blood or body fluids.
5. GOWNS or APRONS must be impervious and worn when there is a potential for blood or body fluid splatters or sprays.
6. MASKS are usually not necessary when contact is only casual but should be worn if there is a chance of splash or splatters to the face or the patient has a disease that is transmitted via respiratory route, or is actively coughing.
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7. AIRWAYS a one-way airway, mouthpiece, resuscitation bag or other ventilation device will be utilized when resuscitation is initiated.
8. In the event of contamination with blood or body fluids, body surfaces should be washed immediately with soap and water.
9. To prevent needle stick injuries, needles should never be recapped, bent, broken, or manipulated by hand. These items and other sharp items such as scalpels, razor blades, etc., should be considered potentially infectious and handled with extraordinary care. Used needles and other sharps should be placed intact into puncture resistant containers. The containers when 3/4 full, are to be properly disposed of.
10. Disposable used supplies, i.e. dressings, gowns, gloves, tissues, etc. are to be bagged in red-colored impervious plastic biohazard bags to be disposed of in the designated trash receptacle.
11. Patient care surfaces soiled by care provided are to be cleaned with soap and water and a 1:10 bleach solution and disposed of in red-colored impervious plastic biohazard bags.
12. Soiled linens should be sealed in plastic bags until laundered. 13. Caregivers should not touch their own mouths or bodies while providing patient
care. 14. Blood spills or body fluid should be decontaminated with a 1:10 bleach solution.
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1. GENERAL OPERATIONS: 1.07 ISOLATION PRACTICES:
PURPOSE: It is likely that certain individuals coming to the shelters may have contagious conditions which will inhibit them from residing in the shelter with the general population.
CONSIDERATION: 1. Each individual will need screening at the time they enter the shelter to detect any possible condition necessitating isolation, for the purpose of preventing spread to other individuals and caregivers.
EQUIPMENT/SUPPLIES: Bleach (1:10 dilution) red-colored impervious plastic biohazard bags Gloves Masks
PROCEDURE: 1. Identify possible contagious individuals at the time of entrance to the shelter. 2. Provide individuals with known TB isolation masks allowing them movement
throughout the shelter. Those with TB disease are infectious until they have completed 2 weeks of appropriate medication.
3. Provide those with topical infestations an opportunity for bathing and decontamination. Assist as needed utilizing appropriate protective equipment.
4. Escort those individuals requiring isolation to the designated area within the shelter.
5. Gloves need to be worn by those having contact and assisting in the decontamination of infected persons.
6. See GENERAL CARE GUIDELINES for procedures for specific contagious conditions.
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1. GENERAL OPERATIONS:1.08 RESTRAINTS:
PURPOSE:For the protection of the patient, caregiver, and provider
CONSIDERATIONS:The decision to restrain a patient should be a last resort with all other options exhausted.If at all possible the caregiver/family should be part of the decision to place restraints.
EQUIPMENT/SUPPLIES:Soft restraints“No no’s”Adequate personnel
PROCEDURE:1. If a patient is combative, confused, disoriented, intoxicated, psychotic or suicidal
and creates a risk for self injury or injury to others restraints may be used only as a last resort.
2. Remove any other patients or shelterees from the area.3. Reduce any external stimuli if possible.4. Remove any potentially dangerous items from the area.5. Try to enlist the aid of a family member or caregiver to gain control of the
situation. If this is not effective, notify shelter supervisor and security for assistance.
6. Inform the patient and family of the reason for restraints.7. Restrain the patient in a manner that does not impair circulation, cause choking
or aspiration. Do not restrain patients in a prone position. Use the least amount of restraint possible to control the situation and maintain safety.
8. Do not leave the patient unattended, caregiver must be present and understand use of restraints. The patient should be reassessed a minimum of every 15 minutes and restraints removed as soon as situation is deemed safe.
9. The shelter director should be notified when restraints are placed and every 2 hours.
10. Documentation of events leading to use of restraints, method of restraint, ongoing assessment of situation and when restraints are removed should be included in medical update.
11. If restraints will be needed for a prolonged period of time due to possible patient injury to self or others, reassessment for transfer to a higher of level of care should be done.
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1. GENERAL OPERATIONS:1.09 VIOLENT OUTBREAK:
PURPOSE: During an emergency situation, tensions run high and available resources become precious. To provide for a safe environment the following will be observed:
CONSIDERATIONS: 1. All weapons are forbidden in the shelter. Law enforcement and/or security
personnel will be on site during all shelter operations. 2. Medical personnel are not trained in defense tactics and thus are not the
appropriate individuals to handle outbreaks of violence.
PROCEDURE: 1. If the potential exists for a violent occurrence in the shelter, immediately notify
the shelter manager and the law enforcement agents located within the shelter. 2. Do not become engaged with the perpetrators. 3. As much as possible, provide for the safety of other sheltered individuals. 4. Report any outbreak to the law enforcement officials if they are not present at the
time of the occurrence. 5. Render first aid as needed to those who may be injured as the result of the
incident.
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2. GENERAL CARE: 2.01 GASTROSTOMY – FEEDING:
PURPOSE: To provide enteral supplementation or primary nutrition for patients with dysphagia or failure to thrive.
CONSIDERATION: 1. Whenever possible, home care plans or primary care physician orders should be
consulted2. Loss of power—or when conservation of power is advisable—may require more
frequent bolus feeds3. Children under stress may not tolerate feeds (i.e. experience emesis, gagging, or
abdominal distension)
EQUIPMENT/SUPPLIES: Tubing, syringes (should be provided by patient) Enteral bag (if necessary)Enteral formula (should be provided by patient)Water for flushClean disposable gloves (non-sterile) Feeding pump (if necessary)
PROCEDURE: 1. Verify correct formula and volume from caregiver or plan of care. Verify
expiration date.2. If power not available or not sure of volume, consult primary care physician (if
possible) or on-site doctor.3. Explain procedure to patient. PROVIDE AS MUCH PRIVACY AS POSSIBLE. 4. Position
a. Where possible, the child should be positioned with their head above the level of the stomach (i.e. car seat for babies)
b. Monitor for intolerance (shortness of breath, gagging, coughing, abdominal distension, or emesis)
c. If intolerance, stop feed and consult physician5. Preparation
a. Utilize clean, dry areab. Wash hands and don gloves c. Connect tubing to gastrostomy and flush with 5-10cc water (may use
smaller volumes for patients with fluid restriction)d. Attach syringe without plunger or bag to the feeding tubinge. Proceed to bolus or pump feeding
6. Bolus feedsa. Attach syringe without plunger or bag to the feeding tubingb. Slowly pour the required amount of formula into the syringe or bagc. Alter the height of the syringe or bag to control the flow of the feed;
optimal feedings time should be between 15-30 minutes.d. May use longer feeding times for patients with history of motility problems
or feeding intolerance e. Flush the tubing after the feed (see preparation for volume)
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f. Monitor for several minutes in upright position7. Pump feeds
a. Set up the pump feed according to the manufacture instructions, paying particular attention to the programmed rate and making sure air is expelled from the tubing and syringe
b. Start the feed and keep child within eye sight during feedc. Flush the tubing after the feed
8. It is not necessary to check for residuals9. Document feed and tolerance on Medical Update. 10. Store extra formula according to shelter/pharmacy protocol.11. Remember importance of hand washing before and after.
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2. GENERAL CARE:2.02 GASTROSTOMY – ROUTINE CARE:
PURPOSE: To maintain optimal hygiene and prevent infection.
CONSIDERATION: 1. Whenever possible, home care plans or primary care physician orders should be
consulted2. New gastrostomy (< 10 days) requires special care and a physician should be
consulted
EQUIPMENT/SUPPLIES: Clean gauze or washclothSoap and water
PROCEDURE: 1. Explain procedure to patient. PROVIDE AS MUCH PRIVACY AS POSSIBLE. 2. Examination
a. Observe for evidence of inflammation, warmth, discharge, or granulation tissue. If present, consult a physician
b. Observe the gastrostomy for evidence of malfunction or breakdown. If present, consult physician
3. Wash hands and don gloves (non-sterile)4. Cleanse site with solution of soap and water once daily. Allow to air dry
thoroughly5. Dressings and topical medications are not necessary, but may be applied if
routine per home protocol6. Document procedure Medical Update. 7. Remember importance of hand washing before and after.
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2. GENERAL CARE: 2.03 DISPLACED GASTROSTOMY TUBE:
PURPOSE: To maintain stoma integrity.
CONSIDERATIONS: The more quickly the tube is found to be out, the more likely the success of replacing the g-tube
EQUIPMENT/SUPPLIES: Replacement g-tube, if available (shelterees should have own equipment) or previous g-tube-cleansed in gentle solution and rinsed well.Red rubber catheterFoley catheter with balloonWater based lubricantSyringe with slip tip or g-tube set to aspirate for placement.Syringe with sterile saline
PROCEDURE: 1. Inspect site to insure stoma is healthy, open and no tear is present.2. Cleanse the site of secretions or debris 3. Check g-tube, make sure the balloon is intact and functional. If g-tube is
unavailable, check foley catheter balloon for function.4. Lubricate g-tube or foley catheter with lubricant.5. Gently insert g-tube or foley using light pressure into the stoma. 6. If resistance is met repeat attempt with red rubber catheter. If successful,
remove red rubber catheter and reattempt placement of g-tube or foley. If still unable to pass, replace red rubber catheter, or smaller foley and seek medical attention.
7. Inflate balloon, normally 3-5 mL of saline, consult with caregiver-may have information of normal inflation volume.
8. Once in, check placement by pulling back with syringe for gastric contents followed by instillation of air while auscultating with stethoscope. If in doubt of placement, see medical attention before use.
AFTERCARE:Document in patient's record.
1. Type of g-tube that was removed or displaced 2. Patient's condition. 3. Type of g-tube replaced or device used, method of confirmation4. How the patient tolerated the procedure
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2. GENERAL CARE:2.04 GASTROSTOMY – BLOCKAGE:
PURPOSE: To maintain gastrostomy patency and resume enteral feedings or medication administration.
CONSIDERATION: 1. Whenever possible, home care plans or primary care physician orders should be
consulted2. Prevent blockages by providing only liquid medications and flushing appropriately
EQUIPMENT/SUPPLIES: Tubing and syringeWaterSoda or other carbonated beverage (if necessary)
PROCEDURE: 1. Explain procedure to patient. PROVIDE AS MUCH PRIVACY AS POSSIBLE. 2. Examination
a. Examine patient for evidence of obstruction (abdominal distension, discomfort, fever, or intolerance of feeds)
b. Inspect gastrostomy for proper placement; consult a physician if dislodged or consider replacement
c. Observe the gastrostomy for evidence of malfunction or breakdown. If present, consult physician
d. Observe for evidence of inflammation, warmth, discharge, or granulation tissue. If present, consult a physician
3. Wash hands and don gloves (non-sterile)4. Attempt to gently flush tubing with 10cc warm water5. Patients < 12 months: consult physician for further instructions or consider
replacement6. Patients > 12 months: if medically indicated, may attempt to flush with
carbonated beverage (soda, soda water, or sodium bicarbonate solution)a. Infuse 5-10cc carbonated beverage into tubingb. If unblocked, flush with 5cc water
7. Document procedure in Medical Update. 8. Remember importance of hand washing before and after.
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2. GENERAL CARE:2.05 OSTOMY CARE:
PURPOSE: To contain drainage and protect peristomal skin.
I. POUCH APPLICATION:
EQUIPMENT/SUPPLIES: Warm water if available. Paper towels and/or wash cloth Scissors Skin barrier* Pouch* Unsterile gloves
PROCEDURE: 1. Wash hands and don gloves. 2. Remove old appliance gently with warm water. 3. Cleanse skin and stoma with water, pat dry ( if soap is used, rinse thoroughly). 4. Cut skin barrier to fit 1/8" larger than stoma. 5. If pre-cut pouch, assure correct size. 6. Remove paper backing from pouch or wafer. 7. Dry skin or moisture can interfere with adhesion. 8. Fill creases, scars, or other skin irregularities with leftover pieces of skin barrier,
stomahesive or karaya paste and allow to dry. 9. Press skin barrier or pouch to skin, running finger around edge closest to stoma
to insure a secure seal. 10. If two-piece system, snap pouch on to wafer. 11. Fasten the end of drain with closure. 12. Empty pouch every 3-4 hours.
*Patient must supply appropriate equipment
II. EMPTY POUCH:
EQUIPMENT/SUPPLIES: One pair non-sterile disposable gloves Wet and dry paper towels Warm water Container
PROCEDURE: 1. Apply gloves 2. Obtain wet and dry paper towels, warm water and container for drainage at
bedside. 3. Unfasten bottom of pouch, holding the end up so as to prevent drainage from
coming out prematurely. 4. Unfold pouch. 5. Direct pouch towards container and empty.
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6. Rinse with warm water until clean. NOTE: if leakage occurs, pouch needs changing!
7. Dry end with paper towel. Be sure that end of pouch and clamp are clean. 8. Refasten end of pouch, as described previously. 9. Remove gloves, discard and wash hands. 10. NOTE:
Pouches should be changed when leaking, odoriferous and every 3-4 days to assess condition of stoma and skin. Patient complaints of burning or itching under appliance require investigation of skin condition and fit of appliance.
11. Types of pouches include Karaya seal with micropore tape or wafer and pouch. These require a clamp at the end to close. Skin barrier is provided attached to pouch. Directions for application of all pouches accompany pouches.
*Patient must supply appropriate equipment.
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2. GENERAL CARE: 2.06 DISPLACED TRACHEOSTOMY TUBE:
PURPOSE: Maintain airway in tracheostomy dependant patientTo maintain stoma integrity.
CONSIDERATIONS: Many reasons exist for the need to replace a tracheotomy tube, the most common being difficulty with breathing or ventilation due to a clogged tube. The second being decannulation
EQUIPMENT/SUPPLIES: Suction and suction cathetersBag valve with appropriate mask sizeOxygen if availableReplacement tracheostomy tube and cannula, if available (shelterees should have own
equipment). Previous trach tube can be reinserted if obturator is available and balloon is still functional. Will need ½ strength hydrogen peroxide for cleansing tube
Equivalent size cuffed endotracheal tubeWater based lubricant5-10 mL SyringeGauze padsScissorsStethoscopeSalineTrach Tape or preferred method of patient to stabilize trach tube.
PROCEDURE: 1. If the child is in distress attempt to ventilate via bag and mask, (NOTE: the
stoma site must be covered for face mask to ventilate the lungs), Activate EMS--Call 911
2. Ask the caregiver if there are any special considerations for the child3. Check all equipment is functional4. If the trach is clogged and needs to be removed:
a. Position with the head and neck slightly hyper extended-like what you would accomplish with a neck role.
b. Apply oxygen to the mouth if available, if the trach has a cuff if may not be possible to ventilate the patient by mouth
c. Release the securing device/tiesd. Connect the syringe and deflate the balloon by drawing air out-cutting the
valve will not collapse the balloon. e. Pull the tracheostomy tube out with slow steady pressure, exerted both
out and down.5. Inspect site to insure stoma is healthy, open and no tear is present, reevaluate
ventilation.6. Cleanse the site of secretions or debris, if trach tube is to be reused, cleanse
secretions and debris and insure that the balloon is still functional
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7. Insert the obturator, if available into the trach tube, if not attempt to stiffen the tube by placing in cold water. If no replacement tube is available, and old tube is not functional use and endotracheal tube of similar size.
8. If using an endotracheal tube for replacement in the stoma, remove the connector portion of the tube and trim the tube to a similar length as the prior trach, then replace the connector.
9. Lubricate the outer portion of the trach tube.10. Gently insert tube, holding it by the flange using pressure in a down and back
direction.11. Gentle traction above and below the stoma may make passage easier. 12. Once in place, remove the obturator.13. Check placement by auscultation for bilateral breath sounds, bilateral chest rise,
and patient response.a. Improper placement maybe suggested by no chest rise, resistance
to ventilation, constant coughing, subcutaneous collection of air and no patient improvement
14. Inflate balloon with air.15. If unable to pass, withdraw the tube and give oxygen or appropriate respiratory
support.16. A repeat attempt may be tried with a smaller size trach tube if available, if not a
smaller endotracheal tube placed in the stoma can be used (as described in step 3).
17. After placement and confirmation, secure with clean trach ties or clean stabilization device.
AFTERCARE:Document in patient's record:
1. Type and size of airway Reassess vital signs and airway frequently
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2. GENERAL CARE:2.07 DIAPER RASH:
PURPOSE: To care for diaper rash.
EQUIPMENT AND SUPPLIES: Clean diapers Gloves Desitin Ointment
PROCEDURE: 1. Encourage parents or companions to change diapers frequently, cleaning and
thoroughly drying skin each time. 2. Apply ointment as needed at each diaper change. 3. Do not use powder.
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2. GENERAL CARE: 2.08 DECUBITUS CARE
PURPOSE: Appropriate care for pressure sore in a shelter setting.
CONSIDERATIONS: 1. Use STERILE TECHNIQUE when uncovering and treating wound. 2. Provide frequent turning and repositioning to relieve pressure on sensitive areas.
EQUIPMENT/SUPPLIES: Sterile normal saline solution Enzymatic or antibiotic agent Non-adherent dressings Hypo-allergenic tape One pair sterile gloves One pair clean disposable gloves
PROCEDURE: 1. Explain procedure to person. 2. Wash hands and don clean gloves. 3. Remove any old dressings. Remove non-sterile disposable gloves and discard. 4. Wash hands and don sterile gloves. 5. Irrigate wound with normal saline if indicated. 6. Apply any enzymatic or antibiotic agent. 7. Clean skin around area. Be gentle with skin around affected areas. 8. Cover with non-adherent sterile dressing, and cover that with a clean, dry
dressing. 9. Assess person for pain and discomfort. 10. Assess dressings for bleeding and other exudate.
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2. GENERAL CARE: 2.09 DRESSING CHANGE – CLEAN TECHNIQUE:
PURPOSE: To protect a wound from trauma, infectious agents, and to enhance healing.
CONSIDERATION: A clean dressing is indicated to cover:
a. recently closed skin (sutured) b. lightly abraded skin c. a stoma
EQUIPMENT/SUPPLIES: Dressings (as necessary) Tape (as necessary) Clean disposable gloves (non-sterile) Normal saline irrigation solution (as necessary)
PROCEDURE: 12. Explain procedure to patient. PROVIDE AS MUCH PRIVACY AS POSSIBLE. 13. Wash hands and don gloves. 14. Remove old dressings (if present) carefully folding the dressing to contain the
drainage, place in red-colored impervious plastic biohazard bags. 15. Observe site for:
a. size of wound b. evidence of healing or deterioration c. c. Signs and symptoms of infection: redness, swelling, pain or discharge.
16. Document dressing change on Medical Update. 17. Cleanse with normal saline. (if indicated) 18. Place new dressing over area. Secure new dressing with tape. (use hypo-
allergenic tape 19. if available) 20. Document dressing change on Medical Update. 21. Label dressing with date and time of change.22. Remember importance of hand washing before and after.
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2. GENERAL CARE: 2.10 DRESSING CHANGE – STERILE TECHNIQUE
PURPOSE: To protect a wound from trauma, infectious agents, and to enhance healing.
CONSIDERATION: To be utilized for wounds with drainage.
EQUIPMENT/SUPPLIES: Sterile dressings Hydrogen peroxide Sterile applicators One pair disposable gloves One pair sterile gloves Tape
PROCEDURE: Soiled portion:
1. Wash hands and put on clean gloves. 2. With both hands, remove the soiled dressings by carefully folding the dressing to
contain the drainage in the center of the soiled dressing. Discard contaminated materials in appropriate manner.
3. Remove gloves by first grasping below the cuff and pulling down over your hand. Turn inside out. Insert your ungloved fingers inside the cuff of the second glove. Grasp and pull down, turning the glove inside out before disposing into the garbage.
Sterile portion: 1. Open the needed number of dressings and sterile applicators. Use the wrappers
as a sterile field, pour cleaning solution on sterile 4x4. 2. Open the sterile gloves and put them on maintaining their sterility. Keep one
gloved hand free for sterile supplies and to serve second hand that is in contact with the wound.
3. Cleanse the area from the center of the wound to the periphery. 4. Apply sterile dressings to the area. 4 x 4's should be cut to fit around and support
any 5. drains so that they do not irritate underlying skin. 6. Remove gloves and place in red-colored impervious plastic biohazard bag. 7. Secure dressing with tape.8. Label dressing with date and time of dressing change9. Document dressing change on Medical Update.10. Remember importance of hand washing before and after.
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3. EMERGENCY CARE: 3.01 BASIC SKILLS AND ASSESSMENT:
BASIC SKILLS:SCENE SAFETY:
1. Are the surroundings safe?2. Is there more than one patient in need of help? 3. What resources are needed?
PRIMARY SURVEY:PEDIATRIC ASSESSMENT TRIANGLE:
1. How are they acting-lethargic, playful, fearful?a. Is it a change from their baseline behavior according to their
caregiver/family?2. How are they breathing?3. What is their color?
AIRWAY, BREATHING, CIRCULATION, DISABILITY, AND EXAMAIRWAY AND C-SPINE:Open airway with jaw thrust, consider oral airway, oxygen and bag-valve-mask ventilation as needed
If Airway is:1. Patent-no intervention, but consider oxygen2. Partially obstructed, conscious patient-allow coughing to expel object3. Partially obstructed, unconscious patient-abdominal thrust in children and
adolescents and for infants chest thrust/back blow per BLS procedures. 4. If tracheostomy present, consider suctioning or tube replacement, refer to
tracheostomy tube replacement.5. Obstructed: attempt to clear airway using BLS procedures (abdominal thrust)
or if available direct laryngoscopy with magill forceps, refer to airway foreign body guidelines.
BREATHING:1. Assess adequacy of respirations, including rate, depth, work of breathing and
breath sounds.2. Are respirations spontaneous, labored or absent?
1. Spontaneous respirations continue with assessment of breath sounds, oxygen as needed.
2. Labored respirations, administer oxygen at 100% with well fitting nonrebreather mask or trach mask.
3. Alternative is nasal cannula oxygen at 6 liters for adolescents,1-2 liters for children, and 0.5-1liter for neonates. Activate EMS--Call 911
4. Absent respirations or agonal respirations, support with BVM 100% oxygen and consider advanced airway management as deemed appropriate by medical director. Activate EMS--Call 911—notify shelter ALS team
CIRCULATION:1. If no spontaneous pulse, begin CPR 2. Assess the rate and quality of pulses both central and peripheral3. Assess skin color, temperature and capillary refill
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DISABILITY:1. Immobilize spine as indicated.2. Using AVPU: A=alert
V=responds to verbal stimuliP=responds to painful stimuliU=unresponsive
EXAM:1. Rapid head to toe survey2. Life threatening hemorrhage should be addressed immediately
3. Watchful for any life or limb threatening finding
SECONDARY SURVEY:1. Reassess AIRWAY2. HEAD: Look for contusions, lacerations, raccoon eyes, battle’s sign, and/or
drainage of blood or fluid from the ears or nose. 3. NECK: Look for lacerations or other signs of direct trauma, contusions,
tenderness, distended neck veins, deviated trachea4. CHEST: Reassess breath sounds 5. ABDOMEN: Look for evidence of blunt or penetrating trauma6. PELVIS: Palpate for tenderness and /or instability7. EXTREMITIES: Look and feel for signs and symptoms of trauma, evaluate distal
pulses, sensory and motor function. Apply splints if needed.8. NEUROLOGIC: Level of consciousness, pupillary exam, strength, balance and
sensation9. Tubes and devices: Intact, functional in good condition.
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3. EMERGENCY CARE:3.02 BAG VALVE MASK VENTILATION:
EQUIPMENT/SUPPLIES: Appropriate size maskBag (preferably self inflating)Oxygen supply
PROCEDURE: 1. Consider potential C-spine injury2. Place oral airway if gag is not present, if present can consider nasal trumpet in
patients over the age of 2 years3. Position the Head maintaining neutral position in possible c-spine injury patients.
For pediatric patients, use the sniffing position.4. Elevate the jaw using a jaw lift with fourth and fifth fingers5. Seal appropriate size mask with two hands using C method
a. Thumbs to bridge of nose and index finger over chin holding jaw with 4-5th
fingers6. Squeeze delivering ventilation over one second with enough volume to see a
chest rise and allowing adequate time to passively exhale between ventilations.
i. Adolescent/Adult rate 8-10 ventilations per minuteii. Pediatric and infant rate 12-20 ventilations per minuteiii. Neonatal rate 40-60 ventilations per minute
7. Oxygen should be delivered at a high enough rate to keep reservoir bag full—if available, otherwise self inflating bags do not require a compressed air source and can be used without oxygen if not available.
8. Sellick’s maneuver of moderate cricothyroid pressure by a third person may help to minimize emesis.
9. If CPR is in progress attempt to ventilate in synchronization with chest compressions.
10. Activate EMS—Call 911, Notify Shelter ALS team
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3. EMERGENCY CARE:3.03 CARDIAC ARREST -- PEDIATRIC BLS:
PURPOSE:To provide resuscitative measures for the patient with cardiac arrest
CONSIDERATIONS:1. Cardiac arrest resuscitation requires a team effort2. Airway management is a vital part of resuscitation of a pediatric
patient, either by bag valve mask or advanced airway means.3. Chest compressions are thought to be a vital intervention in successful
resuscitation of arrest victims, making minimal interruptions in compressions is essential.
PROCEDURES:BLS:
1. Determine patient has no pulse2. Immediately call for help, AED and activate EMS—Call 911—Notify
Shelter ALS team3. Bare chest and begin compressions at a rate of 15 compressions to 2
rescue breaths (if patient is an adolescent use rate of 30 compressions to 2 rescue breaths, neonates use the rate of 5 compression to 1 rescue breath).
4. On arrival of AED, turn on and place pads with minimal interruptions in chest compressions.
5. When AED prompts to analyze rhythm, hold compressions and BVM, press analyze button on AED.
a. If AED recognizes shockable rhythm continue with compression until prompt to Clear patient at which time clear patient and push shock on AED.
i. Resume CPR immediately post shock for a 3 minute cycle.ii. After 3 minutes, hold compressions and repeat “analyze
rhythm”b. If AED recognizes non-shockable rhythm, “No shock advised,
start CPR,” resume CPR.i. Continue with a 3 minute cycle of chest compressions and
BVM at a ratio of 30:2.ii. After 3 minutes, hold compressions and repeat “analyze
rhythm,” check for pulse (<10 seconds).iii. If pulse is detected, continue with rescue breathing and
reconfirm pulse every 1 minute.iv. If no pulse is detected, repeat appropriate sequence.
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2 BLS--Souders, C; Pediatric Pulseless Patient-FR/BLS First on Scene, Houston Fire Department May 2008 Protocols: Protocol 8.05D pg III-76 May 2008
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3. EMERGENCY CARE:3.04 CARDIAC ARREST -- PEDIATRIC ALS:
PURPOSE:To provide advanced life support to a pulseless patientCONSIDERATIONS:Resources are limited in a disaster setting, if possible local EMS/911 should respondShould EMS and 911 not be available, Special needs shelters should consider what level of care they are equipped to provide in an arrest situation and what continuing care is available to the patient.PROCEDURES:
1. If not done, initiate BLS procedure, SEE PEDIATRIC ARREST/BLS2. Confirm patient has no pulse3. Apply lifepak monitor pads, with minimal interruption of chest
compressions.4. Establish IV or IO access, do not stop CPR if possible.5. After 3 minutes of CPR assess rhythm
a. VFib/Vtachi. Continue CPR while charging defibrillator to 2
joules/kg, maximum of 360 joulesii. When charge complete clear patient and defibrillateiii. Immediately post shock resume compressions and
BVM at a ratio of 30:2 for adolescents, 15:2 for children and 5:1 for neonates for 3 minutes.
iv. Check for pulse and reassess rhythm, go to appropriate guideline, unless Vfib persists then give one of the following while performing CPR and repeat sequence increasing defibrillation charge to 4 joules/kg:
1. Epinephrine 1:10,000 0.01mg/kg to maximum dose of 1mg IV/IO
2. Amiodarone 5 mg/kg or maximum dose of 300mg IV/IO (1st dose)
b. Asystolei. Chest resume compressions and BVM at a ratio of 30:2
for adolescents, 15:2 for children and 5:1 for neonates for 3 minutes.
1. While compressions are being performed administer) Epinephrine 1:10,000 0.01mg/kg to maximum dose of 1mg IV/IO
ii. After 3 minutes of CPR reassess pulse and rhythm, go to appropriate guideline
c. Organized Rhythmi. Assess presence of pulseii. If no pulse, treat as Asystoleiii. If pulse is present, continue with ventilation support
and got to appropriate guideline.6. Advanced Airway Placement is left to the discretion and skills of the
team.
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a. Advanced airway should be placed if difficulty ventilating the patient with BVM
b. If chosen to perform advanced airway procedure, all efforts should be made to minimize any interruption in CPR.
7. Disposition and transfer to appropriate level of care.
3 ALS--Souders, C; Pediatric Pulseless Patient-FR/ALS First on Scene, Houston Fire Department May 2008 Protocols: Protocol 8.05E pg III-78 May 2008
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3. EMERGENCY CARE:3.05 DIFFICULTY BREATHING:
PURPOSE: To deal with the cause, maintain a patent airway, provide adequate air exchange and an adequate supply of oxygen.
CONSIDERATIONS: 1. A patent airway is essential for adequate ventilation. 2. Hypoxia can occur in any person with an obstruction of the airway passages, a
disease of the lung or respiratory tract, or a reduced respiratory drive. 3. The brain and heart are very sensitive to the effects of hypoxia. 4. The first signs of hypoxia are: 5. Confusion, anxiety, restlessness, rapid respiratory rate, rapid pulse, irritability,
unconsolable, retractions, diaphoresis 6. Cyanosis is one of the latest symptoms of hypoxemia. 7. Continued hypoxia may lead to respiratory failure or cardiac arrhythmias and
eventual death. 8. Frequent causes of Hypoxemia:
a. Obstruction of the airway, due to: b. Mucus and secretions; c. Inflammation: "croup", asthma, laryngitis d. Foreign bodies: aspiration, vomitus e. Chemical and heat burns f. Near-drowning g. Nasal congestion in infants, (small infants are mandatory nose
breathers)h. Restricted movement of the thoracic cage or pleura, due to:
i. Chest injuries: flail chest, penetrating wounds, blunt trauma ii. Pneumothorax: spontaneous or traumatic iii. Extreme Obesity iv. Diseases: spinal arthritis, peritonitis, ascites
i. Decreased neuromuscular function, due to: i. Depressed central nervous system: drugs, brain trauma, CVA,ii. Muscular dystrophy iii. Coma: diabetic, uremic, head injuries
j. Diseases: chronically ill, myotonic dystrophies, cerebral palsy, spinal cord injury, ALS-Lou Gerhig’s disease, etc
k. Disturbances in diffusion of gases, due to: Diseases: pulmonary fibrosis (ie cystic fibrosis, Bronchopulmonary disyplysia)
l. Trauma: "shock lung", contusion m. Tumors, benign or malignant. n. Environmental causes, due to: o. Decreased oxygen in the atmosphere.
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EQUIPMENT/SUPPLIES: Oxygen Gloves Stethoscope Pulse oximeterNebulizer Kit Albuterol Oxygen tubing Reservoir tube Disposable ambu bag/Pocket Mask/Nasal Cannula/BVM/Non-rebreather in pediatric sizesSmall suction device such as a blue bulb nasal aspiratorNormal saline
PROCEDURE: 1. Activate EMS--Call 911 system 2. Allow patient to assume a comfortable position. 3. Open and maintain a patent airway, by: 4. Removing any foreign bodies, such as - vomitus, secretions, etc. 5. Apply oxygen:
a. Administer 100% OXYGEN by a non-rebreather face mask or Bag- Valve-Mask (BVM) with reservoir to PATIENTS WITH SEVERE RESPIRATORY DISTRESS
1. If the patient is awake, alert and not showing signs of respiratory distress and on home OXYGEN therapy, the initial dose of OXYGEN will be 0.5 liter/minute higher than the dose at home. If the rate is not known or if the patient is awake, alert, and not showing signs of acute respiratory distress, administer OXYGEN at 3 liters/minute via nasal cannula and monitor respirations.
b. Patients not falling under the above categories will be treated based on their need for supplemental OXYGEN with either:
1. OXYGEN at 8-10 liters/min via non-rebreather face mask 2. OXYGEN at 4-8 liters/min via simple face mask 3. OXYGEN at 0.5-3 liters/min via nasal cannula
6. The preferred method of supplemental OXYGEN administration is the non-rebreather face mask
7. Monitor vital signs 8. Administer artificial respirations if indicated with use of a pocket mask or ambu bag.9. In the case of infants, start oxygen and if moderate to severe nasal congestion, use
4-5 drops of nasal saline in the nare and repeat on the other side, repeat as neededa. Keep oxygen “blow-by” during procedure, keeping the oxygen as
close to the face as possible and breaking between the suction as needed to maintain adequate oxygenation.
10. Seek medical attention as soon as possible. 11. If wheezing or stridor is present follow reactive airway disease guidelines or croup
guidelines.
AFTERCARE:Document in patient's record
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3. EMERGENCY CARE:3.06 AIRWAY OBSTRUCTION:
PURPOSE:Relieve or minimize obstruction to optimize ventilation
CONSIDERATIONS:In the special needs population this can result from something as simple as mechanical obstruction of a tracheostomy tube or may be due to an aspiration event.This population may also be prone to aspiration risk.In the pediatric population it may also be due to ingestion of a foreign body or large food particle.
PROCEDURE:1. Is the patient conscious?
a. Conscious patientsi. If fair air movement is present, encourage patient to
coughii. If complete obstruction, continuous abdominal thrusts
or back blows/chest thrusts until foreign body is expelled or patient becomes unconscious.
b. Unconscious patient: BLSi. Call for EMS, ALS teamii. Position airway- Look, listen and feel for air movementiii. Attempt to ventilate with BVM- if initially unsuccessful
reposition and reattempt ventilation.iv. Deliver up to 5 chest compressions or back
blows/chest thrusts1. Examine the oral cavity and remove any foreign
bodies if seen.v. Attempt to ventilate, if unsuccessful repeat sequence.
c. Unconscious patient: ALSi. If unable to ventilate with BVM, directly visualize with
laryngoscopeii. Remove foreign body with Magill forceps if seen.iii. Intubate if necessary or continue to attempt
ventilation with BVM 100% oxygen2. If the patient has a tracheostomy suction trach tube if still unable to
ventilate see guideline for changing tube.
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3. EMERGENCY CARE:3.07 PEDIATRIC ASTHMA, BRONCHIOLITIS, REACTIVE AIRWAY DISEASE:
PURPOSE:To improve breathing and oxygenation in patient with symptomatic wheezing/cough
CONSIDERATIONS1. Many special needs children having an underlying pulmonary disease
that predisposes them to wheezing, especially in times of stress.2. Some children do not “wheeze” but have a cough 3. Be very wary of the child who is having difficulty breathing and has a
“quiet chest.”
PROCEDUREBLS
1. Assess work of breathing and oxygenation2. If not breathing adequately, assist with BVM, activate EMS—call 911,
notify ALS shelter team-MD.3. Administer 100% oxygen by nonrebreathing mask.4. Administer 2.5 mg albuterol in 3 mL of saline by nebulizer, or 4 puffs of
Albuterol/xoponex MDI with spacer and mask.5. If available and oxygen flow source at 8L/min flow should be utilized to
nebulize medication.6. Reassess, if wheezing persists or hypoxia—activate EMS—call 911,
notify ALS shelter team-MD and repeat Albuterol.
ALS1. Place on continuous pulse oximetry2. Assess for wheezing and work of breathing3. If continued wheezing place on continuous albuterol using 3 unit dose
vials per 30 minutes for children less than 2 years and 4 unit dose vials per 30 minutes for children older than 2 years.
4. If available and oxygen flow source at 8L/min flow should be utilized to nebulize medication.
5. In patients sensitive to the side effects of albuterol or cardiac patients, xoponex 1.25 mg may be used and repeated every 30 minutes.
6. Heart rate should be continually monitored and dose held if >200 for children 5 or under or >160 for children over 5.
7. Reassess for wheezing and work of breathing every 15 minutes and discontinue when wheezing resolves and work of breathing improves.
8. Administer Steroids:9. Prednisone/prednisilone 2mg/kg to max of 60 mg orally if able to
tolerate po10.Methylprednisilone 2mg/kg IV to max of 125 mg if unable to tolerate
po11.Be wary of the sleepy or quiet child that may indicate impending
respiratory failure, if patient is continuing to require ongoing nebulizer
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treatments despite ALS intervention, transfer to higher level of care is imperative.
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3. EMERGENCY CARE:3.08 CROUP
PURPOSE:Optimize air movement
CONSIDERATIONS : Croup is a frequent event in children and is characterized by a barky cough and inspiratory stridor.The most common cause of croup is a viral illness but in unimmunized children the symptoms of croup are the same as upper airway foreign body obstruction, tracheitis and epiglottitis
Children are often far more toxic appearing who have tracheitis and epiglottitis.Treatment is similar in that use of medications and interventions to minimize upper airway swelling.
PROCEDURE:BLS:
1. Minimize stress to child, calm environment.2. Cool environment and position of comfort.3. Be wary of the child in the “tripod position’ who is drooling, these children are
very close to losing their airway—Activate EMS—911 and notify shelter ALS team
ALS:1. Continue BLS interventions2. If in significant distress with stridor at rest or hypoxia, nebulize epinepherine
1:10,000 5 mL with 8L/min oxygen flow if available3. Administer IV methylprednisone 2mg/kg or decadrom 0.6mg/kg IV4. If mild symptoms, without stridor at rest, nebulize 5 mL of normal saline.5. Administer prednisilone or prednisone 2mg/kg orally to maximum dose of 60 mg
if able to tolerate po6. Alternative is IV decadron preparation given at 0.6mg/kg orally, IM or IV
AFTERCARE:1. Any patient that requires epinepherine should be very closely monitored for a
minimum of 3 hours.2. Document care and intervention3. Most causes of croup are infectious, consider isolation.
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3. EMERGENCY CARE:3.09 ALLERGIC REACTION/ANAPHYLAXIS:
PURPOSE: Rapid intervention to a severe allergic reaction can be life saving.
CONSIDERATIONS: 1. Signs and Symptoms of anaphylaxis are:
a. Appearance of hives on face and upper chest within seconds after allergen is administered;b. Diffuse erythema and the feeling of warmth with or without itching; c. Respiratory difficulty, acute wheezing, stridor; d. Severe abdominal cramping with associated gastrointestinal or genito-urinary symptoms; e. Vascular collapse with circulatory failure.
2. Penicillin, Peanuts, Seafood, Eggs, and Bee stings; in addition to almost any repeatedly administered parenteral or oral therapeutic agent can cause an anaphylactic reaction. 3. Wait and observe patient for at least 30 minutes after parenteral drug administration. 4. Advise patients with drug sensitivities to wear alert tags. 5. Advise patients with bee sting sensitivities to carry bee sting kits. 6. In some children with cardiac disorders or narrow angle glaucoma, use epinephrine with caution, but is never contraindicated in severe life-threatening anaphylaxis.
EQUIPMENT/SUPPLIES: Gloves Oxygen Alcohol swabs Non-rebreather face mask 1 cc syringe with needle (TB or Insulin syringe) Diphenhydramine, oral preparation or intramuscular preparationAlbuterol 2.5mg unit doseNebulizer and set upEpinephrine (aqueous adrenalin chloride 1:1000) or Epi-pen or Epi-pen Jr.Blanket
PROCEDURE: 1. Remove patient from source of anaphylaxis2. Activate EMS--Call 911 system - request rescue unit.3. If history of anaphylaxis and personal Epi-pen, may assist with administration.4. Determine level of distress
a. Mild: Localized reaction, minimal rash, pruritis, normal vital signsi. Administer Diphenhydramine 1 mg/kg to maximum dose of
50mg. May be given orally or intramuscularly1. This should be repeated every 6 hours if symptoms do not
subside. Max dose of 300 mg daily or 5mg/kg/24 hours. a. ** Continue medication orally for 48 hours
b. Moderate: Mild symptoms plus one or more of the following- generalized hives, decreased perfusion, normal vital signs, mild respiratory symptoms.
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i. Administer Diphenhydramine 1mg/kg maximum dose of 50mg. ii. Consider predinsone 2mg/kg po to maximum dose of 60 mg or if
available 2mg/kg methylprednisone IM/IV to maximum dose of 125mg.
iii. If wheezing: Albuterol 2.5 mg/3 mL saline nebulizediv. Consider epinepherine 1:1000, 0.01mL/kg to maximum dose of
0.3mL intramuscularv. If epinepherine is administered, activate EMS--911 vi. These patients should be evaluated by a physician or midlevel
provider and transported depending on the response and severity of condition.
c. Severe: Moderate symptoms plus one or more of the following- airway comprimise, throat tightening or swelling or sensation of swelling, prolonged capillary refill>4sec, hypotension, hypoxia, altered mental status
i. Activate EMS—911, ALS shelter teamii. Epinepherine 1:1000, 0.01mL/kg to maximum dose of 0.3mL
intramusculariii. Albuterol 2.5 mg/3 mL saline nebulizediv. Administer Diphenhydramine 1mg/kg maximum dose of 50mg IM v. Administer 2mg/kg methylprednisone IM/IV to maximum dose of
125mg if available.5. Administer OXYGEN 100% via non-re-breather face mask with reservoir. 6. Place patient in a moderate head down position, and cover with blanket. 7. Reassess vital signs and respiratory status. 8. If unconscious, check for adequate airway, respirations, and pulse. 9. Start CPR PRN. 10. Carefully document actions taken and provide that information to paramedics
when they arrive.
AFTERCARE:Document in patient's record:
a. Suspected cause of anaphylaxis b. Patient's condition. c. Care providedd. Follow up treatment
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3. EMERGENCY CARE: 3.10 SEIZURES:
PURPOSE: To provide a safe environment and protect patient from injury.
CONSIDERATIONS: 1. Do not place hard objects or fingers between patient's teeth. 2. Do not restrain victim. 3. Do not pour liquid into victim's mouth. 4. Do not place victim in a tub of water. 5. In most cases, a seizure will last 2-5 minutes. 6. Pediatric seizures are often caused by fever and do not need any intervention7. In patients with seizures, assess the medication supply that they have to insure
they are taking the recommended amount.
EQUIPMENT/SUPPLIES: Diazepam rectal preparationOxygen
PROCEDURE:BLS: 1. Alert shelter ALS team. 2. Prevent injury by removing sharp or other dangerous objects from victim's vicinity.
Patient should be in supine position in a safe area. 3. Maintain open airway. Keep air passage free of mucus. Turn victim's face to one side
to prevent aspiration of saliva or vomitus, suction, if needed and available.4. Administer 100% oxygen by nonrebreather mask5. After seizure, allow victim to sleep or rest. Patient may be difficult to arouse,
slur speech or appear confused this is normal and called the postictal phase. This may last for minutes or sometimes up to an hour.
6. Observe regularly for repeated seizures, difficulty breathing, etc.7. Have patient contact physician managing seizures for any dosing changes
recommended.
ALS:1. Consider anticonvulsants in children only if the seizure lasts longer than five (5)
minutes, activate EMS—911a. . Administer Diazepam
i. Pediatric: Rectally at 0.5 mg/kg, may repeat dose once(not to exceed 10mg) NOTE: Watch the airway closely, especially if more than one dose of diazepam is given.
2. Check blood glucose, if less than 60, administer glucoseb. D25W 2ml/kg IVc. Repeat blood glucose 30 minutes after infusion
3. Initiate Cardiopulmonary Resuscitation (CPR) if indicated. 4. After seizure, allow victim to sleep or rest. 5. Observe regularly for repeated seizures, difficulty breathing, etc.6. Have patient contact physician managing seizures for any dosing changes
recommended.
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AFTERCARE:1. Document in patient's record:
a. Type and length of seizure: document if one or both sides were involved, eye deviation, vomiting and if seizure consistent with previous seizure activity.
b. Patient's condition. c. Care providedd. Follow up treatment
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3. EMERGENCY CARE: 3.11 HEAT STROKE, CRAMPS, AND EXHAUSTION:
PURPOSE: To stabilize patient's condition until crisis passes or patient is transported to an emergency facility.
CONSIDERATIONS: 1. It is important to instruct patients and caregivers to maintain adequate fluid and
salt intake, wear loose fitting clothing and rest frequently during hot weather. 2. Persons who are hot and perspiring a lot should avoid drinking ice cold
water/drinks too quickly, or in too large of a quantity, as this may result in muscle cramps of the abdomen.
3. Persons who experience heat cramps, exhaustion, or stroke should avoid immediate re-exposure to high temperatures. This person may remain hypersensitive to increased temperatures for a considerable length of time.
4. Small children and those with impaired ability to expel heat as is common in the special needs population are vulnerable to heat cramps, exhaustion and stroke.Stimulants such as coffee or tea should not be given to patients with symptoms of heat stroke.
EQUIPMENT/SUPPLIES: Cool water Oral rehydration formulaThermometer Ice Packs
PROCEDURE: 1. Heat cramps and muscular spasms in legs and abdomen with faintness and
profuse perspiration. a. Move patient to cool place. b. Give Oral rehydration formula. c. Massage gently to relieve muscle spasms. d. Restrict further activity until cool and well rested.
2. Heat exhaustion is manifested by weak pulse, rapid/shallow breathing, generalized weakness, paleness, clammy skin, profuse perspiration, dizziness, and/or unconsciousness.
a. Treat for shock and arrange transportation to hospital. b. Move patient to cool place. c. Remove as much clothing as possible. d. Administer sips of oral rehydration formula as toleratede. Fan body to cool, but don't chill.f. Monitor vital signs. g. Apply cool cloths to axillae, groin and head, avoid shivering.
3. Heat Stroke is manifested by temperature of 106 degrees F. (41.1 degrees C.) or higher, central nervous system dysfunction (delirium, psychosis, stupor, convulsions, coma); weak, rapid, irregular pulse; dry, hot, flushed skin and/or dilated pupils.
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a. Obtain activate EMS—911, and alert shelter ALS team for assistance as soon as possible.
b. Move patient to cool place. c. Remove clothing, assure open airway. d. Cool body temperature promptly by sponging continuously with ice water
or wrap in wet sheets. (NOTE: if ice packs are available place around neck, under arms and at the ankles.)
e. Monitor vital signs and level or consciousness.
AFTERCARE:Document in patient's record:
a. Document any care providedb. Reassess temperature every 30 minutes until within normal
range
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3. EMERGENCY CARE: 3.12 FAINTING:
PURPOSE: To prevent injury and aspiration.
CONSIDERATIONS: 1. An unconscious person should not be given anything orally. 2. Fainting is usually accompanied by pallor, diaphoresis, coldness of skin,
dizziness, numbness and tingling of hands and feet, nausea, and possible visual disturbances.
3. Patient should be observed carefully after fainting as this might be a symptom of a serious condition.
EQUIPMENT/SUPPLIES: Washcloth Fluids Ammonia ampules
PROCEDURE: 1. If patient feels weak and dizzy, assist to lying position or lower head to knee
level. 2. If available, break ammonia ampule under patient's nose. 3. Loosen tight clothing. 4. If patient vomits, roll onto side or turn head to the side, wiping vomitus from
mouth. 5. Maintain an open airway by tilting the patient's head back. If neck injury is
suspected, use jaw thrust method of opening the airway. 6. Examine the patient to determine if any other injury was sustained from falling. 7. Keep patient warm. 8. Monitor vital signs. 9. When the patient is awake and oriented, attempt a slow challenge of rehydration
fluids.
AFTERCARE:Document in patient's record:
1. What happened-observed or unobserved
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3. EMERGENCY CARE:3.13 ALTERED MENTAL STATUS:
PURPOSE:1. Determine the underlying cause in change in behavior.
CONSIDERATIONS:1. Altered mental status is a symptom and not a diagnosis2. There are multiple causes of AMS, the goal is to discover and correct
the underlying cause.3. Common Causes:
i. Diabetic issuesii. Intoxication (drug and/or alcohol)iii. Metabolic changesiv. Seizures or postictal statev. Toxic exposures (watch for multiple patients: suggestive
of toxic exposure)vi. Hypoxiavii. Sepsisviii. Strokeix. Trauma
PROCEDURE:1. Call for EMS, ALS team2. Review with caregiver/family any change in medications or events
prior to change3. Baseline assessment for signs of trauma4. Spinal immobilization if indicated5. Blood glucose, if less than 60 see diabetic emergencies6. Check vital signs, 7. If hypotensive:
i. Activate EMS--911, alert ALS shelter teamii. If normal lung exam consider placement of IV and
administration of fluids1. 20 mL/kg of normal saline
8. If respiratory rate is less than 10 and pinpoint pupils, consider naloxone:
i. Pediatric: naloxone 0.01 mg/kg IV/IO initial dose, but can be repeated if not effective at 0.1mg/kg IV/IO
1. Remember that the half life of naloxone is shorter than most opiates and may need to be repeated.
9. Support respirations with BVM, advanced airway if indicated by shelter capabilities
10.Assess for any neurological findings or changes, if hyperreflexive consider the possibility of status epilepticus, follow seizure protocol if consistent with findings and history.
11.Transport to higher level of care as soon as possible
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3. EMERGENCY CARE:3.14 BLUNT TRAUMA:
PURPOSE: Prevent further injury, swelling and pain.
CONSIDERATIONS: 1. If trauma occurs to the eye area or serious trauma to the abdomen, medical treatment must be sought as soon as possible. 2. In children with blunt trauma to the chest, there may be no evidence of a rib fracture but may have significant pulmonary contusions.3. A hemophiliac or person on anticoagulant therapy who injures him/herself could deteriorate rapidly and medical treatment must be obtained as soon as possible.
EQUIPMENT/SUPPLIES: Cold compresses or ice pack Stethoscope and BP cuff
PROCEDURE: 1. If life threatening, Activate EMS--Call 911 system—Notify shelter ALS team2. Inspect affected body part for injuries, i.e., abrasions, cuts, fractures,
dislocations, swelling, pain with palpation. 3. If extremity is affected, elevate above the level of the heart. 4. Apply cold compresses or ice pack for 30 minutes. 5. If swelling or pain persists, reapply ice packs intermittently for comfort and refer
to medical care as soon as possible. 6. Monitor vital signs every half-hour for the first hour, then hourly, watching for
signs of shock and mental status changes. 7. Blunt trauma to the abdomen watch for increasing abdominal girth,
decrease in bowel sounds, bruising developing to abdomen, firm or taunt abdomen and/or fluid shift when turned
AFTERCARE: 1. Notify physician if other injuries are suspected or swelling continues to progress past
one-half hour. 2. Document in patient's record.
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3. EMERGENCY CARE:3.15 BURNS – CHEMICAL:
PURPOSE: To provide care for chemical burns.
CONSIDERATIONS: 1. Follow first aid instructions on the label of chemical container if available, if not
call Poison Control for advice. 2. Water temperature should be cool to tepid. Washing should be done with gentle
flow.
EQUIPMENT/SUPPLIES: Water Tape Dry sterile dressing Gloves
PROCEDURE: Chemical Burns of Skin
1. Assure scene safety and don appropriate protective equipment for type of chemical.
2. If chemical is wet, wash away chemical with large amounts of water, using a hose or shower if possible, for at least 5 minutes.
3. If chemical is dry, brush off as much of chemical as possible then rinse with large amounts of water
4. Contact poison control for other instructions, 1-800-222-12225. Remove victim's clothing from the involved areas. Cover the burned area with
clean, dry dressing. 6. Limit handling the clothing and any contaminated materials to protect yourself.7. Refer for follow-up emergency medical treatment as soon as possible.
Chemical Burns of Eye 1. Wash face, eyelid, and eye with large amounts of water for at least 5 minutes. 2. Turn victim's head to the side, hold the eyelid open, pour water from the inner
corner of the eye outward, making sure the chemical does not wash into the other eye.
3. Cover affected eye with dry sterile dressing and tape in place. Do not permit patient to rub his/her eyes.
4. Refer for follow-up emergency medical treatment as soon as possible.
AFTERCARE:1. Document in patient's record:
a. Incident, time and place, type of chemical exposureb. Patient's condition. c. Care providedd. Follow up treatment and any recommendations from poison control
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3. EMERGENCY CARE: 3.16 BURNS -- THERMAL:
PURPOSE: To prevent further tissue damage and lessen pain.
CONSIDERATIONS: 1. Do not open blisters or remove burned tissue. 2. Do not apply antiseptic preparations, sprays, ointments, oil based products or
other home remedies to burns. 3. Consider any second or third degree burn serious and seek medical attention as
soon as possible. 4. A first degree burn covering 15% of body surface of an adult (10% of a child)
may require hospitalization. Percentage of the body surface area involved can be roughly estimated using the "Rule of Nines":
5. Note the type of burna. the depth of the burn through the skin layersb. the extent of the burn as a rough percentage of the child’s total body
surface areac. the location of the burnd. special circumstances*
4
The rule of nines commonly used in adults is inaccurate in the younger child and can lead to marked discrepancies in estimated fluid needs.If possible, a child with any of the following should be routed to a burn center: 1. a third-degree burn over more than 5% of the body;2. second- or third-degree burns over more than 10% of the body in children
4 Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Philadelphia, WB Saunders Company, 1969
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younger than 10 years; 3. second- or third-degree burns over more than 20% of the body in children aged 10 years or older; 4. second- or third-degree burns on the face, hands, feet, genitals, rectal area, or major joints; 5. an electrical burn or a major chemical burn; 6. a second- or third-degree burn that completely encircles the chest, an arm or a leg;7. other major trauma in addition to the burn; 8. burns in combination with an inhalation injury
EQUIPMENT/SUPPLIES: Cold water/Ice Gloves Blanket and Sheet Silvadene Cream Formulary pain medicationDry sterile gauze
PROCEDURE: 1. Wash hands and don gloves.2. Remove any clothing or constricting jewelry 3. Treat for shock as necessary. 4. Elevate burned feet or legs. Keep burned hands above heart level. 5. If person has facial burns, sit or prop him/her up and observe for difficulty in
breathing. 6. If there is soot or charring in the mouth, notify rescue and observe closely for
difficulty breathing7. Do not immerse large areas of body in cold water or apply ice water over large
areas because cold may intensify shock.8. Treat pain with formulary pain medication, if not available mayuse
acetaminophen (see fever dosing). 9. Record the following in the chart:
a. the type of burnb. the depth of the burn through the skin layerc. the extent of the burn as a rough percentage of the child’s total body surface aread. the location of the burne. special circumstances
First degree burn - redness or discoloration, mild swelling and/or paina. Submerge the burned area in cold water for 2-3 minutes or apply ice. b. Blot dry gently with clean cloth or dry sterile gauze. c. Apply dry sterile gauze as a protective bandage if needed and elevate.
Second degree burn - redness, mottling, blisters, pain, swelling, wet appearance of the skin.
a. If skin is not broken, immerse in cold water for 1-2 minutes. b. Blot area dry gently, apply layer of Silvadene Cream and cover with dry sterile gauze or a clean cloth and elevate.
Third degree burn - deep tissue destruction, white or charred appearance, loss of all layers of skin.
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a. Protect burned area from the air with a thick, sterile dry dressing, gauze or clean cloth. b. Immediately arrange for transportation to the hospital or as soon as possible. c. Make no attempt to strip away clothing from charred areas. d. Apply cold pack to face, hands, and/or feet after bandaging.
10. For significant burns, IV access should be obtained and maintenance fluids initiated. Further fluid resuscitation should be done under the direction of the regional burn center
Activate EMS—911—Notify Shelter ALS team and arrange transport to appropriate facility as soon as possible
AFTERCARE:1. Document in patient's record:
a. How injury occurred b. Patient's condition, including extent of burns. c. Care provided
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3. EMERGENCY CARE: 3.17 BITES and STINGS:
PURPOSE: To provide relief of pain and evaluate need for in hospital treatment
CONSIDERATIONS: 1. Mild reactions include local/systemic itching, mild edema and urticaria (hives). 2. Treatment is aimed at making the patient comfortable. 3. Continuously assess for the development of respiratory distress, progression of
reaction and/or anaphylaxis.4. Make sure scene is safe and inciting animal/insect is taken care of
EQUIPMENT/SUPPLIES: Gloves Oxygen Non-rebreather mask or Nasal cannula Syringe Mild soapSkin marker (Sharpie or other permanent ink)
PROCEDURE: 1. Assess patient, if moderate to marked distress, oxygen should be administered
100% by nonrebreather mask.2. Determine bite type
a. Snake bitei. Alert EMSii. Minimize patient movement, remove all jewelry on affected
extremityiii. Mark the degree of swelling and time with a permanent marker.iv. Keep limb at the level of the heart, cool packs may be considered
for pain reliefv. Administer available pain medication, see fever for tylenol dosing
1. Dosing of other meds as per available formularyvi. Confirm tetanus statusvii. If signs of allergic reaction, see Allergic Reactions/Anaphylaxis
guidelinesviii. Notify EMS of type of bite, transport of medical facility
b. Stingi. Remove jewelry from affected extremityii. Wash site with soap and wateriii. Cool compress no direct ice.iv. If site is pruritic Administer Benadryl (Diphenhydramine) in the
following dose: 1. Administer 1 mg/kg to maximum dose of 50mg. This
should be repeated every 6 hours if symptoms do not subside. Max dose of 300 mg daily.
v. If stinger or venom sac is still present, scrape the site with the edge of a card or blade with slight pressure.
vi. If signs of allergic reaction develop, see Allergic Reactions/Anaphylaxis guidelines
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AFTERCARE:1. Document incident and treatment2. Continue to document edema and/or redness at site of bite until
decrease in symptoms
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3. EMERGENCY CARE: 3.18 BITES -- ANIMAL:
PURPOSE: To prevent further damage.
CONSIDERATIONS: 1. Infection, rabies, and tetanus are all possible dangers. 2. A bite on the face or neck should receive immediate medical attention.
EQUIPMENT/SUPPLIES: Sterile or clean gauze Tape Soap and water Td immunization
PROCEDURE: 1. Hold wound under running water and wash thoroughly using soap. 2. Pat dry with gauze. 3. Cover with gauze. Avoid movement of affected part. Control bleeding if present. 4. Assess Tetanus status. Consider tetanus (see Table 1: tetanus
prophylaxis)5. Notify physician as soon as possible.
a. Antibiotic treatment is often indicated, especially in cat bites, notify shelter MD.
6. Be sure the patient and their family understands importance of follow through.
AFTERCARE: 1. Do not let anyone destroy or release the animal. Note color, kind of animal, and
other identifying information, especially name and address of animal's owner. 2. Document in patient's record:
a. Treatment provided b. Patient's condition c. Notification of physician, animal control and Health Department, if
possible d. Patient/client personal record of immunization
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3. EMERGENCY CARE:3.19 BITES – HUMAN:
PURPOSE: To prevent infection or the complications from a human bite.
CONSIDERATIONS: 1. Human bites that break the skin may become seriously infected because the
mouth is a source of bacteria.
EQUIPMENT/SUPPLIES: Gloves Soap and water Clean or sterile gauze Tape *Td immunization *(if over age 7)
PROCEDURE: 1. Wash hands and don gloves 2. Cleanse the wound with soap and water. 3. Control bleeding. 4. Cover with gauze. 5. Determine Tetanus status; consider tetanus (see Table 1: tetanus
prophylaxis).6. Remove gloves and discard.7. Wash hands.
AFTERCARE: 1. Document:
a. The incident in the patient’s medical record. b. Patient's condition. c. Care provided. d. Patient/client personal record of immunizations.
2. Daily reevaluation of wound for signs and symptoms of infection.3. Refer for follow-up treatment.
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3. EMERGENCY CARE: 3.20 CUTS AND ABRASIONS:
PURPOSE: Provide treatment to prevent hemorrhage; relieve shock; prevent infection; and avoid tetanus.
CONSIDERATIONS: 1. Wounds may vary from minor lacerations to severe injuries.
EQUIPMENT/SUPPLIES: Gloves Scissors Tweezers Sterile gauze or clean cloth Sphygmomanometer Blanket Soap & waterNormal Saline Tape Ice/cold pack Stethoscope TD immunization Band-Aids/Steri-strips
PROCEDURE: 1. Wash hands and don gloves. 2. Abrasions:
a. Cleanse with soap and water, normal saline or sterile water. b. Apply clean dressing as needed. c. Assess tetanus status. (see Table 1: tetanus prophylaxis)d. Remove and discard gloves and Wash hands!
3. Punctures: a. Cleanse with soap and water, normal saline or sterile water. b. Use tweezers sterilized over flame or in boiling water to pull out
any foreign matter from the surface tissues. c. Embedded objects may be lifted out with the tip of a needle that
has been sterilized in rubbing alcohol or the heat of a flame. Any object embedded deeper in the tissue should not be removed in the shelter.
d. Cover with clean dressing. e. Assess tetanus status. Give Td as indicated. f. Remove and discard gloves. Wash hands!
4. Small lacerations: a. Cleanse with soap and water, normal saline or a bacteriostatic
solution if available. b. Apply steri-strips and cover with a clean dressing. c. Assess tetanus status. Give Td as indicated. d. Remove and discard gloves and Wash hands!
5. Deep lacerations, Avulsion, and Open Wounds:
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If wound is deep and spurting blood, don mask, gloves, goggles, gloves and then: a. Activate EMS--Call 911 system. b. Apply sterile dressing. Use pressure if bleeding is uncontrolled by
placing the palm of your hand on the dressing directly over the entire area of the wound. Reinforce dressing with additional layers of gauze or cloth, continuing direct hand pressure. Note: Do not disturb blood clots formed on dressing.
c. Apply pressure bandage, if on an extremity check for pulses and capillary refill below the site of the pressure dressing to assess circulation.
d.e. Elevate involved extremity above the level of the heart. f. If direct pressure and elevation of the part do not stop the
bleeding, pressure should also be applied to the artery supplying blood to the area, e.g., femoral or brachial arteries.
g. Continuously monitor vital signs. h. Treat for shock. Keep victims lying down and cover with blanket. i. Remove all protective attire. Wash hands!
6. Assess tetanus immunization status, consider tetanus (see Table 1: tetanus prophylaxis).
AFTERCARE:Document in patient's record and check pressure dressings often to assess for bleeding and circulation.
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3. EMERGENCY CARE:3.21 FRACTURES -- OPEN AND CLOSED:
PURPOSE: To render first aid to the person suffering a fracture. Reduce pain and maintain function of the extremity.
CONSIDERATIONS: 1. The person suffering a fracture may have suffered additional injuries, which
require immediate emergency treatment before initiating care for the obvious injury, address life threatening illness.
2. Signs and symptoms of a fracture are: a. Pain, continues with increasing severity until bone fragments are
immobilized; b. Loss of function; inability to use part; c. False motion; abnormal mobility; d. Deformity (visible or palpable); e. Localized swelling and discoloration of the skin from the trauma and/or
from the hemorrhage that follows; and f. Crepitation, grating sensation from examination, due to rubbing together
of the bone fragments. 3. Fractures are classified as:
a. Open: when skin integrity has been broken. This must be considered even when obvious abrasions are noted, due to unsure if bone made the injury or outside causes.
b. Closed: when the fracture does not break the skin integrity. 4. Fractures may impair circulation requiring immediate medical attention. Signs of
circulatory impairment include coolness, blanching, decreased sensation, and diminished or absent pulses. This is often preceded by severe pain.
5. Splints to immobilize fractures may be provided with household items such as pillows, magazines, blanket rolls, newspapers, cardboard and boards.
EQUIPMENT/SUPPLIES: Splinting material Gloves Sterile or clean dressing Tape Cold compress or ice bag
PROCEDURE: 1. Wash hands and don gloves. 2. Give immediate attention to the patient's respiratory and circulatory condition.
a. Evaluate for airway and breathing difficulties. Initiate the steps for CPR if necessary.
b. Control hemorrhage: Control bleeding by direct pressure initially. c. If not effective, apply digital pressure over the artery closest to the
bleeding area. d. Shock: Assess for signs and symptoms of shock, including falling blood
pressure (late sign in children),, cold and clammy skin, and rapid, thready pulse.
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e. Observe the entire body using methodical head to toe system assessment for angulation, shortening or asymmetry to indicate any other fractures.
3. Cut away clothing if necessary to inspect fractured part. 4. Assess the vascular status of the extremity (below the fracture site)by assessing
pulses and/or capillary refill. Repeat frequently if swelling present as this may gradually cause the extremity to be compromised
5. If there is compromised circulation to the areas below the fracture as indicated by blanching, coolness in the presence of loss of sensation and pulses, contact the medical director for instructions to realign bones.
6. Flush an open fracture copiously with sterile saline7. Cover open fracture with sterile or clean dressing after flushing area. Immobilize
the joint above and below the fracture site. 8. Assess the vascular status of the extremity again after splinting and document. 9. Apply cold compress or ice bag to aid in reducing swelling. 10. Consider ibuprofen or other pain medication if indicated by patient’s pain level.11. Arrange for medical attention as soon as possible. 12. Remove and discard gloves. Wash hands!
AFTERCARE:Document in patient's record:
1. Type of injury and if known, mechanism 2. Care provided3. Reassement of vital signs, and extremity conditions (pulses, capillary refill, movement, pain, edema, bruising etc) every hour for the first 4 hours and then every 4 hours4. If this is an open wound consider tetanus (see Table 1: tetanus prophylaxis).
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3. EMERGENCY CARE: 3.22 JOINT DISLOCATIONS:
PURPOSE: To render first aid to the person suffering a joint dislocation.
CONSIDERATIONS: 1. A dislocation is a displacement of a bone from the joint, particularly at the
shoulder, elbow, finger or thumb, usually as a result of a fall or direct blow. 2. Signs and symptoms of a dislocation are:
a. Pain b. Change in the contour of a joint c. Change in the length of an extremity d. Loss of normal movement e. Change in axis of the dislocated bone
3. Children under six years of age are prone to dislocation of the elbow because of an immature head of the radius. The typical history is that of being pulled or twisted by the arm. Can also be caused by swinging the child by the arms.
4. Dislocation may impair circulation requiring medical attention. 5. Signs of circulatory impairment include:
1. coolness *blanching 2. decreased sensation *diminished/absent pulses
EQUIPMENT/SUPPLIES: Splint and/or sling Cold compresses or ice bag
PROCEDURE: 1. Assess for adequate circulation. 2. Immobilize the affected limb. 3. Apply splint or sling as appropriate. 4. Apply cold compress or ice, if available, to reduce swelling. 5. Arrange for medical attention as soon as possible.6. If the joint involved is an elbow and there is a history of pulling or twisting the
arm, the child holds the arm extended at the elbow at the side and there is no swelling it is likely a nursemaids elbow. If there is swelling or history of a different type of trauma, do not attempt the following:
a. Nursemaids elbow can be treated with gentle hyperpronation-rotating the palmar surface away from the body while holding the elbow at 90 degrees may reduce the dislocation. Often a clunk or click will be felt by the hand stabilizing the elbow at 90 degrees. If it is successful, the child will often resume full function within minutes to a half an hour.
AFTERCARE:Document in patient's record:
1. Type and mechanism of injurya. Document any attempts to reduce the injuryb. Reassess the extremity frequently if splint applied
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3. EMERGENCY CARE:3.23 SPRAINS AND STRAINS:
PURPOSE: To render first aid to a person suffering from a sprain and/or strain.
CONSIDERATIONS: 1. A sprain usually occurs by forcing a joint beyond the normal range of motion.
This motion causes injury to the soft tissue surrounding the joints by stretching or tearing ligaments, muscles, tendons and blood vessels.
2. The signs and symptoms of a sprain are: a. rapid swelling; b. bruising, discoloration of the skin; and c. pain upon movement of the joint.
3. It is usually impossible to tell a sprain from a closed fracture without an x-ray.
EQUIPMENT/SUPPLIES: Cold compress or ice bag Ace wrap Anti-inflammatory drug (Ibuprofen, Acetaminophen, etc.)
PROCEDURE: 1. Elevate and rest the affected part (above the level of the heart, if possible) for at
least 24 hours. 2. Apply cold compresses or ice bag intermittently (15 minutes on, 15 minutes off
during waking hours) for the first 24-48 hours in order to reduce swelling and pain.
3. Ambulate as tolerated. 4. Medicate with acetaminophen or ibuprofen, see FEVER protocol for dosing.
AFTERCARE:Document in patient's record.
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3. EMERGENCY CARE: 3.24 SPLINTING -- FRACTURE OR DISLOCATION:
PURPOSE: To immobilize the affected body parts when a fracture or dislocation is suspected prior to transporting.
CONSIDERATIONS: 1. Unless there is threat to life or loss of limb, there is usually time to splint the
affected body part. 2. When placing the patient in a position of comfort, consider the fracture site and
length of time until emergency care and transportation is to be provided. 3. Avoid twisting, turning, or pulling the spine when moving or transporting the
patient.
EQUIPMENT/SUPPLIES: Splinting materials-cardboard, wood, or commercial splinting materialAce wrap or tape
PROCEDURE: 1. Arrange for emergency care and transportation as soon as possible. 2. Place patient in position appropriate for site of fracture/dislocation. Preferably a
position of function-if tolerated.3. Immobilize the joint above and below the fracture; place one hand distal to the
fracture and apply some traction by placing the other hand underneath the fracture for support.
4. If it is an open fracture, cover the wound with sterile dressing and avoid securing splint near the wound
5. Extend the splints well beyond the joints adjacent to the fracture. The patient's opposite leg, and board, etc, may be used for a splint if necessary.
6. Splint joints in functional position. 7. Check the vascular status of the extremity after splinting; check color,
temperature, pulse, blanching of nail beds.
AFTERCARE:1. Document all location of all splinting2. Reassess splinted extremity frequently for circulation
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3. EMERGENCY CARE: 3.25 INSULIN REACTIONS -- HYPOGLYCEMIA/HYPERGLYCEMIA:
PURPOSE: To prevent and treat hypo/hyperglycemia.
CONSIDERATIONS: Signs and Symptoms Hypoglycemia Hyperglycemia Irritability, Weakness Fatigue, Thirst Headache, NauseaDizziness, Rapid breathing Jitteriness, Frequent urination Hunger, Skin flushed, dry Vomiting, Gradual onset of symptoms Sweating, Not related to skipped meal Possible blurred vision or sudden increased exercise Poor coordination, Recent infection, Personality change stressful event. Skin pale, clammy High blood glucose level Sudden onset of symptoms Acetonuria Skipped meal Fruity breath Sudden increase in exercise Missed insulin dose Not related to stressful event/infection Low blood glucose No acetone in urine No fruity breath No missed insulin dose
EQUIPMENT/SUPPLIES: Insulin and syringes Water Orange juice, sugar, candy, fruit Glucometer and supplies
PROCEDURE: 1. Hypoglycemia -
a. If possible, assess when the client last ate and/or took insulin. b. Test Blood sugar with glucometer.
i. If glucose is less than 601. If patient is conscious and able to swallow, give a snack of
a fast acting sugar, followed by a meal or snack, such as: a. 2 Tbsp. raisins b. 1 fruit roll-up c. 1/2 can regular soda
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2. 1/3 bottle glucose 3. 6-7 lifesavers 4. 1/2 cup fruit juice 5. 5 sugar cubes
ii. Repeat in 15 minutes if pulse rate does not decreaseiii. If not conscious, activate EMS—911 and notify shelter ALS team
1. Administer D25W at 2mL/kg IV2. Repeat glucose in 15 minutes.
2. Hyperglycemia - a. Test blood with glucometer. DO NOT Administer Insulin until
hyperglycemia is determined and a physician's order is obtained. b. Seek medical assistance as soon as possible. c. If patient or caregiver has an established sliding scale for high
glucose, assist with administration and repeat glucose measurement in 30 minutes.
3. Additional Measures: a. Observe for signs of shock and treat as necessary. b. If unconscious, Activate EMS--Call 911 and notify shelter ALS team.
AFTERCARE:Document in patient's record:
a. Level of glucose at initiation of care, symptoms b. Carefully document actions taken and provide that information to medical
personnel when they arrive.
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3. EMERGENCY CARE: 3.26 FEVER:
PURPOSE: To treat temperatures above 101 degrees F. rectally or 100 degrees F. orally.
EQUIPMENT/SUPPLIES: Thermometer Cool Fluids Tepid water for sponge baths
PROCEDURE: 1. Reduce environmental temperature if possible. 2. Instruct patient to dress in light clothing. 3. Push to drink cool fluids. 4. Move to coolest part of shelter, but avoid chilling.5. Wash with cool water, avoid ice or overly cold water, avoid shivering as
that can increase the temperature.
6. Antipyretics as follows: a. Pediatric:
i. Acetaminophen dosing is 15 mg/kg, is available to be given orally or rectally and may be given every 4 hours. Maximum dose is 1000mg per dose, not to exceed 4000mg in 24 hoursii. Ibuprofen dosing is 10 mg/kg, is only given orally and may be given every 6 hours as needed. Maximum dose is 800mg per dose. Maximum daily dose is 2400 mg.Ibuprofen may not be given to any patient under 6 months of age, with cancer receiving chemo therapy, history of bleeding disorder or taking anticoagulation therapy.
b. Adult (14 years of age and older):i. Acetaminophen is 650 to 1000 mg every 4 to 6 hours as needed, not to exceed 4000 mg in 24 hoursii. Ibuprofen 400-800 mg every 6 hours as needed not to exceed 2400mg/day.
AFTERCARE:Document in patient's record:
1. Level of fever, associated symptoms 2. Time and dose of medication given3. Recheck temperature at least every four hours
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3. EMERGENCY CARE:3.27 ABDOMINAL DISTRESS:
PURPOSE: To assess abdominal pain, reduce the pain and promote normal bowel function.
CONSIDERATIONS: 1. Abdominal distension may indicate bowel obstruction, appendicitis or other acute
surgical emergency, especially in the special needs population or it may be as simple as constipation. Knowledge of the past history/illness and caregiver experience helpful
2. Trauma3. Pregnancy in menstruating females4. Onset of food poisoning is usually sudden, with severe nausea, vomiting,
cramps, diarrhea and prostration from 2 to 4 hours after eating.
EQUIPMENT/SUPPLIES: Stethoscope, Lactobacillus, Clear Fluids, Ice Bag
PROCEDURE: 1. Assessment Triangle: How much distress are they in?
a. Unstable patients should have an IV placed if available and activate EMS—911. If not available ALS team should be activated.
i. Altered mental statusii. Accompanying chest painiii. Dyspneaiv. Hypotensionv. Signs and symptoms of respiratory distress
2. Note: * location, character, and duration of pain, and time of occurrence. * nausea, vomiting, or diarrhea. * changes in eating habits, appetite or behavior
3. Observe: * the position assumed by the patient to relieve distress, holds very still-suggests possible surgical problem versus writhing which may indicate a kidney stone. *whether abdomen, chest, and abdominal movements are synchronous with respirations. * If there is a change in pain with stooling, either before or after.
4. Inspect abdomen for distention, rigidity and any previous surgical sites, such as a g-tube or ostomy.
5. Auscultate: bowel sounds. Make note if they are present or not6. Palpate: tenderness, localization, guarding. 7. If at any point in the assessment the patient appears to be worsening,
marked guarding on exam, especially if accompanied by a history of trauma or fever, call a rescue unit or physician to evaluate the patient.
8. Do not administer enemas, laxatives, or heat. 9. Advise patient to rest, apply ice bag to affected area when pain is localized. 10. If you suspect constipation-patient with known history, previous similar symptoms
associated with constipation, advise the patient to begin normal home bowel program for constipation or to contact the physician.
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11. If abdominal pain is not worsening and abdomen is soft, give sips of rehydration; if tolerated progress diet. If continues to vomit, hold all fluids and reassess in 30 minutes.
12. If vomiting continues or becomes bile tinged advise the patient to contact a physician and hold all intake through the GI tract.
13. If the patient appears distended and has a g-tube, open it to air.14. If the patient is having diarrhea, lactobacillus 1 packet three to four times a day
can be mixed with rehydration solution or foods if tolerated. 15. If the patient has diarrhea and a high fever they should be advised to see a
physician.16. If the patient has diarrhea, especially with fever or blood in stools, all attempts to
use contact isolation for the patient in the shelter should be made.
AFTERCARE:1. Document in patient's record2. Contact isolation if diarrhea or vomiting develop.
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3. EMERGENCY CARE:3.28 VOMITING:
PURPOSE: To treat those who are vomiting, preventing dehydration.
CONSIDERATIONS: 1. Vomiting in infants and small children is often the first symptom of an acute or
contagious illness. 2. Check for fever, rash, etc. and be isolated from other people as much as
possible.
EQUIPMENT/SUPPLIES: Ice chips Warm soda, preferably 7-up or Ginger Ale Ondansetron
PROCEDURE: 1. Give nothing by mouth for 3 to 4 hours. 2. May have ice chips or small sips of warm soda.3. General guideline: ½ mL/kg every 5 minutes. 4. If ice chips and warm sodas are retained, gradually add clear liquids. 5. Start light; no fatty or fried foods for 12 to 24 hours. 6. If vomiting persists, seek medical advice and consider ondansetron.
a. Pediatric dosing: Ondansetron 0.15-0.2 mg/kg every 6-8 hours in either liquid or ODT form. Maximum dose is 32mg/day
AFTERCARE:Document in patient's record.
1. Onset of vomiting and associated symptoms 2. Isolation steps taken if any.
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3. EMERGENCY CARE: 3.29 DIARRHEA:
PURPOSE: To treat loose or watery stool, preventing dehydration.
CONSIDERATIONS: 1. Onset of food poisoning is usually sudden, with severe nausea, vomiting, cramps,
diarrhea, and prostration from 2 to 4 hours after eating. 2. Abdominal distention may indicate bowel obstruction. 3. Changes in pattern of elimination (e.g., diarrhea to constipation to diarrhea) may
indicate partial obstruction. 4. Symptoms of dehydration include:
a. dry tongue, in children-no drooling, no tears when crying b. dry axillae c. poor skin turgor d. decreased urinary output e. changes in neurological status, children will be lethargic and irritable.
EQUIPMENT/SUPPLIES: Clear fluids PedialyteLactobacillus (Pediatrics)Loperamide (Adults)
PROCEDURE: 1. Increase fluid intake, eliminating caffeinated drinks. 2. Observe for signs of dehydration. 3. Withhold solid foods and dairy products for 8 hours; give clear fluids only. 4. Administer
a. Pediatrics: Lactobacillus as follows: b. 3 packets TID until diarrhea stops for children under 5c. 4 packets QID until diarrhea stops for children 5 and olderd. The granules can be mixed with fluids or sprinkled on food such as
applesauce.Attempt to keep good contact isolation principles for other shelterees.
AFTERCARE:1. Document in patient record2. Notify Shelter director of isolation steps taken.
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3. EMERGENCY CARE: 3.30 ACCIDENTAL INGESTION:
PURPOSE: To prevent further injury by obtaining prompt medical assistance.
CONSIDERATIONS: 1. Depending on the drug, the patient may have respiratory depression, cold, and
clammy skin, lethargy, dilated or constricted pupils, weak rapid pulse, decreased or increased tendon reflexes, coma, agitation, arrhythmias, hallucinations.
2. Some types of ingestions stimulate the central nervous system and can cause tinnitus, vomiting, hyperventilation, fever and hyperactivity. Severe cases may cause convulsions, dehydration, LOC, respiratory failure and cardiovascular collapse.
EQUIPMENT/SUPPLIES: Water/MilkActivated CharcoalContainer
PROCEDURE: 1. Assess patient's general condition, treat for respiratory distress. Monitor vital
signs. 2. Obtain medical assistance as soon as possible. 3. Note patient's age and estimated weight. 4. Ask the patient or caregiver what medication, amount, dose ingested and at what
time, if known. 5. Call Poison Control Center1-800-222-12226. If you do not know what substance was ingested, look for burns in and around
the mouth, smell the breath for any unusual odors and examine hands and clothing for stains or residue. Ask what medications are kept in the house, who the patient was with and any known cleaning agents or plants in the home.
7. If agent is known, read the label for instructions for accidental ingestion and follow.
8. Activated Charcoal *Recommended for recent ingestion, at 1g/kg. Can mix with juice or syrup to give
a. Contraindications : decreased level of consciousness or unconsciousness, caustic ingestion, shock, or lack of gag reflex.
9. Collect any stomach contents brought up and save - send with patient.
AFTERCARE:Document in patient's record:
1. Time and type of ingestion 2. Interaction with Poison Control and recommendations offered
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3. EMERGENCY CARE: 3.31 HEADACHE:
PURPOSE: To reduce or eliminate head pain.
CONSIDERATIONS: 1. Headaches are frequent symptoms of infectious diseases. 2. Headaches may be a symptom of elevated blood pressure, stroke, aneurysm,
trauma, intercranial bleeding. .
3. Migraine headaches may be accompanied by visual changes, nausea, or vomiting, and pain may be unilateral.
4. Headache may indicate malfunction of a ventro-peritoneal shunt-obtain history of any neurosurgical procedures in the past.
EQUIPMENT/SUPPLIES: Ibuprofen or Tylenol * See FEVER protocol for dosage information. Hot or cold compresses Quiet, dark environment
PROCEDURE: 1. Inspect head and face for evidence of trauma, swelling, pain over sinus area or
temporal area. a. Palpate along the side of the head and neck for subcutaneous
tubing that may indicate a VP shunt. If present with a headache, seek medical attention as soon as possible.
2. Inspect neck for stiffness and pain. If positive for stiffness, not associated with muscular injury, and fever present, separate patient from population and use mask and gloves when attending. Assess for any rashes to the skin Seek medical attention as soon as possible.
3. Assess neuro vital signs and GCS watch for deterioration in patient level of consciousness.
4. Advise to rest in darkened room to allow patient to relax. 5. Apply hot or cold compresses. 6. Give ibuprofen or acetaminophen for children. 7. Encourage sips of clear fluids.
AFTERCARE:Document in patient's record
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3. EMERGENCY CARE: 3.32 CHEST PAIN:
PURPOSE: To maintain adequate cardiovascular circulation.
CONSIDERATION: 1. If possible determine patient's normal pulse rate and blood pressure. 2. Determine if the patient has any cardiac anomaly, previous surgery or history of cardiac problems-cardiac initiated chest pain is a rare event in pediatrics
EQUIPMENT/SUPPLIES: StethoscopeBlood pressure cuffPulse oximeterThermometer Oxygen
PROCEDURE: 1. Have the patient lay down in a quiet environment if possible. 2. Monitor vital signs and document. * Count apical, radial and carotid pulses.3. Perform orthostatic VS. 4. Document the location, duration and radiation of chest pains. 5. Evaluate general appearance - pallor, cyanosis, sweating. 6. Evaluate respiratory status - rate, depth, effort. 7. Evaluate mental status - orientation, dizziness. 8. Gently press on the chest at the midsternum to see if this reproduces the chest
pain.9. If the pain is reproducible, give ibuprofen 10mg/kg orally and repeat assessment
in 30 min. If pain has subsided, continue with every 6-8 hour dosing of ibuprofen and rest.
10. If the patient does have a history of cardiac disease, Activate the EMS system if available, otherwise contact the SHELTER DIRECTOR
11. Administer oxygen by face mask at 4-8 liters per minute. 12. Titrate carefully the amount in children with a history of cyanotic heart
disease, by increasing flow rate at 0.5L/min increments. Initiate CPR if indicated.
13. Observe for 1 hour after normal pulse returns. 14. Check status every 4 hours for 24 hours, or more frequently if indicated. 15. Seek medical attention as soon as possible.
AFTERCARE:Document in patient's record
1. Care provided.2. If positioning and/or non pharmacological factors that alleviated pain.
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3. EMERGENCY CARE: 3.33 EYE INJURY/INFLAMMATION:
PURPOSE: To prevent loss of vision and reduction of pain.
CONSIDERATIONS: 1. Eye infections may be highly contagious, especially among children. 2. Eye injuries usually heal quickly, if movement and use is reduced.
EQUIPMENT/SUPPLIES: Gloves Eye patches Tape Sterile water for irrigation
PROCEDURE: Inflammation:
1. Determine onset/progression of symptoms, amount and characteristics of drainage, vision loss or impairment.
2. Wash hands and don gloves! 3. For inflammation without foreign body:
a. Suggest patient wear dark glasses to avoid or relieve photophobia. b. Advise patient to use separate face cloth and towel.
4. If patient wears contact lenses have them remove them. 5. Refer to medical assistance as soon as possible. 6. Remove and discard gloves, Wash hands!!
Injury/Foreign Body: 1. Wash hands and don gloves. 2. Determine:
a. If something is in eye. b. If blow to eye was sustained. c. If puncture wound was sustained. d. Duration of time since injury.
3. Check for: a. Redness of conjunctiva. b. Sensitivity to light. c. Burning sensation in eye. d. Overproduction of tears. e. Pain and headache. f. Bleeding.g. Visual acuity
4. To remove foreign object from eye, pull down lower lid to locate object. Lift object gently with corner of sterile cotton applicator. If object is under upper lid, grasp lid gently between thumb and forefinger while having victim look down. Pull upper lid forward and down over lower lid. If foreign body does not dislodge by tears, depress upper lid with matchstick or similar object placed horizontally on top of cartilage, and invert lid by pulling upward on lashes against matchstick. Lift off foreign object with clean cotton applicator and replace lid by pulling gently downward on the lashes. Flush eye with water. If object is still not removed, apply dry, protective dressing.
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5. If object is impaled DO NOT REMOVE!!! Stabilize the object and patch unaffected eye. Keep lying down to reduce movement to eye.
6. Seek medical attention as soon as possible. 7. If blood is noted pooling in the bottom of the pupil area, keep the patient’s head
elevated at a 30 degree angle, limit activity and seek medical attention as soon as possible
Blunt Injury: 1. Apply sterile or clean dressing. 2. Keep patient lying down until other medical personnel arrive.
Eyelid Injury: 1. Stop bleeding with gentle pressure. 2. Cleanse wound. 3. Apply dressing.
AFTERCARE:Document in patient's record
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3. EMERGENCY CARE: 3.34 EARACHE:
PURPOSE: To reduce pain.
CONSIDERATIONS: 1. Infection can be present in both painful and nonpainful ears. 2. Upper respiratory infections commonly lead to middle ear complications. 3. Children may present by pulling on the affected ear.
EQUIPMENT/SUPPLIES: Sterile gauze Hydrogen peroxide Tylenol Ibuprofen
PROCEDURE: 1. Determine onset, character, and duration of pain. 2. Determine if associated with vertigo. 3. Observe for evidence of hearing loss. 4. Inspect ear for drainage. 5. To relieve pain:
a. Apply heat (if available) while patient is lying on affected side. b. Tylenol or ibuprofen.
Pediatric: i. Acetaminophen dosing is 15 mg/kg, is available to be given orally or rectally and may be given every 4 hours. Maximum dose is 1000mg per dose, not to exceed 4000mg in 24 hoursii. Ibuprofen dosing is 10 mg/kg, is only given orally and may be given every 6 hours as needed. Maximum dose is 800mg per dose. Maximum daily dose is 2400 mg.Ibuprofen may not be given to any patient under 6 months of age, with cancer receiving chemo therapy, history of bleeding disorder or taking anticoagulation therapy.
Adult (14 years of age and older):i. Acetaminophen is 650 to 1000 mg every 4 to 6 hours as needed, not to exceed 4000 mg in 24 hoursii. Ibuprofen 400-800 mg every 6 hours as needed not to exceed 2400mg/day.
6. Clean drainage from external ear with sterile gauze soaked in hydrogen peroxide.
AFTERCARE:Document in patient's record
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3. EMERGENCY CARE: 3.35 NOSEBLEED (EPISTAXIS):
PURPOSE: To control bleeding and prevent hemorrhage.
CONSIDERATIONS: 1. Nosebleed may be from dry air or may indicate an underlying disease, recent
upper respiratory tract infection, low platelets or other bleeding disorder. 2. Most nosebleeds stop when direct pressure is applied. 3. Assess for symptoms of hypovolemic shock caused by severe blood loss. 4. Check for Medic-Alert bracelet which may indicate that patient has a blood
dyscrasia or is on a blood thinner-although rare in pediatrics. 5. A patient with a nosebleed should remain quiet, sitting up and leaning slightly
forward. If is necessary to lie down, the head and shoulders should be elevated.
EQUIPMENT/SUPPLIES: 4 x 4 gauze pads Gloves Cold compress or ice packNeosynepherine
PROCEDURE: 1. Wash hands and don gloves. 2. Place patient in a seated position with head slightly forward. 3. Have patient press the bleeding nostril toward the center using a 4 x 4 gauze
pad, continuously for 20 minutes. (The nurse may have to do this for the patient) DO NOT stop pressure to “check for bleeding” if this occurs again apply pressure for another full 20 minutes.
4. An ice pack may be applied to the site of bleeding. 5. If bleeding persists, one squirt of neosynepherine in each nostril can be given,
followed by repeat pressure.6. Obtain medical history and current medications if possible. 7. Remove and discard gloves. 8. Wash hands!
AFTERCARE:Document in patient's record.
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3. EMERGENCY CARE:3.36 TETANUS PROPHYLAXIS:
PURPOSE:To prevent the development of Tetanus
CONSIDERATIONS:1. Most children who attend public school have been immunized. Make sure to
confirm this with the family or caregiver, since there are some families that elect to forego immunizations in special needs children.
2. If there is good certainty that the child has received the immunizations, do not give them “just in case” too many immunizations may increase the risk of a reaction.
3. Do NOT give pediatric tetanus toxoid to a child over the age of 7, it is a significantly more concentrated dose than the adult tetanus toxoid.
PROCEDURE:1. No history of tetanus immunization within the last 5 years, Tetanus immunization
needs to be given:a. Child < 7 years give pediatric diphtheria and tetanus toxoid—DTb. Child > 7 years give adult tetanus and diphtheria toxoid—Td
2. If there is question of the patient having not received the initial series of immunizations:
3. Tetanus immune globulin 250 mg IM, which will need to be repeated in one month and six months from injury.
4. If there is a known allergy or reaction to tetanus toxoid, give tetanus immune globulin as above.
Table 1:
Tetanus prophylaxis in wound management for adults and children 7 years and up
IMMUNIZATION HISTORY CLEAN MINOR WOUND
ALL OTHER WOUNDS
1. Fewer than 3 doses; or2. Uncertain number of doses; or3. No immunization
Give Td only Give TdGive TIG
At least 3 previous doses of tetanus vaccine, but the most recent more than 10 years ago
Give Td only Give Td only
At least 3 previous doses of tetanus vaccine, but the most recent more than 5 and less than 10 years ago
no immunization required
Give Td only
At least 3 doses of tetanus, with the most recent 5 years ago or less
no immunization required
no immunization required
TIG - Tetanus Immune Globulin Td – Diptheria toxoid
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4. CONTAGIOUS CONDITIONS: 4.01 CHICKEN POX:
PURPOSE: To treat and contain this highly contagious rash.
CONSIDERATIONS: 1. Anorexia, fever, general malaise, and headache precede the rash, usually within
a 24-hour period. 2. Highest temperature is usually at the time of greatest eruption of lesions. 3. Rash appears in crops first on trunk, then scalp, face, and extremities. 4. Lesions sometimes found on palate, around genitalia, and in vagina. 5. Transmitted by direct contact, air-borne droplet, and indirect contact through third
person. 6. Patient is infectious to others 1-2 days prior to eruption of rash and until all
lesions are dry and crusted. 7. Incubation period is 10-21 days.
EQUIPMENT/SUPPLIES: Tylenol Gloves, Masks Fluids Calamine lotionBenadryl
PROCEDURE: 1. Isolate in separate area or room. 2. Keep on bed rest. 3. Control fever - Follow FEVER protocol for medication. DO NOT GIVE ASPIRIN!!! 4. Maintain nourishment and oral fluids. 5. Control itching with cool starch water baths. 6. Avoid rubbing; pat dry. 7. Apply calamine lotion to lesions. 8. Dress in loose fitting, cool and lightweight clothing.9. For severe symptoms or to promote rest, Benadryl may be given at 1mg/kg every
6 hours up to 50 mg.
AFTERCARE:1. Document in patient's record:
a. Onset of illness b. Isolation measures instituted
2. Suspected or Chicken pox disease should be reported to the health department. ( It is routinely reportable within one week but in a shelter situation it should be reported immediately)
3. In addition to specified reportable conditions, any outbreak, exotic disease, or unusual group expression of disease that may be of public health concern should be reported by the most expeditious means available to the local health department
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4. CONTAGIOUS CONDITIONS: 4.02 INFLUENZA:
PURPOSE: To treat and contain this highly disease.
CONSIDERATIONS: 1. Sudden onset of fever, headache, myalgias and non productive cough. 2. Through the natural course of the disease, respiratory symptoms,
including sore throat are more prominent. 3. In young children, respiratory symptoms may or may not be present. 4. It may mimic sepsis in young infants. 5. Refusal to walk secondary to acute myositis may also be present
(Influenza B)6. Transmitted by direct contact, air-borne droplet, and contact with articles
with contaminated secretions. 7. Patient is infectious for 24 hours prior to and 7 days after symptoms
begin, but in children and those with immune problems may shed the virus for longer periods.
8. Special needs populations are at particular risk for complications arising from influenza, especially pneumonia.
9. Incubation period is 1-4 days.
EQUIPMENT/SUPPLIES: Tylenol GlovesMasks Fluids Osteltamivir or Zanamivir if available
PROCEDURE: 1. Isolate in separate area or room. 2. Keep on bed rest. 3. Control fever - Follow FEVER protocol for medication. DO NOT GIVE ASPIRIN!!! 4. Maintain nourishment and oral fluids. 5. If available or Oseltamivar > 1 yr of age6. < 15 kg, 30 mg po twice daily for 5 days
15 kg, 45 mg po twice daily for 5 days 7. >23 kg, 60 mg po twice daily for 5 days 8. >40 kg, 75 mg po twice daily for 5 days. 9. If oral suspension is not available, capsules can be mixed with sweetened liquids 10. Alternative is Zanamivar > 7yrs 10mg inhaled twice daily for 5 days
AFTERCARE:1. Document in patient's record: 2. Onset of illness 3. Isolation measures instituted 4. Prophylaxis for shelter population and workers:
a. Oseltamivar, started within 2 days of exposure:
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i. < 15 kg, 30 mg po once daily for10 daysii. > 15 kg, 45 mg po once daily for 10 daysiii. >23 kg, 60 mg po once daily for 10 daysiv. >40 kg, 75 mg po once daily for 10 days.
b. Alternative is Zanamivar > 5yrs of age started within 1 day of exposurei. 10mg inhalation daily until dispersal of shelter or 10 days-
whichever is longer.5. In addition to specified reportable conditions, any outbreak, exotic disease, or
unusual group expression of disease that may be of public health concern should be reported by the most expeditious means available to the local health department
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4. CONTAGIOUS CONDITIONS: 4.03 MENINGITIS:
PURPOSE: To treat and contain this highly contagious disease
CONSIDERATIONS: 1. Sudden onset of fever, chills and rash. May or may not have headache and
neck symptoms. 2. Initial rash may vary, but characteristic rash is petechial to purpuric. 3. Symptoms of meningitis from meningococcus are the same as for other bacterial
and nonbacterial causes. 4. Transmitted by air-borne droplets. 5. Patient is infectious to others 24 hours prior to symptoms and until 24 hours of
antibiotic treatment is completed.6. Incubation period is on average 4 days, but may be as long as 10 days.
EQUIPMENT AND MEDICATIONS: Tylenol Gloves, Masks Fluids If available, appropriate evaluation materials-antibiotics
PROCEDURE: 1. Isolate in separate area or room. 2. Keep on bed rest. 3. Notify shelter director, medical director of suspicion—if available notify EMS4. Control fever - Follow FEVER protocol for medication.5. Diagnostic testing, lumbar puncture, blood culture should be performed if at all
possible before initiation of antibiotics.6. If purpuric lesions present, cultures may be obtained from scrapings of lesions 7. Maintain fluids. 8. Initial treatment may be started with ceftriaxone at 100mg/kg/day to maximum
dose of 2g if suspected. If however, suspicion of pneumococcus is present vancomycin 40 mg/kg/dose should be initiated.
9. These patients are BEST managed in a hospital setting and should be evacuated as soon as possible.
AFTERCARE:4. Document in patient's record:
a. Onset of illness b. Isolation measures instituted
5. Prophylaxis of close contacts, shelter workersa. Children:
i. Rifampin1. < 1 month 5mg/kg orally every 12 hours for 4 doses2. > 1 month 10 mg/kg orally every 12 hours for 4 doses
ii. Ceftriaxone 1. < 15 yrs 125 mg intramuscular one dose2. > 15 yrs 250 mg intramuscular one dose
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b. Adults: i. As above for Rifampin and Ceftriaxoneii. Ciprofloxin
1. > 18 yrs 500 mg po for one dose.6. In addition to specified reportable conditions, any outbreak, exotic disease, or
unusual group expression of disease that may be of public health concern should be reported by the most expeditious means available to the local health department
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4. CONTAGIOUS CONDITIONS:4.04 GERMAN MEASLES (RUBELLA):
PURPOSE: To treat and prevent transmission.
CONSIDERATIONS: 1. Symptoms include: sore throat, stiff neck, slight enlargement of lymph nodes of
neck and head, pin-point size reddish spots on palate, malaise, anorexia, low-grade fever, headache, cough, coryza, and mild conjunctivitis.
2. Rash first appears on face and spreads rapidly down the neck, arms, trunk, and extremities. Begins to fade from face but remains on the extremities and in diffuse erythematous blush on the abdomen.
3. Duration of the rash is 1 - 5 days. 4. Communicable 1 week before to about 5 days after appearance of rash. 5. Transmitted by airborne droplets, direct contacts, or contaminated articles. 6. Incubation period is 14 - 21 days.
EQUIPMENT/SUPPLIES: Tylenol Cool fluids
PROCEDURE: 1. Provide isolation; especially from pregnant women. 2. Allow activity as tolerated as long as it is isolated from general population. 3. Control fever and discomfort with Tylenol (see FEVER protocol for dosages) 4. If arthritis of weight-bearing joints occurs, patient should remain in bed. 5. Encourage nutrition and fluids.
AFTERCARE:1. Document in patient's record:
a. Onset of illness b. Isolation instituted
2. Suspected or Diagnosed Measles is immediately reportable to the health department
3. In addition to specified reportable conditions, any outbreak, exotic disease, or unusual group expression of disease that may be of public health concern should be reported by the most expeditious means available to the local health department.
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4. CONTAGIOUS CONDITIONS: 4.05 IMPETIGO:
PURPOSE: To treat this contagious skin condition. May start as an infected mosquito bite, or in young children after a cold from break down of the skin under the nose and spread forming more sores.
EQUIPMENT/SUPPLIES:Medication and Dosage:
1. Polymyxin-Neomycin-Bacitracin Ointment: Apply liberally to the affected skin surfaces 1 to 2 times a day after cleansing. Cover areas with a sterile bandage. For external use only avoid use in young infants.
2. Bactroban Ointment: Preferred for young infants. Apply to affected areas 3 times a day (t.i.d.) after cleansing. Cover areas with a sterile bandage. For external use only.
PROCEDURE: 1. Wash hands and don gloves. 2. Soften the crust by soaking the sores in warm soapy water. 3. Once the sores are soft, gently remove crust with a separate piece of gauze for
each crust. 4. Apply Ointment on infected areas. 5. Keep towels and clothing separate. 6. To prevent spread to others, keep lesions covered with loose clothing or
bandage.7. Monitor wounds for increased redness surrounding the wounds.
AFTERCARE:Document in patient's record
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4. CONTAGIOUS CONDITIONS: 4.06 LICE (PEDICULOSIS):
PURPOSE: To destroy nits and pediculi from infested areas, and to relieve itching.
CONSIDERATIONS: 1. Prevent medications from coming in contact with eyes or mucous membranes. 2. Prevent transference of nits from one patient to another. 3. Protective clothing should be worn. 4. All of the patient's clothing, bed linen and towels are considered contaminated,
separate from regular laundry. 5. All Toiletry items used by the patient must be disinfected by soaking them in the
pediculicide. Live lice may be reintroduced onto the patient's scalp after treatment by using a contaminated comb.
6. Items that cannot be scrubbed or soaked - place in a plastic bag tightly closed for 10 days. Nits & lice will die in that environment.
EQUIPMENT/SUPPLIES: Pediculicidal medication Shampoo Gloves Towels and washcloth Disposable Gown Antibiotic ointment
PROCEDURE: 1. Explain procedure to the patient, instructing to cover eyes with washcloth, if
treating head lice. Assemble equipment. 2. Wash hands and don gloves and gown. 3. Wash and dry the hair4. Saturate affected area of body with medication as directed and leave on for the
time indicated in package insert. 5. Wash affected area. If head lice, comb hair with fine-tooth comb to remove nits. 6. Apply antibiotic ointment to irritated areas on body. 7. Remove gloves and gown, and dispose. Wash hands!
AFTERCARE:Document in patient's record:
1. Noted prior or after shelter placement 2. Isolation steps taken.
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4. CONTAGIOUS CONDITIONS:4.07 MEASLES (RUBEOLA):
PURPOSE: To treat and prevent transmission.
CONSIDERATIONS: 1. The first day typically presents with fever of 101 or higher and general malaise,
followed by cold symptoms, cough, conjunctivitis, an increase in temperature and anorexia in 24 hours.
2. Koplik spots (small, irregular, reddish spots with bluish-white centers) on buccal mucosa two days prior to development of rash.
3. Generalized enlarge lymph nodes. 4. Patient may develop photophobia (sensitivity to light). 5. Rash appears on scalp, hairline, and forehead, spreading downward to chest and
feet. 6. Infectious from 4 days before to 5 days after rash appears. 7. Most common transmission is by cough or sneeze (droplets). Isolation is very
important.8. Incubation period: 7 to 14 days.
EQUIPMENT/SUPPLIES Tylenol Cool fluids Saline irrigation solution
PROCEDURE: 1. Provide isolation. 2. Provide patient with mask to reduce transmission. 3. Provide bed rest, in quiet dimly lit room. 4. Instruct to wear light weight, cool clothing. 5. Cleanse eyelids with warm saline solution to remove secretions or crusts. 6. Instruct patient not to rub eyes. 7. Notify nursing director or public health. 8. Assess other shelterees for at risk populations, unimmunized children, or
immunosuppressed.
AFTERCARE:1. Document in patient's record:
a. Onset of symptoms b. Isolation measures instituted
2. Suspected or diagnosed Rubella is reportable to the local health department. ( Routinely reportable within one working day but in a shelter we should probably make this immediate).
3. In addition to specified reportable conditions, any outbreak, exotic disease, or unusual group expression of disease that may be of public health concern should be reported by the most expeditious means available to the local health department
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4. CONTAGIOUS CONDITIONS: 4.08 RINGWORM:
PURPOSE: To treat the contagious disease which appears as a spreading reddish circle which becomes larger if left untreated.
EQUIPMENT/SUPPLIES:Medication and Dosage: 1. Lotrimin Antifungal Cream: (Clotrimazole, USP 1%) Wash and dry infected area morning and evening. Then apply cream and rub gently on infected area. Spread evenly to help prevent recurrence. Continue treatment for 2 weeks after disappearance of all symptoms. Keep out of eyes.
PROCEDURE: 1. Bathe or have person bathe with soap and water daily. 2. Apply lotrimin as directed above. 3. Lightly cover exposed lesions to avoid spread4. If bathing a patient, don gloves first and afterwards, discard the gloves and Wash
hands.
AFTERCARE:Document in patient's record:
1. Location of lesions 2. Isolation steps taken
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4. CONTAGIOUS CONDITIONS: 4.09 SCABIES:
PURPOSE: To rid the patient of scabies, and to relieve the itching and skin irritation caused by the mite.
CONSIDERATIONS: 1. Instruct the patient to avoid scratching the rash as scratching can cause skin to
bleed and become infected. Wearing gloves at night can help. 2. The use of 5% Permetherin lotion can completely cure scabies, if used correctly.
Read label before beginning. 3. Itching will continue for several weeks to months after treatment even though the
scabies mites are dead. 4. A second treatment in 7-10 days may be necessary.
EQUIPMENT/SUPPLIES: Scabicidal medication (Permethrin 5%) Soap & Water Towel & Washcloth Gloves
PROCEDURE: 1. Explain procedure to patient and assemble equipment. 2. Don gloves. 3. Rub Permethrin in thoroughly from neck to toes, including soles of feet for older
children and adolescents, for infants, make sure to also treat the forehead and scalp.
4. Medication must be allowed to remain on for 8-12 hours. Read package insert for specifics.
5. After 8 to 12 hours (according to insert), wash, rinse, and dry entire body. 6. All clothes, bed linens, washcloths, towels and all other articles that came into
contact with skin must be washed with hot soapy water and dried on the hot cycle of the dryer.
7. All items that came into contact with the patient's skin that cannot be washed must be placed in a sealed plastic bag and remain untouched for 10 days. After 10 days, items can be removed and used once again after normal wash cycle.
8. It is not necessary to treat furniture, etc. 9. Remove gloves and discard. Wash hands! 10. Screen close contacts to patient for possible infestation.
AFTERCARE:Document in patient's record:
1. Location of lesions 2. Isolation steps taken
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4. CONTAGIOUS CONDITIONS: 4.10 SCARLET FEVER:
PURPOSE: To treat and prevent transmission.
CONSIDERATIONS: 1. Abrupt onset with fever, vomiting, sore throat, headache , chills, and general
malaise. 2. Swollen tonsils covered with patches of exudate. Tongue has white strawberry
appearance that changes by the 4th or 5th day to a bright red strawberry-like color. Lesions and petechiae on soft palate most often seen in children 2-8 years of age.
3. Most commonly seen in the winter and spring months. 4. Rash develops 12-72 hours after onset of symptoms. 5. Begins on base of neck, axillae, groin, and trunk, rapidly spreading within 24
hours. 6. Typically the rash does not cover the face, but there is flushing of the checks and
circumoral pallor. 7. Transmitted by direct or intimate contact with patient or carrier. 8. Communicable for 10-21 days without treatment. 9. Isolate until 24 hours after initial treatment.
EQUIPMENT/SUPPLIES: Throat Lozenges Cool Fluids Tylenol
PROCEDURE: 1. Requires antibiotic therapy. Seek medical assistance as soon as possible. 2. Isolate. 3. Wash hands and don gloves before and after every contact. 4. Encourage bed rest especially during febrile period. 5. Provide symptomatic relief of sore throat by using lozenges and gargling. 6. Encourage fluids. 7. Administer acetaminophen or ibuprofen for fever control. * See FEVER Protocol
for dosages. 8. Monitor vital signs.
AFTERCARE:Document in patient's record:
1. Location of lesions 2. Isolation steps taken
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4. CONTAGIOUS CONDITIONS: 4.11 ABSCESS:
PURPOSE: To treat and prevent transmission.
CONSIDERATIONS: 1. Often initially thought to be a bug or spider bite2. Starts with a small break in the skin where bacteria set in3. Most commonly caused by S. aureus, and in the Gulf region there is a high rate
of methicillin resistant species4. Reservoir is often the nares
EQUIPMENT/SUPPLIES: BactrobanCleansing solutionChlorine bleach
PROCEDURE: 1. If the abscess is larger than one centimeter, rapidly expanding, painful and does
not have an area of drainage it may require incision and drainage-seek medical assistance, especially if associated with fever.
2. Wash hands and don gloves before and after every contact.3. Warm soaks 3-4 times daily may help promote drainage. Keep wound covered
to prevent spread4. After warm soak and cleansing, cover area with bactroban.5. Keep area covered loosely, to prevent contact with other areas of skin and other
shelterees. 6. Administer acetaminophen or ibuprofen for fever control. * See FEVER Protocol
for dosages. 7. Wash all of patients clothing, cleanse bedding areas and surface areas with
chlorine solution.8. Treat patient and contacts with bactroban to nares twice daily.9. Consider adding 1cup of chlorine bleach to bath water when bathing in a regular
tub to reduce carriage on the skin.
AFTERCARE:Document in patient's record:
1. Location of lesions
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5. END OF LIFE: 5.01 DETERIORATION OF MEDICAL CONDITION:
PURPOSE: To care for those individuals whose condition deteriorates into a medical emergency during their stay in the Special Needs Shelter.
CONSIDERATIONS: 1. Shelters are not equipped to provide acute interventions. 2. During the height of the storm (event), 911 service is not available. 3. Prior to and after the storm (event), 911 service will be available but
communications could be affected. PROCEDURE:
1.2. When the assessment is made that an individual is deteriorating, remove the
individual from the shelter population. Removing or isolating the person will assist in reducing panic by others and provide the individual with privacy.
3. Provide comfort measures when possible such as elevating the person's head and providing oxygen. Assess the patient for any obvious medical problems by checking the vital signs and reviewing the medications.
4. During the height of the storm (event), call the Medical Special Needs Branch Director at the Emergency Operation Center cal manager to receive additional direction for care.
5. Prior to and after the storm (event), activate the EMS system for emergency treatment and transportation of the individual.
6. If the individual becomes unresponsive and pulseless, initiate CPR until help arrives to relieve you, or the onsite physician gives other direction.
AFTERCARE:Document in patient's record:
1. Description of event
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5. END OF LIFE:5.02 OUT OF HOSPITAL DNR ORDERS::
Health and Safety Code Chapter 166 defines the Out-of-Hospital Do Not Resuscitate (DNR) law for the State of Texas. A DNR order may exist as a written order or as an identification device such as a bracelet or necklace.
These should be honored if the identity of the patient as the person who executed the DNR order or for whom the DNR order was executed, and;
1. It is a VALID Out-Hospital DNR order, and:2. It is an original or copy of the Texas Department of State Health Services form.
An Out-of-Hospital DNR order is considered valid if it includes:1. Written responses in the places designated for the names, signatures and information required of persons executing or witnessing the execution of the order.2. Date and place that the order was executed.3. The signature of the declarant or persons executing the order and the attending physician’s signature in designated areas.4. Photocopy or other complete facsimile of the complete form
If these conditions are not met the DNR order should not be honored and resuscitation as indicated by shelter guidelines or shelter medical direction should begin.
Honor DNR orders if:1. No pulse2. Pulse with no respirations3. Valid DNR order
-State of Texas DNR bracelet
Do not honor DNR orders if:1. Order is not considered valid2. Suspicion of non-natural cause of death (i.e. homicide, suicide, etc)3. Patient is pregnant4. DNR is contested by declarant, attending physician, legal guardian/parent, spouse or adult child of the patient or person with durable power of attorney for health care5. Request by patient or caregiver that CPR or life sustaining procedures be initiated or continued.
If unsure, contact shelter director.
Advanced directives may be honored as DNR’s provided it is apparent to the shelter staff and caregiver/family that the patient suffers an irreversible and terminal condition.
A verbal declaration from a patient’s physician (in person or by phone if identified as the patient’s physician by the healthcare facility) with regard to DNR status or the wish to terminate resuscitative efforts should be treated as a DNR and well documented in the medical update. Preferably the medical director should confirm this situation.
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5. END OF LIFE:5.03 TERMINATION OF RESUSCITATION:
Termination of resuscitation applies to nonpregnant adult patients who meet specific criteria:
1. Adult age >17 years of age2. Primary cardiac arrest not associated with hypo/hyperthermia, drug overdose, toxicological exposure, submersion, airway obstruction, electrocutions or other possible reversible causes of arrest.3. Patient has a standing DNR order.4. Patient has sustained a mortal injury5. Adequate ventilation, IV access and standard available ALS or BLS measures applied without success6. Resuscitative ALS measures have been attempted for a minimum of 20 minutes, or for the length of time that shelter resources will allow.7. Notification and presence of Shelter Director.
Resuscitative efforts will continue with these criteria:
1. Shelter resources allow for ongoing resuscitation2. Cardiac arrest may be associated with hypo/hyperthermia, drug overdose, toxicological exposure, submersion, airway obstruction, electrocutions or other possible reversible causes of arrest.3. There has been a return of spontaneous pulse4. Presence of neurological response (for example eye opening)
In all cases the Shelter Director must be notified and medical director consulted at the soonest available opportunity.
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5. END OF LIFE:5.04 EXPIRATION:
PURPOSE: If an individual in the shelter cannot be resuscitated, an area in the shelter will be designated as the Morgue to hold the body until after the event. To preserve as much dignity for the individual as possible and privacy for the family until which time the remains may be removed.
CONSIDERATION: 1. Individuals who have expired may not be removed from the shelter during the
height of the storm (event). It will be necessary to locate them in an inconspicuous location at the shelter until such time when the remains can be removed.
PROCEDURE: 1. After it has been determined that the individual is no longer living and further
medical intervention will not revive the person, it will be necessary to remove them to a more inconspicuous location in the shelter.
2. If space is not available to permit a separate "morgue", the remains may be moved to the isolation area and covered with a sheet or blanket at the perimeter of the room.
3. Care must be taken to log the person's name, time of death, and any extenuating issues for further follow up by the law enforcement agency which will need to be notified.
4. Call the Medical Special Needs Branch Director at the Local Emergency Operation Center notifying them of the expiration, allowing them to notify the appropriate law enforcement agency and to arrange for the removal of the remains.
5. Keep any personal effects of the deceased with the body.
AFTERCARE:Document in patient's record:
1. Time and circumstances of death 2. Care rendered prior to death if applicable. 3. Time of notification of family
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5. END OF LIFE:5.05 DEATH PROCEDURES:
In the event that a client expires in the shelter during the emergency, these procedures are to be followed. Once an official declaration of demise has occurred, quietly relocate the expired client to a holding area away from the general area. Notify local law enforcement of the death. If no body bags are available, cover the body with the sheets. Notify the Nursing Manager who will report to the Medical Special Needs Operations Branch Chief at the local emergency operation a caregiver or next of kin is available in the shelter, their wishes should be expressed to the Nursing Manager. The body will not be removed until released by law enforcement. The client’s chart will be annotated with all information concerning the event and the directions received from the Medical Special Needs Branch Director at the local emergency operation center.
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