Primary Clinical Care Manual
Primary Clinical Care Manual 10th edition 2019
10th edition 2019 Criteria for early notification of trauma for interfacility transfer1 ALL trauma patients - do rapid assessment of vital signs, injuries and mechanism of injury
Newborn Infant Child Child Adult < 4 weeks 1 - 12 mths 1 - 8 years 9 - 15 years Respiratory rate/min < 10 or > 30 < 40 or > 60 < 20 or > 50 < 20 or > 35 < 15 or > 25
O2saturation in room air < 90% < 95% < 95% < 95% < 95% Systolic BP mmHg < 90 n/a < 60 < 70 < 80
Vital signs HR/min > 120 < 100 or > 170 < 90 or > 170 < 75 or > 130 < 65 or > 120 GCS < 14 Altered LOC Altered LOC Altered LOC Altered LOC
• All penetrating injuries –– head/neck/chest/abdomen/pelvis/axilla • Blunt injuries –– patients with significant injuries to a single region - head/neck/chest/abdomen/pelvis/axilla –– patients with injuries involving 2 or more of the above body regions • Specific injuries –– limb amputation/life threatening injuries –– suspected spinal cord injuries Injuries –– burns: adult > 20% total body surface area (TBSA), child > 10% TBSA –– suspected respiratory tract burns –– serious crush injury –– major compound fractures or open dislocation –– fracture to 2 or more: femur, tibia, humerus –– fractured pelvis
• Ejection from vehicle • Prolonged extrication > 30 minutes • Motorcyclist impact > 30 kph • Pedestrian impact • High speed motor vehicle collision > 60 kph • Fall from height > 3 metres • Vehicle roll over • Struck on head by falling object > 3 metres • Fatality in same vehicle • Explosion Mechanism of injury of Mechanism
If ANY of the above are present PROMPTLY CALL RSQ 1300 799 127 for management support, retrieval advice and destination decision or your local/state trauma escalation service
If none of the above is present, follow usual local processes for assessment and transfer of the patient Copyright i
10th
Copyright and once Primary Clinical Care Manual Primary Clinical Care Manual is distributed by Queensland Health and the is distributed by Queensland Health and the Head of Clinical Governance Head of Clinical Section) Doctor Service (Queensland Royal Flying Street 12 Casuarina Queensland 4006 Brisbane Airport, [email protected] 07 3708 5069 Executive Director Clinical Support Unit Rural and Remote PO Box 7193 4870 Cairns, Queensland [email protected] Primary Clinical Care Manual 10th edition 2019 : 978-1-876560-05-8 The email: [email protected] Intellectual Property Officer, Health Innovation, Investment and Research Office, Queensland Health Intellectual Property Officer, Health Innovation, http://creativecommons.org/licenses/by-nc-sa/4.0/deed.en this licence contact: For copyright permissions beyond the scope of any derivative work only under the same licence and you comply with the licence terms. To any derivative work only under the same (Queensland Health) and the Royal Flying Doctor Service (Queensland Section), you distribute (Queensland Health) and the Royal Flying the work for non-commercial purposes, as long as you attribute the State of Queensland the work for non-commercial purposes, as into this publication by reference 4.0 International licence (CC BY-NC-SA 4.0). You are free to copy, communicate and adapt copy, communicate You are free to 4.0 International licence (CC BY-NC-SA 4.0). costs, liability, demand, any claim, action, proceeding, for negligence) for liability (including liable be or reliance on or inability to use the information or instructions provided in this publication, or incorporated Copying and reproduction Commons Attribution Non-Commercial Share Alike This work is licensed under a Creative advice in relation to the application of the information should not be relied upon as such. Specialist Flying Doctor Service of Australia (Queensland Section) In no event shall Queensland Health or the Royal use of Flying Doctor Service of Australia (Queensland Section) arising out of or in connection with a person's view a copy of this licence visit: as an information source only and does not replace Royal Flying Doctor Service (Queensland Section) for responsible be will readers that basis the on solely provided is information The judgment. clinical herein and readers are advised to verify all relevant making their own assessment of the matters presented The information does not constitute clinical advice and representations, statements and information. necessary to ensure the application is clinically appropriate presented in this publication must be sought as limitation, direct, indirect, punitive, special or damages, expenses or loss (including without the Royal consequential) whatsoever brought against or made upon or incurred by Queensland Health or Controlled copies and uncontrolled copies Controlled copies and is the only controlled version of the The electronic version Queensland Health, Royal Flying Doctor Service (Queensland Section), Flying Doctor Service (Queensland Section), Queensland Health, Royal Suggested citation © State of Queensland (Queensland Health) 2017 and the Royal Flying Doctor Service (Queensland Section) Section) (Queensland Service Doctor Flying Royal the and 2017 Health) (Queensland Queensland of State © feedback Comments and write or email: are welcome. Please feedback to this edition Comments and ISBN Cairns , the Rural and Remote Clinical Support Unit, Torres and Cape Hospital and Health Service, Clinical Support Unit, Torres and Cape Hospital 2019, the Rural and Remote edition downloaded it is no longer a controlled copy. The A5 print and downloaded versions are longer a controlled copy. The A5 print downloaded it is no at: available version recent most the accessing for responsible are Users uncontrolled. https://www.health.qld.gov.au/rrcsu/html/PCCM - updated19 April 2021 April - updated19 2019 edition 10th Manual Care Clinical Primary The ii Contents |Primary Clinical Care Manual 10th edition | .Emergency 3. P 2. Patient assessment and transport 1. Acknowledgements Endorsements Contents Cardiovascular emergencies Critical emergencies Resuscitation Nauseaand vomiting Acute pain management Patient retrieval/evacuation Clinical consultation Adult presentation Patient presentation -adult and child What's newinthis edition Health Management Protocols and Clinical Care Guidelines Authority to administer and supply medicines Recognising and responding to clinical deterioration (RRCD) inacute health care The PCCM and collaborative practice Endorsing thePCCM inQueensland Introduction ain, nausea and vomiting
Oxygen delivery Laryngeal mask airway (LMA)insertion Foreign body airway obstruction (choking) Meningitis Sepsis/septic shock Shock Unconscious/altered level of consciousness Drowning/submersion Acute asthma Hypoglycaemia Hyperglycaemia Fits/convulsions/seizures Anaphylaxis Intraosseous inf dvanced lif R S ABCD esuscitation/the collapsed p
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109 128 102 130 119 113 115 3 53 17 80 99 28 20 69 48 64 29 56 67 54 54 73 73 35 10 77 91 19 13 3 x 8 9 1 7 7 7 i i contents i 4 171 151 175 157 157 191 161 155 135 217 217 215 154 147 231 197 195 185 185 158 163 183 130 14 212 194 149 198 190 189 180 225 227 227 234 234 238 238 224 222 229 209 Contents
Cardiac arrhythmias arrhythmias Cardiac Acute abdominal pain abdominal Acute Decompression illness (DCI/bends) illness Decompression Hypothermia stroke/hyperthermia exhaustion/heat Heat bleed/epistaxis Nose Burns (general) (general) Burns burns Major Minor burns burns Chemical Sprains/soft tissue injury injury tissue Sprains/soft syndrome Compartment wounds related Water bites animal and (tooth-knuckle) Human bite/scratch Bat Simple fracture of limbs limbs of fracture Simple fractures Compound Fractured pelvis mandible/jaw Fractured Dislocations Delirium Delirium injuries Chest injuries Head injuries Spinal injuries Abdominal Acute hypertensive crisis leg ischemia lower Acute (DVT) thrombosis vein Deep (spontaneous) haemorrhage Subarachnoid stroke and (TIA) attack ischaemic Transient Chest pain assessment pain Chest (ACS) syndromes coronary Acute oedema pulmonary Acute shock Electrocution/electric Ears, nose and throat (ENT) emergencies throat and nose Ears, emergencies Gastrointestinal Burns emergencies Environmental Acute wounds Acute Fractures, dislocations and sprains and dislocations Fractures, Traumatic injuries Traumatic Neurological emergencies Neurological iv Contents |Primary Clinical Care Manual 10th edition | Toxinology (bites and stings) Toxicology (poisoning and overdose) Genitourinary emergencies Gamma-hydroxybutyrate (GHB) Cannabis (marijuana) Amphetamines and cocaine Paraquat ingestion/inhalation/contact Paracetamol Organophosphates/carbamates (pesticides) Opioids Ingestion of non-steroidal anti-inflammatory drugs (NSAID) Lithium Petrol, fuels and otheroils (hydrocarbons) -ingestion/aspiration oil Eucalyptus C Corrosive/caustic substance ingestion Carbon monoxide inhalation Aspirin/salicylates Antipsychotics Antihistamines Tricyclic antidepressants (TCAs) Serotonin and noradrenaline reuptake inhibitors (SNRIs) Antidepressants (general) Other anticonvulsants Carbamazepine Anticonvulsants (general) Anticholinergic agents Specific poisons Toxicology (poisoning and overdose) -general approach Testicular/scrotal pain Acute retention of urine colic Renal Bowel obstruction Rectal bleeding Upper gastrointestinal bleeding Alcohol related epigastric pain Acute gastoenteritis/dehydration Redback spider bite Funnel-web (big black) spider bite Spider bites (general) Snakebite including sea snake Sedatives/hypnotics Sniffing petrol/glue/aerosol yanide
288 280 286 268 268 266 289 289 296 269 282 299 264 264 249 292 292 283 265 265 287 278 270 276 267 279 256 259 259 297 243 247 254 272 254 252 273 274 257 291 275 271 251 contents v 3 351 315 371 314 312 375 374 355 316 33 301 310 353 352 327 347 367 379 358 358 336 363 336 338 338 344 324 324 304 329 342 362 302 348 369 320 320 309 366 306 308 380 319 Contents
Foreign body/corneal abrasion abrasion body/corneal Foreign eye to burn Flash eye to burn Chemical injury eye Blunt injury eye Penetrating vision of loss painless Sudden cellulitis cellulitis/periorbital Orbital Conjuctivitis conjunctivitis Bacterial Assessment of the eye the eye of Assessment Toothache Caries Dental Pneumonia Tuberculosis headache chronic and Acute teeth to Trauma Mouth ulcers abscess Dental haemorrhage extraction Post (dry socket) osteitis Alveolar disease Periodontal thrush) (oral Candidiasis eye or painful Red Urticaria,allergic rhinitis Urticaria,allergic (URTI) infection tract Upper respiratory sinusitis bacterial Acute Fish stings stings Fish injuries Stingray injuries urchin Sea Sponges poisoning Ciguatera Scorpion stings and centipede bites bites centipede and stings Scorpion bites Tick envenomation fleckeri) (Chironex jellyfish Box syndrome Irukandji stings other jellyfish and (Physalia) Bluebottle envenomation shell cone and octopus Blue-ringed ye problems ye Nervous system problems system Nervous problems dental Mouth and Mild and moderate allergic reactions allergic moderate and Mild problems Respiratory E 4. General v i Contents |Primary Clinical Care Manual 10th edition | 5. Mental health and substance misuse Skin problems Urinary tract problems Dementia Be Foot infection with diabetes Chronic conditions Chronic wounds Suicidal behaviour Mental health assessment Supply of chronic condition medicines ATSIHP and IHW Secondary prophylaxis for acute rheumatic fever (ARF) Communicable diseases havioural disturbances disturbances havioural Ross River Virus and Barmah Forest Virus Acute hepatitis C Folliculitis/furunculosis (boils)/carbuncles Acute glaucoma Acute iritis (anterior uveitis) Corneal ulceration Trachoma Acute gonococcal and chlamydial conjunctivitis Allergic conjunctivitis Viral conjunctivitis Inter Suic Dengue fever Acut Osteomyelitis inthefoot of patient with diabetes Nappy rash Head lice/nits Scab Leprosy (Hansen's Disease) Tinea versicolor (pityriasis versicolor) Candidiasis (skin) Tinea/ringworm Cellulitis Behavioural and Psychological Symptoms of Dementia (BPSD) Acute severe behavioural disturbance (ASBD) Suic Acut Foot infection inpatient with diabetes Impetigo Urinary tract infection (UTI) ide risk assessment idal behaviour e hepatitis B e hepatitis A ventions innon-consenting patients ies
449 406 409 386 398 420 389 389 440 382 384 464 442 442 392 392 439 478 478 450 383 456 456 385 387 445 467 467 427 425 433 401 433 437 435 418 474 381 421 421 413 415 411 . contents ii v 511 511 513 521 516 481 535 537 572 552 481 597 579 592 565 565 558 544 530 562 586 508 487 588 487 526 569 540 540 548 582 599 484 494 586 500 484 498 498 490 595 497 Contents
Secondary postpartum haemorrhage postpartum Secondary Unintended pregnancy Unintended pregnancy Ectopic prophylaxis Streptococcus B Group resuscitation Neonatal Psychosis, schizophrenia, drug-induced psychosis and puerperal psychosis puerperal and psychosis drug-induced schizophrenia, Psychosis, anxiety and mania Depression, intoxication alcohol Acute Breech birthBreech abscess Mastitis/breast Postnatal check Vaginal bleeding in early pregnancy in early bleeding Vaginal in pregnancy infection tract Urinary in pregnancy Diabetes in pregnancy Hypertension Preeclampsia/eclampsia (APH) haemorrhage Antepartum membranes of rupture prelabour Preterm labour Preterm stage 1st Labour birthImminent the newborn of care Immediate perineum of repair and Episiotomy or presentation prolapse cord Umbilical (PPH) haemorrhage postpartum Primary dystocia Shoulder Antenatal care Antenatal prophylaxis (anti-D) Rh(D) immunogloblun Alcohol withdrawl withdrawl Alcohol Other drugs/substances Long-acting hormonal contraception contraception hormonal Long-acting Contraception general Contraception Antenatal Psychotic disorders disorders Psychotic Postnatal Pregnancy complications Pregnancy birth and Labour birth and labour during Emergencies Mood disorders Mood other drugs and Alcohol 7. health reproductive and Sexual 6. neonatal and Obstetrics v iii Contents |Primary Clinical Care Manual 10th edition | .Paediatrics 8. Progestogen only pills Combined hormonal contraceptives Po Button battery ingestion/insertion Sexually transmitted infections Barrier methods of contraception Emergency contraception Ear problems Respiratory problems Paediatric presentation st streptococcal diseases streptococcal st Croup /epiglottitis Donovanosis B Chlamydia/gonorrhoea/trichomonas/mycoplasma genitalium Intrauterine contraceptive device (IUCD) S Medroxyprogesterone acetate Otitis media with effusion (OME) Acute otitis media (AOM) with /without perforation Ear infections (general) Ear and hearing assessment Acute rheumatic fever (ARF) Pneumonia Bronchiolitis Pertussis (whooping cough) Sore throat Differential diagnosis R Human immunodeficiency virus (HIV)infection Genital warts S Genital herpes simplex virus (HSV) Genital sores/ulcers Low abdominal pain infemale Epididymo-orchitis Candidiasis/vaginal (thrush) Sexually transmitted infections general Combined oral contraceptive pill/vaginal ring History and physical examination Acute post streptococcal glomerulonephritis (APSGN) Upper respiratory tract infection (URTI) ape and sexual assault yphilis yphilis ub-dermal progestogen implant acterial vaginosis
663 608 680 682 628 640 664 689 646 682 630 650 605 700 708 700 603 664 656 659 632 599 623 643 605 708 685 653 695 601 697 635 705 673 614 691 615 615 712 611 717 711 x
contents i 3 7 6 721 771 719 747 743 725 754 72 749 746 773 740 754 724 722 729 736 730 738 787 758 785 778 728 730 782 789 760 768 786 791 76 79 Contents
https://www.health.qld.gov.au/rrcsu/html/PCCM
available at available s externa externa s ussuception ussuception y perforation y raumatic rupture of the eardrum of rupture raumatic Acute gastroenteritis / dehydration gastroenteritis Acute Medication reconciliation Medication (BPMH) history medication possible Best Lactose intolerance intolerance Lactose Giardiasis worms Intestinal Constipation Int Anaemia (UTI) infection tract Urinary program Immunisation immunisation health Sexual immunisation Tetanus Chronic suppurative otitis media (CSOM) (CSOM) media otitis suppurative Chronic Ear discharge in the presence of grommets grommets of the presence in discharge Ear Dr Cholesteatoma mastoiditis Acute Otiti T in ear / insect body Foreign Pyloric stenosis Pyloric stenosis e use of paracetamol of e use asgow Coma Scale/AVPU asgow Coma astrointestinal problems astrointestinal Administration tips for benzathine benzylpenicillin (Bicillin benzylpenicillin benzathine for tips Administration penicillin) (procaine benzylpenicillin procaine LA®) and techniques De-escalation Medication history and reconciliation and history Medication Gl Urinary tract problems tract Urinary Child protection Child Saf Bone and joint problems joint Bone and death patient a of Notification G Immunisations Index References References Abbreviations and acronyms and Abbreviations 10. Appendices 9. Endorsements
Queensland Health ord The Primary Clinical Care Manual (PCCM) 10th edition provides guidelines and protocols that support health professionals in isolated, rural and remote areas to provide quality care and medications. The interventions recommended in the PCCM 10th edition are evidence based and expert clinicians have confirmed these as best practice.
The PCCM 10th edition is the result of a successful partnership between Queensland Health and the Royal Flying Doctor Service (Queensland Section). Both organisations share ownership of the PCCM, this being forged through the collaborative development of this manual over the more than 20 years of its existence. The PCCM is also used extensively within other states and by all branches of the Australian Defence Forces. The protocols included in the PCCM set out the circumstances, conditions and restrictions under which various medicines can be provided. In Queensland the PCCM contains protocols that support the following health practitioners:
Indigenous Health Worker Isolated Practice Area Aboriginal and Torres Strait Islander Health Practitioner – Isolated Practice Area Queensland Ambulance Service Isolated Practice Area Paramedic Rural and Isolated Practice Area Registered Nurse Sexual Health Program Nurse (including Reproductive Health) Midwives Immunisation Program Nurse
Queensland Health staff working in rural and remote ambulatory care settings use the clinical care guide- lines contained in the PCCM 10th edition as their guide to practice. I commend the PCCM 10th edition as the principal clinical reference and policy document for rural and remote practitioners.
Michael Walsh Director-General, Queensland Health
x | Primary Clinical Care Manual 10th edition | Royal Flying Doctor Service (Queensland Section)
It has been over twenty years since the first edition of thePrimary Clinical Care Manual (PCCM) was co-authored by Dr Geoff King and Lyn Overton. Whilst reflecting upon Dr King’s belief that “the best health outcomes are achieved when well prepared health professionals work in collaboration and partnership in both practice and educational settings” we recognise and celebrate this important milestone.
The Royal Flying Doctor Service (Queensland Section) (RFDS) acknowledges the many challenges faced when providing high quality health care in rural and remote locations. Particularly, where clinicians frequently experience limited access to support, or reliance on external support delivered by remote consultation. In these circumstances, the PCCM provides a readily available, concise reference text which the treating clinician can consult, knowing that the advice contained in this manual is current, evidence based, and reflective of the best clinical practice. The PCCM provides support for appropriately authorised clinicians to initiate treatment prior to consultation and ongoing collaboration with a Medical Officer, thus ensuring timely interventions and, ultimately, better health outcomes for those living and working in rural and remote Australia.
Importantly, the RFDS acknowledges the generous sharing of time and expertise by clinical staff, from both Queensland Health and the RFDS, which is essential to the review and revision of each new edition of the manual. The tenth edition of the PCCM is very much a shared success story, and through its support of the treating clinician, helps to overcome the ‘tyranny of distance’ for rural and remote communities, ensuring they receive the same standard of care available in Australian urban centres.
Trent Dean Head of Clinical Governance Royal Flying Doctor Service (Queensland Section)
Queensland Ambulance Service
Queensland’s vast size and its diversity in geography and demographics present a unique challenge for all health care professionals in this State. We must continue to develop innovative methods of service delivery to cater for the specific needs of our rural and remote communities. The lack of a centralised population in this state and the increasingly complex health care needs of our rural and remote communities will ensure that Queensland remains at the forefront of healthcare innovation. The use of Registered Nurses, Paramedics and other Health Care Workers in meeting this challenge is a great example of one such model
As Medical Director of the Queensland Ambulance Service, I commend this 10th edition of the Primary Clinical Care Manual and am confident that it will continue to be of great benefit to our communities
Professor Stephen Rashford ASM MBBS FACEM Medical Director Queensland Ambulance Service
xi Australian Defence Force
As the provider of primary health care to the men and women of the Australian Defence Force (ADF), one of the key provisions of the Defence Health Services is the delivery of the highest quality health care, both on our bases and when we deploy on military and humanitarian operations. This directly enables the Australian Defence Force to carry out its role of protecting Australia’s interests locally and abroad.
As Surgeon General of the Australian Defence Force I fully support the evidence-based approach of the Primary Clinical Care Manual (PCCM) and its alignment to National Health and Medical Research Council Guidelines on Clinical Protocols. These two factors, together with the PCCM's particular focus on the delivery of health care by a range of practitioners in isolated and regional areas make the PCCM a valuable resource for the Defence Health Service.
I recognise the extensive knowledge and experience of those individuals who have revised the content for this edition, building on an excellent foundation. My intent is that the ADF will remain a significant contributor to this high quality publication through representation on the Editorial Committee to work in collaboration with the Royal Flying Doctor Service (Queensland Section) and Queensland Health.
I have endorsed the PCCM for use by authorised health personnel across the Australian Defence Force for practice when deployed in the field, at sea and overseas, within the ADF guidance I set.
It is with great pleasure that I commend to you this 10th edition of the Primary Clinical Care Manual (PCCM).
Tracy Smart AM Air Vice-Marshal Surgeon General, Australian Defence Force
xii | Primary Clinical Care Manual 10th edition | Department of Health and Human Services, Victoria
Victoria’s rural and regional health services work to improve coordination of care and optimisation of health outcomes for rural people through providing safe, high-quality care. An integral clinical model of care provided from our rural and regional health services is delivered by Scheduled Medicines Rural and Isolated Practice Registered Nurses (RIPRN). The Primary Clinical Care Manual and its health management protocols are an integral resource in delivering current, evidence based health care to rural people for RIPRN. I commend and fully support Queensland Health, Royal Flying Doctor Service (Queensland Section) and other members of the Editorial Committee in the ongoing production of the Primary Clinical Care Manual.
In rural Victoria the experience of using the ‘collaborative practice model’ to implement RIPRN has led to the development of a more flexible clinical workforce which through the Primary Clinical Care Manual is well resourced to meet the community’s primary and urgent health care needs. The RIPRN assessment skills and ability to supply and administer medicines under these comprehensive drug therapy protocols has improved Victorian rural health services’ ability to provide the right care, at the right time in the right place to rural people.
I am also pleased that a Victorian RIPRN is a member of Queensland’s Primary Clinical Care Manual Editorial Committee. I recognise all committee members’ expertise in reviewing and revising the content of this manual. It is a pleasure to endorse the use of the 10th edition of the Primary Clinical Care Manual across the state of Victoria by appropriately trained RIPRN supported by strong clinical governance under the collaborative practice model from Victoria’s rural health services.
Adj. Assoc. Professor Ann Maree Keenan Deputy CEO/Chief Nurse and Midwifery Officer Safer Care Victoria
xiii xiv Contents |Primary Clinical Care Manual 10th edition | Page leftintentionallyblank ACKNOWLEDGEMENTS 1 Acknowledgements respects to their Elders past, present and emerging their Elders past, present respects to We acknowledge the Traditional Owners of country throughout Australia and Australia throughout of country Owners the Traditional We acknowledge recognise their continuing connection to land, waters and culture. We pay our and culture. We pay to land, waters continuing connection recognise their
Caitlyn Fletcher, Pharmacist, Lady Cilento Children's Hospital Kordinelija Stott, Nurse Practitioner, Remote areas Kordinelija Stott, Nurse Practitioner, Remote areas Dr Tim Wellingham, Senior Medical Officer, Obstetrics/Anaesthetics, Dalby Hospital Tomi Newie, Program Manager, St Paul's Health Centre, Moa Island Tomi Newie, Program Manager, St Paul's Health Development, Office of the Medical Director, Office Lachlan Parker, Executive Manager, Clinical Policy of the Commissioner, Queensland Ambulance Service Community Hospital, Victoria Jason Phieler, Acute Nurse Unit Manager, Lorne Daniel Winters-McAppion, Nurse Manager, Clinical Manuals, Rural and Remote Clinical Support Unit Daniel Winters-McAppion, Nurse Manager, Clinical of Army Health, Australian Defence Force LtCOL Peter Nasveld, SO1 Population Health, Directorate (Apr 2017–Apr 2018) Teresa Hazel, Nurse Manager, Clinical Manuals, Rural and Remote Clinical Support Unit (Jan 2017 to Teresa Hazel, Nurse Manager, Clinical Manuals, Jan 2018) Rural and Remote Clinical Support Unit Susan Muirhead, Nurse Manager, Clinical Manuals, Michael Maw, Nurse Practitioner (Emergency), Director The Mordun Group and Institute of Education Michael Maw, Nurse Practitioner (Emergency), Director and Training Pty Ltd, NSW and Remote Clinical Support Unit Sean Booth, Nurse Manager, Clinical Manuals, Rural Adam Hogan, A/Senior Pharmacist, Atherton Hospital Senior Medical Technician-Army, Directorate of Nathan Holdforth, WO1, Australian Regular Army, 2018) Army Health, Australian Defence Force (Jun 2017–Aug Centre Danielle Jess, Nurse Educator (RIPRN), Cunningham Thennarasu Dharmalingam, A/Director of Pharmacy, Torres and Cape Hospital and Health Service Thennarasu Dharmalingam, A/Director of Pharmacy, (Apr 2017–Mar 2018) Theodore Roslyn Heywood, Health Consumers Queensland, Maree Cummins, Nurse Manager, Aeromedical Training and Clinical Resources, Royal Flying Doctor Manager, Aeromedical Training and Clinical Resources, Maree Cummins, Nurse Service (Queensland Section), Brisbane Dr Jill Newland, Chair, Medical Advisor, Rural and Remote Clinical Support Unit Advisor, Rural and Remote Clinical Support Dr Jill Newland, Chair, Medical (Queensland Section), Cairns Medical Officer, Royal Flying Doctor Service Dr Donal Watters, Co-Chair, Health Care Manuals (CARPA, (Remote), Midwife, Chair, Remote Primary Lyn Byers, Nurse Practitioner book) CRANA+ Procedure Manual and Medicines Women's Business Manual, Susan Muirhead, Nurse Manager, Clinical Manuals, Rural and Remote Clinical Support Unit Manager, Clinical Manuals, Rural and Remote Clinical Susan Muirhead, Nurse Remote Clinical Support Unit Nurse Manager, Clinical Manuals, Rural and Daniel Winters-McAppion, Sean Booth, Nurse Manager, Clinical Manuals, Rural and Remote Clinical Support Unit Manuals, Rural and Remote Nurse Manager, Clinical Sean Booth, Support Unit (Jan 2017 to Clinical Manuals, Rural and Remote Clinical Teresa Hazel, Nurse Manager, Jan 2018) • • • • • • • • • • • • • • • • • • • • • • • • •
Editors: Acknowledgements Proxy committee representatives: Editorial committee: 2 ACKNOWLEDGEMENTS and otherstakeholderswhoparticipatedinthereview,developmentendorsementof10thedition Section 1.Patientassessmentandtransport The Section 3.Emergency Section 2.Painmanagement,nauseaandvomiting |Primary Clinical Care Manual 10th edition | • • • • • • • • • • • • • • • • • • • • • • • • Primary ClinicalCareManual Hospital, RoyalFlyingDoctorService(QueenslandSection),MtIsa Dr PaulButel,StaffSpecialist,RuralGeneralist(EmergencyMedicine),EmergencyDepartmentLogan Dr DeanTaylor,MedicalOfficer,RoyalFlyingDoctorService(QueenslandSection) Joe Rosta,Pharmacist,TorresandCapeHospitalHealthService Michelle Mutzelburg,NurseEducator,CunninghamCentre Lorraine Horn,Pharmacist,TorresandCapeHospitalHealthService Andy Harris,Pharmacist,MareebaHospital FCICM, Queensland Children'sHospital Associate Professor DrLuregnSchlapback,Paediatric IntensiveCareUnit,SeniorStaffSpecialist Clinical Research, QueenslandChildren’sHospital Dr AdamIrwin,SeniorLecturerPaediatric InfectiousDisease,TheUniversityofQueenslandCentrefor Collaboration, QueenslandChildren’s Hospital Nicolette Graham,PharmacistAdvanced-Antimicrobial Stewardship,StatewidePaediatricSepsis Dr PaulaLister,DirectorPaediatricCritical Care,SunshineCoastUniversityHospital Research Unit,CairnsandHinterland HospitalandHealthService Wendy Cannon,ClinicalNurseEducator RuralandRemote,Nursing/MidwiferyEducation Dr PeterStewart,MedicalOfficer,CardiologyDepartment,RoyalBrisbane andWomen’sHospital The PrinceCharlesHospital Dr ScottMcKenzie,StaffSpecialistCardiologist,AdvancedHeartFailure andCardiacTransplantUnit, Hospital Associate ProfessorAndrewWong,DirectorNeurologyandStroke,Royal BrisbaneandWomen’s Hospital Associate ProfessorUlrichOrda,StaffSpecialist,RuralGeneralist,Director ofEmergency,MtIsa Hospital, RoyalFlyingDoctorService(QueenslandSection),MtIsa Dr PaulButel,StaffSpecialist,RuralGeneralist(EmergencyMedicine), Emergency DepartmentLogan Dr ClintonGibbs,StaffSpecialist,EmergencyDepartment,TownsvilleHospital Department ofHealth Aeromedical RetrievalandDisasterManagementBranch,PreventionDivision,Queensland Dr BrettHoggard,StatewideMedicalDirectorEmergencySpecialist,RetrievalServicesQueensland, Dr DonalWatters,MedicalOfficer,RoyalFlyingDoctorService(QueenslandSection),Cairns Prevention Division,QueenslandDepartmentofHealth Dr MarkElcock,ExecutiveDirectorAeromedicalRetrievalandDisasterManagementBranch, Dr PreetyGeorge,MedicalOfficer/FACRRM,RoyalFlyingDoctorService(QueenslandSection) Service (QueenslandSection),Brisbane Maree Cummins,NurseManager,AeromedicalTrainingandClinicalResources,RoyalFlyingDoctor Peter McCormack and RemoteClinicalSupportUnit Tazz Harding,MichelleGuilliatt,KylieHuyser,EmmaBroe,MaryKing,NaomiGallagher-Rural editorialcommitteegratefullyacknowledgesthecontributionofclinicians ACKNOWLEDGEMENTS 3 Acknowledgements Judith Murrells, Clinical Nurse Consultant Respiratory, Chronic Disease Programs Transitional Care Judith Murrells, Clinical Nurse Consultant Respiratory, Chronic Disease Programs Transitional Care Service Dr Lea Merone, Public Health Registrar, Apunipima Cape York Health Council Dr Lara Wieland, Medical Officer, Royal Flying Doctor Service (Queensland Section), Kowanyama Dr Lara Wieland, Medical Officer, Royal Flying Dr Welwyn Aw-Yong, Registrar, Statewide ED Network, Barcaldine Hospital and Multipurpose Health Service Statewide Trauma Clinical Network, Clinical Excellence Division, Queensland Department of Health Statewide Trauma Clinical Network, Clinical Excellence Statewide Respiratory Clinical Network, Clinical Excellence Division, Queensland Department of Statewide Respiratory Clinical Network, Clinical Health Division, Queensland Department of Health Statewide Cardiac Clinical Network, Clinical Excellence Division, Queensland Department of Health Statewide Stroke Clinical Network, Clinical Excellence Queensland Emergency Department Strategic Advisory Panel, Healthcare Improvement Unit, Clinical Queensland Emergency Department Strategic Advisory Health Excellence Division, Queensland Department of Division, Queensland Department of Health Statewide Diabetes Clinical Network, Clinical Excellence Professor Michael Muller, Senior Visiting Medical Officer, General Surgery, Burns and Trauma Professor Michael Muller, Senior Visiting Medical Professor, Royal Brisbane and Women’s Hospital Brisbane and Women’s Hospital Dr Jason Brown, Staff Specialist Burns Unit, Royal Dr Sridhar Atresh, Director Spinal Injuries Unit, Princess Alexandra Hospital Dr Sridhar Atresh, Director Spinal Injuries Unit, Princess Cooktown Multi-Purpose Health Service Steve Wallin, Senior Radiographer/Sonographer, Royal Brisbane and Women’s Hospital Dr Krispin Hajkowicz, Director Infectious Diseases, Joseph Sharpe, Clinical Nurse Consultant, Trauma, Townsville Hospital Joseph Sharpe, Clinical Nurse Consultant, Trauma, Medicine and Intensive Care, Townsville Hospital Dr Adam Holyoak, Staff Specialist Emergency Dr Gregory Starmer, Specialist, Cardiac, Cairns Hospital Dr Gregory Starmer, Specialist, Surgery, Cairns Hospital Dr Christina Steffan, Director, Barcaldine Hospital and Multipurpose Health Dr Welwyn Aw-Yong, Registrar, Statewide ED Network, Service Dr Theron Sather, Respiratory Sleep Physician, Princess Alexandra Hospital Dr Theron Sather, Respiratory Programs Transitional Care Nurse Consultant Respiratory, Chronic Disease Judith Murrells, Clinical Service Physician, The Prince Charles Hospital Dr Philip Masel, Thoracic Professor Jerry Wales, Director Endocrinology, Lady Cilento Children’s Hospital Professor Jerry Wales, Director Endocrine Centre Educator, Queensland Diabetes and Helen D’Emden, Dietician/Diabetes Dr Deanne Crosbie, Clinical Director, Telehealth Emergency Management Support Unit (TEMSU), Director, Telehealth Emergency Management Dr Deanne Crosbie, Clinical Emergency Medicine, Disaster Management Branch, Staff Specialist Aeromedical Retrieval and Townsville Hospital Dr Oliver Dodd, Staff Specialist, Emergency Medicine, Townsville Hospital Medicine, Townsville Staff Specialist, Emergency Dr Oliver Dodd, Hospital Lady Cilento Children’s Senior Medical Officer, Dr Peter Snelling, Clinical Excellence Division, Improvement Unit, Clinical Nurse, Healthcare Trina Maturanec, Department of Health Queensland Dr Trent Yarwood, Staff Specialist, Infectious Diseases, Cairns Hospital Diseases, Infectious Staff Specialist, Yarwood, Dr Trent Medicine, Griffith School of Disease, Infectious Paediatric Professor Keith Grimwood, Professor Coast University Gold Kathryn Wilks, Infectious Diseases Physician and Medical Microbiologist, Sunshine Coast University University Coast Sunshine Microbiologist, and Medical Physician Diseases Infectious Wilks, Kathryn Hospital • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Section 4. General 4 ACKNOWLEDGEMENTS Section 6.Obstetricandneonatal Section 5.Mentalhealthandsubstancemisuse |Primary Clinical Care Manual 10th edition | • • • • • • • • • • • • • • • • • • • • • • • • • • • • Professor StephenMargolis,MedicalOfficer,RoyalFlyingDoctorService(QueenslandSection) Dr MikeHill,MedicalOfficer,RoyalFlyingDoctorService Community WellnessCentre,ThursdayIsland Ghislaine Wharton,ClinicalNurseConsultant,OphthalmologySpecialistClinics/AdgirGubauGiz Branch, PreventionDivision,QueenslandDepartmentofHealth Dr StephenLambert,SeniorMedicalOfficer,EpidemiologyandResearch/CommunicableDiseases Dr GarryBrian,Ophthalmologist Queensland DepartmentofHealth Kate Lynch,ClinicalNurseConsultant,CommunicableDiseasesBranch,PreventionDivision, Department ofHealth Dr PeterOsborne,DirectorOralHealthServices,OfficeoftheChiefDentalOfficer,Queensland Hospital, RoyalFlyingDoctorService(QueenslandSection),MtIsa Dr PaulButel,StaffSpecialist,RuralGeneralist(EmergencyMedicine),EmergencyDepartmentLogan Dr KrispinHajkowicz,DirectorInfectiousDiseases,RoyalBrisbaneandWomen’sHospital Hospital Christine Latimer, ClinicalNurseConsultantNeonatal RetrievalsANTS–NQ,NeonatalUnit Townsville Dr ChristopherEdwards, StaffSpecialist,GeneralPaediatrics, BundabergHospital Alexandra Gosden,MidwiferyNurse Practitioner,JoycePalmerHealthService,PalmIsland Anne EatonMidwiferyManager,Proserpine Hospital Dr SusanIreland,SpecialistGeneral Paediatrics/Neonatal,TownsvilleHospital and Women’sHospital Jeanette Tyler,ClinicalNurseMidwifery Consultant,Women’sandNewbornServices,RoyalBrisbane Health Service Victoria Cluff,ClinicalMidwiferyEducator,NursingandMidwifery,Torres andCapeHospital Hospital andHealthService Joanne Leamy,Men’s,Women’sandSexualHealthCoordinator,Family Health Unit,TorresandCape Hospital Dr KathleenBraniff,ClinicalDirector,StaffSpecialist,Obstetricsand Gynaecology, MackayBase Dr HelenBarrett,EndocrinologistandObstetricPhysician,RoyalBrisbane andWomen’sHospital Service Dr EdwardStrivens,ClinicalDirectorGeriatricMedicine,CairnsandHinterland HospitalandHealth and OtherDrugsBranch,QueenslandDepartmentofHealth Janet Martin,DirectorClinicalGovernanceUnit,OfficeoftheChiefPsychiatrist,MentalHealthAlcohol Health Statewide RespiratoryClinicalNetwork,ExcellenceDivision,QueenslandDepartmentof Statewide DiabetesClinicalNetwork,ExcellenceDivision,QueenslandDepartmentofHealth Health Erin Howel,A/Manager,RheumaticHeartRegisterandControlProgram,QueenslandDepartmentof Services CairnsDivision Dr AnniePreston-Thomas,PublicHealthMedicalOfficerSexualHealth,Tropical Dr AlisterKeyser,PublicHealthRegistrar,TropicalUnitCairns Dr SharonO’Rourke,StaffSpecialist,PublicHealthDiabetes,CairnsDiabetesService Ewan Kinnear,DirectorofAlliedHealthPodiatrist,ThePrinceCharlesHospital ACKNOWLEDGEMENTS 5 Acknowledgements Jasmyn Adams, Primary Health Team Leader Bonny Marsh, Advanced Speech Pathologist Maggie Allen, Advanced Audiologist Amanda Wood, Clinical Nurse Consultant Anette Smith, Nurse Unit Manager Whitney Tatten, Senior Health Worker Matthew Brown, Director – – – – – – – – – – – – – – Dr Lea Merone, Public Health Registrar, Apunipima Cape York Health Council Dr Lea Merone, Public Health Registrar, Apunipima Dr Kristie Bell, A/Dietitian Consultant, Dietitian Clinical Lead Ambulatory Care and Rehabilitation, Children's Health Queensland Hospital and Health Service Statewide Child Protection Clinical Partnership, Child Protection and Forensic Medical Service, Children's Health Queensland Hospital and Health Erin Howel, A/Manager, Rheumatic Heart Register and Control Program, Queensland Department of Erin Howel, A/Manager, Rheumatic Heart Register Health Hospital and Health Services Deadly Ears Program, Children’s Health Queensland Dr Sally Webb, Specialist General Paediatrics, Cairns Hospital Dr Sally Webb, Specialist General Paediatrics, Cairns Public Health Unit Cairns Dr Alister Keyser, Public Health Registrar, Tropical Dr Les Griffiths, Forensic Medical Officer, Clinical Forensic Medicine Unit, Queensland Department of Dr Les Griffiths, Forensic Medical Officer, Clinical Health Therese Howard, Public Health Nurse, North Queensland Syphilis Surveillance Service, Tropical Therese Howard, Public Health Nurse, North Queensland Public Health Service Cairns Officer Sexual Health, Tropical Public Health Dr Annie Preston-Thomas, Public Health Medical Services Cairns Division Associate Professor Darren Russell, Director of Sexual Health, Cairns Sexual Health Service Russell, Director of Sexual Health, Cairns Sexual Associate Professor Darren Health Unit, Torres and Cape and Sexual Health Coordinator, Family Joanne Leamy, Men’s, Women’s Hospital and Health Service Dr Amanda Blinco, Regional Medical Officer, True Relationships and Reproductive Health Medical Officer, True Relationships and Reproductive Dr Amanda Blinco, Regional Boulia Primary Health Care Centre Karen Savage, Nurse Practitioner, Statewide Maternity and Neonatal Clinical Network, Clinical Excellence Division, Queensland Neonatal Clinical Network, Clinical Excellence Statewide Maternity and Department of Health Department of Health Network, Clinical Excellence Division, Queensland Statewide Diabetes Clinical Yoie Thomas, Midwifery Nurse Educator, Workforce Development Unit, People and Culture, South Unit, People and Culture, Workforce Development Midwifery Nurse Educator, Yoie Thomas, Service West Hospital and Health Health Service Women’s Health, Cooktown Multi-Purpose Kym Boyes, Nurse Practitioner Ruth Davison, Clinical Nurse Midwife Consultant Women’s Health, Mackay Hospital and Health Mackay Hospital Consultant Women’s Health, Clinical Nurse Midwife Ruth Davison, Service Culture, South Unit, People and Workforce Development Midwifery Nurse Educator, Meagan Benson, and Health Service West Hospital Dr Susan Ireland, Specialist General Paediatrics, Neonatal Unit, Townsville Hospital Unit, Townsville Neonatal Paediatrics, Specialist General Ireland, Dr Susan Cairns Hospital Service Coordinator, Maternity A/Regional Griffiths, Jacqueline Jeanette Tyler, Clinical Nurse, midwifery Consultant, Women’s and Newborn Services, royal Brisbane royal Brisbane Services, and Newborn Women’s Consultant, midwifery Nurse, Clinical Tyler, Jeanette Hospital and Women’s • • • • • • • • • • • • • • • • • • • • • • • Section 8. Paediatrics Section 7. Sexual and reproductive health Section 7. Sexual and reproductive 6 ACKNOWLEDGEMENTS Section 10.Appendices Section 9.Immunisation |Primary Clinical Care Manual 10th edition | Cover Images • • • • • • • • Erin Howel,A/Manager,RheumaticHeartRegisterandControlProgram,QueenslandDepartmentof and HealthcareRegulationBranch,QueenslandDepartmentofHealth Josie Quin,SeniorMedicationSafetyOfficer,ServicesQueensland,ChiefMedicalOfficer and HealthcareRegulationBranch,QueenslandDepartmentofHealth Fiona McIver,ManagerMedicationSafety,ServicesQueensland,ChiefMedicalOfficer Service Erin Finn,DirectorClinicalGovernance,GovernanceUnit,WestMoretonHospitalandHealth Hospital andHealthService Joanne Leamy,Men’s,Women’sandSexualHealthCoordinator,FamilyUnit,TorresCape Service Ann Richards,PublicHealthManagerSouth,Unit,TorresandCapeHospital Sandyl Kyriazis,NurseEducator,CunninghamCentre Service © 2018RoyalFlyingDoctorService(QueenslandSection)andTorresCapeHospitalHealth Health introduction 7
-
Introduction Edition of the PCCM is published th Registered Nurse and Pharmacist 10 non-Queensland Health employing organisation non-Queensland Health employing organisation interdisciplinary health team e.g. Executive team, consisting of at least a Medical Officer, interdisciplinary health team e.g. Executive team, The use of the PCCM must be supported at the Hospital and Health Service (HHS) level by an and Health Service (HHS) level by an The use of the PCCM must be supported at the Hospital The HHS Chief Executive Officer (CEO) must endorse the PCCM for use in the HHS, or CEO of a The HHS Chief Executive Officer (CEO) must endorse in collaboration and partnership in both practice and educational settings are supported by the health facility and the health organisation are supported by the health facility and the health is an Clearly defined levels of accountability with an acceptance that joint clinical decision making integral component of collaborative practice work A belief that the best health outcomes are achieved when well-prepared health professionals Mutual respect and acknowledgment of each profession's role, scope of practice and unique Mutual respect and acknowledgment of each contribution to health outcomes that comply with relevant legislation and Clear protocols and guidelines for clinical decision-making Authorised Indigenous Health Workers (IHW) Authorised Indigenous Health Service - Isolated Practice Area Paramedics (IPAP) Queensland Ambulance Immunisation Program Nurses (IPN) Immunisation Program Nurses Midwives (MID) Islander Health Practitioners (ATSIHP) Aboriginal and Torres Strait Rural and Isolated Practice Registered Nurses (RIPRN) Rural and Isolated Practice Nurses (SRH) Sexual Health Program Registered
Once endorsed the PCCM applies to all rural hospitals and isolated practice areas within the HHS Once endorsed the PCCM applies to all rural hospitals • • • • • • • • • • •
the collaborative practice relationship in the rural and isolated context are: the collaborative practice relationship in the rural relationship between health professionals who use the PCCM as a guide. The collaborative practice relationship between health professionals who and delegation. The defining characteristics of relationship incorporates the dual notions of collaboration The PCCM promotes a collaborative approach to patient care. Collaborative practice describes the The PCCM promotes a collaborative approach The PCCM and collaborative practice The PCCM and collaborative practice Endorsing the PCCM in Queensland Endorsing the PCCM who have undergone additional education and have additional authorities to administer and supply med authorities to administer and have additional additional education who have undergone icines, including: Council practice of clinicians the expanded to support requirements legislative the PCCM meets Queensland, In developed and reviewed according to the principles set out by the National Health and Medical Research and Medical Research by the National Health to the principles set out reviewed according developed and The Primary Clinical Care Manual (PCCM) supports and enables rural, remote and isolated clinicians to clinicians and isolated rural, remote enables supports and (PCCM) Care Manual Clinical The Primary been It has in these areas. people living for the and safe care based evidence the best possible provide Introduction 8 introduction EWARS tools: Standards andtheNationalConsensusStatement,availableat: deteriorating patients.TheycomplywithStandard8oftheNationalSafetyandQualityHealthService been developed to address human factor elements associated with failures to recognise and manage The PCCMsupportstheuseof health care Recognising andrespondingtoclinicaldeterioration(RRCD)inacute |Primary Clinical Care Manual 10th edition | • • • • • • • • In jurisdictionsoutsideofQueensland,uselocalearlywarningandresponse systemtools Ordering information: – – – – and safetymaybecomplementedby: Clinical incidentanalysisinvolvingtheEWARStoolshasdemonstratedthatqualitypatientcare threshold fornotification clinician hasaconcernregardingpatient,regardlessifthepatient’svitalsignshavereached Are not a substitute for sound clinical judgment - an urgent consultation should take place if the Services QueenslandorRoyalFlyingDoctorService observations andfacilitateearlynotificationtoamedicalofficer,nursepractitioner,Retrieval Provide anoverallscorethat corresponds with an actionforclinicianstoescalatecare,increase Provide atrackandtriggersystemtofacilitatethedetectionofdeterioration Present themostimportantvitalsignsfordetectingdeteriorationinpatients In Queensland,useageandpatientappropriateruralremoteEWARStoolsasperlocalpolicy:
– – – NEWT -neonatal(28daysoldorless) CEWT -paediatric MEWT -maternity Q-ADDS -adult
taking actionasindicatedbythescore complete recordingofallrequiredobservationsandcalculatingscore consistent useofthetools 1 Always calculateandrecordthescore,evenifscoreiszero(0) [email protected] Early WarningandResponseSystem(EWARS)tools.EWARStoolshave https://www.safetyandquality.gov.au/
introduction 9
- Introduction https://www.tga.gov.au/ was under review. For current was under review. For current medicines medicines https://www.health.qld.gov.au/system-governance/licences/ supply supply Health (Drugs and Poisons) Regulation 1996 Health (Drugs and Poisons) https://www.health.qld.gov.au/system-governance/licences/medicines-poi https://www2.health.vic.gov.au/hospitals-and-health-services/rural-health/
administer and and administer The legislation provides definitions and conditions related to a persons authority to use to a persons authority and conditions related provides definitions The legislation
legislation, and ensure they practise within their legal authority for that state/territory when using when state/territory that for authority legal their within practise they ensure and legislation, medicines and poisons If practising elsewhere, clinicians are still able to use the PCCM if their employer authorises them to If practising elsewhere, clinicians are still able to state and territory medicines and poisons do so. Clinicians must be familiar with the relevant rural-endorsed-nurse/ripern-roles local policies If a RIPRN in the Australian Defence Force refer to In Queensland see sons/legislation-standards/acts-regulation In Victoria see: medicines and poisons in rural and isolated areas scope, and in accordance with conditions and Clinicians must practise within their individual for example, Drug Therapy Protocol (DTP) circumstances of practice relevant to their authority, (or equivalent) as required by current legislation. The PCCM incorporates Health Management Protocols to enable clinicians with extended authority Health Management Protocols to enable clinicians The PCCM incorporates the Australian Defence Force) to administer and supply in Victoria and in Queensland (and RIPRNs medicines-poisons/legislation-standards/acts-regulation At the time of print, the At the time of print, the see: laws poisons and medicines Schedules of medicines (S2, S3, S4, S8) within the PCCM are stated according to the current are stated according S8) within the PCCM medicines (S2, S3, S4, Schedules of available at: Medicines and Poisons, Uniform Scheduling of Standard for publication/poisons-standard-susmp medicines Note: administer, supply) medicines (e.g. Authorisation for clinicians to administer and supply medicines is provided by the medicines and medicines the by provided is medicines supply and administer to clinicians for Authorisation familiarise themselves advised to are practise. Clinicians territory of the state or law within poisons for using and adhere to local policies for updates/changes, legislation, check with the relevant
• • • • • • • • • •
Practising in other states or territories Clinicians with extended authorities to use medicines - Queensland, extended authorities to use medicines Clinicians with Australian Defence Force Victoria and the
Queensland Authority to Authority 10 introduction Example ofHMPintopictitle Health ManagementProtocolsand |Primary Clinical Care Manual 10th edition | Information relatedtodrugboxes • • • • • – – – – – – Clinicians should: the medicine Drug boxesarenotintendedtocontainallinformationrequiredforsafeadministrationorsupplyof be administeredorsupplied are the sameasa CCG, but also includeadrugboxprovidingdetailsof the medicine authorised to HMPs arerequiredforclinicianswhopractisingwithanextendedauthorityinQueensland.They HMPs areeasilyidentifiedwiththelettersHMPintopicheader.CCGallothertopics (CCG) Each topic – – – – – – adhere tolocalpoliciesandanyotherlegislativerequirementsinregards tomedicines consult withamedicalofficer,nursepractitionerorpharmacistasneeded, orifunsure practise withintheirindividualscope medical-info/medicine-finder source additional consumer medicineinformationasrelevante.g. be awareofcontraindicationsandknownsideeffectsadvisethepatient accordingly interactions andcontraindications resource priortousingmedicinesforadditionalinformationsuchasadverseeffects, refer tothecurrent • •
in thePCCMiseitheraHealthManagementProtocol(HMP)orClinicalCareGuideline Example ofa Example ofa Drowning/submersion Australian MedicinesHandbook HMP Clinical CareGuideline Health ManagementProtocol Anaphylaxis Clinical CareGuidelines
topic title- -adult/child -adult/child orotheradultpaediatricpharmacology topic title-
no
HMP intitle HMP intitle https://www.nps.org.au/ introduction 11 1,6,7 Introduction
stat 3 days Duration
Extended authority 1 g ATSIHP/IHW/IPAP/RIPRN/SRH ATSIHP/IHW/IPAP/RIPRN/SRH dosage Anaphylaxis, page 102 M. genitalium Recommended For give 500 mg daily only: after stat dose
Take with or without food. May cause rash, diarrhoea, Take with or without food. May cause rash, diarrhoea, : Aboriginal and Torres Strait Islander Health Practitioner and Torres Strait Islander : Aboriginal Oral : Rural and Isolated Practice Registered Nurse : Rural and Isolated Practice Consult MO/NP. See Route of : Isolated Practice Area Paramedic : Isolated Practice Azithromycin : Sexual Health Program Nurse : Sexual Health Program : Authorised Indigenous Health Worker : Authorised : Midwife : Immunisation Program Nurse : Immunisation Program administration ATSIHP IHW IPAP RIPRN SRH MID IPN – – – – – – – – – – – – – – Note abbreviations: Clinicians who have extended authority identified here have extended authority Clinicians who
Always located within an HMP. Identifies which clinicians have extended have which clinicians Identifies an HMP. located within Always . 4 500 mg Strength order Extended authority Extended
obtain an order proceed without an or are authorised to Form if they are required to Clinicians are advised Clinicians are Tablet
Schedule
Provide Consumer Medicine Information: nausea, abdominal cramps and candidiasis Management of associated emergency: RIPRN and SRH may proceed ATSIHP, IHW, IPAP and RN must consult an MO/NP ATSIHP, IHW, IPAP and RN
Example 1: Example an order or requires can proceed clinician details if the topic, and in this (in Queensland) authority Drug box examples box Drug 12 introduction |Primary Clinical Care Manual 10th edition | Midwife. Notrelatedtoanextendedauthority who asausualpartoftheirprofessionareauthorisedtoadministermedicinesonanordere.g.RNor Example 3: Example 2:
ATSIHP, IHW,IPAP,MID,RIPRNandRNmayproceed Management ofassociatedemergency: applied 1or2timesamonthafterinitialtreatment Provide ConsumerMedicineInformation: Schedule MID, RIPRNandRNonly.MustbeorderedbyanMO Management ofassociatedemergency: tissue necrosis.SubcutandIMroute contraindicated respond toIVfluidsandparenteral calcium israrelynecessary.Avoidextravasationaswillcause Note Provide ConsumerMedicineInformation: Injection Shampoo Schedule Form Form Clinicians areadvisediftheyrequiredtoobtainanorder : administer medicinesonanorderasperusualscopeoftheir Only tobeadministeredbyclinicianswhoareauthorised High riskmedicinewhichcanberapidly fatalinoverdose Prescribingguide.Mustbeorderedbyanauthorisedprescriberandonlygivenclinicians Not relatedtoanextendedauthority.Anordermayornotberequired or areauthorisedtoproceedwithoutanorder Must beorderedbyanauthorisedprescriber. (2.2 mmol) Strength Unscheduled in 10mL 25 mg/mL Strength (2.5 %) 10% Unscheduled profession e.g.RN,Midwife
administration Route of administration Calcium gluconatemonohydrate IV Route of Topical Consult MO/NP ConsultMO. Completecourse.Tohelppreventrecurrence,canbe
Givenforoverdoseofmagnesiumsulfate Selenium sulfide
2.2 mmol(10mL) Recommended See dosage Anaphylaxis, page102 Leave onforatleast10 minutes orovernight Apply towetskin. Recommended . Hypotensionalonewillgenerally
dosage Daily Prescribing guide in alargeperipheral Inject slowlyover Prescribing guide
5-10 minutes
identified Duration left blank vein stat 7-10 days Duration 5,8 1,3 introduction 13
Water Introduction Renal colic has been changed to Marine lacerations Appendices Mental health and substance misuse Mental health and substance Obstetrics and neonatal health Sexual and reproductive Paediatrics Immunisations Patient assessment and transport and transport Patient assessment and vomiting Pain, nausea Emergency General
9. 10. 6. 7. 8. 4. 5. 2. 3. 1. related wounds alignment with common usage of terms e.g. –
Topic name changes considered: – Some topics have had name changes. The index includes previous topic names to enable easy Some topics have had name changes. The index includes previous topic names to enable navigation to the new name Subsections are now identified by the title being contained within a coloured bar Subsections are now identified by the title being rather than individual topic titles Coloured side bars now contain subsection titles navigation to topics within this section Obstetrics and neonatal was previously included in the Sexual and Reproductive health section Obstetrics and neonatal was previously included of obstetrics and neonatal care, and enables easier Separating this section recognises the specialty Where there is a specific indication for medicine management of pain or nausea for a given Where there is a specific indication for medicine that HMP e.g ketorolac in presentation, the drug box has remained within Consolidates the presentation, assessment, management and follow up around pain, nausea and Consolidates the presentation, assessment, management vomiting from all HMPs vomiting by clinicians Allows broader consideration of pain, nausea and Colour coding for each section is used in page side bars, headings, tables, flow charts and drug box drug and charts flow tables, headings, bars, side page in used is section each for coding Colour shading as follows: The 10th edition of the Primary Clinical Care Manual has been increased from 8 to 10 sections from been increased Manual has Clinical Care the Primary edition of The 10th
• • • • • • • • • • •
Topic name changes Sub-sections more clearly identified
New Section: Section 6, Obstetrics and neonatal New Section: Section 6, Obstetrics New Section: Section 2, Pain, nausea and vomiting New Section: Section 2, Pain, nausea
New Section structure Section New What's new in this edition this in new What's 14 introduction New topics New HMPforsupplyofmedicinesbyATSIHPandIHW |Primary Clinical Care Manual 10th edition | Non-acute topicsremoved • • • • • • • • • • • • • The – – – – – guidance Conditions Manual:PreventionandManagementofChronicinAustralia Non-acute topicshavebeenremovedfromthePCCMwithusersbeingreferredtoThe Therapy Protocol(orequivalent) and IHWareadvisedtoinsteadcheckthemedicineislistedwithintheirrelevantDrug conditions tobelistedinthePCCM.DrugboxesarethereforenolongerincludedthisHMP.ATSIHP The ATSIHPandIHWDrugTherapyProtocolsnolongerrequireallmedicinesforsupplychronic ATSIHP andIHW. The HMPs have been consolidatedintoasingle HMP – – – – – – chronic conditionsbyATSIHPsandIHWs,including: In thepreviouseditionofPCCM,severalHMPsexistedtoenablesupplymedicinesfor – – – Urticaria, allergicrhinitis Breech birth Shoulder dystocia Unintended pregnancy Dental caries Deep veinthrombosis(DVT) Nausea andvomiting Acute painmanagement – – – – – – – – – – – – – – Dementia Poor growthinchildren Health check-women Alcohol misuse Tobacco smoking Diabetes Chronic heartdisease(CHD) Chronic kidneydisease(CKD) Hypertension Chronic obstructivepulmonarydisease(COPD) Chronic asthma reflect theinclusionofHyperosmolarhyperglycaemicstate expansion ofcontente.g. emergencies alignment withcontemporaryterminologyintheliteraturee.g. ischaemia ease ofindexingtoaidnavigatione.g. Eating disorders : https://publications.qld.gov.au/dataset/chronic-conditions-manual hasbeenchangedto This doesnotchangethescopeofpracticeATSIHPorIHW and Insomnia Diabetic ketoacidosis(DKA) topics havebeenremoved(notwithinthescopeofPCCM) Acute severebehaviouraldisturbance(ASBD) New topics • • • • • • Arterial occlusion De-escalation techniques (Appendix) Donovanosis Genital herpessimplexvirus(HSV) dementia (BPSD) Behavioural andpsychologicalsymptoms of Interventions innon-consentingpatients and IHW Supply ofchronicconditionmedicinesbyATSIHP Supply ofchronicconditionmedicinesby hasbeenchangedto hasbeenchangedto Mental healthbehavioural
including: Hyperglycaemia Acute lowerleg Chronic for to
introduction 15 Emergency Introduction and placed into and placed and placed into Section into placed and stage st Emergency Consolidated/expanded Imminent birth Immediate care of the newborn Acute pain management Acute wounds Specific respiratory presentations e.g. Acute asthma, Pneumonia Specific marine toxinology fish, presentations i.e. Box jelly Fish stings, etc Urticaria, allergic rhinitis Adult and child History and physical examination (skin assessment) Hypertension in pregnancy Vaginal bleeding in early pregnancy - up to 20 weeks gestation Preterm labour Labour 1 Acute pain management support (ALS) Advanced life Chest pain assessment Acute coronary syndromes • • • • • • • • • • • • • • • • and placed into Section 3 Paediatrics has been relocated from relocated been has
Mental health and substance misuse Original name Original Topic consolidation or expansion consolidation Topic has been relocated from Prevention of neonatal distress syndrome Normal labour and birth Simple analgesia (back cover fold out) pressure in pregnancy Chronic hypertension Vaginal bleeding in early pregnancy Miscarriage/incidental bleeding in pregnancy Suppression of preterm labour Assessment and examination of skin, hair and nails Hypertensive disorders in pregnancy Hypertension in pregnancy Management overview - blood Subungual haematoma Breathlessness Marine envenomation reaction Mild and moderate allergic Cardiorespiratory arrest Cardiorespiratory Chest pain fish Removal of small embedded hook Removal of tight ring Pain management for Pain management transfer interfacility • • • • • • • • • • • • • • • • • • • • Paediatrics has been relocated from relocated been has Emergency Button battery ingestion/insertion - child - ingestion/insertion battery Button Delirium 3 Section 8 Meningitis-adult/child – – –
Section – The following topics from the 9th edition have been relocated in this edition: The following topics from the 9th edition have been – –
• Simple analgesia neonatal Obstetrics and General Emergency assessment and assessment transport Patient Topic consolidation, expansion or relocation or expansion consolidation, Topic 16 introduction |Primary Clinical Care Manual 10th edition | Page leftintentionallyblank 1
Patient assessment and transport
17 Patient assessmentSection 4 Page left intentionally blank andGeneral transport
18 | Primary Clinical Care Manual 10th edition | Patient Patient presentation - adult and child
General principles
The first priority is to assess whether the patient is seriously ill and needs immediate p management, or is less acutely sick giving time to obtain a full history re
Always ask 'open' questions sentation In children, pay particular attention to history from parent/carer where available
Rapid assessment • Does the patient look well or sick • Airway - compromised • Breathing - not breathing, significant respiratory distress • Circulation - pulse absent, slow, rapid or profuse bleeding • Level of consciousness - Alert, Voice, Pain, Unresponsive • Rapid history, allergies
• RR, SpO2, HR, BP, T - full emergency Q-ADDS/CEWT or other local EWARS Is the patient immediately at risk?
Yes No
Perform immediate If this is a trauma presentation e.g. fall/hit by an object/ stabilising or life saving measures. As motor vehicle accident, immediately assess patient against relevant see DRS ABCD resuscitation/ Criteria for early notification of trauma for interfacility the collapsed patient, page 54 transfer (inside front cover) If meets criteria contact RFDS, RSQ Consult MO/NP as soon as 1300 799 127 or your local/State escalation circumstances allow
Obtain a history and perform physical examination as relevant See History and physical examination - adult, page 20 or History and physical examination - child, page 664
Form a clinical impression
Is there an appropriate Health Management Protocol (HMP) or Clinical Care Guideline (CCG)
Yes No
Initiate appropriate Contact MO/NP as management as per HMP/ appropriate CCG
Section 1: Patient assessment and transport | Patient presentation 19 Adult presentation tion a History and physical examination - adult
Recommend • For paediatric presentations see History and physical examination - child, page 664 in Section 8, Paediatrics • This section is designed to assist clinicians to document their findings clearly, concisely and in logical sequence Adult present Adult • Opportunistic health promotion and screening should occur during visit whenever appropriate. For screening tools and checks, see the Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://publications.qld.gov.au/ dataset/chronic-conditions-manual Background • The history is the most powerful tool for identifying the likely diagnosis in most cases2,3 • Types of history taking:4 –– complete - comprehensive history of the patient's past and present health status. Usually done at initial visit in a non-emergency situation –– episodic - is shorter and specific to the patient's current presenting concern –– interval or follow up - builds on a preceding visit. Documents the follow up required from the prior visit –– emergency - only information required immediately to treat the life-threatening condition is gathered from patient or witnesses. A more comprehensive history may be taken once patient is stabilised
Related topics Mental health assessment, page 450 How to perform an STI check, page 617 History and physical examination - child, page 664 Traumatic injuries, page 163
Adult approximate normal values - can vary by person, age, activity and time of day1,2 Temperature (oral) (T) 36.5-37.5°C1 Heart rate (HR) 60-100 beats/minute3 Respiration rate (RR) 12-20 breaths/minute1 Blood pressure (BP) Systolic < 130 mmHg AND diastolic < 85 mmHg3 2 O₂ saturation (SpO2) ≥ 94% Conscious level (AVPU) Alert Always document clinical observations on Q-ADDS rural and remote or other local Early Warning and Response Tool Calculate and act on Q-ADDS score if indicated If pregnant, use Q-MEWT rural and remote antenatal tool
20 | Primary Clinical Care Manual 10th edition | Adult present Step 1: Obtain history of the presenting concern/problem3
• Taking the history is the first step in making a diagnosis • The history will be used to direct the physical examination/further investigations • More often than not an accurate history suggests the correct diagnosis, whereas the physical examination and subsequent investigations merely serve to confirm this impression3 a t ion History of the presenting concern/problem3 Presenting • Ask what the problem is concern/ • Use open ended questioning problem • Ask about length of illness and details of symptoms • For each symptom, as relevant, ask about: Site: where is the symptom - localised or diffuse Onset: –– gradual, rapid or sudden onset –– continuous or intermittent History of –– what were they doing when it started presenting Character: e.g. sharp, dull or burning concern Radiation of pain or discomfort Alleviating factors: does anything make it better e.g. sitting up, medicine, analgesic Timing: when did it first begin; have they had it before Exacerbating factors: does anything make it worse e.g. movement Severity: if pain; mild, moderate or severe See pain assessment tools in Acute pain management, page 35 • e.g. nausea, vomiting, photophobia, headache, appetite, urine, bowels, Any associated/ energy other symptoms • Ask specifically aboutfever, pain, shortness of breath, diarrhoea, weight loss Treatment and/ or medicine(s) • What, how much, when, how often, effectiveness taken during this illness • Ask if there are any other concerns • Consider possible differential diagnosis • Use closed ended questioning to help confirm or eliminate various possibilities
Section 1: Patient assessment and transport | Adult presentation 21 Step 2: Ask about past history3
tion • Review and update past history in clinical records each visit a • Consider relevant past history that may assist with differential diagnosis this visit • Always ask about allergies and medicines
Past history3 • Significant illnesses in the past Past medical • Ask about diabetes, hypertension, angina and heart attacks, epilepsy, asthma, Adult present Adult and surgical mood/mental health problems history • Previous hospital admissions, operations or injuries: where, when and why • Health problems in the family, especially siblings and parents e.g. diabetes, Family history hypertension, ischaemic heart disease, epilepsy, asthma, malignancies, mental health • Job, marital status, housing, who else lives at home and what responsibilities do they have in the family • Smoking - ever smoked, how many a day, ever tried giving up Social history • Alcohol - how much and how often. Express in standard drinks per day or week • Ask about the use of recreational drugs • Recent overseas travel - where/when • Diet/exercise • Regular and prn medicines: prescribed, complimentary, alternative, bush medicines, over the counter: –– generic name Medicines –– dose, frequency –– taken correctly • Ask females if they are taking oral or other contraception • See Medication history and reconciliation, page 778 • Ask about adverse reactions/allergies to: –– medicines –– other allergies e.g. honey bee stings, sticking plaster, food • Specific reaction: Allergies –– anaphylaxis, skin reaction, bronchospasm, other and adverse • Is an adrenaline (epinephrine) autoinjector e.g. EpiPen® used medication • Check for medic alert jewellery and accessories: reactions 5 –– may be normal jewellery or other accessory –– e.g. key ring, USB stick, shoe tag, anklet, watch, tattoo • Check clinical records • If adverse medication reactions/allergies ensure documented as per local policy6 • Check if up to date Immunisations • Offer opportunistic immunisation as appropriate • See Immunisation program, page 768 • Check if due for routine health check e.g: –– STI/BBV; Cervical Screening Test; mammogram Opportunistic –– adult health check. See the Chronic Conditions Manual: Prevention health checks and Management of Chronic Conditions in Australia available from: (if appropriate) https://publications.qld.gov.au/dataset/chronic-conditions-manual • Offer or refer for health checks as appropriate
22 | Primary Clinical Care Manual 10th edition | Adult present Step 3: Perform physical examination3
• Most information will be gained from history taking –– use information from history of presenting concern to guide your examination • In an adult who is not sick: –– examine the relevant system first –– proceed to further examination if required - be guided by your findings
• In a sick adult: a
–– examine the relevant system first followed by ALL other systems t ion • Use a systematic approach to physical examination
Physical examination - adult3 • RR
• SpO2 • BP • HR • T • Conscious state - AVPU ± GCS. See Glasgow Coma Scale/AVPU, page 785 Standard clinical observations - for all • If indicated: patients presenting –– BGL –– capillary refill time: < 2 seconds
• Always document on Q-ADDS rural and remote/other local Early Warning and Response Tool. Calculate score • If pregnant, use Q-MEWT rural and remote tool
• Do they look well or sick • What posture are they assuming • Observe: –– mobility –– any breathlessness –– conjunctiva and nail beds: are they pale General appearance –– lips, tongue and fingers: are they blue –– general skin colour - pale/jaundiced –– agitation, distressed –– body/breath odours –– sweating –– are they well nourished • Weight, BMI, waist measurements • Eyes - normal or sunken • Mouth and tongue - wet or dry • Skin turgor normal or reduced - Pinch skin: normal skin returns immediate- Hydration ly on release (normal to be reduced in elderly) • Dry axillae • Recent weight loss/weight gain (continued)
Section 1: Patient assessment and transport | Adult presentation 23 Physical examination - adult (continued) tion
a • Be guided by history and presentation • Check the whole body in a sick patient: –– consider removing clothing to underwear • Look for: –– rashes - non-blanching, petechiae, purpura –– signs of infection - redness, swelling, tenderness –– bruising, unexplained or unusual marks Skin –– general pigmentation - areas where skin is lighter or darker
Adult present Adult • Any skin lesions or sores: –– colour, shape, size, location, distribution on body –– exudate e.g. clear, pus, bloody –– any family members/close contacts with similar lesions • Palpate noting: –– temperature, dryness/moisture, clamminess • Are there palpable/tender lymph nodes in the neck, axillae or groin • Any pain/pressure in neck, chest, arms • Any shortness of breath on exertion • Skin colour - pink, white, grey, mottling. Compare trunk with limbs • Skin temperature - hot, warm, cool or cold. Compare trunk with limbs • Central perfusion - blanch skin over the sternum with your thumb for 5 Cardiovascular seconds. Time how long it takes the colour to return system • Peripheral perfusion - blanch the skin on a finger or toe for 5 seconds. Time how long it takes for the colour to return • Any evidence of oedema, particularly feet, hands, face or sacrum • Look for distended neck veins • If skilled, listen to heart sounds • See Chest pain assessment, page 130 for detailed assessment • Most information is gained from simple observation • Inspect anterior/posterior chest - equal chest expansion, abnormal chest movement, use of accessory muscles of respiration, tracheal tug • Can they talk in full sentences, or only in single words, or unable to talk at all • Measure the respiratory rate over one minute - note rhythm, depth and Respiratory system effort of breathing • Listen for extra noises - cough (loose, dry, muffled, ± sputum), wheeze, stridor, hoarseness • Auscultate for air entry into both lung fields: equal, adequate, any wheezes or crackles. Do they occur on inspiration or expiration • Percuss lung fields - dull, resonant, hyper-resonant • Can they lie flat without breathlessness (continued)
24 | Primary Clinical Care Manual 10th edition | Adult present
Physical examination - adult (continued) • Inspect abdomen for scars, distension, hernias, bruising, striae, masses • Auscultate bowel sounds in all 4 quadrants - present or absent • Palpate abdomen: –– soft or firm –– any obvious masses
–– tender to touch. Identify abdominal quadrant and exact area a t
–– any guarding or rigidity even when the patient is relaxed ion –– any rebound tenderness i.e. press down and take your hand away very quickly, is pain greater when you do this Gastrointestinal/ • Change of bowel habits reproductive system • Ask women: –– date of last normal menstrual period –– abnormal vaginal bleeding or discharge –– do point of care pregnancy test on all females of childbearing age with abdominal pain • In men: –– if relevant check the testes - any redness, swelling or tenderness –– enquire about penile discharge • See Acute abdominal pain, page 238 for detailed assessment • Assess conscious state. See Glasgow Coma Scale/AVPU, page 785 • Any dizziness, fainting, blackouts, problems with speech, vision, weakness in arm/leg, altered sensation, neck stiffness • Pupils - size, symmetry, response to light • Assess orientation to time, place and person: –– ask the patient their name, date of birth, location Nervous system –– ask them to tell you the time, date and year • Look for inequality between one side of the body and the other. Compare the tone and power of muscles of each side of the face and limbs • Test touch and pain sensation using cotton wool and the sharp end of the percussion hammer • Test finger nose coordination and if possible observe the patient walking • Ask if any painful or stiff joints or muscular pain Musculoskeletal • Observe gait system • Inspect joints for redness, swelling and pain • As indicated, test the visual acuity of each eye, use a Snellen chart at 6 metres in good light • Look at the eyes and surrounding structures - any redness, discharge or swelling Eyes • Look at the pupils - are they equal in size and regular in shape. Check pupillary reflex to light • Check eye movements • See Assessment of the eye, page 358 for detailed assessment (continued)
Section 1: Patient assessment and transport | Adult presentation 25 tion Physical examination - adult (continued) a Ears • Inspect the pinna - redness, swelling, nodules • Any obvious swelling or redness of the ear canal. If there is, looking with an otoscope will be painful • Look inside with an otoscope and inspect ear canal - any redness, swelling, discharge • Inspect eardrum - normal/redness, dullness, bulging/retraction, fluid or
Adult present Adult air bubbles, perforations or discharge • Check behind the ear (mastoid) for redness/swelling/pain Ears, nose and throat • See Ear and hearing assessment, page 708 for detailed assessment Nose • Feel for facial swelling (sinuses) inflammation, pain • Any discharge or obvious foreign body Throat • Inspect the lips, buccal mucosa, gums, palate, tongue, throat for: –– colour changes/swelling/bleeding/pus/fissures • Teeth - condition • Inspect tonsils - redness, enlargement or pus • Examine the urine of all sick patients, all patients with abdominal pain or urinary symptoms and all patients with a history of diabetes • Note colour • Presence of deposits/crystals/foam Urine • Note odour • Perform urinalysis • Perform point of care pregnancy test in all females of childbearing age with abdominal pain
Step 4: Consider differential diagnosis • If unsure, collaborate with MO/NP Step 5: Select Health Management Protocol or Clinical Care Guideline • To guide further assessment and management • Document the page number of the HMP/CCG referred to in the clinical record Step 6: Order/collect pathology if indicated • RIPRN:7 –– may order pathology as per a HMP –– name and signature of the MO, NP or RIPRN must be on request form or follow local protocol for electronic ordering –– if RIPRN orders pathology, they are responsible for following up the result –– consult MO/NP if results are abnormal • Other clinical staff may be able to request pathology if there is a local agreement in place between the director of the clinical unit and Pathology Queensland/local health service • Write or record on electronic request ‘copy of report to…’ RFDS/other collaborative health provider on the pathology form as appropriate
26 | Primary Clinical Care Manual 10th edition | Adult present • Point of care testing is available in some facilities e.g. iSTAT® • See Pathology Queensland for: –– pathology test list –– rural and remote pathology request forms –– see https://www.health.qld.gov.au/healthsupport/businesses/pathology-queensland/ healthcare • If outside Queensland refer to local pathology services a t
Step 7: Collaborate with MO/NP as needed ion • Have Q-ADDS score completed • Use ISOBAR to guide your communication. See Clinical consultation, page 28 • Always consult with MO/NP if you are not sure • Check your local facility guidelines to find out who to contact - during and after hours
Queensland contacts may include: Local/onsite MO/NP Check contact details/on call roster at your workplace
• Routine and emergency medical advice, support and coordination 1300 697 337 Royal Flying Doctor to primary health care facilities at (1300MYRFDS) Service (RFDS) which RFDS provide GP services, Cairns RFDS base: 07 4040 0500 (Queensland Section) aeromedical retrieval and Mount Isa RFDS base: 07 4743 2802 transport services Charleville RFDS base: 07 4654 1443 • 24 hour telehealth, coordination and emergency medical advice 1300 799 127 Retrieval Services • For critically unwell, high acuity Keep your video conferencing equip- Queensland (RSQ) patients e.g. if local doctor not ment switched on at all times. RSQ available, or if RSQ is your first will make a video conference call. point of contact No need to use remote control • For lower acuity, non-critical clinical support and advice via video conference • 24 hour, 7 day a week nursing 1800 11 44 14 Telehealth Emergency support to rural and remote Management Support nursing staff in Queensland https://qheps.health.qld.gov.au/ Unit (TEMSU) Health facilities temsu • Medical and subspecialty support may be available depending on locally agreed pathways
Section 1: Patient assessment and transport | Adult presentation 27 Clinical consultation
Consulting with MO/NP/retrieval co-ordinator1 • Be clear and methodical sultation • Write your findings down first time permitting on Advise early if you think the patient may need evacuation c • • Say what you think is wrong. Your assessment is important al al
c Identify yourself AND identify name and spelling of receiving MO/NP • I am ... (your name and role) I • I am calling from ... (location) Clini Situation and status - why are you calling • I have a patient ... (name, age and gender) • I think the patient is/has ... (clinical impression/sus- S pected diagnosis/unsure but worried) • Who is ... (stable/unstable/deteriorating/improving)
Observations • Most recent observations • The Q-ADDS/MEWT/CEWT score is ... (or other local Early Warning and Response tool O score) • General appearance • Weight
Background • History of presenting problem, relevant past history • Evaluation - physical examination, findings, investigation findings • Allergies B • Current medicines
• I have …(taken the following actions e.g. given O2, inserted IV, started IV sodium chloride 0.9%)
Agree to a plan • I am wanting … (advice, orders, evacuation) A • Level of urgency is ... • Agree on plan of action with MO/NP/retrieval co-ordinator
Recommendations and read back • Confirm shared understanding of what needs to happen - who is doing what and when • Read-back critical information R • Identify parameters for review or escalation • Identify any risks
28 | Primary Clinical Care Manual 10th edition | Patient retrieval/evacuation Patient retrieval/evacuation 1. Who to contact • Usually the MO/NP or DON (if possible) will arrange evacuation if required • Be guided by local facility policy as to which retrieval service to contact: –– RSQ 1300 799 127 –– some facilities contact RFDS (Qld section) directly –– if the community is normally serviced by the RFDS for advice and evacuation, RFDS will advise RSQ of evacuation requirement • If you think a patient may need evacuation/retrieval, contact the relevant retrieval service early: –– even if transport requirement not confirmed –– this helps allocate resources • Notify change of clinical condition of patient if worsening or improving: –– flight priority can always be reassessed
Retrieval Services Queensland (RSQ) • Provides clinical coordination for aeromedical transfer for patients from parts of Northern NSW to the Torres Straits • Utilises multiple government and non-government organisations to achieve aeromedical coverage of Queensland - e.g. RFDS Qld, QAS, QGAir Helicopter Rescue, Life Flight Retrieval Medicine • Provide specialist medical and nursing coordinators in adult, paediatric, neonatal and high-risk obstetrics • Return of patients to referring centres where aeromedical transfer is required • Emergency retrieval and transport criteria of patient –– meets early notification of trauma criteria. See Criteria for early notification of trauma for interfacility transfer (inside front cover) – requires aeromedical evacuation – Q-ADDS/CEWT/MEWT: ≥ 6 or E – > 2 hours/200 km by road to receiving hospital – requires medical escort – all neonate/high-risk obstetric, critically ill/injured adult and paediatric patients • For further information: https://qheps.health.qld.gov.au/rts
Section 1: Patient assessment and transport | Patient retrieval/evacuation 29 2. Retrieval preparation
Retrieval preparation • Complete the RFDS Aeromedical retrieval checklist • Ensure all appropriate documentation, as per local protocol and as part of the clinical handover, accompanies patient including: –– pre-hospital documentation –– referral letter Documentation –– copy of nursing/medical records –– pathology results –– ECG print out –– X-rays –– if digital radiology available, if possible electronically transfer x-rays to receiving facility • Handover location will be determined during the retrieval coordination
Patient retrieval/evacuation Patient process Handover • If patient stabilised and prepared, handover at airport/airstrip may occur location • Critical and unstable patients will be reviewed at the referring facility by the retrieval team prior to transport Patient escort • If room, an escort may be carried at the discretion of the pilot and baggage –– name, weight of escort required Space and weight • Maximum baggage allowance is one (1) small bag with a weight of 5 kg restrictions apply • Medical aids/additional baggage at the pilot’s discretion General preparation Consideration Requirements Rationale Allergies/ • Apply ID bands if available • Rapid correct identification identification • Give analgesia as clinically indicated • Movement of the patient Analgesia prior to transfer. See Acute pain may exacerbate pain management, page 35 • Parenteral antiemetic essential if: –– head, spinal, or penetrating • Vomiting may exacerbate certain eye injury clinical conditions by raising • Consider for: ICP and intraocular pressure Antiemetic –– history of motion sickness • Puts airway at risk –– general nausea • Motion sickness common in • Give 30 minutes prior to transfer aeromedical environment • See Nausea and vomiting, page 48 • Ensure most patients have at least 1 • Venous access may be difficult Intravenous IVC during flight due to space cannula (IVC) • Insert 2 x IVC in critically ill and restrictions and turbulence disturbed patients • Get patients to empty their bladder prior to transfer • No toilet facilities on aircraft • Use of bedpans is avoided due to Urinary catheter Insert urinary catheter in: limitations of space and waste • Incontinent or potentially incontinent disposal patients (continued)
30 | Primary Clinical Care Manual 10th edition | Patient retrieval/evacuation
General preparation (continued) Consideration Requirements Rationale • Prior to transfer prepare infusions • Time is saved if infusions Parenteral medicine using compatible equipment, if are prepared prior to infusion possible, when using RFDS RFDS arrival or other retrieval services • Allow for drainage of • Ensure NGT/OGT inserted in: Nasogastric tube (NGT) or stomach contents and –– all ventilated patients orogastric tube (OGT) reduce risk of vomiting and –– patients with bowel obstruction aspiration Specific medical conditions Consideration Requirements Rationale • Reliable IV access. If possible 2 x IVC • For aviation safety, special • Complete RFDS risk assessment requirements apply to Transfer of disturbed patients transportation of patients Mental illness/disturbed including patient with a mental showing signs of disturbed behaviour illness behaviour, or regarded • Sedation and physical restraint may as being a danger to be required. Seek medical advice themselves or others • Always advise retrieval coordinator • Limited ability to isolate Infectious conditions of infectious conditions patients in aircraft • Transport on vacuum mattress • Insert urinary catheter Spinal injury • To maintain stabilisation • Insert NGT if have altered level of consciousness • Insert NGT - leave on free drainage • Trapped gas will expand or attach anti-reflux valve in volume at altitude Bowel obstruction (do not spigot) and cause pain. NGT • Give parenteral antiemetic and will allow gas to escape adequate analgesia prior to transfer and reduce vomiting • Trapped gas in the pleural • Ensure intercostal catheter in place cavity will expand at • Connect to Heimlich valve or altitude and may result in Portex® ambulatory chest drain respiratory compromise Pneumothorax system • Underwater seal drains are • Suspected pneumothorax should be avoided due to the risk of excluded, if possible, by appropriate retrograde flow during imaging transfer • Trapped gas in the globe will expand at altitude and • Give antiemetic to all patients with potentially worsen the proven or suspected eye injury Penetrating eye injury injury • Patients may be transported • Vomiting may also at reduced cabin altitude exacerbate injury by raising intraocular pressure
Section 1: Patient assessment and transport | Patient retrieval/evacuation 31 Patient assessment and transport
RFDS Aeromedical Retrieval Checklist
Date and time of request for ETA retrieval / transport (Will be confirmed in flight) PATIENT TRANSPORT DETAILS Patient Patient Weight Valuables - specify Name (kg) Date of Sex Small bag <5 kg
Birth M F Any other luggage must be approved by RFDS flight crew Address Escort (Must be approved by Approval RFDS flight crew) Weight (kg) Escort Name Escort Relationship to Patient Diagnosis
Infectious Y N Next of Kin Contact Number condition Specify Patient retrieval/evacuation Patient e.g. MRSA
Mobility Able to manage stairs Requires stretcher PLEASE NOTE Please advise RFDS MO or Clinical Coordinator immediately if clinical status deteriorates Any patient with a fear of flying; who is claustrophobic; who is confused, agitated or aggressive must be discussed in full with the RFDS MO or RSQ Clinical Coordinator REFERRAL DETAILS Referring Facility Referring Clinician Receiving Facility Receiving MO CLINICAL INFORMATION (where applicable) Infusion concentrations and rates must be documented on fluid order sheet and a copy sent with the patient Size Site Date inserted Infusion IV Cannula (1) IV Cannula (2) Toilet prior to flight Urinary Catheter ICC Heimlich valve Fracture Immobilisation Gastric tube (Free drain for flight) Chest drainage bag Other (Specify) Medicines given prior to transfer must be documented on a medication sheet and copy sent with the patient Ensure adequate analgesia and antiemetic is given if necessary Medication given prior to flight Dose and route given Time given Analgesia Antiemetic Sedative Other DOCUMENTATION All patients must be accompanied with appropriate documentation Copies / originals of all the following must accompany Other documentation that may be relevant during transfer LETTER Current Medication Sheet Inpatient Notes QAS MATT Form Medical Fluid Orders Emergency Dept flowsheet Request for Assessment Nursing Fluid Balance Chart QAS Report Form OBSERVATION FORMS ECGs Theatre Notes PATHOLOGY SPECIMENS Vital Signs Pathology Results Immunisation Status IATA Packing Instruction Neurological Observations Xrays PTSS Form 650 Blood Sugar Levels HANDOVER Handover location and road transport details will be discussed during the coordination of the retrieval Hospital handover RFDS to arrange ambulance Discuss any questions with the RFDS MO or RSQ Clinical OR OR Coordinator and / or refer to Airport handover Hospital to arrange ambulance Primary Clinical Care Manual Additional comments Name
Signature
24 UncontrolledControlled copy copy V1.0 Primary Clinical Care Manual 2013 32 | Primary Clinical Care Manual 10th edition | 2
Pain, nausea and vomiting
33 Section 4 Page left intentionally blank General
34 | Primary Clinical Care Manual 10th edition | acute pain management 35 Acute pain management pain Acute 130 Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, Chest pain assessment, page page assessment, pain Chest
786 1,2 management pain pain
1 2 appropriate analgesia appropriate reassessment of the pain assessment of the pain assessment – – – other cause earache renal colic cardiac pain gout in the diagnostic process) abdominal pain (note: analgesia does not impact headache toothache burns back pain herpes zoster fracture or dislocation soft tissue injury e.g. wound, abrasion, contusion Acute Acute
– – – – – – – – – – – – – previous pain experience, beliefs expectations, mood and ability to cope previous pain experience, others involved in their care others involved in their with actual or potential sensory and emotional experience associated Pain is 'an unpleasant in terms of such damage' tissue damage, or described other things, by culture, multifactorial experience influenced, among Pain is an individual, This topic is intended for initial management of acute pain in rural and isolated areas or during rural and isolated areas in pain acute of management initial for intended is topic This inter-facility transfers and MO/NP patient, the between process collaborative a be should management pain Ongoing – – Effective management of pain requires: Effective management – If chest pain, immediately see If severe acute pain or pain due to an emergency obtain rapid patient history – – – – – – – – – – – Could present as/be related to: – – Self-report of acute pain anger, grimacing Emotional responses to pain e.g. crying, screaming,
Safe use of paracetamol, page page paracetamol, of use Safe
Related topics • • • • • • • • • •
Recommend Background
HMP HMP 2. Immediate management
1. May present with Acute pain management pain Acute 36 acute pain management .Clinical 3. | Primary Clinical Care Manual 10th edition | Pain assessmentscales • • • • • • • Warning (full observations clinical standard Perform – Verbal analoguescale Verbal ratingscale – – Obtain pastmedicalhistory,inparticular: – – Ask about: – – – – – – – – Ask aboutthepain: Always seektoidentifythecauseofpain – – – – – – – – – – – – – ask thepatienttoindicateapositionalonglineindicatingtheirpain level allergies current medicines;overthecountermedicines pain reliefusedinpast-whatworked/didnotwork;sideeffects – any painreliefalreadygiven/takenpriortopresentatione.g.bycarer,self,orambulancestaff – Severity -atrest;onmovement – Exacerbating orrelievingfactors: – – Timing -duration,constantorintermittent Associated symptomse.g.nausea,vomiting,sweating,fever Radiation -doesitspreadanywhereelse Characteristics e.g.sharp,throbbing,aching,burning,stabbing – – Onset Site -whereisit – – – – – – – when, what,dose,howeffective assess usingappropriatepainscaleforpatient e.g. rest,medicines,eating,positionchanges,ice/splinting ever hadthispainbefore;howoftendoesitoccur has anythingchangedthepain result oftrauma/activity/cold/stress sudden orgradualonset -whendiditstart and ResponseTools) assessment pain No 0 12345 678910 the worstpainyoucouldimagine,wherewouldrate “On ascaleof1to10,withzerobeingnopainatalland10 1,2 - adults/olderchildren 2 - adults/olderchildren 2 you areexperiencingrightnow” ADDS/MEWT/CEWT score or other local Early local other or score Q-ADDS/MEWT/CEWT possible Worst pain acute pain management 37 point to each 2 Acute pain management pain Acute
Frequent to constant quivering chin, clenched jaw Kicking or legs drawn up Arched, rigid or jerking Crying steadily, screams, sobs, frequent complaints Difficult to console or comfort ] 8 10 right now 1 ]. It shows very much pain. Point to the face 2 months-7 years 2 months-7 - Uneasy, restless, tense Squirming, shifting, back and forth, tense Moans or whimpers, occasional complaint Reassured by touching, hugging or being talked to, distractible Occasional grimace or frown, withdrawn, disinterested 2,3 - 4-12 years Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, 2,4 ] shows no pain. The faces show more and more pain [ ] shows no pain. The faces show more and more point to right-most face 0 that shows how much you hurt [ one [ These faces show how much something can hurt. These faces show how much something can hurt. this 4 6 No cry (awake or asleep) Content, relaxed Normal position or relaxed Lying quietly, normal position, moves easily No particular expression No particular expression or smile ] up to point to left-most face 2 0 = relaxed and comfortable 0 = relaxed 1-3 = mild discomfort pain 4-6 = moderate 7-10 = severe discomfort/pain observe legs and body uncovered legs and body observe and tone assess body for tenseness or observe activity; reposition patient interventions if needed initiate consoling – – – – – – – clinician to score the chosen face clinician to say 'hurt' or 'pain' (language child understands) do not use words like 'happy' or 'sad' – – – calculate score: – – also use if unable to verbally communicate if unable also use 2-5 minutes: for at least behaviour observe – – – – – – – – – FACES pain scale revised (FPS-R) – – – – – FLACC behavioural pain assessment scale assessment pain behavioural FLACC Behaviour ctivity onsolability ry egs ace This face [ • • C C A L F from left to right 0 38 acute pain management 4. Management | Primary Clinical Care Manual 10th edition | • • • • • • • • • • • • Massage, heatpack In youngchildren:distraction,positioning, sucroseandcoldapplicationmaybehelpful Distraction, imagery Reassurance -explanationsofcausepainandexpectedoutcome(to relieve anxiety) Repositioning Elevation andsplintingofinjuries Ice – – Use astepwiseapproachtoacutepainmanagement: – – – – – – – – Some causesmayrequirealternativetreatment/considerations: – – – – – – Select analgesiabasedonclinicalassessment/judgement,withconsiderationof: – – – – – – Consult MO/NPif: – If severepain,consultMO/NPassoonable: – – – – – – – – – – – – – – – – – – – – – – – titrate updependingonpatient’sresponse start withdosestowardslowerendofrangeornonpharmacologicaloptions 787 (procaine penicillin)injection.See administration ofbenzathinebenzylpenicillin(BicillinLA eyes -topicaloxybuprocaineeyedropsmaybeindicated.See 292 bites and stings - hot water immersion may be effective. See pregnant womaninlabour.See renal colic-considergivingketorolactrometamol.See headache -alwaysconsiderseverecauses. neurosurgeon. head injury-opioidsshouldonlybegivenafterconsultationwithanemergencyphysicianor chest pain.See likely causeofpain current opioiduse(ifany) severity ofpain allergies medicine(s) thatmayhavealreadybeengivenpriortopresentatione.g.paracetamol age clinician hassuspicionofopioidseekingbehaviour recurrence ofpre-existingcondition unable toidentifythesourceofpain analgesia isnoteffective pregnant womanorinlabourifclinicianisnotamidwife child withseverepain(foranalgesiaadvice) evacuation/hospitalisation willlikelyberequired 6 ConsultMO/NP.See Chest pain assessment, page Non-pharmacological options Labour 1st stage, page Administration tips for benzathine benzylpenicillin, page
Head injuries, page 2 See 130
Acute and chronic headache, page 7
548 Renal colic, page ® 175 ) andprocainebenzylpenicillin Toxinology (bites and stings), page 2 Red orpainful eye, page
254
2,5 336 362 acute pain management 39 5 Acute pain management pain Acute 2 Practice points ) 2 ® Note: analgesia will not interfere with diagnostic processes in acute abdominal pain and should still be given Intranasal fentanyl is effective for children with severe pain - must be on MO/NP order The paracetamol content of all The paracetamol content medicines must be considered and Combination of oral paracetamol ibuprofen is generally more effective than the use of either alone Consider oxycodone only if pain is not adequately relieved by paracetamol and/or ibuprofen Carefully monitor the sedation score of all patients receiving IV opioids Do not give if sedation score ≥ 2 Preferably titrate via the IV route 2,5,7 • • Methoxyflurane (Penthrox Nitrous oxide (Entonox®) • • • • • • )
Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, OR OR leading to inadequate pain relief leading to inadequate pain Step 1 2 Step 3 Step 2 options AND/OR AND/OR AND/OR AND/OR Ibuprofen As for step 1 Paracetamol (adults only) As for Step 2 Non-pharmacological Fentanyl (adults only) Morphine (adults only Oxycodone (adults only) Increase dose of oral opioid Analgesia (if not allergic) Mild 1-3 4-6 7-10 Severe be aware absorption may be impaired in conditions of poor perfusion e.g. hypovolaemia, shock, perfusion e.g. hypovolaemia, in conditions of poor may be impaired be aware absorption hypothermia or immobility effects for at least 2 hours due to delayed absorption/adverse if given subcut, monitor titrate dose against patient response and sedation score against patient response titrate dose or IM routes consider subcut better patient acceptance effective as IM and has subcut is as insert IV cannula insert available equipment resuscitation ensure Severity – – – – – – – Moderate – – – care: delay analgesia and IV access will unreasonably If obtaining – – IV is preferred for severe pain: for IV is preferred – – Use oral route wherever possible for mild to moderate pain to moderate for mild possible wherever oral route Use p wise approach to acute pain management p wise approach to acute • • • Acute trauma or other quick procedures < 10 minutes e.g. laceration repair, administration of IM penicillin, IV cannulation Short term options Acute trauma e.g. while transferring in ambulance, quick procedures Ste 40 acute pain management | Primary Clinical Care Manual 10th edition | Sedation score Pasero Opioid-InducedSedation Scale(POSS) • • • • Score Patient mustbewokentoassesssedation indicated. See Nausea andvomitingisafrequentadverseeffectofopioidanalgesia.Considerantiemeticif Continue tomonitorstandardclinicalobservationsasappropriate – – Monitor effectofanalgesia: 2 0 3 1 – – – – regularly assesseffectofanalgesiausingpainscale: opioid inducedrespiratorydepression) monitor sedationscorecloselyaftergivingmorphineorfentanyl(mosteffectivewayofdetecting – – 5-15 minutelyifseverepain 30-60 minutelymild/moderatepain • • • • • • • • AND 8 easy towake or asleepbut Slightly drowsy Awake andalert physical stimulation response toverbalor and minimalorno Sleepy/drowsy un-rousable Difficult torouseor > 10seconds Unable tostayawake during conversation Drifts offtosleep rousable Frequently drowsy, complete question able toanswera ≥ 10seconds, Stays awakefor Nausea and vomiting, page Description 1,2 8
modifiedtoalignwith Queensland GovernmentEarlyWarningandResponse tools • • • Unacceptable • • • Acceptable • • • • • • Unacceptable • • 48 – – Monitor: Do notgivefurtheropioids Stay withpatient further opioidanalgesia Recheck sedationscorepriortogiving May increaseopioiddoseifneeded No actionneeded resuscitation/the collapsed patient, page Initiate resuscitationifneeded.See – – – Monitor (minimum5minutely) Give 0 Contact MO/NPurgently Give naloxone Stay withpatient,callforhelp Contact MO/NP Give O – – – – – – – status issatisfactory until sedationlevelstableat<2and respiratory sedation level respiratory status(rate,depth,regularity) + sedation levelclosely respiratory status(rate,depth,regularity)+ status issatisfactory until sedationlevelisstableat<2andrespiratory 2 2 tomaintainSpO tomaintainSpO Action 2 2 ≥94% ≥94%
DRS ABCD
54 acute pain management 41 9
Safe use of use Safe 283 stat stat Duration 48 hours MO/NP orders as required for Then 4-6 hourly Further doses on ATSIHP/IHW/IPAP Extended authority Extended Acute pain management pain Acute 9 Paracetamol, page page Paracetamol,
to the nearest dose 131 126. See dosage 1-2 tablets 500 mg-1 g down Recommended Recommended 15 mg/kg/dose measurable dose (max of 60 mg/kg (max. 4 g in 24hrs) suppository strength to a max. of 1 g/dose to a max. 8 tabs/day up to 4 g in 24 hours) Round down to nearest Adult and child ≥ 12 years Adult and child ≥ 12 years Adult and child Round Child > 1 month to < 12 years Child > 1 month to < 12 years 15 mg/kg/dose to a max. 1 g/ Paracetamol
Too much paracetamol can cause liver damage. Consider Too much paracetamol can cause liver damage. Consult MO/NP. Recognise and treat suspected paracetamol Consult Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, PR Oral Authority to administer and supply medicines, page page medicines, supply and administer to Authority Route of administration 2 Rectal absorption can be erratic and delayed: oral administration preferred. administration delayed: oral erratic and can be absorption Rectal 125 mg 250 mg 500 mg 500 mg Strength 786 100 mg/mL 120 mg/5 mL Clinicians should be aware risk factors of paracetamol toxicity before giving. See giving. before toxicity paracetamol of factors risk aware be Clinicians should Form Tablet Schedule Oral liquid Suppository Management of associated emergency: Centre toxicity without delay. Contact Poisons Information Note: page paracetamol, < 38-38.5⁰C well, and often respond to fluids and Infants and children tolerate low grade fever e.g. no evidence that paracetamol prevents febrile seizures comfort and may not need paracetamol; there is Provide Consumer Medicine Information: If further pain relief is required after 48 hours paracetamol content of other medicines being taken. return to the clinic for re-assessment RN may administer; for supply see RN may administer; ATSIHP, IHW, IPAP, MID and RIPRN may proceed MID and RIPRN IHW, IPAP, ATSIHP, 42 acute pain management | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency:ConsultMO/NP.See last fewdaysbeforeexpectedbirth.Mayincreaserateofmiscarriage Use inpregnancy: coagulation disorders peptic ulcerdiseaseorGIbleeding,severerenalfailure,heartliverfailureand Contraindication: Severeorimmediateallergicreactiontoibuprofen/NSAIDs,dehydration,active lithium andanticoagulants in patientswithasthma,cardiovasculardiseaseorincreasedriskandtaking Note: hypertension May causenausea,indigestion,GIbleeding,diarrhoea,headache,dizziness,fluidretentionand (particularly childrenorelderlypeople).Takewithaglassofwater.Ifupsetsstomachtakefood. Provide ConsumerMedicineInformation:Donottakeifdehydratede.g.duetovomitingordiarrhoea RN mayadminister;forsupplysee ATSIHP, IHW,IPAP,MIDandRIPRNmayproceed Tablet liquid Form Oral Schedule If renalimpairment,thosetakingdiuretics,ACEIsorARBsseekMO/NPadvice.Usewithcaution 20 mg/mL Strength 400 mg 200 mg Seek specialistadviceforuseinthesecondhalfofpregnancy;donotduring 2 administration Route of Oral Authority to administer and supply medicines, page 9 5 -10mg/kg/dosetoamax.of Round downtothenearest Adult andchild≥12years Ibuprofen measurable dose Child >3months Recommended 400 mg/dose 200-400 mg dosage Anaphylaxis, page 102 Extended authority
ATSIHP/IHW/IPAP May supply48hours hourly asrequired of tabletsorone bottle ofliquid Then 6-8 Duration stat 10 acute pain management 43 11
stat Duration Give naloxone to Repeat after Further doses
on MO/NP order 4 hours if needed. 102 Acute pain management pain Acute ATSIHP/IHW/RIPRN Extended authority authority Extended
Anaphylaxis, page page Anaphylaxis, ) 5 mg ® dosage Adult only Recommended Recommended Endone
May cause nausea, vomiting, itch, drowsiness, dizziness May cause nausea, vomiting, Consult MO/NP. See Oxycodone ( Oxycodone Oral Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, Route of administration 8 5 mg Hypersensitivity to opioids, acute or severe bronchial asthma or other obstructive acute or severe bronchial asthma or other Hypersensitivity to opioids, Strength Contraindicated If renal or hepatic impairment seek MO/NP advice. Monitor sedation score and respiratory rate seek MO/NP advice. Monitor sedation score If renal or hepatic impairment Form Tablet Schedule release) (conventional ICP, respiratory depression, severe renal or hepatic impairment, acute alcoholism, delirium tremens severe renal or hepatic impairment, acute alcoholism, ICP, respiratory depression, emergency: Management of associated After naloxone pain will return reverse opioid-related sedation. Pregnancy: Contraindications: inhibitors, head injuries, raised colic, GIT obstruction, concurrent use with MAO airways disease, biliary Provide Consumer Medicine Information: Provide Consumer Medicine mouth when moving to standing, indigestion, dry headache, low blood pressure Note: ATSIHP, IHW and RN must consult MO/NP must consult IHW and RN ATSIHP, RIPRN may proceed 44 acute pain management | Primary Clinical Care Manual 10th edition | reverse opioid-relatedsedation.After naloxonepainwillreturn Management ofassociatedemergency: raised ICP or other obstructive airways disease, biliary colic, concurrent use with MAO inhibitors, head injuries, Contraindication: or liverdisease(reducedose).Fentanylismoreappropriate Note: headache, lowbloodpressurewhenmovingtostanding,drymouth,sweating, dysphoria Provide ConsumerMedicineInformation: MID mayproceedforintrapartumuseonly:IM/subcutroutesonly RIPRN mayproceedEXCEPTforpregnantwomen ATSIHP, IHWandRNmustconsultMO/NP Injection Schedule Form Monitor sedationscoreandrespiratoryrate.Usewithcautionin>70years andsignificantrenal 10 mg/mL Strength Hypersensitivity to morphine or other opioids,acuteorseverebronchialasthma 8 ATSIHP mayNOT concentration of administration Note: IHWand administer IV for injections 9 mLwater Dilute with IM/Subcut to makea 1 mg/mL Route of IV ConsultMO/NP.See May causenausea,vomiting,itch,drowsiness,dizziness
Morphine score to responseandsedation range andtitrateaccording Start atlowerendofdose Age (years) 0.5-2 mgincrementstoa 60-69 40-59 70-85 < 39 > 85 Recommended max. of10mg Adult only Adult only dosage Anaphylaxis, page
2.5-7.5 7.5-10 2.5-5 5-10 2-3 mg ATSIHP/IHW/MID/RIPRN Extended authority 102 sedation score)to Inject slowlyover . on responseand Further doseson on MO/NPorder
a max.of10mg needed Give naloxoneto 3-5 minutesif Further doses MO/NP orde Repeat every 4-5 minutes Duration stat stat
(based 12,13,14
r acute pain management 45
to a 5,6,7,15,16 stat stat max. of minutes Duration Give naloxone to
Repeat every MO/NP order MO/NP order 100 microgram Further doses on Further doses on 102 ATSIHP/IHW/RIPRN Extended authority authority Extended sedation score) Acute pain management pain Acute Inject slowly over 3-5 5-10 minutes if needed (based on response and 100 40-75 30-50 75-100 40-100 Anaphylaxis, page page Anaphylaxis,
microgram dosage Adult only Adult only 100 microgram Recommended Recommended 10-20 microgram > 85 < 39 Age 40-59 60-69 70-85 (years) Use with caution in > 70 years increments to a max. of Fentanyl
May cause rash, itch, erythema, bradycardia, drowsiness, May cause rash, itch, erythema, bradycardia, drowsiness, Consult MO/NP. See IV Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, Subcut Route of to facilitate slow injection Use undiluted chloride 0.9% or add sodium administration 8 100 Hypersensitivity to fentanyl or other opioids, acute or severe bronchial asthma or Hypersensitivity to fentanyl or other opioids, acute Strength microgram/2 mL Monitor sedation score and respiratory rate. Schedule Form Injection reverse opioid-related sedation. After naloxone pain will return reverse opioid-related sedation. After naloxone Contraindication: concurrent use with MAO inhibitors, head injuries and other obstructive airways disease, biliary colic, raised ICP Management of associated emergency: dizziness, headache, low blood pressure when moving to standing, indigestion and dry mouth. May dizziness, headache, low blood pressure when than other opioids have a lower incidence of nausea and vomiting Note: Provide Consumer Medicine Information: ATSIHP, IHW and RN must consult MO/NP must consult IHW and RN ATSIHP, RIPRN may proceed 46 acute pain management | Primary Clinical Care Manual 10th edition | page Management of associated emergency: pressure, musculardystrophies recent vitroretinalsurgery,pneumocephalus, bowelobstruction,gasembolism,increasedintracranial Contraindication: monitor closely opioid hasbeenadministered.Debilitatedpatientsmoresensitivetoadverse andanaestheticeffects: Note: (not clinicianorparent).Maycausenausea,vomiting,dizziness,drowsiness orshivering Provide ConsumerMedicineInformation: ATSIHP, IHW,RIPRNandRNmustconsultMO/NP Schedule Management ofassociatedemergency: not useonconsecutivedays.Doexceed15mLinoneweek respiratory depression,headinjury,lossofconsciousness,historymalignanthyperthermia.Do Contraindications: patient exhaledmethoxyflurane;usethecarbonscavengerunitprovidedinconfinedareas with cautioninliverdisease,andpeopleaffectedbyalcoholordrugs.Staffshouldlimitexposureto not beassistedbyparentsorothers.Onlyuseinhaemodynamicallystableconsciouspatients.Use Note: Can occasionallyproducelossofconsciousness,hypotension minutes afteruse.Maycausedizziness,drowsiness,headache,shivering,nauseaandvomiting. Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHWandRNmustconsultMO/NP Inhalation Premix gas Schedule solution (clear) Form 64 Form Monitor sedationscoreandrespiratoryrate.Usewithcautionifvitamin B12deficiencyorif Patientmustself-administerviainhalationdeviceunderdirectobservation-childrenshould 99.9% in1.5mL 99.9% in3mL nitrous oxide50% Strength Air containingcavitiese.g.pneumothorax, obstructionofmiddleearorsinuscavities, 4 oxygen 50% Severe orimmediateallergicreactiontoinhaledanaesthetics,renalimpairment, 4 Strength + administration Inhalation Route of administration Inhalation Nitrous oxide+oxygen Route of Consult MO/NP.Giveoxygenifoverdose. See Consult MO/NP.See Patient mustselfadministeri.e.holdthemouthpieceormask Pain reliefafter6-8breathsandcontinuesforseveral Methoxyflurane (
Entonox
Adult andchild Recommended ® ≥ 6years self administeredas ) dosage 3 mL Adult andchild Recommended
Anaphylaxis, page needed dosage minutes toamaximumof May berepeatedafter20 Extended authority ATSIHP/IHW/RIPRN 102 6 mLinoneday Extended authority
short termuseonly Duration
ATSIHP/IHW stat Duration
Oxygen delivery, 5,17,18
2,21
acute pain management 47
19,20 stat Duration max. of 2 mg 2-3 mins to a at intervals of ATSIHP/IHW Can be repeated Extended authority Extended Acute pain management pain Acute 102 Adult Anaphylaxis, page page Anaphylaxis,
400 microgram Recommended dosage Recommended Naloxone
Consult MO/NP. See IV/IM Section 2: Pain, nausea and vomiting | vomiting and nausea Section 2: Pain, Route of (IV preferred) administration 400 Do not use in opioid dependent women; risk of withdrawal in fetus Do not use in opioid dependent 3 Strength microgram/mL if further analgesia is required and maximum dose has been administered if further analgesia is required and maximum dose for anyone with severe pain, when able for all children with severe pain cause of pain is uncertain Use with caution in opioid dependance: may have an acute withdrawal syndrome e.g. anxiety, dependance: may have an acute withdrawal Use with caution in opioid – – – –
Form – – – – Consult MO/NP: Patients who receive parenteral opioid analgesia will likely require transfer to hospital for further Patients who receive parenteral opioid analgesia management
Injection • • respiratory depression may return as the naloxone wears off. Continued observation and monitoring return as the naloxone wears off. Continued respiratory depression may required of respiratory function is Use in pregnancy: Management of associated emergency: agitation, tachycardia, confusion, or rarely more severe effects e.g. seizures, pulmonary oedema or or rarely more severe effects e.g. seizures, agitation, tachycardia, confusion, diagnosis if no response be an improvement within 1 minute. Reconsider arrythmias. There should action than naloxone and been given. Opioids have a longer duration of after a total of 10 mg has Provide Consumer Medicine Information: Provide Consumer Medicine Note: ATSIHP and IHW may proceed for one dose only. Must then consult MO/NP then consult only. Must for one dose proceed and IHW may ATSIHP may proceed RIPRN and RN Schedule
6. Referral /consultation 5. Follow up 48 nausea and vomiting Nausea andvomiting | Primary Clinical Care Manual 10th edition | 3. 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend Clinical assessment • • • • • • • • • • • • • Acute gastroenteritis/dehydration -child, page Acute gastroenteritis/dehydration -adult,page Related topics – – – – – – – – – Include inhistorytaking: Obtain completepatienthistory Always seektoidentifythecauseofnausea/vomiting If associatedwithchestpain.See Antiemetic indicatedinanotherHMPwithinthePCCM Requires prophylacticantiemeticpriortoaeromedicaltransfer Vomiting Nausea – – One medicineisnomoresuperiortoanotherinthetreatmentofacutenauseaandvomiting In acutenauseaandvomitingacauseisoftenabletobeidentified infections medicines, acutenauseaandvomitingisusuallytheresultofself-limitedgastrointestinal In theabsenceofacuteabdominalpain,significantheadache,orrecentinitiationcertain areas orduringinter-facilitytransfers This topicisintendedforinitialmanagementofnauseaand/orvomitinginruralandisolated ischemia, acutepancreatitisandmyocardialinfarction Always considerlifethreateningcausesofvomitingincluding:bowelobstruction,mesenteric – – – – – – – – – – – Nausea andvomiting what doesthevomituslooklike-any blood/coffeegrounds,bile,undigestedfood current gastrointestinalsymptomsinfamilymembersorclosecontacts timing ofvomitinginrelationtomeals frequency ofvomiting recent travel recent alcohol/drug intake.See exposure totoxins/poisons/bites/stings recent traumaorheadinjury recent weightloss pregnancy food eateninthepreceding24hours -coulditbefoodpoisoning 2
1 2
Acute coronary syndromes, page
Acute alcohol intoxication, page 730 243 Pyloric stenosis, page Differential diagnosis - child, page 487 135 2
746 673 3 nausea and vomiting 49 5 Pyloric stenosis, page 746 page Pyloric stenosis, Q-ADDS/MEWT/CEWT score or other local Early 1,2,4 Nausea vomiting and | Nausea vomiting and nausea Section 2: Pain, Acute abdominal pain, page 238 page pain, abdominal Acute and Response Tools) consider hypo/hyperglycaemia as cause – Acute gastroenteritis/dehydration - child, page 730 page - child, gastroenteritis/dehydration Acute – 243page - adult, gastroenteritis/dehydration Acute abdominal examination. See plus as determined from history taking of reproductive age perform point of care testing for pregnancy for women BGL if cause unknown or history of diabetes: recent initiation of a new medicine recent initiation of a new diabetes abdominal surgery dysuria or frequency of urine allergies the counter medicines; previous antiemetics current medicines; over fever neck stiffness confusion vertigo or dizziness vertigo or dizziness diarrhoea last bowel motion; related to motion/travel abdominal pain, distension or tenderness or pain, distension abdominal chest pain headache heartburn Lack of nausea Alerted consciousness, seizures, focal abnormalities History of head trauma Projectile vomiting in an infant 3-6 weeks of age. See Projectile vomiting in an infant 3-6 weeks of age. Bulging fontanelle in neonate or young infant Headache Marked abdominal distension and tenderness Rectal bleeding Vomiting blood/bile Prolonged vomiting: > 12 hours in neonate; > 24 hours in child Prolonged vomiting: > 12 hours in neonate; > 24 Lethargy Significant weight loss – – – – – – – – – – – – – – – – – – – – – – – Assess hydration. See: – – – – – Perform standard clinical observations (full Warning Perform physical examination: – – – – Obtain past history including: – – – – – – – – – – – – Ask about other symptoms in particular: symptoms other about Ask • • • • • • • • • • • • • Warning signs in children vomiting that may indicate a serious cause Warning signs in children vomiting that may • • • • 3 2 Differential diagnosis - child, page 673 child, - diagnosis Differential 746 page Pyloric stenosis, Acute alcohol intoxication, page 487 page intoxication, alcohol Acute Acute coronary syndromes, page 135 page syndromes, coronary Acute 2 1 2 frequency of vomiting timing of vomiting in relation to meals or close contacts current gastrointestinal symptoms in family members grounds, bile, undigested food what does the vomitus look like - any blood/coffee food poisoning food eaten in the preceding 24 hours - could it be pregnancy recent weight loss recent trauma or head injury exposure to toxins/poisons/bites/stings recent alcohol/drug intake. See recent travel Nausea and vomiting and Nausea This topic is intended for initial management of nausea and/or vomiting in rural and isolated initial management of nausea and/or vomiting This topic is intended for transfers areas or during inter-facility initiation of certain abdominal pain, significant headache, or recent In the absence of acute gastrointestinal and vomiting is usually the result of self-limited medicines, acute nausea infections a cause is often able to be identified In acute nausea and vomiting and vomiting superior to another in the treatment of acute nausea One medicine is no more Always consider life threatening causes of vomiting including: bowel obstruction, mesenteric bowel obstruction, of vomiting including: life threatening causes Always consider infarction pancreatitis and myocardial ischemia, acute – – – – – – – – – – – Nausea Vomiting transfer Requires prophylactic antiemetic prior to aeromedical PCCM Antiemetic indicated in another HMP within the If associated with chest pain. See Always seek to identify the cause of the nausea/vomiting Obtain complete patient history Include in history taking: Related topics 243 - adult, page gastroenteritis/dehydration Acute 730 page - child, gastroenteritis/dehydration Acute • • • • • • • • • • • • • Recommend Background HMP 1. May present with 2. Immediate management 3. Clinical assessment Nausea and vomiting and Nausea 50 nausea and vomiting 4. Management | Primary Clinical Care Manual 10th edition | • • • • • • • • Be guidedbyMO/NPforcontinuedmanagementasrelevant Monitor effectofantiemetic – – – – – Offer antiemeticasneededfor: – – – – – – – – – Contact MO/NPif: – – If relatedto: Treat causeifknown:beguidedbyrelevantHMP – – – – – Urgently contactMO/NPifnausea/vomitingisrelatedto: If relatedtochestpain.See – – – – – – – – – – – – – – – – – – – – – an indicationfromwithinanotherHMPinthePCCM gastroenteritis/dehydration -child, page an adjunctforacutegastroenteritisinchildrenifunabletotolerateoral fluids.See aeromedical retrievalprophylaxis nausea/vomiting relatedtoopioidsgivenasanalgesia initial symptomaticreliefofnauseaandvomiting re-presents tofacility unintended weightloss does notrespondtoantiemetic diabetic suspected poisoning looks sick dehydrated/unable totoleratefluids no obviouscause/unsureofcause child/infant – – probable gastroenteritis.See: pregnancy -seekadvicefromMidwifeorMO/NPavoidantiemeticifpossible child withwarningsigns severe dehydration/fluiddepletion head injury severe acuteonsetheadache – severe abdominalpainordistension – – – Acute gastroenteritis/dehydration -child, page Acute gastroenteritis/dehydration -adult,page note: reliefofabdominalpainwithvomitingsuggestsbowelobstruction 1,4
Acute coronary syndromes, page 730 730 243 135 6 Acute Acute nausea and vomiting 51
7,8,10,12 stat years) Duration MO/NP order over 5 minutes Further doses on
Give IV dose slowly (or 15 minutes if > 75
ATSIHP/IHW/RIPRN Extended authority 102 IV 7 Oral 8 mg Anaphylaxis, page page Anaphylaxis, Adult
4-8 mg dosage Recommended 15-30 kg - 4 mg 8- <15 kg - 2 mg > 30 kg - 8 mg 0.15 mg/kg to a max. of Child > 6 months - 16 years Ondansetron
Place ODT place on top of the tongue to dissolve, then Place ODT place on top of the tongue to dissolve, Nausea vomiting and | Nausea vomiting and nausea Section 2: Pain, Consult MO/NP. See Antiemetic selection Antiemetic IV Oral Route of administration www.catag.org.au line therapy for hyperemesis gravidarum (on MO order) for hyperemesis gravidarum line therapy hepatic impairment; phenylketonuria or prolonged QT interval or risk factors hepatic impairment; phenylketonuria or prolonged nd General use useful if related to migraine Particularly Oral, IM or IV years of age Avoid use in patients < 20 gastrointestinal tract is dangerous Avoid if stimulation of the or perforation e.g. suspected bowel obstruction adverse effects (dystonic reactions) Can rarely cause extrapyramidal Nausea and vomiting related to acute gastroenteritis in children acute gastroenteritis related to and vomiting Nausea is 'off label' use and vomiting in adults General nausea 2 4 mg 4 • • • • • • Indication • • • Strength 4 mg/2 mL Use for non specific nausea and vomiting is off-label. When used off-label, clinicians should Use for non specific nausea and vomiting is off-label. Oral Form Wafer Injection Schedule tablet (ODT) / disintegrating Metoclopramide Ondansetron Medicine Management of associated emergency: ensure documentation and evaluation is undertaken as per CATAG guiding principles for the quality ensure documentation and evaluation is undertaken use of off-label medicines. See Seek MO/NP advice if: for prolonged QT interval Provide Consumer Medicine Information: swallow. May cause constipation, headache, dizziness Note: RIPRN may proceed for child only - must consult MO/NP for adult RIPRN may proceed for child ATSIHP, IHW, MID and RN must consult MO/NP ATSIHP, IHW, MID and RN 52 nausea and vomiting | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup ATSIHP, IHWandRNmustconsultMO/NP Management ofassociatedemergency: motility maybeharmfule.g.GIobstruction,haemorrhageorperforation Contraindications: Note: or operatingheavymachineryifaffected.Reportuncontrolledrepeatedbodymovementse.g.tongue Provide ConsumerMedicineInformation: MID andRIPRNmayproceed women) andacutedystonicreaction.Canoccurinminutestodays.Treatwithbenzatropine extrapyramidal adverseeffects,includingtardivedyskinesia(morecommoninelderly,especially Management ofassociatedemergency: Contraindication: dystonic reaction.Usewithcautioninheartdisease,feverandelderly Note: increase effectsofalcohol Provide ConsumerMedicineInformation: RIPRN mayproceed.MIDproceedwithoraldoseonly ATSIHP, IHWandRNmustconsultMO/NP • • Injection Tablet Schedule Form Injection Schedule As requireddepending oncauseofnausea/vomiting Contact MO/NP asindicated above Tablet Form If renalimpairmentseekMO/NPadvice Used asanantidoteforextrapyramidalsideeffectssuchtardivedyskinesia andacute 10 mg/2mL Strength 10 mg GIT orurinaryobstruction,myasthenia gravis 2 mg/2mL Parkinson's disease,pheochromocytomaandconditionswhereincreasedGI Strength 4 2 mg 4 administration Oral/IM/IV Route of ConsultMO/NP.See administration Consult MO/NP.See May causedrowsiness,dizzinessorheadache.Avoiddriving Metoclopramide Route of May causedrowsiness,dizzinessorblurredvision. IM/Oral
Benzatropine
Adult ≥20years Recommended dosage 10 mg Anaphylaxis, page Anaphylaxis, page Recommended Adult only dosage 1-2 mg ATSIHP/IHW/MID/RIPRN ATSIHP/IHW/RIPRN/MID Extended authority Extended authority 102 102 over atleast3minutes Inject IVdoseslowly
Can cause
Further doseson MO/NP order Further doseson Duration MO/NP order Duration stat stat
11 9 3
Emergency
53 54 resuscitation DRS ABCDresuscitation/the Resuscitation | Primary Clinical CareManual 10th edition | 4 3. Clinicalassessment 2. 1. Maypresentwith . Management Recommend Background Immediatemanagement • • • • • • • • • • • • • • • • • Urgently contactMO/NPforfurther management – – Continue CPRuntil: – – – – Otherwise continuewithBLS (ALS), page If skilledinadvancedlifesupportcontinuetoresuscitate – – – If unresponsiveandnotbreathingproperlycommenceCPR If unresponsivebutbreathingnormally,see DRS ABCD Unresponsive andnotbreathingnormallye.g.gasping Sudden collapse Control bleeding Prevent furtherharm orinjurytopatient – – – – – – – – – Agonal breaths(occasionalirregulargasps)arecommonintheearlystagesofcardiacarrest resuscitation Palpation ofapulseisunreliableandshouldnotbeperformedtoconfirmtheneedfor Airway takesprecedenceoveranyinjury the hipsabout15-30⁰,butleavehershouldersflat If pregnant, once CPRin progress put padding such as a towel under thewoman’srighthipto tilt Do notroutinelyrollontosidetoassessairway,unlessobstructedwithfluidormatter from suddencardiacarrest Good qualityCPRandreducingtimetodefibrillationarethehighestprioritiesinresuscitation MO/NP instructsotherwise responsiveness ornormalbreathingreturnsOR continue CPR-minimiseinterruptionstochestcompressions deliver shock(s)ifindicated follow prompts attach automatedexternaldefibrillator(AED) a loopis5setsofCPRin2minutes each setofCPRis30compressions:2breaths rate of100-120compressionsperminute 1,2 3 56 as per
Basic lifesupportflowchart 3 -
as perimmediatemanagement 2,3,4 : collapsed patient
Unconscious/altered levelofconsciousness,page : - as per adult/child/infant Advanced life support Advanced lifesupport 73 resuscitation 55
Resuscitation Section 3: Emergency |
Other first aid measures depending on circumstances depending first aid measures Other Protect from the weather the from Protect
• • Basic life support flowchart life support Basic
Reproduced with permission from Australian Resuscitation Council. 2018
56 resuscitation A 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 2 1. Maypresentwith . Immediatemanagement dvanced lifesupport(ALS) Recommend Background • • • • • • • • • Related topics DRS ABCDresuscitation/thecollapsedpatient,page • • • • • • – Assess rhythm – – Attach defibrillator – – – – Commence CPR As soonaspossibleALStreatmentsareusedtosupplementBLSmeasures DRS ABC-see Unresponsive andnotbreathingnormallye.g.gasping Sudden collapse Always contactMO/NPassooncircumstancesallow According topatient'scondition/presentation – – – – – – – loss, severedehydration problem e.g.inhaledforeignbody,anaphylaxis,orlackofadequatetissueperfusionblood In children,themajorityofcardiorespiratoryemergenciesareduetoeitheraprimaryrespiratory Effective BLSbuystimeuntilreversiblecausescanbediagnosedandtreated uncertain aboutpresenceofpulsestartCPR Pulse checkmaybeusedbyclinicianbutshouldnotdelayCPRformorethan10seconds.If Minimise interruptionstoCPRduringALSinterventions As soonaspossible,ALStreatmentsareusedtosupplementBLSmeasures from suddencardiacarrest Good qualityCPRandreducingtimetodefibrillationarethehighestprioritiesinresuscitation Note: 1loop=5setsof30compressions: 2breaths=minutes give 100-120compressionsperminute for childrenstartwith2breathsthen15compressions: for adults30compressions:2breaths determine ifshockable ornon-shockable for infants-consideranterior/posterior placement other ontherightparasternalareaover the2 adults -onexposedchestthemid-axilliary lineoverthe6 1,2 2,3 DRS ABCDresuscitation/thecollapsedpatient,page : : 2,4 -placementofpaddlesorpadsfor: 1,5,7 -adult/child/infant nd 54 intercostalspace th leftintercostalspaceandthe 54 resuscitation 57
Resuscitation : Section 3: Emergency | (on MO/NP order only) loop of CPR loop - approximately every 4 minutes loop - approximately nd sible cause of arrest nd : 1,5,7
amiodarone
for all shocks for all shocks give adrenaline (epinephrine) give : joules 3,5,6 joules PLUS look for rever i.e. shock, CPR for 2 minutes, reassess rhythm, treat as per rhythm) i.e. shock, CPR for 2 minutes, reassess rhythm, ( attempt attempt VF OR pulseless VT when available when
2 - reassess rhythm: failed shock failed shock nd rd 4 joules/kg monophasic shock 360 biphasic shock 200 – – – repeat adrenaline (epinephrine) after every 2 direct treatment as per rhythm i.e. if shockable rhythm administer another shock direct treatment as per rhythm i.e. if shockable to CPR, then continue another 2 if rhythm assessment results in a significant interruption minutes of CPR before more shocks are delivered unless responsiveness or breathing become apparent unless responsiveness or breathing become apparent do not delay commencing CPR to assess the rhythm infants and children to 8 years: infants and children to 8 – adults and children > 8 years: – – Administer adrenaline (epinephrine) every 2 (epinephrine) Administer adrenaline circumstances should be considered depending on the individual Other medicines/electrolytes Consider airway adjuncts e.g. LMA, but attempts to secure the airway should not interrupt airway should not interrupt but attempts to secure the adjuncts e.g. LMA, Consider airway than 5 seconds CPR for more if available Waveform capnography Minimise interruptions during ALS interventions during interruptions Minimise 100% O Administer intraosseous access Obtain IV or – – – – – – – Urgently contact MO/NP as soon as circumstances allow Urgently contact MO/NP as soon as circumstances Continue above loop After 2 – After 3 – – – – After 2 minutes – Immediately resume CPR for 2 minutes Administer a single shock – During CPR in all cases CPR in all During • • • • • • • SHOCKABLE rhythm • • • • • • • If 58 resuscitation | Primary Clinical CareManual 10th edition | If NON-SHOCKABLErhythm- • (EMD) or ElectromechanicalDissociation Pulseless electricalactivity(PEA) • Asystole • • (pulseless VT) Ventricular tachycardia • • Ventricular fibrillation(VF) • • • • (pulse) detectable cardiacoutput electrical rhythmwithouta Presence ofacoordinated electrical activity Absent ofanycardiac not alwaysbethisrapidinrate compromising VTrhythmmay Pulseless orhaemodynamically output clinically detectablecardiac tachycardia associatedwithno A widecomplexregular smaller inamplitude appear coarsee.g.canbe VF rhythmmaynotalways produces nocardiacoutput ventricular activitythat Asynchronous chaotic Look forreversiblecause – Give adrenaline(epinephrine) Continue withCPR Do notdefibrillate – repeat afterevery2 nd loopofCPR
Asystole ORPulselessElectricalActivity(PEA
Non-shockable rhythms : Shockable rhythms 1 1 ) 1,5,7 resuscitation 59
nd = ≤ 9 years Resuscitation 1,2,3,10,12 loop shock rd 1,2,4,10,11,12 Duration ≤ 9 years for adults) stat chloride 0.9% children; 20mL Rapid injection (small bolus for stat then every 2 stat then every Flush with sodium Duration NIL = 10 kg; Rapid bolus after 3 20 mL for adults) = 10 kg; 1 year Flush with glucose 5% Prescribing guide (small bolus for children; Extended authority Extended 1 year
Section 3: Emergency | = 3.5 kg; 1 mg 1 mg Child Adult dosage = 3.5 kg;
Recommended Recommended 10 microgram = 0.1 mL Newborn : adrenaline 1:10,000 Adult years dosage 300 mg 300 mg Birth (at term) - 18 years 10 microgram/kg to a max. 10 microgram/kg to a max. Newborn NOTE Recommended MO/NP Child 1 month - 18 5 mg/kg to a max. of (epinephrine) An additional dose of Amiodarone
150 mg can be considered During IV administration monitor BP; severe hypotension During IV administration monitor BP; severe hypotension : Consult
Route of Adrenaline Adrenaline administration = age x 3.3 kg IV/Intraosseous 5% = age x 3.3 kg Route of administration 4 Dilute 150 mg in IV/Intraosseous 10 mL of glucose ≥ 10 years 3 ≥ 10 years OR 0.9% 1:10,000 Strength with 9 mL 3 mL (1mg/10mL) If unavailable 150 mg/ 1:1000 solution Strength sodium chloride dilute 1 mL of the Schedule : Approximate weights of children according to age: : Approximate weights of : Infuse amiodarone in glucose 5% injection. Incompatible with sodium chloride 0.9%. : Infuse amiodarone in glucose 5% injection. Incompatible Schedule Form Form = (age x 2) plus 8 kg; emergency Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine Note Injection RN and RIPRN may proceed RIPRN may RN and Approximate weights of children according to age: Approximate weights of children according to age: (age x 2) plus 8 kg; Management of associated emergency: Contact MO/NP and circulatory collapse can occur with rapid infusion. Note Injection RIPRN and RN only. Must be ordered by an MO/NP 60 resuscitation 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 4. Management Post resuscitationcare • • • • • • • • • • – – – – – – – – – – – – – In collaborationwithMO/NP: Commences oncereturnofspontaneouscirculationoccurs Be guidedbyMO/NPastowhenceaseCPR Contact MO/NPassooncircumstancesallow Undertake interventionsbasedonthepresumedcauseincollaborationwithMO/NP – – – Obtain historyfromwitnessesifable: both) occurringinnumerousdiseasesandtraumaticevents In paediatrics,cardiacarrestisusuallytheresultofestablishedhypoxaemiaorhypotension(or – – Common causesofsuddencardiacarrest: – – – – – – – – During CPRlookforreversiblecauses-4H'sand4T's: See Immediatemanagement – – – – – – – – – – – – – – – – – – – – – – – – – – – – maintain temperature.Avoidhyperthermia MO/NP mayconsiderantiarrhythmictopreventrecurrentVF monitor BGLfrequently maintain systolicBP continuous cardiacmonitoring and ResponseTools) perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarning maintain SpO re-evaluate patient-airway,breathing,circulation,disabilityandexposure precipitating events medicines/allergies physical circumstances haemorrhage, pulmonaryembolism,drowning,airwayobstruction non-cardiac related-approx.25%ofcasese.g.trauma,bleeding,drugintoxication,intracranial coronary heartdisease/cardiacrelated-approx.70%ofcases Thrombosis (pulmonary/coronary) Toxins Tamponade pneumothorax Tension Hypothermia/hyperthermia acidosis Hyper/hypokalaemia/metabolic Hypovolaemia Hypoxia continue toinvestigate forreversiblecauses urgent evacuation required consider replacementofIVlines assess forresuscitationrelatedinjuries thrombolytics orpercutaneouscoronary intervention assess theadequacyofperfusionand considertheneedforreperfusiontherapye.g. obtain ECGandchestx-ray 1,9 2 ≥94%.See 1,8 Oxygen delivery,page 64 resuscitation 61
Resuscitation Section 3: Emergency | 1
Always contact MO/NP as soon as circumstances allow during a cardiac arrest allow during MO/NP as soon as circumstances Always contact Sensitive, professional debriefing of people involved in resuscitation is valuable in resuscitation involved of people debriefing professional Sensitive, family members support for Provide • • •
6. Referral/consultation 5. Follow up Follow 5. 62 resuscitation Reproduced withpermission fromAustralianResuscitationCouncil. 2018 | Primary Clinical CareManual 10th edition | Advanced lifesupport algorithms resuscitation 63
Resuscitation Section 3: Emergency | Reproduced with permission from Australian Resuscitation Council. 2018 64 Oxygen delivery Oxygen delivery Oxygen delivery | Primary Clinical CareManual 10th edition | Recommend Definitions neurologic symptoms) (musculoskeletal or of decompressionsickness patients developingsigns Diving emergenciesin Hypotension Carbon monoxidepoisoning Acute stroke Acute coronarysyndromes Other criticalillnesses Sepsis Major trauma Shock • • • • • • • • FiO Hypoxaemia -LowO SaO SpO of thepatientandamountO In selectingtheproperdeliverymethod,considerationshouldbegiventoclinicalcondition concentrations thatmayvaryconsiderably Nasal prongs,simplefacemasksandnon-rebreathing documented asSpO In theprimaryclinicalcaresettingarterialO Frequent clinicalassessmentisrequiredinallpatientsreceivingO 2 2 -FractionofinspiredO 2 -O -Arterialoxygensaturationmeasuredbypulseoximetry 3 Scenario 1,2 2 saturationobtainedfromarterialblood -adult/child 2 2 tensionintheblood
Oxygen 2 concentration(%) • • • • • • • • as soonpossibletoincreaserate ofnitrogenwashout Treat withhighflowconcentrationO Administer untilhypoxiacandefinitelybeexcluded if thepatienthasbreathlessness,hypoxaemia Supplemental oxygenshouldbeinitiatedonly O Manage initiallywithhighconcentration oxyhaemoglobin butalowreadingis clinicallysignificant Pulse oximetrymaynotdifferentiate carboxyhaemoglobinfrom mask recommended Routine useofhighdosesupplementalO recommended unlesshypoxic(SpO Routine useofsupplementalO in uncomplicatedmyocardialinfarction Hyperoxaemia maybepotentiallyharmful shock. Routineuseisnotrecommended (SpO 2 fromareservoirmask 2 use inspecificscenarios needed 2 <94%),signsofheartfailureor 2 saturationismeasuredviapulseoximetry Recommendation 2 deliver O not 1,4,5 2 2 2 <94%) therapy via 2
percentage Venturi facemask 2 via reservoir
Target ≥ 94% SpO2 Oxygen delivery 65
8-15 L/min Flowrate Oxygen delivery Target SpO2 Target 88-92% 88-92%
2 1,4,5 User guide High flow device during the whole respiratory cycle i.e. Ensure the flow from fully inflated reservoir the wall to the mask is adequate to maintain a Section 3: Emergency | inspiration and expiration 2 Recommendation 2
is NOT recommended is NOT recommended is not recommended can lead to elevated SpO2 2 2 2 bag Routine use of supplemental use of supplemental Routine O (can be hazardous) Only give if needed of supplemental Routine use O (can be hazardous) SpO In this population, normal is sometimes 90-92%. Excess O ( > 95%) which reduces respiratory drive and under-ventilation Use capnometry if available Partial delivers • • • • • delivers 70-85% O 8-12 L/min 10-15 L/min 80-95+% O reservoir bag 1,2,3 approximately approximately face mask with mask with reservoir Full non-rebreathing non-rebreathing face ) 2 Oxygen use in specific scenarios (continued) scenarios use in specific Oxygen delivery systems Scenario Oxygen Non-rebreathing mask depressant drugs with Musculoskeletal disorders respiratory muscle weakness Morbid obesity (BMI > 40 kg/m Morbid obesity (BMI > 40 Overdose of opioids, respiratory benzodiazepines or other Bronchiectasis Severe kyphoscoliosis Severe ankylosing spondylitis past TB Severe lung scarring from COPD Cystic fibrosis flow meters - high and low flow meters are available • • • • • • • • • 2 failure e.g: Paraquat poisoning injury Bleomycin lung of hypercapnic respiratory Patients at risk O Low flow ranges from 0-3 L/min and high flow ranges from 4-15 L/min 66 Oxygen delivery | Primary Clinical CareManual 10th edition | Nasal cannula(prongs) Venturi facemask Simple facemask Oxygen deliverysystems
Flow rate Child >2years/ L/min Child <2years 1,2,3 0.125-2 L/min 0.125-4 L/min Colour coded 2 4 3 1 dilution jets 6-10 L/min delivering: 5-6 L/min 50-65% 35-50% adult 28% 40% 24% 50% 35% 31% % O 29 25 33 37
2 manufacturer's instructions Best suitedtopatientswho low flowO Inspired FiO rate, masksizeandfit and arethemostcommon and willnotbeharmedby the lackofprecisecontrol do notrequireahighFiO coloured dilutionjetand O 4 L/minuseafacemask Ensure goodmaskfitfor comfortable forpatients is dependantonO the patient'sventilation Available intwosizes- Nasal cannulaarevery Select theappropriate 2 paediatric andadult If requiremorethan
flow rateaccordingto 10 L/minusenon- If needmorethan rebreathing mask High flowdevice Low flowdevice Low flowdevice User guide max. O 2
rate delivery device 2
varies asthis
2 2
flow 2
Flowrate
0.125- 4 L/min 4 0.125- 4-10 L/min 4-10 5-10 L/min 5-10 Laryngeal mask airway (LMA) 67
1 Laryngeal mask airway (LMA) insertion Continue to advance the LMA until a definite resistance is felt Keep patient neck flexed using the Keep patient neck flexed head non-dominant hand behind Press the tip of cuff against hard palate and advance into the pharynx Push down into the pharynx as far as possible Pre-oxygenate patient. Use a non- Pre-oxygenate for patients who are rebreather mask In patients who breathing adequately. adequately a are not breathing can be used to bag-valve-mask pre-oxygenate the patient Check LMA cuff for leaks from aperture Deflate cuff so folds back and lubricate back of LMA the neck. Take Extend the head and flex suspected precautions if there is a cervical spine injury • • • • • • • • - adult/child
Section 3: Emergency |
LMA) insertion LMA)
Laryngeal mask airway (LMA) insertion (LMA) airway mask Laryngeal Laryngeal mask airway ( airway mask Laryngeal 68 Laryngeal mask airway (LMA) | Primary Clinical CareManual 10th edition | Photos demonstrateSupreme®LMA.TechniqueCairnsSkillsCentre,2011 • • • • • • Confirm placementwithendtidalCO prevent thepatientbitingLMA oropharyngeal airwayatthispointto LMA'), youmayneedtoinsertan without abiteguard(suchasthe'Classic guard. HoweverifyouareusinganLMA Many LMAsnowhaveabuiltinbite Attach bag-valveensuringO inflated out ofthemouthalittleascuffis holding thetube.TheLMAmay'riseup' Immediately inflatethecuffwithout LMA positionthenproceedtonextstep Once resistanceisfeltdoublecheckthe available atyourfacility Become familiarwiththeequipment monitor ifavailable (ETCO 2 ) disposabledetectorand/or 2 isattached 2
2
Intraosseous infusion 69 Intraosseous infusion 22 RecommendationsRecommendations Section 3: Emergency | tibia 1 - 3 cms below the tibial tuberositytibia 1-3 cm below the tibial tuberosity insert needle at 90° to skin surface into Insert needle at 90° to skin surface into the the medial surface of the tibia, 2 - 3 cms medial surface of the tibia, 2-3 cm proximal proximal to the medial malleolusto the medial malleolus insert needle at 90° to skin surface 1 cm Insert needle at 90° to skin surface 1 cm above the anterolateral proximal humerusabove the anterolateral proximal humerus insert needle at 90° to skin surface into the Insert needle at 90° to skin surface into the anterior (flat) medial surface of the proximal anterior (flat) medial surface of the proximal needle set needle set - adult/child 2,3,7 IntraosseousIntraosseous Intraosseous sites and recommendationsIntraosseous sites and recommendations 15mm (3 - 39kg)15 mm (3-39 kg) 45mm45 mm 45mm (if excessive tissue)45 mm (if excessive tissue) 25mm (> 40kg)25 mm ( > 40 kg) 15mm (3 - 39kg)15 mm (3-39 kg) 45mm (if excessive tissue)45 mm (if excessive tissue) 25mm (> 40kg)25 mm ( > 40 kg) Any Any AgeAge Adults Adults Any Any 1 after 2 minutes or 2 attempts to insert an IV cannula have failed after 2 minutes or 2 attempts unable to be established time consuming likely to be difficult and – – – Intraosseous infusion Intraosseous SiteSite Generally IV access should be established within 2-3 hours and the intraosseous infusion Generally IV access should be established within ceased manufacturer's recommendations on correct usage and safe work practices manufacturer's recommendations brittle by disease, needle into a site if the bone is broken, made Do not insert an intraosseous or if the tissue over the bone is burnt or infected (lignocaine) 2% is recommended in delivering large volumes with pressure infusion cuffs are effective Bilateral intraosseous lines shock quickly in cases of severe and follow themselves with available intraosseous devices Clinicians should familiarise – insertion using local anaesthetic for intraosseous In a responsive patient consider lidocaine intraosseous can be extremely painful. Intraosseous Administration of fluid via Use this route when IV access is immediately needed and: when IV access is immediately Use this route – – Intraosseous provides a route for the administration of parenteral fluids and medicines in life fluids and medicines administration of parenteral provides a route for the Intraosseous situations in any age threatening
Palpate landmarks to identify distal tibia or proximal tibial site (or humerus in an adult) Palpate landmarks to identify distal tibia or proximal Check the needle/battery powered handheld drill/driver to ensure that the bevels of the outer needle and the internal stylet are properly aligned Prepare injection site using aseptic technique with antiseptic solution Prepare injection site using aseptic technique with periosteum with 1% lidocaine (lignocaine) Anaesthetise the skin, subcutaneous tissue and adult) on a firm surface Stabilise and support the leg (or humerus in an • • • • • • • •
• • • • • Recommend HumerusHumerus Distal tibiaDistal tibia Proximal tibiaProximal tibia Preparation of intraosseous site
HMP Intraosseous Infusion Intraosseous 70 Intraosseous infusion | Primary Clinical CareManual 10th edition | Manual insertionofintraosseousneedle • • • • • • • • • • • intraosseous hub Do notattachasyringedirectlytothe tape secure theneedlewithacleardressingand set witha3waystopcockattheluerlockand If flowisgoodconnecttheIVlineextension confirms theneedleiscorrectlyplaced injection of5mLsodiumchloride0.9% Aspiration ofbloodandmarrowand/oreasy the skinsurface - inachild,thisisrarelymorethan1cmfrom and standrigidlyinthebonewithoutsupport The intraosseousneedleshouldbestable bone andmarrow intra-medullary cavity/marroworcancellous penetrated andtheneedleisnowin This meansthebonycortexhasbeen sudden lossofresistanceisfelt maintaining aperpendicularapproachuntil clockwise andanticlockwisemotionwhilst needle withstylet)intothebonearotary Push theintraosseousneedle(or16-18G intraosseous fluidinfusioncanbepainful intraosseous lidocaine(lignocaine)as For thoseresponsivetopainconsider Aspirate tocollectbloodsampleifrequired stopcock administering manuallyviathe3way drawing 20mLbolusesfromtheIVbagand Faster ratesofinfusionisachievedby gravity, therateistooslowforresuscitation Although fluidmayruninviatheIVlineby (escaping intothesurroundingtissues) the fluidislikelytobeextravasating If IVfluidsdonotflowviagravitybewaryas . This willriskdislodgement
Intraosseous infusion 71 firms the : this is Note Intraosseous infusion 2 Section 3: Emergency | 2 slowly infuse 20 mg of lidocaine (lignocaine) intraosseous for adults slowly infuse 20 mg of lidocaine (lignocaine) intraosseous intraosseous for children (and those < 80 kg) slowly infuse 0.25 mg/kg of lidocaine (lignocaine) slowly infuse 40 mg of lidocaine (lignocaine) intraosseous for adults slowly infuse 40 mg of lidocaine (lignocaine) intraosseous (lignocaine) intraosseous for children (and slowly infuse 0.5 mg/kg (max. 40mg) of lidocaine those < 80 kg) note that the priming volume of the intraosseous connection set is approximately 1 mL note that the priming volume of the intraosseous be approximately 20 mg if primed with 2% lidocaine (lignocaine), this will – – – – – – – – Allow lidocaine (lignocaine) to dwell in intraosseous space for 60 seconds (1 minute) Allow lidocaine (lignocaine) to dwell in intraosseous chloride 0.9% for adults and children Flush the intraosseous catheter with 5 mL of sodium Over 60 seconds (1 minute): Over 120 seconds (2 minutes): – – Prime intraosseous extension set with lidocaine (lignocaine): Prime intraosseous extension set with lidocaine – – manually via the 3 way stopcock or by using a pressure infusion cuff manually via the 3 way stopcock or by using a pressure Continue to monitor for signs of extravasation Connect the IV line and begin the infusion. Observe for extravasation (fluid escaping into the begin the infusion. Observe for extravasation (fluid Connect the IV line and tissues) mL boluses from the IV bag and administering Faster rates of infusion is achieved by drawing 20 secure the needle with clear dressing and tape, or the specific stabiliser dressing. Tape the line to dressing and tape, or the specific stabiliser secure the needle with clear dislodgement the leg (or shoulder) to prevent as intraosseous fluid pain consider intraosseous lidocaine (lignocaine) For those responsive to infusion can be painful needle is correctly placed sample if required Aspirate to collect blood the proximal end, and to the intraosseous hub with a 3 way stopcock at Attach an extension set obtained; release drill trigger and stop insertion process drill trigger and stop obtained; release and the stylet is removed from the needle The needle cap is unscrewed chloride 0.9% con marrow and/or easy injection of 5 mL of sodium Aspiration of blood and the depth of insertion. For large or obese patients a longer needle is recommended is recommended patients a longer needle insertion. For large or obese the depth of and applying gentle steady the drill/driver trigger bone cortex by squeezing Penetrate the downward pressure depth is space and the desired into the intra-medullary or pop indicates entry A sudden give Position the drill/driver at insertion site with needle set at a 90° angle to the bone at a 90° angle needle set site with at insertion the drill/driver Position the bone tip touches needle and tissue until the skin press through Gently and the needle hub. visible between the skin at least 0.5 cm of space There must be • • • • • • • • • • • • • • • • • • For those responsive to pain (due to intraosseous fluid infusion) For those responsive to pain (due to intraosseous Battery powered handheld drill/driver handheld powered Battery 72 Intraosseous infusion | Primary Clinical CareManual 10th edition | MO/NP. See Management ofassociatedemergency: Note: or tremors Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP RIPRN andRNonly.MustbeorderedbyanMO/NP MO/NP. See Management ofassociatedemergency: Note: or tremors Provide ConsumerMedicineInformation: Injection Injection Schedule Form Form Schedule Usethelowestdosethatresultsineffectiveanaesthesia Usethelowestdosethatresultsin effective anaesthesia 50 mg/5mL 400 mg/20mL Anaphylaxis, page (is equivalent to 20mg/mL) 100 mg/5mL Anaphylaxis, page Strength 40 mg/2mL Strength 1% 2% 4 4 administration 102 102 administration Route of Subcut Intraosseous Route of Lidocaine (lignocaine)
Ensureresuscitationequipmentreadilyavailable.Consult Ensureresuscitationequipmentreadily available.Consult Lidocaine (lignocaine) Reportanydrowsiness,dizziness,blurredvision,vomiting Reportanydrowsiness,dizziness,blurredvision,vomiting
then 0.25mg/kglidocaine(lignocaine) up to3mg/kgatotalmax.of 5 mLrapidsodiumchloride0.9%flush 40 mglidocaine(lignocaine)followed Adult andchild≥12yearsor>80kg lidocaine (lignocaine)followedbya child ≥12yearsor>50kg 0.9% flushthen20mglidocaine by a5mLrapidsodiumchloride
up tomax.of3mg/kg 0.5 mg/kgtoamax.of40mg Child andthose<80kg Child <12years Recommended (lignocaine) again Adult and 200 mg Recommended dosage dosage again ATSIHP/IHW/IPAP/RIPRN
Extended authority Prescribing guide
NP forfurther Duration Consult MO/ Duration stat doses 2,3,4,5,6 stat 3,4,5,6
Critical emergencies 73
3 54 - adult/child/infant Section 3: Emergency | Critical emergencies 785 consciousness consciousness 1,2,3,4 1,3 Glasgow Coma Scale/AVPU, page altered level of level altered DRS ABCD resuscitation/the collapsed patient, page DRS ABCD resuscitation/the collapsed patient, page 1 1,2 handle gently, avoid twisting or forward movement of head and spine handle gently, avoid twisting or forward movement years use head tilt/chin lift for adults and children > 1 infants - keep head neutral metabolic problems e.g. overdose, intoxication, low blood sugar metabolic problems e.g. injury, stroke, tumour, epilepsy brain problems e.g. head low brain oxygen levels e.g. fainting, abnormal heart rhythms heart and circulation problems – – – – – – – insert 2 x IV cannula - use the largest possible gauge given age and vascular status measure BGL – call for help do GCS. See promptly stop any bleeding assist patient onto the ground/bed and position on side assist patient onto the ground/bed and position any injury ensure airway open - airway takes precedence over – – as unconscious if not breathing properly, start BLS if fails to respond, or shows only a minor response e.g. groaning without eye opening, manage if fails to respond, or shows only a minor response change from normal skin colour blurred or changed vision nausea yawning, dizziness, sweating
– – Causes of unconsciousness include: Causes of unconsciousness – – Management should aim to avoid hypoxia, hypotension, hyperthermia and hyperglycaemia; to avoid hypoxia, hypotension, hyperthermia Management should aim in ICP and cerebral perfusion; minimise any increase maintain normovolaemia, Never leave an unconscious/altered LOC patient alone if possible an unconscious/altered Never leave until proven otherwise Assume a serious cause continue a thorough search for other causes should If alcohol consumption suspected, Unconsciousness is a time sensitive medical emergency - early stability and diagnosis are vital stability and diagnosis medical emergency - early is a time sensitive Unconsciousness patient outcomes to optimise – – – – – – – – – – – – – – – – – – – – – If unconscious and breathing normally: Assess as per – – – – Unresponsiveness Before loss of consciousness, patient may experience: – Confusion, drowsiness Poor response to stimulation
• • • • • • • • • • • •
Background Recommend
2. Immediate management 1. May present with
Unconscious/ Critical emergencies Critical 74 Critical emergencies 3. Clinicalassessment | Primary Clinical CareManual 10th edition | • • • • • • • • • • • – Perform neurologicalobservations- usestandardneurologicalobservationchart: – – – Note patternandregularityofbreathing: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – – – – Obtain pasthistoryasable(fromrelatives/friends/clinicalnotes): – – – – – – – – Look forclueswhichmayindicatereasonunconsciousstatee.g: – – – – Obtain rapidhistoryfromfriends/relativesorbystanders: – – – Continually observeairwayforanysignsofobstructione.g: Constantly re-checkthepatient’sconditionforanychange airway (LMA)insertion,page If GCS≤8considerLMAforairwaysupportuntilpatientabletobeintubated.See – – Contact MO/NPpromptly,urgentlyifpatientisachild-particularlyif: – – ECG – – – – – – – – – – – – – – – – – – – – – – – – – – – – recent surgery/hospitalisation medications e.g.anticoagulants allergies any epilepsy,diabetes,cancer known underlyingillness allergy jewelleryoraccessory(keyring,USBstick,shoetag,anklet,watch, tattoo) snake bite/otherenvenomation bruising/minor injuries infection -especiallyelderly note: ifalcoholintoxicationsuspected,continuetolookforothercauses alcohol orsubstance/druguse overdose e.g.suicidenote,emptymedicinepacket(s),needleandsyringe trauma – – – any witnessof: did thepersoncomplainofaheadache/chestpain/othersymptom when/what happenedprior/whatweretheydoing was thelossofconsciousnesswitnessed abdomen movesinandout,butlossofnaturalrisechest in-drawing ofspacesbetweenribsandcollarboneduringinspiration laboured ornoisybreathing,nosoundofbreathing GCS drops2ormorepointssincelastassessment GCS <15 give O attach cardiacmonitor GCS, motorresponses, pupilsizeandreaction hyperventilation shallow withextremelydepressedRR (seeninopiateoverdose) deep, laboured(Kussmaulrespiration, oftenassociatedwithdiabeticacidosis) – – – seizures/abnormal movements trauma ingestions, IVdruguse 2 tomaintainSpO 1,2 2 ≥94% 67 2,3 . See 2 Oxygen delivery,page 3 4
64 2
Laryngeal mask Laryngeal mask Critical emergencies 75 77 Shock, page
115 Section 3: Emergency | Critical emergencies Differential diagnosis for altered level of Hypoglycaemia, page table on next page 1,2 - consider point of care testing: - consider point 2
chest x-ray evacuation for further investigations and management treatment according to suspected cause. See consciousness LFT, clotting screen LFT, clotting level paracetamol, salicylate and blood alcohol toxicology screen; including FBC, blood glucose, urea and electrolytes urea and electrolytes FBC, blood glucose, calcium any odour noted any odour (snake bite) wounds sites, puncture drug injection bruising, skin e.g. rash, check privacy down, maintaining as you move all clothing remove warm keep patient – – – – – – – – – – –
– – – If BGL < 4 mmol/L treat immediately. See If BGL < 4 mmol/L treat immediately. See rapid IV sodium chloride 0.9% 10-20 mL/kg. If hypotensive, commence may include: Be guided by MO/NP for further management, which See Immediate management Urinalysis for pregnancy for women of reproductive age Perform point of care testing on suspected cause - be guided by MO/NP Additional pathology depending – – take blood cultures If fever or sepsis suspected, Take bloods – – – – – – Perform thorough head to toe examination: to toe head thorough Perform • • • • • • • • • • 4. Management 76 Critical emergencies | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • • • • • Low brainoxygenproblems • • • • • • Brain problems Differential diagnosesforalteredlevelofconsciousness • • Seizure/post ictal Meningitis/encephalitis Epilepsy Tumour Stroke young child) Head injury(thinkofnon-accidentalin Hypoxia Pulmonary oedema Pulmonary emboli Respiratory failure Pneumonia Drowning Asthma/COPD Smoke/gas/steam inhalation Lung problems Burns Allergy/anaphylaxis Choking/foreign body Croup/epiglottitis Airway obstruction Always contactMO/NP According topossiblecauseforunconsciousness
• • • • • • • • • • • • Heart andcirculationproblems • • • • • • • • • Metabolic problems Hypertension Hypotension Hyperthermia Hypothermia Intracranial haemorrhage Cardiac arrhythmia Cardiac arrest Leaking aorticaneurysm Ectopic pregnancy Gastrointestinal bleed Trauma Haemorrhage Electrolyte derangement Sepsis -especiallyintheelderly Kidney failure Liver failure Encephalopathy Poisoning Intoxication -alcohol,inhalants Drug overdose-oral,inhaled,IV Hypoglycaemia/hyperglycaemia (diabetes) 1,2 Critical emergencies 77
80 Section 3: Emergency | Critical emergencies 54 Sepsis/septic shock, page 1,3 2,3 102
2,3 1 readings in shock can be unreliable due to poor peripheral perfusion readings in shock can be 2 cardiogenic e.g. myocardial infarction cardiogenic e.g. myocardial embolism pneumothorax, cardiac tamponade, pulmonary obstructive e.g. tension injuries allergic reactions, severe brain/spinal distributive e.g. severe infection, hypovolaemic - due to a large amount of blood or fluid loss from the circulation e.g. from large amount of blood or fluid loss from the circulation hypovolaemic - due to a or scalds, severe multiple fractures or major trauma, severe burns severe bleeding, major or severe sweating and dehydration diarrhoea and vomiting, DRS ABCD resuscitation/the collapsed patient, page - adult/child - adult/child
– – – – SpO – – – Types of shock: – Shock is a clinical state in which hypotension occurs, due to haemorrhage/cardiac failure/ to haemorrhage/cardiac hypotension occurs, due clinical state in which Shock is a may look The patient in shock inadequate tissue perfusion. tone, resulting in decreased vascular such as the brain, heart make sure enough blood reaches vital organs pale and the body tries to e.g. from the skin. Many organs can stop functioning and liver, by diverting it may be achieved by replacing lost intravascular fluid and/or increasing vascular tone and/or increasing vascular intravascular fluid and/or by replacing lost may be achieved output increasing cardiac The aim of management is to increase tissue oxygenation by improving tissue perfusion. This by improving tissue increase tissue oxygenation to is of management The aim
Urgently contact MO/NP when able Place into supine position Control any major bleeding - by direct pressure with a bandage and/or apply traction and splint See Call for help nose bleed, gastrointestinal bleeding, septicaemia, heart attack, tubal/ectopic pregnancy, nose bleed, gastrointestinal bleeding, septicaemia, anaphylaxis Warm peripheries in distributive shock Thirst and injuries, burns, fractures, acute wounds, As part of clinical picture of emergencies e.g. trauma Altered mentation, irritability, confusion, drowsiness, altered conscious state (not due to head Altered mentation, irritability, confusion, drowsiness, injury) Very low or high temperature Increased respiratory rate (tachypnoea) - 'air hunger' Shortness of breath ↓ urine output Collapse Hypotension with increased HR (tachycardia) poor capillary return ( > 2 secs) May look pale with cool, clammy, moist skin with
• • • • Anaphylaxis, page Related topics • • • • • • • • • • • • • • • •
Background Recommend 2. Immediate management
1. May present with Shock Shock 78 Critical emergencies | Primary Clinical CareManual 10th edition | Management 4. Clinicalassessment 3. • • • • • • • • • • • • • • • • • • •
– – – and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning from: Suspect internalbleedingifinjured and/or shockedandnotobviouswherebloodhasbeenlost septic shock,page80 If indistributiveshockconsiderearly antibiotictherapyinconsultationwithMO/NP.See Use cautionwhentreatingelderlypatients andthoseonbetablockers Monitor responsetointervention Consult MO/NPurgentlytoorganiseevacuation Pay particularattentiontothetrendsinvitalsigns – – – – Monitor BP,HR,RR,SpO medicines Obtain patienthistoryincludingcircumstancesthatmaysuggestthecause ofshockincluding Insert IDCandmonitorhourlyurineoutput Children compensateverywellintheearlystagesofshock,butcandecompensaterapidly – – – Theaiminadultsistokeep: – – – For hypovolaemicshockanddistributiveshock: For cardiogenicshockandobstructiveshock,thecauseshouldbetreated.MO/NPwilladvise Take emergencyhistoryfrompatientandrelativesand/orfriends,ifpresent – – Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus Give O Assess consciousstate.SeeGlasgowComaScale/AVPU,page785 Diagnostic evaluationshouldoccuratthesametimeasresuscitation fracture(s) ifpossible – – – – – – – – – – – – – – check bodyandskintemperature capillary refilltime BGL consider pregnancytest conscious state urine output capillary refill urine output>0.5mL/kg/hour systolic BP>90-100mmHg HR <120/min bolus mayneedrepeatingonMO/NPorder reassess give sodiumchloride0.9%orHartmann'ssolution10-20mL/kgbolus if unabletoattainIVorintraosseusaccessconsultMO/NPimmediately intraosseous cannula if IVaccessisunabletobeestablishedorlikelydifficultandtimeconsuminginsert pregnancy, page511 abdomen (rupturedspleen/liver/kidneys). See 2 tomaintainSpO 1 1 2 2 . SeeIntraosseousinfusion,page69 , BGL,bodyandskintemperatures+ 1 >94%adult 4 or>95%child.SeeOxygendelivery,page64 1 2,3 Abdominal injury,page 183andEctopic
1 2
Sepsis/ Critical emergencies 79 190 Section 3: Emergency | Critical emergencies 171 243 730 586 185 572 249 Fractured pelvis, page page pelvis, Fractured 135 234 Chest injuries, page page Chest injuries, 163 198 251 217 102
Upper gastrointestinal bleeding, page Upper gastrointestinal bleeding, Primary postpartum haemorrhage, page Primary postpartum haemorrhage, Rectal bleeding, page page Secondary postpartum haemorrhage, Traumatic injuries, page Burns (general), page Burns (general), sprains, page Fractures, dislocations and Nose bleed/epistaxis, page Acute gastroenteritis/dehydration - child, page - child, Acute gastroenteritis/dehydration page Anaphylaxis, page Acute wound(s), chest (haemothorax). See (haemothorax). chest page syndromes, Acute coronary page - adult, Acute gastroenteritis/dehydration fractured femur (thigh), pelvis. See See pelvis. (thigh), femur fractured – – – – – – – – – – – – – – –
Consult MO/NP on all occasions of shock According to possible cause for shock According to possible cause in suitably equipped facility Patient will need evacuation/hospitalisation – – – – – – – – – – – – as per: with MO/NP consultation condition in coexisting Manage – – – • • • •
6. Referral/consultation 5. Follow up 80 Critical emergencies | Primary Clinical CareManual 10th edition | 1. Maypresentwith HMP Recommend Background • Related topics Shock, page • • • • • • • • • • • • • – – – – – – – – – Screen ALLpatientsforsepsisifANYofthefollowing: – – – – – – – – – arterial pressureof65mmHgorhigher,andaserumlactate>2mmol/Ldespiteadequatevolume Clinically presentsaspersistinghypotensionthatrequiresvasopressorstomaintainamean Septic shockisasubsetofsepsiswithprofoundcirculatory,cellularandmetabolicabnormalities. infection Sepsis isalife-threateningorgandysfunctioncausedbydysregulatedhostresponseto Use sepsisclinicalpathwaystoguidemanagementandantibioticchoiceifavailable services) isessentialforoptimisingoutcomes Early involvementofpaediatricintensivecareunit(PICU)services,RSQ(orlocalevacuation If sepsisissuspected,initiatetreatmentandinvestigationsuntilhasbeenexcluded A diagnosisofsepsisismadeusingclinicaljudgementsupportedbylaboratorytesting young infants, Initial presentationcanbevague,soalwayshaveahighindexofsuspicioninneonatesand Sepsis mustbeconsideredinevery Sepsis isamedicalemergency-earlyrecognitionandrapidtreatmentimperativeforsurvival the causativeorganismisknown Streptococcal toxicshocksyndrome(TSS)ismanagedlikesepticintheearlystages,until therapeutic response An elevated serum lactate > 2 mmol/Lmayindicate the severity of sepsis and is used to followthe systems areunabletowardoffseverepathogens Neonates andinfants<1yearareathighestriskofsepsisbecausetheirimmatureimmune A childcanhavesepsiswithnormalBP.Hypotensionisalatesignofshock resuscitation Sepsis/ Q-ADDS orCEWTscore≥4 signs ofdeteriorationduringcurrentillness patient, familyorcarer/parenthasconcerns you suspecttheymayhavesepsis looks sick unexplained pain/restlessnessinchildren re-presentation within48hours altered behaviourOR↓levelofconsciousness fever orhypothermia(T<35.5⁰c) 1,2,3 77 6
septic shock 7 theelderlyorimmunocompromised 1,2,4,8 5 - adult/child 9
patient with feveroracuteillness 1,3 patients withsuspectedsepsis Critical emergencies 81 : Section 3: Emergency | Critical emergencies AND/OR
1,2,4,8 1,2,4
if T ≥ 38.5⁰C x 1 OR 38⁰C x 2 one hour apart AND suspected neutropenia OR chemotherapy x 2 one hour apart AND suspected neutropenia if T ≥ 38.5⁰C x 1 OR 38⁰C suspect febrile neutropenia given within the past 2 weeks, – record weight - bare weight if < 2 years assess against Risk criteria for illness/sepsis on following page do thorough clinical assessment consult MO/NP for advice There any reason to suspect an infection - respiratory tract, urinary, abdomen/GIT, skin, joint, There any reason to suspect an infection - respiratory family members suspect infection, other, prosthesis, CNS, meningitis, new onset confusion, source unclear Represented within 48 hours IV drug use or alcoholism neutropenia, unimmunised Immunocompromised, asplenia, – Indwelling medical device invasive procedure, wound within last 6 weeks Recent trauma or surgery, Post partum/miscarriage Aboriginal and Torres Strait Islander, Pacific Islander or Maori Torres Strait Islander, Aboriginal and condition Chronic disease or congenital Malnourished or frail Age < 3 months – – – –
In ALL children, and if there are ANY risk factors present in adults In ALL children, and if there are ANY risk factors – – – – ADDS, MEWT, CEWT score or other local Early local Early score or other MEWT, CEWT Q-ADDS, (full clinical observations standard Perform Tools) and Response Warning are present if ANY risk factors for sepsis Check to see If no risk factors are present in adults, there is a low risk of sepsis: If no risk factors are present in adults, there is a Risk factors for sepsis Risk factors • • • • • • • • • • •
• • • • 2.management Immediate 82 Critical emergencies | Primary Clinical CareManual 10th edition | • • • Risk criteriaforillness/sepsis
Child <16years Note • • • • • • • • or asclinicallyindicated Reassess ifdeteriorates Consult withMO/NP and examination Complete history • • • • • • • • Child <16years Hypothermia (CEWTtemperaturescore2) Non-blanching rash Altered AVPU Lactate ≥2ifknown Hypotension (CEWTBPscore≥2) (CEWT heartratescore3) Severe tachycardiaorbradycardia apnoea (CEWTrespiratoryscore3) Severe respiratorydistress/tachypnoea/ Needs O Parental/health careworkerconcern Reduced urineoutput Pale orflushed/mottled/coldextremities Low BGL Unexplained painorrestlessness Capillary refill≥3seconds score 2) Moderate tachycardia(CEWTheartrate (CEWT respiratoryscore2) Moderate respiratorydistress/tachypnoea : CEWTreferstotheQueenslandChildren’sEarlyWarningTools(2017) Low riskforsepsis NO 2 NO tokeepSpO
Step 2.CheckforANYfeaturesofmoderateillness 2 ≥92% Step 1.CheckforANYfeaturesofsevereillness 2,4 moderate illness ANY
ANY severe illness
featuresof featuresof YES YES
• • • • • • • • • • • • • • • • ≥ 16yearstoadult ≥ 16yearstoadult Recent chemotherapy Not passedurinein18hours Change inmentalstatus:GCS<15 HR ≥130/min Needs oxygentokeepSpO RR ≥25breaths/min ashen/cyanotic Non-blanching rash/mottled Lactate ≥2ifknown normal) Systolic BP<90mmHg(ordrop>40from HR 90-129/minORnewdysrhythmia Systolic BP90-99mmHg RR 21-24/min Acute deteriorationinfunctionalability Not passedurineinlast12-18hours status Relatives concernedaboutmentalhealth T <35.5⁰Cor≥38.5⁰C
• • • See Take pointofcarelactate examination Targeted historyand Consult MOurgently or septicshockuntilproven Assume patientHASsepsis Patient MAYhavesepsis Consult MOurgently Step 3 otherwise 2
≥92% on followingpage
Critical emergencies 83
64 4 91 2,4 Oxygen delivery, page Oxygen delivery,
: Meningitis, page 2,11
Section 3: Emergency | Critical emergencies 1,2,4 if needed. See 2 2,4,11,12,13 for empirical antibiotic choices 91 2 - use the largest possible gauge given age and vascular status: possible gauge given - use the largest 4,12 ≥ 94% (88-92% if COPD). Give O ≥ 94% (88-92%
2 unless this will delay antibiotics > 1 hour: unless this will delay antibiotics 2 Meningitis, page page Meningitis, MRSA infection risks - chronic underlying disease (e.g. renal failure, MRSA infection risks - chronic underlying disease See > 16 years - MO may consider replacing antibiotic regimen above with meropenem AND vancomycin blood cultures - aim for 2-6 mL (one aerobic bottle) blood cultures - aim for possible add Chem20 or LFT, UEG, CMP, CRP lactate/VBG and FBC. If BGL 2 sites (2 sets of aerobic and anaerobic bottles) blood cultures - 2 sets from lipase and VBG lactate, FBC, UEC, BGL, LFT, studies if septic shock add coagulation If ANY indications this is likely sepsis or septic shock septic or sepsis likely this is indications If ANY – – – – – – – – ≥ 16 years to adult: if meningitis can not be excluded: – during November to May (tropic wet season) - areas north of Mackay, Tennant Creek, Port during November to May (tropic wet season) - areas Hedland: – if at risk of MRSA ADD vancomycin See if meningitis can not be excluded ADD ceftriaxone. cefotaxime PLUS gentamicin PLUS vancomycin gentamicin PLUS flucloxacillin cefotaxime if at risk of MRSA ADD vancomycin cefotaxime PLUS ampicillin if at risk of MRSA ADD vancomycin diabetes),immunosuppression, chronic wounds or dermatitis, living in close quarters or diabetes),immunosuppression, chronic wounds colonisation with MRSA communities with high MRSA prevalence, known local patterns of resistance to be considered target to source of infection if known use sepsis clinical pathways for guidance note: – – – – < 16 years: – – obtain intraosseous access if 2 failed attempts access if 2 failed obtain intraosseous arrange early evacuation arrange early if available use sepsis pathways senior medical officer to diagnose sepsis where possible sepsis to diagnose medical officer senior – – – – – – – – – – – – – – – – – – – – – – – – Additional considerations ALL ages If child has septic shock/critically ill REPLACE above with: If child has septic shock/critically ill REPLACE above – > 16 years to adult: – 2 months to 16 years: – – < 2 months: – – – – – – Check BGL and allergies do not delay Give IV/intraosseous antibiotics within 1 hour - – – Insert 2 x IV cannula Insert 2 x IV – Measure lactate Take bloods – – Maintain SpO Call for help Call for MO urgently: Consult – • • • • • • • • • • • • • Empirical antibiotics - if not allergic MO/NP may order Empirical antibiotics - if not allergic MO/NP Step 3: Step 84 Critical emergencies | Primary Clinical CareManual 10th edition | 3. Clinicalassessment If timelyIV/intraosseousaccessnotpossible: informed consentwheretheriskofmusclenecrosisisdiscussedwith patient/carer Volumes ofupto2.4mLinoneinjectionareusedexceptionalcircumstances withdocumented • • • • • • • Ventrogluteal Muscle group Past history: – – – Askaboutrecenthistoryof: below See Guidelinesformaximalamountsofsolutionstobeinjectedintopaediatricmuscletissue IM routecanbeusedformostantibiotics – – – Commence IV/intraosseousfluids administer antibioticswithshorterinfusiontimesfirst – – Ask about/lookfor possiblesourceofinfection: – Maximus lateralis Gluteus Deltoid Vastus – – – – – – – – – Guidelines formaximalamountsofsolutionstobe – – – – – <16years: use sodiumchloride0.9%orHartmann's – if encephalitissuspected: cough, sputum,breathlessness diabetes,immunosuppressive medications,chemotherapy travel -whereto/when antimicrobial usewithintheprevious 3months illness, operations/hospitalisation, post-partum,skininfections – – – – ≥ 16years/adults: – – – – – – – – – – further IVfluidsonMO assess response,givefurtherbolusifindicated rapidly infuse consider patient’sweight,cardiacfunction,co-morbiditiesandcurrentvolumestatus if hypoglycaemicMO/NPmayorder2mL/kgglucose10% on MO/NPordermayrepeatupto40-60mL/kgwithinfirsthour assess response observe forhepatomegaly(enlargedliver) give rapidfluidbolus10-20mL/kg ADD aciclovir.See 0 to18months recommended recommended recommended bolus 250mL-500mLover5minutesifclinicallyindicated 0.5 mL 4 Not Not Not
Meningitis, page /NP orders : other sitesareavailable other sitesareavailable 2,4 18 monthsto3years Not recommendedif Not recommendedif
(do notexceed30mL/kgwithoutSMOinput) 91 Not recommendedifothersitesareavailable 0.5 mL 1 mL 1 mL 1 mL 8,14 1,2,4 8 -whichone(s),whatfor injectedintopaediatricmuscletissue 2 3 to6years 0.5 mL 1.5 mL 1.5 mL 1.5 mL 6 to15years 1.5-2 mL 1.5-2 mL 1.5-2 mL 0.5 mL 14 Critical emergencies 85 10 Section 3: Emergency | Critical emergencies 2,4 Glasgow Coma Scale/AVPU, page 785 page Scale/AVPU, Coma Glasgow 2,4,8 Persistent tachypnoea, hypotension, tachycardia Persistent tachypnoea, hypotension, tachycardia Reduced level of consciousness despite resuscitation Lactate ≥ 4 or not reducing or If patient critically ill at any time Meningitis, page 91 See Meningitis, page
8 MO will urgently seek specialist/RSQ advice if patient STILL has: MO will urgently seek specialist/RSQ advice • • • •
ADDS/MEWT/CEWT score or other local Early Warning and standard clinical observations (full Q-ADDS/MEWT/CEWT score or other local Early Warning infuse at 0.05 to 0.5 microgram/kg/min noradrenaline (norepinephrine) 5 microgram/min > 0.5 to 1.0 mL/kg/hour for ≥ 16 years/adults adrenaline (epinephrine) infusion for a final concentration use 1 mL of 1:1000 adrenaline (1mg/mL). Mix with 49 mL glucose 5% 0.02 mg/mL Response Tools) - aiming for systolic BP in adults ≥ 100 mmHg Response Tools) - aiming for systolic BP in adults capillary refill time AVPU. See > 1 mL/kg for < 16 years/children crackles or wheezes - pneumonia is the most common cause of sepsis the most common cause - pneumonia is crackles or wheezes air entry – – – – – – – – – – – ≥ 16 years/adults - vasopressors for hypotension – – – – < 16 years old - inotropes (on intensive care specialist advice): < 16 years old - inotropes (on intensive care specialist monitor urine output aiming for: – – – – re-check lactate - aiming for < 2mmol/L re-check lactate - aiming perform frequent: bruising/bleeding bruising/bleeding and purpura do not points and under clothing. Note: petechiae skin rash especially at pressure fade on pressure auscultate chest for: auscultate chest – – abdominal pain, distension abdominal infection device related wound, infected septic arthritis, cellulitis, vomiting, headache, onset confusion, rash, new non-blanching photophobia, neck stiffness, nausea. dysuria, frequency dysuria, – – – – – – – – – – – –
Further doses of antibiotics required in 6-8 hours - consult with MO/NP if still waiting to be Further doses of antibiotics required in 6-8 hours evacuated – Continue to monitor closely until evacuated Monitor fluid balance If no or limited improvement MO may consider: – – Consider IDC as appropriate Reassess and monitor response to resuscitation: Reassess and monitor response – – Check vaccination status Check bowel sounds - paralytic ileus may be present Check bowel sounds - paralytic Note: source might be unclear and ß-hCG if possible Urinalysis + MSU for MCS Inspect all skin surfaces for: Inspect all skin – – – – – – –
• • • • • • • • • • • 4. Management 86 Critical emergencies | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: with aminoglycosidese.g.gentamicin Contraindication: at injectionsite Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Injection Schedule Form Strength 500 mg 1 g Severehypersensitivitytopenicillins,carbapenemsandcephalosporins.Donotmix 4 Reconstitute 500mgvialwith Reconstitute 500mgvialwith 4.7 mLwaterforinjections 1.7 mLwaterforinjections (OR 1gvialwith9.3mL) (OR 1gvialwith3.3mL) to giveconcentrationof to giveconcentrationof administration 250 mg/mL 100 mg/mL Route of IM IV ConsultMO/NP.See Maycause
Ampicillin rash, Neonates andinfants 50 mg/kgtoamax. diarrhoea, nausea, pain and inflammation Anaphylaxis, page Recommended < 2months dosage of 2g
102 Extended authority ATSIHP/IHW/IPAP See paediatric muscle maximal amounts over 3-5minutes, Inject dose<1g be injectedinto otherwise over of solutionsto 10-15 minutes tissue table Guidelines for Duration stat IM IV 2,15,16
Critical emergencies 87 2,17,18 IM stat than Child Adult Duration Guidelines for tissue table IV/Intraosseous least 3-5 minutes See Inject slowly over at Inject slowly maximal amounts of into paediatric muscle 102 multiple injection sites 4 mL divide and give in Inject deep into gluteal solutions to be injected muscle. If volume more ATSIHP/IHW/IPAP Extended authority Extended Cefotaxime can be given IM years dosage Infant and max. of 2 g Anaphylaxis, page page Anaphylaxis, child up to 16 50 mg/kg to a Recommended Recommended Section 3: Emergency | Critical emergencies
Cefotaxime May cause diarrhoea, nausea, vomiting, pain and May cause diarrhoea, nausea, vomiting, pain and Consult MO/NP. See IM OR THEN Route of 200mg/mL 250 mg/mL mL or weaker administration IV/Intraosseous to give concentration of Reconstitute 1 g vial with Reconstitute 1 g vial with 3.6 mL water for injections 2 g vial: add 9 mL water for 2 g vial: add 9 mL water concentration of 100 mg/mL concentration Reconstitute 1 g vial with 9.6 Reconstitute mL water for injections to give mL water for 4 0.9 % to concentration of 150mg/ 0.9 % to concentration of Dilute DOSE with sodium chloride Dilute DOSE with sodium injections to give concentration of injections to give concentration Severe hypersensitivity to penicillins, carbapenems and cephalosporins. Do not Severe hypersensitivity to penicillins, carbapenems 1 g 2 g Strength Schedule Rapid injection < 1 minute can cause life threatening arrythmias. Rapid injection < 1 minute can cause life threatening : Form Injection Contraindication: mix with aminoglycosides e.g. gentamicin Management of associated emergency: inflammation at injection site, rash, headache and dizziness. Can cause severe colitis due to Cl. inflammation at injection site, rash, headache and difficile Note but it is extremely painful Provide Consumer Medicine Information: ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, 88 Critical emergencies | Primary Clinical CareManual 10th edition | ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Consult MO/NP. Management ofassociatedemergency: upper body,musclespasmofthechestandbackrarelyhypotensionshocklikesymptoms red-man syndrome.'Red-mansyndrome'presentsastingling,flushingorrashoftheface,neckand faster thanrecommendedrate Give through Note ‡ SeeTherapeuticGuidelines(eTG)forsubsequentdosingorinobesityadults Provide ConsumerMedicineInformation: Management ofassociated emergency: Contraindication Note: injection site Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Injection Injection Form Form : Schedule Cannot begivenIM Rapid IVadministrationmaycauseseizures Schedule Strength 500 mg Strength securely fastenedcannula 500 mg 1 g 1 g See : Severehypersensitivity topenicillins,carbapenems and cephalosporins Anaphylaxis, page 2 mL(1gvialwith2.5mL)water 10 mLOR1gvialwith15-20 Reconstitute 500mgvialwith Reconstitute 500mgvialwith OR lidocaine(lignocaine)1% . Workoutdoseaccordingtoactualbodyweight. 10mL ofwaterforinjections(20mL 4 0.9% tomakeconcentrationofat Dilute DOSEinsodiumchloride to 1g)giveconcentrationof Reconstitute 500mgvialwith 4 water forinjections -cancauseseverereactionsincludingprofoundhypotensionand IV/Intraosseous administration for injections IV/Intraosseous Route of administration least 5mg/mL 102 50 mg/mL IM Route of
asextravasationmaycausetissuenecrosis. ConsultMO/NP.See THEN If 'redmansyndrome'occursdecrease/ceaseinfusion. May causediarrhoea,nausea,pain and inflammationat Flucloxacillin
Vancomycin
> 16yearsto Recommended Anaphylaxis, page Recommended dosage loading dose max. 750mg Body Weight > 16yearsto ‡ >1month 2 g useActual 30 mg/kg 15 mg/kg dosage up toa adult adult Extended authority ATSIHP/IHW/IPAP
Extended authority ATSIHP/IHW/IPAP 102 muscle. Nomorethan Inject deepintolarge doses over500mgis Inject slowlyover IV/Intraosseous Infuse overatleast 1 gineachsite Maximum ratefor IV/Intraosseous 6-8 minutes 10 mg/minute Do notinfuse Duration 60 minutes Duration stat IM stat
2,4,19,20 12,21
Critical emergencies 89
IM stat 2,4,12,22,25 Adult Child Child Adult
minutes Duration each site Guidelines for tissue table 3-5 minutes than 4 mL at of solutions to be injected into IV/Intraosseous muscle - no more Inject slowly over Inject into a large Infuse over 20-30 maximal amounts paediatric muscle See Gentamicin can be https://www.health. ATSIHP/IHW/IPAP
Extended authority Extended 102 http://www.rch.org.au/ adult (Apr 2018): OR OR years 4 dosage 640 mg 5mg/kg Anaphylaxis, page page Anaphylaxis, Section 3: Emergency | Critical emergencies Recommended Recommended
max. of 500 mg max. of 700 mg for septic shock ≥ 16 years to 7mg/kg up to a max. critically ill/septic shock Child > 1 month to < 10
5 mg/kg IBW/AdjBW to a 7 mg/kg IBW/AdjBW to a Term neonates ≤ 1 month Term neonates if Child 10 years to < 16 years 6 mg/kg up to max. 560 mg 6 mg/kg up to max. 560 7.5 mg/kg up to max. 320 mg 7.5 mg/kg up to max. 320
Gentamicin Gentamicin
Consult MO/NP. See IM Child Adult weaker) Route of Dilute with administration sodium chloride IV/Intraosseous (i.e. to 10mg/mL or injection if required Dilute to 20 mL with 0.9% to enable slow to convenient volume sodium chloride 0.9% sodium chloride Aminoglycoside Dosing in Adults Guidelines 4 : Previous vestibular/auditory toxicity with aminioglycocides, Severe allergic : Previous vestibular/auditory toxicity with aminioglycocides, Strength 10 mg/mL 80 mg/2 mL Gentamicin is dosed according to Ideal Body Weight (IBW) or actual body weight, whichever Gentamicin is dosed according to Ideal Body Weight use ideal body weight to calculate dose, unless actual body weight is lower. If greater than use ideal body weight to calculate dose, unless Form Schedule Injection function Management of associated emergency: Contraindication Use with caution if > 80 years, pre-existing reaction to aminoglycoside, myasthenia gravis. other nephrotic agens, rapidly changing renal vestibular/auditory impairment, renal impairment, Child - Determine ideal weight by using corresponding 20% over ideal body weight use ideal body weight. charts available from weight for height percentile on a growth chart. Growth childgrowth/Growth_Charts dosing calculations or patients with known or likely pre-existing renal impairment see Therapeutic dosing calculations or patients with known or likely Guidelines (eTG) or QH qld.gov.au/__data/assets/pdf_file/0019/713323/aminoglycoside-guidelines.pdf of age given as a single dose in adults with sepsis, regardless inactivated by cephalosporins and penicillins. Flush line well before giving gentamicin or administer inactivated by cephalosporins and penicillins. Flush at separate sites to prevent inactivation Adults - use Adjusted Body Weight (AdjBW). For adjusted is less. Where actual body weight is > 20% of IBW, Provide Consumer Medicine Information: toxicity. IV gentamicin is *Note: Rapid IV administration may result in ototoxicity/vestibular ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, 90 Critical emergencies | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup Management ofassociatedemergency cephalosporins Contraindication history ofseizuredisorders Note injection site. Provide ConsumerMedicineInformation: RIPRN andRNonly.MustconsultMO/NP Schedule • • Injection Form Urgent treatmentandevacuation/hospitalisationrequired hospital All patientswithsuspectedorconfirmedsepsisshouldbemanagedinanappropriatelyequipped : Riskofseizures:usecautiouslyinpatientswithCNSinfections,renaldysfunctionor Can causeseverecolitisdueto Strength 500 mg : NotforIMinjection. 4 1 g with 9.6mLwaterforinjections Reconstitute 500mgvial to giveconcentrationof Shake wellbeforeuse (9.1 mLto1gvial)
IV/Intraosseous administration
Severe hypersensitivitytopenicillins,carbapenemsand 50 mg/mL : ConsultMO/NP.See Route of Maycausenausea,vomiting,headache,phlebitisof Meropenem Cl. difficile
Anaphylaxis, page > 16yearsto Recommended dosage 1 g 102 adult Prescribing Guide Inject over 5 minutes Duration 2,4,23,24 stat Critical emergencies 91
or positive ° Section 3: Emergency | Critical emergencies notify Public Health Unit within 6 hours notify Public - 109 or local pathway as relevant Acute Management of Suspected Meningococcal Disease Clinical Pathway Acute Management of Suspected Meningococcal 5,6,7 - adult/child at least one of:
Kernig's sign - resistance to extension of the knee when hip is flexed to 90 Kernig's sign - resistance to extension of the knee 1,2 2,3,4 https://clinicalexcellence.qld.gov.au/resources/clinical-pathways/meningococcal- seizures focal neurological deficit petechial rash - does not fade on pressure positive Brudzinski's sign - reflex flexion of the hip and knee when the neck is passively flexed shock photophobia irritability vomiting and/or nausea anorexia altered mental status, confused, lethargic headache - typically severe and generalised neck stiffness or resistance - often not present in young children or infants who may present neck stiffness or resistance - often not present with exaggerated head lag with passive or active flexion of the neck they Note: may not complain of neck stiffness, but cannot touch the chin to chest fever
Meningitis at: diseaseclinical-pathways and remote areas where expert clinicians may not be available, commence antibiotic treatment antibiotic commence available, be not may clinicians expert where areas remote and without a lumbar puncture Use the Queensland types of infective bacterial and viral organisms types of infective bacterial 0.18% or sodium solutions e.g. glucose 4% with sodium chloride Do not use hyponatraemic increase the risk of cerebral oedema chloride 0.45% which can contraindicated. In rural meningitis need a lumbar puncture unless All patients with suspected should not be ignored can be caused by several of the meninges and spinal cord and Meningitis involves inflammation Careful management of fluid and electrolyte balance is important in the treatment of meningitis. in the treatment of balance is important of fluid and electrolyte Careful management as soon as possible Discuss with Paediatrician state. Their concerns early, subtle changes in the child's conscious Parents or carers may notice Meningococcal infection is a notifiable disease infection is a notifiable Meningococcal symptoms infection to explain their no obvious source of in a sick child with Suspect meningitis must be suspected cause, meningitis a fever and no identified In a child with Meningitis is a medical emergency - early recognition and treatment is imperative early recognition and treatment a medical emergency - Meningitis is – – – – – – – – – – – – – – – – – – – – – – – – Other symptoms may include: – – – Will usually have –
• • • • • • • • • • Fits/convulsions/seizures, page Related topics • • Recommend Background
HMP HMP 1. May present with 92 Critical emergencies .Immediatemanagement 2. | Primary Clinical CareManual 10th edition | Clinicalassessment 3. • • • • • • • • • • • • • • • • •
– and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning – – – – – Perform physicalexamination: Weigh -bareweightif<2years – Obtain acompletehistoryofthepresentingconcernasable.Inparticular any: Consider sepsisasadifferentialdiagnosis.See Arrange urgentevacuation – – Commence fluidresuscitationasclinicallyappropriatewithin30minutes: MO/NP willorderantibiotics-givewithin30minutesDONOTDELAY Check allergies – Check BGL: – – – Take bloodsunlessthiswilldelayantibiotics>30minutes: – Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus: Give O Consult MO/NPurgently If fittingseeFits/convulsions/seizures,page109 – – – – – In infant<3monthsofagelookfor: Check vaccination status,especiallyHib/meningococcal/pneumococcal – – – – – – – – – – – – – – – – – – – – central capillaryrefilltime is rehydrated clothing. Note:petechiaeandpurpuradonotfade on pressure.Rashmaynotappearuntilchild inspect allskinsurfacesforrashesespeciallyatpressurepointsandunder nappiesand headache, irritability,fever,rash,neckstiffness,lethargy,confusion repeat onMO/NPordersifneeded give sodiumchloride0.9%20mL/kgfluidbolus if requiredMO/NPmayorderglucose10%2mL/kg – – blood cultures: FBC, coagulationtests,LFT,UE,glucose meningococcal PCR(adult4mLinmauvetoptube;child1EDTApinktube) consider intraosseousifIVunabletobeobtained seizures apnoea poor feedingorvomiting high pitchedcry bulging fontanelle auscultate thechest forairentryandanyaddedsounds (cracklesorwheezes) check forneckstiffness -withpatientlyingdown,put handbehindheadandgentlyraise palpate thefontanelleininfants-feel forfullness inspect andpalpatetheears,nose throat assess hydration – – if >16yearsoradult-2setsfromsites(2ofaerobicandanaerobicbottles) if <16years-aimfor2-6mL(oneaerobicbottle) 2 tomaintainSaO 2 4,5,6,7,8 ≥94%.SeeOxygendelivery,page64 1 Sepsis/septic shock, page 80 1 Critical emergencies 93
https:// 1,19,12,13 at: IM stat muscle minutes Duration IV/Intraosseous Inject into gluteal Inject slowly over 3-5 ATSIHP/IHW/IPAP Extended authority 102 Adult 10 mg dosage Anaphylaxis, page page Anaphylaxis, Section 3: Emergency | Critical emergencies Recommended
2 months MO/NP may ADD: ≥ may only administer via IV route Dexamethasone for dosing May cause transient perineal itching or burning IM 80 0.9% Consult MO/NP. See Route of 19 Dilute in 10 mL administration sodium chloride IV/Intraosseous dexamethasone BEFORE or with the first dose of antibiotic dexamethasone BEFORE or local pathway as relevant pathway as or local
4 2 months and adults: 1,19 ≥ 4 mg/mL Strength The vial formulation in patients with a known hypersensitivity to sulphites 8 mg/2 mL Acute Management of Suspected Meningococcal Disease Clinical Pathway Clinical Disease Meningococcal of Suspected Management Acute Sepsis/septic shock, page page shock, Sepsis/septic aciclovir benzylpenicillin ceftriaxone OR cefotaxime gentamicin PLUS vancomycin See ampicillin PLUS cefotaxime – – – – – – – – – debilitated, to cover Listeria MO/NP may ADD: – – suspected MO/NP may ADD: if herpes simplex encephalitis – heavy alcohol consumption, pregnant or if immunocompromised, > 50 years old, history of if critically ill immunocompetent child if critically ill immunocompetent – – for adults only, for children – – for neonates and infants < 2 months: for neonates and infants – – – – – – – –
Give before or with first dose of antibiotic as benefit lost if given after first dose. Do not delay Give before or with first dose of antibiotic as Further doses of antibiotics required in 6 hours if still waiting to be evacuated - consult with MO/NP Further doses of antibiotics required in 6 hours – – – – – If not allergic, MO/NP may order: If not allergic, – Monitor clinical observations + BGL closely observations + BGL Monitor clinical access not possible be used if timely IV/intraosseous IM route can See the Qld See the clinicalexcellence.qld.gov.au/resources/clinical-pathways/meningococcal-disease- clinicalpathways Form
Schedule Injection • • • • • antibotics if dexamethasone not available Contraindication: Management of associated emergency: Provide Consumer Medicine Information: Note: ATSIHP, IHW, IPAP must consult MO/NP and RIPRN and RN must consult MO/NP Antibiotics - give IV within 30 minutes on MO/NP order: - give IV within 30 minutes Antibiotics
4. Management 4. 94 Critical emergencies | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: with aminoglycosidese.g.gentamicin Contraindication: at injectionsite Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP injection Powder Form for Schedule Strength 500 mg 1 g Severehypersensitivitytopenicillins,carbapenemsandcephalosporins.Donotmix Reconstitute 500mgvialwith Reconstitute 500mgvialwith 4.7 mLwaterforinjections 1.7 mLwaterforinjections 4 (OR 1gvialwith9.3mL) (OR 1gvialwith3.3mL) to giveconcentrationof to giveconcentrationof administration 250 mg/mL 100 mg/mL Route of IM IV Consult MO/NP.See Maycauserash,diarrhoea,nausea,painandinflammation
Ampicillin Neonates andinfants 50 mg/kgtoamax. Recommended Anaphylaxis, page < 2months dosage of 2g
Extended authority ATSIHP/IHW/IPAP 102 solutions tobeinjected 3-5 minutes,otherwise into paediatricmuscle tissue tablein Inject dose<1gover maximal amountsof septic shock, page See 10-15 minutes Guidelines for Duration over stat IM IV 1, 15,16,19 Sepsis/
80 Critical emergencies 95
80 1,17,19,23 IM stat sites Child Adult Cl. difficile page page Duration Guidelines for tissue table in of solutions to be injected into Inject deep into IV/Intraosseous gluteal muscle. If least 3-5 minutes Sepsis/septic shock, Sepsis/septic maximal amounts paediatric muscle volume more than See Inject slowly over at Inject slowly in multiple injection 4 mL divide and give ATSIHP/IHW/IPAP Extended authority Extended 102 2 g Adult of 2 g dosage Recommended Recommended Neonate and child Anaphylaxis, page page Anaphylaxis, 50 mg/kg to a max. Section 3: Emergency | Critical emergencies May cause diarrhoea, nausea, vomiting, pain and May cause diarrhoea, nausea, vomiting, pain Cefotaxime
Consult MO/NP. See IM OR THEN Route of injections 200mg/mL mL or weaker administration Adult/2 g dose Child/part dose IV/Intraosseous Reconstitute 1 g vial with Reconstitute 1 g vial with Reconstitute 1 g vial with 2 g vial: add 9 mL water for 2 g vial: add 9 mL water concentration of 100 mg/mL concentration of 250 mg/mL 3.6 mL water for injections to give Dilute DOSE with sodium chloride Dilute DOSE with sodium 9.6 mL water for injections to give 9.6 mL water for injections Reconstitute with 20 mL water for Reconstitute injections to give concentration of injections to give concentration 0.9 % to concentration of 150 mg/ 0.9 % to concentration of 4 : Severe hypersensitivity to penicillins, carbapenems and cephalosporins. Do not mix : Severe hypersensitivity to penicillins, carbapenems 1 g 2 g Strength : rapid injection < 1 minute can cause life threatening arrhythmias. Reduce dose in renal impairment. : rapid injection < 1 minute can cause life threatening for Form Schedule Powder injection ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, with aminoglycosides e.g. gentamicin Management of associated emergency: inflammation at injection site, rash, headache, dizziness. Can cause severe colitis due to inflammation at injection site, rash, headache, Note is required ceftriaxone is the preferred agent Can be given IM but it is extremely painful. If IM Contraindication Provide Consumer Medicine Information: 96 Critical emergencies | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: aminoglycosides. Donotuseinneonates Incompatible withcalciumcontainingIVfluidse.g.Hartmann'ssolution. Donotmixwith Contraindication impairment Note difficile inflammation attheinjectionsite,rash,headache,anddizziness.Can causeseverecolitisdueto Provide ConsumerMedicineInformation: injection and mustconsultMO/NPassooncircumstancesallow RIPRN must consult MO/NP unless circumstances do not allow, ATSIHP, IHW,IPAPandRNmustconsultMO/NP Powder Form Schedule for : Rapid IV administration may result in seizures. Interacts with warfarin. Reduce dose in renal Strength 1 g : Severehypersensitivitytopenicillins,carbapenemsandcephalosporins. 4 If givingviainfusion,dilutefurther injections togiveconcentrationof (final concentration250mg/mL) 1.8 mLOR1gvialwith3.6of in 40mLsodiumchloride0.9% Reconstitute 500mgvialwith concentration of40mg/mL Reconstitute withwaterfor 40 mLwaterforinjections lidocaine (lignocaine)1% 500 mgvialwith4.8mL Dilute DOSEfurtherto 2 gvialwith19.2mL 1 gvialwith9.6mL Reconstitute with IV/Intraosseous Child/part dose Adult/2 gdose administration 100 mg/mL: Route of ConsultMO/NP.See IM Ceftriaxone May causediarrhoea,nausea,vomiting,painand
Anaphylaxis, page 50 mg/kgtoamax. Child ≥2months Recommended in which casemay administer IM only dosage of 2g Adult 2 g ATSIHP/IHW/IPAP/RIPRN 102 Extended authority Note: should begivenby See paediatric muscle maximal amounts Sepsis/septic shock, OR infuseover30 large muscle.No IV/intraosseous Inject deepinto be injectedinto least 3minutes 1 gineachsite of solutionsto tissue tablein Injectoverat more than Guidelines for Duration Doseover1g infusion minutes page Adult Child stat IM 1,18,19,22 80
Cl. Critical emergencies 97
19,20,21 IV IM stat minutes Duration 1 g in each site Inject deep into large muscle. No more than Infuse over at least 30 ATSIHP/IHW/IPAP 102 Extended authority Extended 2.4 g Adult dosage Recommended Recommended Anaphylaxis, page page Anaphylaxis, Section 3: Emergency | Critical emergencies
Benzylpenicillin IV IM THEN : May cause diarrhoea, nausea, pain and inflammation at the : May cause diarrhoea, nausea, pain and inflammation Consult MO/NP. See Route of injections: administration 3 g vial with 13 mL 1.2 g vial with 10 mL 600 mg vial with 5 mL 600 mg vial 1.6 mL water for injections 1.6 mL water for injections 0.9% and give via infusion Reconsititute with water for Reconsititute concentration of 300 mg/mL 4 Reconstitute 600 mg vial with Reconstitute 600 mg vial dilute in 100 mL sodium chloride dilute in 100 mL sodium (OR 1.2 g vial with 3.2 mL) to give a (OR 1.2 g vial with 3.2 mL) Severe hypersensitivity to penicillins, carbapenems and cephalosporins Severe hypersensitivity to penicillins, carbapenems 3 g 1.2 g 600mg Strength Schedule Rapid IV administration may result in seizures. Max. daily dose of 6 g if renal impairment Rapid IV administration may result in seizures. Form injection Powder for ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, Management of associated emergency: Provide Consumer Medicine Information injection site Note: Contraindication:
98 Critical emergencies | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup Provide ConsumerMedicineInformation: RIPRN andRNonly.MustconsultanMO/NP Management ofassociatedemergency Contraindication: impairment Stop theinjectionifrednessorpain.Useincautionneurologicalabnormalities.Adjustdoserenal Note: dose), headache,encephalopathy,injectionsitereactions • • • • • Powder for injection Schedule Consult MO/NPasabove Public HealthUnitwithin6hours Perform hearingtest3monthsafterdischarge Health Unitwilladvise Unvaccinated contactsofHibmeningitis<5yearsshouldbeimmunised assoonpossible.Public meningitis Chemoprophylaxis willberequiredforclosecontactsofapatientwitheither meningococcalorHib Form Monitorinjectionsiteclosely-extravasationcancausesevereinflammationandtissuenecrosis. Forallsuspectedorconfirmedcases ofmeningitisormeningococcaldiseasenotifythelocal 19 Strength 500 mg 250 mg IMorIVinjection. 4
Shake tomixthoroughly Dilute dosewithsodium to amax.concentration Reconstitute withwater give aconcentrationof (i.e. 250mgtoatleast 50 mLor500mgtoat 500 mgwith20mLto 250 mgwith10mL IV/Intraosseous administration chloride 0.9% for injections: least 100mL)
Allergy toaciclovirorvalaciclovir 25 mg/mL 5 mg/mL Route of THEN : ConsultMO/NP.See of Maycausenausea,vomiting,diarrhea,hallucinations(high
Aciclovir Neonates, infantsand 10 mg/kgtoamax.of Child andadolescent Note: dosinginterval varies byage-seek 20 mg/kgtoamax. children <12years of 1000mg/dose specialist advice Anaphylaxis, page Recommended 1000 mg/dose 12-16 years 10 mg/kg dosage Adult 102 Prescribing guide IV/Intraosseous Infuse overat least 1hour Duration stat 1,19,25,26 Critical emergencies 99
163 691
54 - adult/child Section 3: Emergency | Critical emergencies Croup/epiglottitis, page Traumatic injuries, page choking) choking) 680 1 on next page 1,2 (severe airway obstruction): (mild airway obstruction): DRS ABCD resuscitation/the collapsed patient, page DRS ABCD resuscitation/the collapsed patient, page 102 airway obstruction ( obstruction airway 1 1 give reassurance encourage coughing until foreign body is expelled Choking flowchart
– – – call for help – call for help the airway use a finger sweep if solid material is visible in start CPR. See urgently contact MO/NP Children often put objects into their mouths. There is risk of inhalation or swallowing. Most swallowing. or inhalation of risk is There mouths. their into objects put often Children months to 4 years commonly occurs aged 6 trauma to the airway, anaphylactic reaction, angioedema, croup, epiglottitis or mass (tumour or angioedema, croup, epiglottitis or reaction, airway, anaphylactic trauma to the abscess) are more subtle than in or partial. Presenting symptoms in adults Obstruction can be complete children there is a possibility of a spinal injury there is a possibility body, foreign to inhalation of be due patient may obstruction in the conscious airway Upper facility with advanced airway management capability is recommended in the event of severe of severe event the in recommended capability is airway management advanced with facility foreign object or an unseen positional airway obstruction where over any injury, including airway takes precedence patient, care of the In an unconscious There is the risk of laryngeal and upper airway oedema developing over time. Early transfer to a over time. Early airway oedema developing risk of laryngeal and upper There is the – – – – –
If ineffective cough – If conscious assess for effective cough If effective cough – – – – See If unconscious: Cyanosis Collapse Stridor (high pitched noise caused by inspiration) Drooling Ineffective respiratory effort Shortness of breath Coughing or loss of voice (hoarseness) Clutching the neck with thumb and finger Extreme anxiety, agitation, gasping sounds
• • • • • Anaphylaxis, page Button battery ingestion/insertion, page Related topics • • • • • • • • • • • • • •
Background Recommend 2. Immediate management
1. May present with Foreign body body Foreign 100 Critical emergencies | Primary Clinical CareManual 10th edition | Reproduced withpermissionfrom AustralianResuscitation Council.2018 Choking • • – – – If obstructionstillnotrelieved: – – – – – If backblowsareunsuccessfulperformupto5chestthrusts: – – – – – – – – – – – – – – – – – – urgently contactMO/NP if losesconsciousness,useafingersweepsolidmaterialisvisibleintheairwayandstartCPR if personremainsresponsive,continuealternating5backblowswithchestthrusts with eachchestthrust,checktoseeiftheairwayobstructionisrelieved children andadultsmaybetreatedinsittingorstandingposition place infantinaheaddownwardspositionontheirbackacrossyourthigh thrusts aresimilartochestcompressionsbutsharperanddeliveredatgreaterintervals identify thesamecompressionpointasforCPR your lap infants maybeplacedinaheaddownwardspositionpriortodeliveringbackblowsi.e.across the aimistorelieveobstructionwitheachblowratherthangiveall5blows check toseeifeachbackblowhasrelievedtheobstruction use theheelofyourhandinmiddlebackbetweenshoulderblades perform upto5sharpbackblows flowchart 1 Critical emergencies 101 680 Section 3: Emergency | Critical emergencies Oxygen delivery, page 64 See Oxygen delivery, 3
1 ≥ 94%. 2 1
to maintain SpO to maintain 2
consult MO/NP if the patient has any symptoms e.g. an increased HR, increased temperature or consult MO/NP if the patient has any symptoms any chest finding - evacuation may be required –
Consult MO/NP on all occasions of severe choking – Button battery ingestion/insertion, page a button battery, see Button battery ingestion/insertion, If choking as a result of Advise patient to be reviewed the next day: If the choking episode is minor and cause is a foreign body which has been dislodged and minor and cause is a foreign body which has been If the choking episode is patient can be allowed asymptomatic and chest findings are normal, then removed, the patient is observation home after a period of Perform chest x-ray if indicated on MO/NP orders Perform chest x-ray if indicated in cases of near a facility with advanced airway management capability Prepare for evacuation to foreign object choking or unseen positional ADDS/CEWT score or other local Early Warning and score or other local Early (full Q-ADDS/CEWT clinical observations Perform standard Response Tools) Listen to the chest for air entry and added sounds (crackles or wheezes) sounds (crackles chest for air entry and added Listen to the Give O Take emergency patient history - with attention to the circumstances which occurred leading to leading which occurred circumstances to the - with attention history patient Take emergency choking ribs and the in of the spaces between expansion and drawing observe chest for During inspiration clavicles
• • • • • • • • • • •
6. Referral/consultation 5. Follow up
4. Management 3. assessment Clinical 102 Critical emergencies
| Primary Clinical CareManual 10th edition | 1. Maypresentwith HMP Recommend Background • • • Croup/epiglottitis, page Acute asthma,page Related topics • • • • • • • • • – – – – Mild andmoderateallergicreactions: – – Consider anaphylaxisinANYacuteonset: Onset canrangefromminutestohoursafterexposureasubstance – – – – – – – – – – Common causesofanaphylaxis: occur -fluidresuscitationisimportant During severeanaphylaxiswithhypotension,markedfluidextravasationintothetissuescan normal jewelleryorotheraccessorye.g.keyring,USBstick,shoetag,anklet,watch,tattoo Always checkformedicalertjewelleryandaccessoriesinemergencysituations and medicalalertdevice agents/ confirmedallergensandhaveareadilyaccessibleanaphylaxisactionplan,medicine People withdiagnosedallergiese.g.nuts,honeybeesand/ormedicine,shouldavoidtrigger seconds ifapatientstandsorsitssuddenly Do notallowsomeonewithsuspectedanaphylaxistostandorwalk-fatalitycanoccurwithin Anaphylaxis ispotentiallylife-threateningandmustbetreatedasamedicalemergency Adrenaline (epinephrine)isfirstlinetreatmentinanaphylaxisandshouldbegivenwithoutdelay https://allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines/ For furtherinformationseeASCIAGuideline: Antihistamines arenotrecommendedintreatinganaphylaxis – – Anaphylaxis – – illness with: present hypotension orbronchospasmupperairwayobstruction-eveniftypical skinfeaturesarenot See abdominal pain,vomiting-note:these aresignsofanaphylaxisforinsectallergy tingling mouth hives orwelts swelling oflips,face,eyes – – – – – – latex venom frombites(ticks)orstingse.g.honeybees,waspsants medicine e.g.penicillin food -especiallynuts,eggs,cow'smilk,wheat,seafood,fish,soy,sesame toms PLUS involvementofrespiratory,cardiovascular,orpersistentseveregastrointestinal symp typical skinfeatures-urticarialrash,erythema/flushing,and/orangioedema Mild andmoderate allergicreactions,page 1,2,3 119 -adult/child 691 1,4 1 2
Tick bites,page Mild andmoderateallergicreactions,page 320 Acute ManagementofAnaphylaxis 302 3 320 2 -maylooklike . Availableat - Critical emergencies 103
® Section 3: Emergency | Critical emergencies
302 2
1,2 Tick bites, page Give IM adrenaline (epinephrine) into outer mid-thigh without delay Give IM adrenaline (epinephrine) into outer if available 2
: Give adrenaline (epinephrine) FIRST then asthma reliever if someone with known asthma and : Give adrenaline (epinephrine) FIRST then asthma draw up using 1 mL syringe OR use autoinjector if available e.g. EpiPen draw up using 1 mL syringe OR use autoinjector repeat every 5 minutes as needed and allow to drop off. See and allow to drop off. See do not delay adrenaline (epinephrine) administration to do this do not delay adrenaline product stop infusion of medicine/blood spray (if available) ticks with liquid nitrogen or ether containing flick out insect stings, freeze vomiting and/or abdominal pain - for insect stings/bite abdominal pain - for vomiting and/or wheeze or persistent cough wheeze or persistent or collapse persistent dizziness (young children) pale and floppy difficult/noisy breathing difficult/noisy of tongue swelling in throat swelling/tightness and/or hoarse voice difficulty talking – – – – – – – – – – – – –
Note breathing difficulty (wheeze, persistent cough or allergy to food, insects or medicine has sudden hoarse voice) - even if no skin symptoms – Give O Urgently consult MO/NP – If unconscious place in recovery position and maintain airway If unconscious place in recovery allow the patient to sit If breathing is difficult Call for help hypotension allow them to stand or walk - can result in fatal Lay patient flat - do not Prevent further exposure to allergen if possible: Prevent further exposure – – – – – – – – – – – Anaphylaxis - ANY ONE of the following: of the ONE - ANY Anaphylaxis • • • • • • • • • 2. Immediate management 104 Critical emergencies | Primary Clinical CareManual 10th edition | 3. Clinicalassessment ATSIHP andIHWmayproceedwithfirst2doses MID, RIPRNandRNmayproceed Jr EpiPen e.g. Management ofassociatedemergency 0.3 mLof1:1,000adrenaline(epinephrine),howeverdonotdelayadministration tocheckifpregnant useful -consultMO/NP.Instructionsforautoinjectorondevicelabels. Note palpitations inconsciouspatients Provide ConsumerMedicineInformation: EpiPen e.g Injection • ® Form Schedule – Obtain emergencypatienthistory-from patient,relativesorfriends: – – – : Ifpatientonbetablockertheymayberesistanttoadrenaline(epinephrine). Glucagonmaybe – – – – current medications, useof anautoinjectore.g. EpiPen any previousepisodes, treatmentusedandeffect known allergiesand reaction food, medicine,sting/bite,herbalmedicines, otherexposuresintheprevious6-8hours ® 1 mg/mL 1:1,000 Strength 0.15 mg /0.3 mL /0.3 mL 0.3 mg 3 Deep injectioninto Deep injectioninto mid-lateral thigh mid-lateral thigh Use 1mLsyringe with 21Gneedle administration 25 mmlength (not insulin 2 Route of syringe OR ifusing IM IM
)
: Consult Adrenaline (epinephrine) Maycauserestlessness,anxiety,headacheand autoinjector > 12and (years) 10-12 adult MO/NP 7-10 Age 4-6 2-3 1-2 < 1 Adult* andChild>12years 10-20 kg-about1-5years Dosage basedonageand
to amaxof0.5mg/dose > 20kg-about5years approximate weight . See 0.01 mg/kg/dose Recommended 0.5 mg/dose Weight Child 5-10 ® (kg) > 50 Anaphylaxis, page 0.15 mg 20 40 30 dosage 10 15 0.3 mg ≤
12 * Give 0.05-0.1 mL 0.15 mL Volume 1:1,000 0.2 mL 0.4 mL 0.3 mL 0.5 mL 0.1 mL pregnant women 102 Extended authority
ATSIHP/IHW Repeat every 5 minutesas Duration required stat
1,2,5 Critical emergencies 105 OR Croup/epiglottitis, page Croup/epiglottitis, 54 MO/NP may consider: Section 3: Emergency | Critical emergencies Acute asthma, page 119 page asthma, Acute falling: 2 Acute asthma, page 119 page asthma, Acute , ECG, conscious state 2 64 6-8 L/min. See Oxygen delivery, page 2 2
691 oral prednisolone 1 mg/kg (maximum 50 mg). See oral prednisolone 1 mg/kg (maximum 50 mg). See IV hydrocortisone 5 mg/kg (maximum 200 mg) first 30 minutes) sodium chloride 0.9% (maximum 50 mL/kg in the consider IV glucagon bolus if cardiogenic shock (especially if taking beta blockers) nebulised adrenaline (epinephrine) 5 mL (5 ampoules of 1:1,000). See nebulised adrenaline (epinephrine) 5 mL (5 ampoules a spacer OR salbutamol 8-12 puffs of 100 microgram using 5 mg via nebuliser. See insert 2 x IV cannula - use the largest possible gauge given age and vascular status insert 2 x IV cannula - use the largest possible gauge palpate radial or brachial pulse and determine pressure at which this disappears determine pressure at which or brachial pulse and palpate radial difficult in children may be more – – – – – – – – – – aggressive fluid resuscitation AND IV adrenaline (epinephrine) bolus consider cricothyrotomy if trained commence CPR. See DRS ABCD resuscitation/the collapsed patient, page prolonged CPR should be considered PLUS intubation may be required if skills/equipment available intubation may be required if skills/equipment prolonged attempts at intubation should be avoided for persistent hypotension/shock: – – – – – – for upper airway obstruction: – for persistent wheeze: adrenaline (epinephrine) infusion in consultation with emergency medicine/critical care adrenaline (epinephrine) infusion in consultation specialist give rapid IV sodium chloride 0.9% 20 mL/kg administer O needed provide airway support if and hypotensive children: obtain IV access in adults – monitor HR, BP, SpO hypertension or pulmonary oedema - especially if respiratory distress or hypotension were distress or hypotension - especially if respiratory or pulmonary oedema hypertension absent initially ↑systolic BP, this vomiting, or has tachycardia but normal or if patient is nauseous, shaky, toxicity rather than worsening anaphylaxis may be adrenaline (epinephrine) simple palpable systolic BP is a reliable measure of initial severity and response to treatment and response to measure of initial severity systolic BP is a reliable simple palpable – – check affected body systems - skin changes, face, throat, breathing, HR, neurological state HR, neurological breathing, face, throat, - skin changes, systems affected body check – – – – – – – – – – – – – – – – – – –
– – If overwhelming anaphylaxis (cardiac arrest): – – If airway not able to be maintained and SpO – – – – – – or ineffective MO/NP may order: If adrenaline (epinephrine) infusion unavailable If hypotensive: – or deterioration If inadequate response to adrenaline (epinephrine) – – – See Immediate management are available: When skills and equipment – Be alert to over treatment: Be alert to over – – – Perform physical examination: Perform – monitor response to treatment: Assess and ADDS/CEWT score or other local Early Warning Warning local Early other or score ADDS/CEWT (full Q- observations clinical standard Perform Tools) and Response
• • • • • • • • • • • 4. Management 106 Critical emergencies | Primary Clinical CareManual 10th edition | RIPRN andRNonly.MustbeorderedbyanMO/NP Management ofassociatedemergency: Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: ischemia orarrhythmia DO NOTGIVEIVbolusofadrenaline(epinephrine)unlessincardiacarrestsituation adrenaline (epinephrine)toxicitye.g.nauseas,shaky,vomiting,tachycardia,butwithnormalBP Note Provide ConsumerMedicineInformation: Injection reconstitution) (powder for Form Schedule Injection : Monitorcontinuously-ECG,SpO Form Schedule 1 mg/mL 1:1,000 Strength of waterforinjectionsor Reconstitute with2mL sodium chloride0.9% 4 3 in separateIVline IV INFUSIONonly Strength 100 mg administration Route of 2
Adrenaline (epinephrine) , frequentBPtomaximisebenefitandminimiseriskof ConsultMO/NP.See ConsultMO/NP.See MaycauseincreasedBGLandaffectmoodsleep Hydrocortisone administration Dilute in1,000mL sodium chloride Recommended 1:1,000 (1mL) Route of dosage IV 0.9%
Anaphylaxis, page Anaphylaxis, page 5 mg/kgtoamax.of Recommended (~0.1microgram/kg/minute) 200 mg dosage according toresponseand Titrate rateupordown Prescribing guide 102 102 Start infusionat: ~ 5mL/kg/hour Extended authority ATSIHP/IHW/IPAP using apump side effects Duration -riskofcardiac
Inject over30 Duration seconds stat
2,3 1,2 Critical emergencies 107 https://www.allergy.org.au/ 2 https://www.health.qld.gov.au/cdcg/
available at Section 3: Emergency | Critical emergencies http://www.tga.gov.au/form/national-adverse-events- 2 Action Plan for Anaphylaxis
ASCIA . If practising outside of Queensland use local reporting systems . If practising outside of Queensland use local reporting 1 For adverse reactions caused by medicines, report directly to the TGA Australian Adverse Drug For adverse reactions caused by medicines, report Promptly report any significant adverse event following immunisation (AEFI) directly to Promptly report any significant adverse event following provide education on how to use provide education on how will require an adrenaline (epinephrine) autoinjector prescribed prior to discharge (epinephrine) autoinjector prescribed prior to will require an adrenaline lives alone and is remote from medical care is remote from medical lives alone and late in evening presents for medical care severe reaction e.g. required repeated doses of adrenaline (epinephrine) or IV resuscitation doses of adrenaline e.g. required repeated severe reaction anaphylaxis of asthma or severe/protracted has a history illness e.g asthma has other concomitant relapse/protracted and/or biphasic (two phase) reactions may occur reactions (two phase) and/or biphasic relapse/protracted – – – – – – – –
Reaction Reporting System available at following-immunisation-aefi-reporting-form Will require referral to allergy specialist available at Queensland Health by completing an AEFI form index/adverse Consult MO/NP on all occasions If not evacuated advise patient to be reviewed the next day, or earlier if they are concerned If not evacuated advise patient to be reviewed the Advise patient to see MO/NP at next clinic Discuss medical alert jewellery with the patient Discuss medical alert jewellery record Document allergy in clinical – Provide patient with an hp/anaphylaxis/ascia-action-plan-for-anaphylaxis Advise patient to avoid re-exposure of allergen (if known) Advise patient to avoid re-exposure e.g. stings, food, unknown cause: If there is a risk of re-exposure – – – to manage as per MO/NP instructions If not evacuated, continue Evacuation may be required - particularly if any of the following: be required - particularly Evacuation may – – – Monitor closely for at least 4 hours after last dose of adrenaline (epinephrine): dose of after last at least 4 hours closely for Monitor – for 2 hours then hourly state 15 minutely BP, RR, conscious
• • • • • • • • • • • • • • • When stable When
6. Referral/consultation 5. Follow up 108 Critical emergencies | Primary Clinical CareManual 10th edition | • • • • • • • • • For persistentwheeze -bronchodilators,oralprednisolone orordrocortisoneorhydrocortisone For persistenthypotension/shock -sodiumchloride0.9% (maximum50mL/kginfirst30 minutes) For upperairwayobstruction-nebulised adrenaline(epinephrine)±intubation/cricothyrotomy Adrenaline (epinephrine)infusion- in consultationwithemergencymedicine/criticalcarespecialist IV access-adults+hypotensivechildren Support airway Give O Monitor HR,BP,RR,SpO 20 mL/kgRAPIDLY Give IVsodiumchloride0.9% • • • • • • 2 CPR ifneeded Remove allergenifstillpresent If difficultybreathing,allowtosit If unconscious,placeinrecoveryposition,maintainairway Lay patientflat-donotallowtostand Call forassistance • • • • • If hypotensive Give intramuscularADRENALINE(EPINEPHRINE)withoutdelay When able – – Any acuteonset: Difficulty talking/hoarsevoice Swelling/tightness inthroat Swelling oftongue Difficult/noisy breathing – – persistent severegastrointestinalsymptoms illness withskinfeatures+respiratory/cardiovascularor hypotension, bronchospasmorupperairwayinstruction,OR Additional measuresMO/NPmayconsider 2 Watch forANYONEofthefollowing Anaphylaxis management Deep IMintomid-lateralthigh Repeat 5minutelyasneeded
IMMEDIATE ACTION > 12andadult • • • • (years) 10-12 pain -forinsectstings/bites Vomiting and/orabdominal Pale andfloppy(youngchildren) Persistent dizzinessorcollapse Wheeze orpersistentcough 7-10 Age 4-6 2-3 1-2 < 1
Adrenaline
Deep IMintomid-lateralthigh 1,2,4 Weight
5-10 (kg) (epinephrine) doses > 50 20 40 30 10 15
volume 1:1,000 0.05 mL-0.1mL Adrenaline 0.15 mL 0.2 mL 0.4 mL 0.3 mL 0.5 mL 0.1 mL
Critical emergencies 109 3 259 530 3 Section 3: Emergency | Critical emergencies ) need to be treated urgently, as prolonged fitting can ) need to be treated urgently, - adult/child Preeclampsia/eclampsia, page Toxicology (poisoning and overdose), page seizures status epilepticus 490 (fits associated with fever) usually occur in children aged between 3 months between aged children in occur usually fever) with associated (fits 115 91
convulsions/ 1,2 1,2 are sleep deprived hypoglycaemia/hyperglycaemia - for example in a diabetic hypoglycaemia/hyperglycaemia - for example in do not take epilepsy medications regularly drink excess alcohol faints (syncope) - episodes of low systemic blood pressure possibly due to pain, fear, faints (syncope) - episodes of low systemic blood dehydration or medicines cardiac arrhythmia - causing a drop in blood pressure
– – – – – – Fits/ – – of seizures if they: In a patient with known epilepsy, they are at risk – – – – Paracetamol has not been shown to reduce the risk of further febrile convulsions Paracetamol has not been Some conditions can mimic a fit: cause damage to the brain. Multiple seizures with incomplete recovery between also need to be Multiple seizures with incomplete recovery cause damage to the brain. stopped urgently medical condition for prolonged seizures in children Specialist advice is needed Fits lasting > 5 minutes ( Consider meningitis in all children presenting with convulsions/fits and fever until proven and fever presenting with convulsions/fits in all children Consider meningitis otherwise underlying serious a have may fever, and convulsions with present who age of months 6 < Children Do not attempt to open teeth or wedge mouth open during a seizure mouth open during a to open teeth or wedge Do not attempt and 6 years of age and are associated with a temperature > 38°C and 6 years of age and are First seizure can occur at any age, but new onset epilepsy is more common in young children and any age, but new onset epilepsy is more common First seizure can occur at elderly and are self-limiting requiring no drug treatment Most fits last < 2 minutes Febrile convulsions
• • • • • • • • • • • Meningitis, page Alcohol withdrawal, page Hypoglycaemia, page Related topics Background Recommend HMP HMP 110 Critical emergencies 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | Generalised - Febrile convulsions Partial -complexpartialseizures Focal seizures • • • • • • • • • • • • • • • • • • • • Typically patientscannotrememberthefit,althoughtheymayrecallsomewarningsigns(aura) – – – Reported historyof'havingafit': – – Clinical signsoffitsinchildrenmaybesubtle.Ininfants: has atemperature.Anothercauseshouldbeconsidered Fits inolderchildrenandadultscannotbeputdownto'febrileconvulsions', evenifthepatient Prolonged febrileconvulsions(>5minutes)needtobestoppedurgently Commonly associatedwithviralURTI,otitismedia Mostly benigntemperature>38°C Common inyoungchildren3monthsto6years – – – – Signs mayinclude: a minuteortwo Impaired consciousness,butmayremainstanding/sitting,althoughbehavingoddly.Usuallylasts Localised areaofjerking(mayreflectaTIAorbraintumour) – – May be: While thepatient is stilljerkingitusuallybetternot totryputanythingintothemouth In thepostictalphase anoropharyngealairwaywillhelp protectairwayifitcanbeinserted easily. SpO If adult or>95%child.See After theseizurehasstoppedO If fittinge.g.jerking,islasting>5 minutes treatwithmidazolam Time thedurationoffitandnote characteristicsoffit Turn ontosideinrecoveryposition Protect patientfrominjury,especiallythehead See – – – – – – – – – – – 'biting tongue'duringtheseizure 'eyes rollback'and'frothatthemouth' 'falling andshakingallover' smiling inappropriateforage flicking eyemovements usually nomemoryoftheeventandmaydenyepisodesareoccurring head andeyesmayturntooneside.Maystareblankly focal jerkingofonelimb licking lipsrepetitively,orfidgetingwithhands of theairway during thisphasebreathingoftensoundsheavy,withloud'snoring',duetopartialobstruction phase) drowsy, confused,incontinentorpossiblyagitatedafterthefitforabout10minutes(postictal DRS ABCDresuscitation/thecollapsedpatient,page 2 notmaintainedconsult MO/NP tonic-clonic seizure( 1,2,4 Oxygen delivery,page 2,4 2 maybeadministeredviaHudsonmask tomaintainSpO
grand mal) 64 54 2,4
2 >94% Critical emergencies 111
Alcohol See 2 259 1,2,4,6,7 Section 3: Emergency | Critical emergencies Preeclampsia/eclampsia, page 530 Preeclampsia/eclampsia, see Hypoglycaemia, page 115 6 77 See Sepsis/septic shock, page 80 and Shock, page See 6 dose of midazolam, MO/NP may advise to give IV dose of midazolam, MO/NP may advise to give 1 nd 2,4 Toxicology (poisoning and overdose), page and overdose), Toxicology (poisoning or 1,2,4,5
check for skin rashes BGL –
withdrawal, page 490 withdrawal, page Consider eclampsia in pregnant women. Consider eclampsia Any febrile illness, alcohol use or sleep deprivation alcohol use or sleep Any febrile illness, by withdrawal. related seizure caused of alcohol or drug Consider possibility Take emergency patient history from witnesses history patient Take emergency fits and previous presenting regarding history more detailed recovered obtain has Once patient anticonvulsant medicine is taking their regular Check patient ADDS/CEWT score or other local Early Warning observations (full Q-ADDS/CEWT score or other Perform standard clinical Any patient who presents with their first fit/convulsion/seizure usually needs full investigation Any patient who presents with their first fit/convulsion/seizure including EEG and CT scan Usually allowed home after a period of 4 hours observation, if patient has returned to normal level of Usually allowed home after a period of 4 hours be in care of a responsible person awareness after consultation with MO/NP. Must Patient information sheets available at: https://clinicalexcellence.qld.gov.au/resources/ emergency-department-patient-information-sheets Monitor for sepsis and shock in children. fit has finished, give oral (if fully conscious) or If child is uncomfortable with febrile illnesses, once 35 for doses rectal paracetamol. See Acute pain management, page If BGL < 4 mmol/L or < 3 mmol/L in children MO/NP may order another dose of midazolam If BGL is within normal limits and/or fit continuing If seizure continues in a child despite 2 Consult MO/NP do not require treatment with medicines Most seizures are brief and given age and vascular status Insert 2 x IV cannula - use the largest possible gauge MO/NP may order electrolytes, calcium and magnesium and serum anticonvulsant levels calcium and magnesium and serum anticonvulsant MO/NP may order electrolytes, Perform physical examination checking for any injury which may have occurred if patient fell or hit checking for any injury which may have occurred Perform physical examination themselves during the seizure: – and Response Tools) + – phenytoin or IV phenobarbital (phenobarbitone) 15-20 mg/kg phenytoin or IV phenobarbital (phenobarbitone)
• • • • • • • • • • • • • • • • • • • •
4. Management 3. assessment Clinical 112 Critical emergencies | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Provide ConsumerMedicineInformation: Management ofassociatedemergency: Note: over atleast2-5minutes drops atatimeintoalternatenostrilsuntilfulldoseisgiven(overabout15seconds). syringe orsqueezedirectlyfromtheampoule. Administration advice: RIPRN mayproceed ATSIHP, IHWandRNmustconsultMO/NP Injection Follow up • • • Form Schedule medical review Any patientwithrecurrentseizuresdespiteanticonvulsantmedicationneeds MO/NPandspecialist Consult MO/NPonalloccasions Advise tobereviewedthenextdayandMO/NPclinic Monitor forsedationandrespiratorydepression 5 mg/5mL 5 mg/1mL Strength 4
Buccal: (ATSIHP andIHWmay NOT administerIV) administration Intranasal Route of Slowly dripintothepatients’mouthbetweengumsandcheekusinga Buccal IV/IM
ConsultMO/NP.See
Maycausedrowsinessorrespiratorydepression Midazolam Intranasal: use mucosalatomisationdevice(MAD)or1-3 to amax.of10mg to amax.of10mg Recommended 0.1-0.2 mg/kg Anaphylaxis, page 0.2 mg/kg 5-10 mg dosage
10 mg
Adult Child Child Adult
Extended authority ATSIHP/IHW/RIPRN 102 IV: Further doses slowly over at least2-5 inject slowly on MO/NP If IVinject Duration minutes order stat
1,3,8,9 Critical emergencies 113 insulin 73 1,3 1,2 It results in four 1,3,4,5 Section 3: Emergency | Critical emergencies 3 54 Unconscious/altered level of consciousness, page Unconscious/altered level of consciousness, page 109 2,4 2,4
pump disconnection or malfunction at the onset of type 1 diabetes mellitus and therefore leads to its diagnosis at the onset of type 1 diabetes trauma, insulin doses, acute myocardial infarction, as a result of infection, omitted as a result of infection, omitted antihyperglycaemic medicine, pancreatitis, myocardial antihyperglycaemic medicine, pancreatitis, as a result of infection, omitted a side effect of some drugs infarction, stroke, or as – – –
primary metabolic derangements - hyperglycaemia, severe dehydration, acidosis and - hyperglycaemia, severe dehydration, primary metabolic derangements See Queensland Health diabetes resources: https://qheps.health.qld.gov.au/caru/networks/ diabetes DKA may occur: – – Diabetic ketoacidosis (DKA) occurs primarily in type 1 diabetes mellitus. Diabetic ketoacidosis (DKA) hypokalaemia – Commence initial treatment as early as possible as may progress to coma and death as possible as may progress treatment as early Commence initial It is characterised state (HHS) occurs primarily in type 2 diabetes. Hyperosmolar hyperglycaemia little or state with mental change in and hyperosmolality, dehydration by severe hyperglycaemia, occur: no ketoacidosis. HHS may Check capillary blood and urine ketones in any patient with altered consciousness or a with altered consciousness ketones in any patient blood and urine Check capillary abnormality neurological
Take emergency patient history if possible Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) See DRS ABCD resuscitation/the collapsed patient, page Recent weight loss (in undiagnosed type 1 diabetes) Hypotensive, tachycardia, hypothermic Altered level of consciousness Breathing patterns altered - deep slow laboured breathing (Kussmaul breathing) Breathing patterns altered - deep slow laboured Rigid abdomen Nausea and gastrointestinal problems Large glucose and ketones in urine Dehydrated - excessive thirst and urination Odour of breath - fruity/acetone High BGL High blood ketone level
• • • • • •
Related topics Fits/convulsions/seizures, page • • • • • • • • • • • • • •
Background Recommend
2. Immediate management 1. with May present (HHS) Hyperosmolar Hyperglycaemic State State Hyperglycaemic and Hyperosmolar (DKA) ketoacidosis Diabetic - adult/child Hyperglycaemia 114 Critical emergencies .Clinicalassessment 3. | Primary Clinical CareManual 10th edition | Management 4. • • • • • • • • • • • • • •
– – and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning – In childrenandadolescents: Monitor BGL,bloodgases(particularly pH)andelectrolytes-initiallyeveryhourwherepossible Record fluidbalance-allinputand output Observe closelyandmonitorpatient's vitalsignsandconsciousstate – – Consult MO/NPassoonpossiblewhowillorganise/advise: venous gasrecommended Collect bloodforgasesandelectrolytes.Usepointofcaretestingwhere appropriate.Inchildren, Collect MSUforMCS weight loss In patientswithoutahistoryofdiabetes,assessforpolyuria,polydipsiaandrecent – – – – – – – – – Take comprehensivepatienthistorywhenablewithattentionto: If usinginsulinpumptherapy,discontinueandgiveIVuntilDKAresolved – – Always contactMO/NPifBGL>15mmol/L: – – – – Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus. occur Contact MO/NPimmediately ifconfusion,irritability,headache ispresentorneurological changes – – – – – – – – – – – – – – – – – – test forketonesinbloodandurine: ECG -lookforlargeTwaves MO/NP mayadviseimmediate,aggressivefluidresuscitation commence IVsodiumchloride0.9%1000mL-ratetobeadvisedbyMO/NP infusion one cannulaforfluid±potassiumadministrationandthesecondmedicinei.e.insulin do hourlyneurological observationsfor24hours may initiallybehighornormalbutwill decreasewheninsulincommenced potassium replacementwillbeneededearlyintreatmenttopreventhypokalaemia. Potassium evacuation toappropriatelyequippedfacility – – possible dehydration urine output,fluidintake infections orpossibleinjury chest pain recent alcoholintake exercise food intake insulin current diabetesstatus if unabletoaccessIVroute,IMorsubcutaneousmaybeused MO/NP mayadviseashortactingIVinsulin situation. ConsultMO/NP in childrenfluidreplacementwhichistoorapidcanresultcerebraloedemaandworseningof – – record urineresultasnegative,+,++ record bloodketonelevelasanumber(normalvalue<0.6)e.g.'0.6'or '1.4' 1 3,5 3,5 5,3 1 Critical emergencies 115 73 : 558 Section 3: Emergency | Critical emergencies 3 558 https://qheps.health.qld.gov.au/caru/networks/ Immediate care of the newborn, page Unconscious/altered level of consciousness, page NOT suffering alcohol induced hypoglycaemia 109 and/or 4,5 109
- adult/child 521 4 Immediate care of the newborn, page
1,2 give IV glucose OR if IV access not available glucagon IM or subcut in newborns (BGL < 2.8 mmol/L) and sick children in newborns (BGL < 2.8 mmol/L) medical conditions as a result of some rare in people with diabetes taking oral glucose-lowering tablets or insulin e.g. BGL < 4.0 mmol/L taking oral glucose-lowering tablets or insulin e.g. in people with diabetes intake as a result of heavy alcohol Fits/convulsions/seizures, page
– – – – – – – – check BGL do not give oral fluid or food if patient NOT malnourished intensive one-on-one education by Diabetes Educator and Dietitian education by Diabetes intensive one-on-one minimum 3 monthly review by a Diabetes Specialist/Endocrinologist/Paediatrician. In children In children Specialist/Endocrinologist/Paediatrician. a Diabetes review by 3 monthly minimum as soon as possible afterwards of hyperglycaemia or recommend at time and adolescents, Hypoglycaemia See Queensland Health diabetes resources: diabetes – – elderly Hypothermia can prolong hypoglycaemia in the Hypoglycaemia or low BGL in diabetes, may occur: Hypoglycaemia or low BGL – – Check BGL in any patient with altered consciousness or a neurological abnormality Check BGL in any patient – – – – –
If decreased level of consciousness: – – – See If neonate see Confusion, drowsiness, tiredness, anxiety, amnesia, unconscious, fitting or coma Confusion, drowsiness, tiredness, anxiety, amnesia, Loss of consciousness, seizures Pale, sweating, tremor, rapid HR, palpitations of mouth or fingers Hunger, headache, dizziness, irritability, tingling Aggressive behaviour, may appear drunk BGL < 4 mmol/L Consult MO/NP on all occasions Consult MO/NP – Advise to have: Advise –
• • • • Fits/convulsions/seizures, page Diabetes in pregnancy, page Related topics • • • • • • • • • • •
Background Recommend HMP HMP
2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up Follow 5. 116 Critical emergencies | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: Do notgive50%glucosetochildrenoradolescents-cancausedeath Note: thrombosis Provide ConsumerMedicineInformation: RIPRN andRNmayproceed ATSIHP, IHW,IPAPmustconsultMO/NP Intravenous • • Injection infusion Form Check BGLevery15minutesuntilwithinnormallimits mmol/L concentration ofglucoseinfluidifnecessarytomaintainbloodabove4 fluids), atmaintenanceratetopreventfurtherhypoglycaemia.MO/NPmayorderincreaseof repeat onceifnecessary.Followbysodiumchloride0.45%withglucose5%IV(maintenance over If childoradolescent – – – – – Schedule – – – – – # Inject intolargeveinusingsmallgaugeneedle-extravasioncancause seriousnecrosis. – re-check BGL-if≤3mmol/L: – – if noimprovementwithin10minutes: recovery shouldbealmostimmediateorideallywithin6minutes consult MO/NPassoonpossible – – – – if patientISmalnourished – – – – – – –
20 repeat doseofIVglucose 0ne cannulapreferablyintoantecubitalveinduetoriskofthrombophlebitis insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus Further dosesmayberequired possible -highdoseglucoseinthesepatientscanprecipitateWernicke'sencephalopathy. note THEN giveIVglucose give IVthiamine do notgiveglucagon
8 minutes, untilbloodglucoseconcentrationnormalises(morethan4mmol/L).MO/NPmay : ifthiamineunavailableproceedwithIVglucoseandadministerassoon Adult only Strength 500 mL 50% in 10% in 50 mL Unscheduled
MO/NP willorderIV10%glucose2mL/kg(maximum100mL)-giveslowly administration
for adultonly. Route of IV IV and/or 11
ConsultMO/NP.See 1,5,6 suffering May causepain,veinirritation,phlebitisorvenous Must consultMO/NPforchild
Child andadolescent to amaxof100mL Glucose Recommended alcohol inducedhypoglycaemia 150-200 mL
Adult only 2 mL/kg dosage 20 mL Adult
Anaphylaxis, page 11 Infuse over20minutesuntil Inject slowlywithextreme Infuse over15minutes 102 BGL >4mmol/L : 3 mL/min Duration caution stat 11,12,13,14,16 # Critical emergencies 117 7,8,11 9,10,15 stat Duration MO/NP order Further doses on Further doses stat minutes Duration
ATSIHP/IHW Extended authority Extended Inject IV dose slowly over 10 1 mg 0.5 mg dosage Anaphylaxis, page 102 page Anaphylaxis, Child ≤ 25 kg Anaphylaxis, page 102 page Anaphylaxis, Section 3: Emergency | Critical emergencies Recommended Recommended Adult/child > 25 kg Adult/child Adult dosage 300 mg Recommended Thiamine Glucagon Route of IM/Subcut administration IV or diluent provided Reconstitute with Reconstitute 0.9% dilute in Route of 3 10-20 mL of IM undiluted administration sodium chloride 1 mg Unscheduled Strength 3 mL 300 mg/ Strength
Schedule urinalysis pregnancy exercise recent alcohol intake illness or injury current diabetes status insulin food intake Form – – – – – – – Injection – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – – – – Obtain comprehensive patient history when able, in particular: Obtain comprehensive patient history when able, – – – Schedule
(powder for
Form • • reconstitution) Injection ATSIHP, IHW, RIPRN and RN may proceed and RN may IHW, RIPRN ATSIHP, May cause nausea, vomiting and allergic reactions Information: May cause nausea, vomiting Provide Consumer Medicine within 10 minutes Note: Response should occur emergency: Consult MO/NP. See Management of associated Management of associated emergency: Consult MO/NP. See ATSIHP, IHW, IPAP must consult MO/NP ATSIHP, IHW, IPAP must RIPRN and RN may proceed 3. assessment Clinical 118 Critical emergencies 4. Management | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • • • • Refer toDiabetesEducator Consult MO/NPonalloccasions Advise patienttobereviewedthenextdayandatMO/NPclinic treat a'hypo'themselves Review treatmentofhypoglycaemiawiththepatient.Patientsshouldknow howtorecogniseand Review signsandsymptomsofhypoglycaemiawiththepatient – – – – – Review eventswithpatientwhichmayhaveledtohypoglycaemicepisode: If knownalcoholmisuse,continuewithoralthiamine300mgdaily Review nextdoseofinsulin/diabetesmedication If causeofhypoglycaemianotimmediatelyreversibleconsultwithMO/NP – – Check BGLin15minutes: Follow withasandwich,pieceoffreshordriedfruitmeal – – If BGL<4mmol/Landpatientisconsciousabletoswallow: If pregnant,see – – – – – – – – – end stagekidneyfailure ensure thattheyeatcarbohydratetoreducetheriskofhypoglycaemia had toomuchalcohol.Peopleconsumingalcoholareadvisedtolimittheirconsumptionand not enoughcarbohydratefood/forgottoeatmeal unplanned exercise was toomuchdiabetesmedicationorinsulintaken mmol/L monitorevery1-2hoursfor4 if <4.0mmol/L,repeatabovetreatment,checkin15minutesandlater> depending oncause,andinconsultationwithMO/NP if >4.0mmol/L,checkagaininanother15minutesandstillmmol/Lpatientcangohome, (OGTT) drink in remotelocationsifnoneoftheaboveavailable,considerusingoralglucosetolerancetest – – – – giverapidlyabsorbedformsoforalsugar(carbohydrate)suchas: – – – – 2-3 sweetbiscuits 5-6 jellybeansorotherchewablesweets ½ cupordinarysoftdrink(notdietdrink)orcordialsweetenedjuice 3 teaspoonsorsachetsofsugareitherstraightaddedtoanon-sweeteneddrink
Diabetes inpregnancy,page 4,11 4
521 4
1 Critical emergencies 119 Critical emergencies 16 https://www.
16 695 available from: Section 3: Emergency | https://www.nationalasthma.org.au/living-with- Bronchiolitis, page Asthma Action Plan page 104 page 1,2 Step 1 - adult/child urgently contact MO/NP: 2 102 asthma
1 http://www.asthmahandbook.org.au/acute-asthma see Anaphylaxis for doses, repeat every 3-5 minutes if needed
– – wheezing should not be treated initially as asthma airways as cause consider acute viral bronchiolitis or small floppy give IM adrenaline (epinephrine) 1:1,000 – – Acute Acute Antibiotics are rarely needed in asthma Antibiotics are rarely needed available from: Peak flow monitoring chart asthma/resources/health-professionals/charts/peak-flow-chart Patients, relatives and friends of people with asthma should know asthma first aid available friends of people with asthma should know asthma Patients, relatives and from: require an All patients with asthma asthmahandbook.org.au/management/action-plans Viral chest infections in infants may cause wheeze that may not respond to bronchodilators cause wheeze that may in infants may Viral chest infections does not always mean unequal in asthma due to mucous plugging and Air entry can often be pneumothorax or pneumonia wheeze, this indicates severe/acute asthma indicates severe/acute wheeze, this less likely to episode. Asthma is of severity of asthma is determined by assessment Management < 12 months of age of wheezing in children be the cause Beware of the patient with asthma in distress who is unable to speak and without audible to speak and without in distress who is unable patient with asthma Beware of the – – –
– – Rapidly assess severity. See Sit up to assist with breathing If < 12 months of age – If unresponsive, cannot inhale bronchodilators, or respiratory arrest imminent: If unresponsive, cannot inhale bronchodilators, Cyanosis Symptoms continue despite reliever medications chest indicate a life-threatening episode Cyanosis, impaired conscious state and a quiet Wheeze/cough In distress Tiredness/exhaustion Breathlessness, speaking in short sentences
• • • • • • • • Anaphylaxis, page Related topics • • • • • • • • • • •
Recommend HMP HMP
2. Immediate management 1. May present with 120 Critical emergencies | Primary Clinical CareManual 10th edition | • • • • • • 1 to<6years Step 1:Rapidassessmentofseverity ≥ 6years • • • • Step 2:Givesalbutamol±ipratropium Mild/moderate Mild/moderate MDI withspacer 4-12 puffs Give children) for younger (plus mask With spacer via MDI 2-6 puffs Give SpO around andspeakinphrases For youngchildren,canmove sentences inonebreath Can walk,speakwhole and aftersalbutamolisadministered Note: – – – If severeorlife-threateningatanytime Within minutesreassessforseverity.See Give salbutamolimmediately – – – salbutamol resuscitation/the collapsedpatient,page prepare forrapiddeteriorationandpossiblecardiorespiratoryarrest.See arrange forurgentevacuation notify MO/NPimmediately 2 salbutamol >94% Mild/Moderate Ifpatientisnotdistressed,checkspirometry(FEV)orpeakexpiratoryflowrate(PEFR)before
2 via 2
• • • • • • • ≥ 95%for6-12year olds for adultsand Start O Add ipratropium500microg air inadultsunlessO nebulisation withO Salbutamol 5mg via MDIwithspacer AND Give Start O ipratropium 250microg intermittent O Salbutamol 2.5mg for youngerchildren) MDI withspacer(plusmask AND Give ipratropium ipratropium 4puffs salbutamol 6puffs salbutamol 12puffs 2 2 andmaintainSpO and maintainSpO . See • • • • • Any SpO recession inspiration orsubcostal Tracheal tugduring Use ofaccessorymuscles Obvious respiratorydistress in sentences Unable tospeak 2 ofthefollowing:
Step 2 nebulisation.Add Severe Severe
OR OR 2 8 puffs 90-94% via intermittent 2 : via 2 inchildren; Step3 2 for routesdependingonseverity 54 needed Severe via to NEB
2 2 92-95% ≥95% toNEB • • • • • • – – Start O NEB ADD nebulisation nebules Give Maintain SpO NEB ADD nebulisation nebules Give • • • • • Any • • – – ≥ 95%for6-12year olds child >12years 92-95% foradultsand Poor respiratoryeffort Cyanotic Exhausted Collapsed Drowsy SpO Soft/absent breathsounds ipratropium250microg ipratropium 500microg salbutamol 2x5mg salbutamol 2x2.5mg of thefollowing: 2 2 Life-threatening Life-threatening andmaintainSpO viacontinuousO <90% via continuousO Life-threatening DRS ABCD DRS ABCD 2 ≥95% 2 2
2
to to
Critical emergencies 121 2,3 2,3
stat Duration stat hour if needed minutes for first Duration Then every 20-30 (or sooner if needed) ATSIHP/IHW ATSIHP/IHW/RIPRN Extended authority first hour if needed 102 102 (or sooner if needed) Extended authority Extended
Then every 20-30 minutes for Adults: drive nebuliser with air unless
. Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, Section 3: Emergency | Critical emergencies dosage 2-6 puffs 4-12 puffs years dosage 5-10 mg Child < 6 years 2.5-5 mg Recommended Recommended Child < 6 years Recommended Adult and child ≥ 6 years Adult and child Adult and child ≥ 6 Salbutamol Salbutamol Salbutamol
2
May cause tremor, palpitations and headache May cause tremor, palpitations May cause tremor, palpitations and headache Consult MO/NP. See Consult MO/NP. See device Route of Route of Nebulised Inhalation Inhalation with air or O With spacing administration administration (at least 6 L/min) 2 3 4 100 dose Strength microgram/ Strength 5 mg/2.5 mL 2.5 mg/2.5 mL
Use with mask for young children Use with mask for young Form
(MDI)
Schedule inhaler
Form needed. Children: use O Schedule
2 Nebule
O Management of associated emergency: Provide Consumer Medicine Information: inappropriate Note: Only give NEB if use of MDI via a spacer is RN must consult MO/NP consult MO/NP ATSIHP and IHW may proceed with first dose then RIPRN may proceed Management of associated emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine Note: Metered dose Metered dose ATSIHP and IHW may proceed with first dose then consult MO/NP then consult with first dose proceed and IHW may ATSIHP may proceed RIPRN and RN
122 Critical emergencies | Primary Clinical CareManual 10th edition | Consciousness Step 3:Reassessseverity ausculation Respiratory Skin colour Heart rate Breathing Posture Criteria Speech Chest SpO rate 2 ≥ ≥ ≥ ≥ 6yearsand 6yearsand 6yearsand 6yearsand Age group < 6years < 6years < 6years < 6years All ages All ages All ages All ages All ages adults adults adults adults # Notapplicable-maybethesameasmoderate anddoesnotdetermineseveritycategory 2 Can walkorcrawl Adults: <110bpm < 25breaths/min Children: normal sentence inone Mild/Moderate distress isnot Normal lung Can finisha Respiratory Can talkor Can walk vocalise Wheeze sounds Normal Normal Normal severe breath (all of) > 94% range Alert OR movement: chestsucks inward whenbreathing Paradoxical chestwall intercostal musclesor Children: tachycardia Can onlyspeakafew in andoutwardwhen Unable tolieflatdue Subcostal recession ‘tracheal tug’during to dyspnoea.Sitting words inonebreath muscles ofneckor Adults: ≥110bmp ≥ 25breaths/min hunched forward Use ofaccessory Severe (anyof) breathing out Tachypnoea Tachycardia inspiration Lethargic 90-94% OR OR # # # # Poor respiratoryeffort Bradypnea (indicates Cardiac arrhythmia Unable tovocalise Severe respiratory respiratory arrest) Bradycardia (may Reduced airentry occur justbefore Clinical cyanosis due todyspnoea Life-threatening unconscious Collapsed or exhaustion) Silent chest Can’t speak respiratory exhausted Drowsy or Cyanosis distress (any of) < 90% OR OR OR OR Critical emergencies 123 DRS ABCD Life-threatening 2 As per Step 2 2 Continuous nebulisation until Continuous nebulisation breathing difficulty improves Then consider changing to MDI plus spacer or intermittent nebuliser (use doses as per Severe)
• • Section 3: Emergency | Critical emergencies Severe 2 54 Repeat dose every 20 minutes Repeat dose every 20 minutes for first hour (3 doses) or sooner as needed
• , no fever, symptoms resolve and patient responds well to treatment: if oral route not possible, IV hydrocortisone oral prednisolone OR IV methylprednisolone oral prednisolone OR hour for ALL adults and children aged ≥ 6 years (regardless of severity of asthma): hour for ALL adults and children aged ≥ 6 years Mild/moderate st – – – – – – avoid systemic corticosteroids if mild/moderate wheezing responds to initial bronchodilator avoid systemic corticosteroids if mild/moderate initial bronchodilator treatment MO/NP may if mild/moderate wheezing does NOT respond to order: start systemic corticosteroids: – – prepare for rapid deterioration and possible cardiorespiratory arrest. See prepare for rapid deterioration and possible cardiorespiratory arrange urgent evacuation resuscitation/the collapsed patient, page add ipratropium bromide i.e. Magnesium sulfate MO/NP may consider add on treatment options for when to give repeat doses Step 4 for when to give repeat repeat salbutamol. See consult MO/NP urgently severity of this and previous episodes of asthma and previous episodes severity of this episodes to ICU for acute previous admissions use history, in particular steroid medication – – – – – – – – – – – – If no improvement or worsening after 1st salbutamol dose: If no improvement or worsening Patient may return home after 1 hour of observation with advice to continue usual asthma medicines, including salbutamol, every 4 hours as needed MO/NP may consider chest x-ray to exclude pneumothorax Continue to manage in collaboration with MO/NP Reassess response to treatment 1 hour after starting bronchodilator. children > 6 years Check for dyspnoea while supine in adults and – – – If < 6 years: – In 1 – – – – – – – – ADDS/CEWT score or other local Early Warning Early Warning or other local score Q-ADDS/CEWT (full clinical observations standard Monitor Tools) and Response patient history (if time permits): Obtain rapid If continued poor response to salbutamol:
Repeat dose every 20-30 Repeat dose every 20-30 minutes for first hour or sooner as needed • • • • • • • • • • •
Step 4: Repeat salbutamol as per Step 2 Step 4: Repeat salbutamol • If mild/moderate episode
4. Management 3. assessment Clinical 124 Critical emergencies | Primary Clinical CareManual 10th edition | Management ofassociatedemergency:ConsultMO/NP.See If usingnebuliser,patientshouldclosetheireyesorweareyeprotection Note: OnlygiveNEBifuseofMDIviaaspacerisinappropriate disturbance andnausea. Provide ConsumerMedicineInformation:Maycausedrymouth,throatirritation,headache,taste RIPRN mayproceed ATSIHP, IHWandIPAPmayproceedwithfirstdosethenconsultMO/NP RN mustconsultMO/NP dose inhaler • • • • Inhalation Metered solution
Nebule – – alladultsandchildren≥6yearshaveoralprednisolone Ensure: Advise toreturnthefollowingdayforreview – Ensure patienthasanAsthmaActionPlan,and – Check andcoachincorrectinhalertechnique (MDI) Form Schedule – – child hasregularinhaledpreventerifindicated patients/carers areabletofollowtheirPlanathomeand/orsupportedschool provide spacerifneeded microgram/mL microgram/mL microgram/mL 21 microgram/ Strength dose 500 250 250 4 Using spacingdevice Added tonebulised administration salbutamol Ipratropium bromide Inhalation Inhalation Route of Anaphylaxis, page 102 . Avoidgettingmistintopatientseyes. Adult andchild≥6 Adultandchild 500 microgram 250 microgram Recommended Child <6years Child <6years ≥ 6years dosage 8 puffs 4 puffs years ATSIHP/IHW/IPAP/RIPRN Extended authority 20 minutesfor Further doses on MO/NP Give dose Duration 1 hour every order stat 2,5 Critical emergencies 125 6,7 Monitor Monitor Duration Infuse over 20 minutes Critical emergencies Prescribing guide Prescribing dosage 10 mmol
Child > 2 years Recommended Recommended 102 0.1-0.2 mmol/kg to a max. of 10 mmol Section 3: Emergency | Adult and child ≥ 6 years Adult and child
Magnesium sulfate Magnesium Anaphylaxis, page page Anaphylaxis, IV Route of continuously until stable (for at least 20 minutes), urine continuously until stable 2 . Hypotension alone will generally respond to IV fluids and . Hypotension alone will generally respond to IV May cause nausea, vomiting and transient hot flushing May cause nausea, vomiting administration Contact MO/NP. Cease infusion. Calcium gluconate 2.2mmol in Contact MO/NP. Cease infusion. 530 Unscheduled Strength (or weaker) Heart block and hypermagnesaemia 10 mmol/5mL to make 0.8 mmol/mL Dilute in at least 7.5 mL Dilute in at least Preeclampsia/eclampsia, page page Preeclampsia/eclampsia, of sodium chloride 0.9% of sodium chloride 0.9%
Schedule For life threatening acute asthma epsiodes where unresponsive to other treatment. asthma epsiodes where unresponsive to For life threatening acute : Form Injection Provide Consumer Medicine Information: Provide Consumer Medicine Note RIPRN and RN only. Must be ordered by an MO/NP by an Must be ordered and RN only. RIPRN if available of magnesium sulfate for administration Use local protocols parenteral calcium is rarely necessary. Also see parenteral calcium is rarely necessary. Also see Contraindication: emergency: Management of associated See Calcium gluconate available in case of respiratory depression/overdose. 10 mL should be readily drug box in paralysis, blurred or double vision, CNS depression and loss of reflexes. Monitor BP, heart rate and vision, CNS depression and loss of reflexes. paralysis, blurred or double minutes, and SpO respiratory rate every 5 treatment output and reflexes during for signs of magnesium toxicity: nausea, vomiting, flushing, hypotension, muscle weakness, muscle toxicity: nausea, vomiting, flushing, hypotension, for signs of magnesium 126 Critical emergencies | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: initial bronchodilatortreatment Note with foodtohelpreducestomachupset Provide ConsumerMedicineInformation: RIPRN mayproceedforadultandchild≥6only ATSIHP, IHW,IPAPandRNmustconsultMO/NP Tablet liquid Form Oral Schedule :
For children<6years Strength 5 mg/mL 25 mg 5 mg 1 mg administration 4 Route of avoidsystemiccorticosteroidsifmild/moderatewheezingrespondsto Oral
Consult MO/NP.See MaycauseincreasedBGLandaffectmoodsleep.Take (and child<6yearswithsevere Prednisolone 2 mg/kgtoamax.of50mg 1 mg/kg/dosetoamax.of Ongoing doses Recommended Child ≥6years 37.5 to50mg 50 mg/dose Initial dose wheeze) dosage Adult Anaphylaxis, page ATSIHP/IHW/IPAP/RIPRN Extended authority 102 Then repeatonceeach Then giveongoing morning ondays dose onceeach morning for Initial dose 5-10 days Duration 2 and3 stat stat
2,8,9 Critical emergencies 127
2,13,14 once 6 hourly 12 hourly stat stat once 2,10,11,12,15 Duration Then give authority 6 hourly 12 hourly Initial dose
Day 3: IHW/IPAP stat then 6 hourly / ongoing doses Day 1: Day 2: IHW/IPAP Duration 5 minutes Critical emergencies / Day 3: Day 1: Day 2: ATSIHP Extended 102 102 Then give ongoing doses ATSIHP Inject slowly over at least Extended authority Extended
Adult 100 mg dosage 300 mg Initial dose Child ≥ 6 years Child ≥ 6 years Recommended Recommended Ongoing doses severe wheeze) Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, Section 3: Emergency | 4-5 mg/kg/dose to a max. of 300 mg/dose dosage 8-10 mg/kg to a max. of 8-10 mg/kg to a max. of (and child < 6 years with (and child < 6 years with Initial dose 2 mg/kg to a max. of 60 mg 1 mg/kg/dose Child < 6 years Recommended Ongoing doses avoid systemic corticosteroids if mild/moderate avoid systemic corticosteroids
IV
0.9% Hydrocortisone May cause increased BGL and affect mood and sleep May cause increased BGL May cause disturbances in mood, sleep or behaviour Route of Consult MO/NP. See Consult MO/NP. See 2 mL of water IV administration for injections or sodium chloride Reconstitute with Route of Methylprednisolone sodium succinate administration For children < 6 years 4 100 mg 1 g Strength 40 mg 500 mg 4 Strength Rapid IV administration of high doses may cause arrhythmia, cardiovascular collapse or cardiac Rapid IV administration of high doses may cause Form Form : Inject over 30 seconds. : Inject over 30 seconds. Schedule Injection Injection (powder for (powder for Schedule reconstitution) reconstitution) Management of associated emergency: Provide Consumer Medicine Information: Provide Consumer Medicine Note wheezing responds to initial bronchodilator treatment ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, Management of associated emergency: Provide Consumer Medicine Information: Note: arrest ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP 128 Critical emergencies 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 1. Maypresentwith Drowning/ Recommend Background • • • • • • • • • • • DRS ABCDresuscitation/thecollapsedpatient,page Unconscious/altered levelofconsciousness,page Related topics • • • • • • Vomiting andcoughing Hypotension, shock Hypothermia Altered consciousness;unconscious on thelung) Respiratory arrest,distress,cyanosis, cracklesorwheezeinthelungs(pulmonaryoedema-fluid Cardiorespiratory arrest History ofsubmersion/immersionfaceinwater People withsevereasthmarequirespecialistreferral additional advice,informationandongoingcare Australia edition of Ensure patientsorparents/carersareabletomonitorandmanageasthmaathome.Seethecurrent Advise tobereviewedafter5daysdetermineifcorticosteroidsneedcontinued – – If discharged,advisetobereviewedthenextday,orsoonerifwheezereturns: – – Ventilation andoxygenationarepriorities The aimofmanagementistoreversehypoxia-lackO of risk,immobilisationthespineshouldnotbeallowedtointerferewith resuscitation Spinal injuryisnotcommonlyassociatedwithneardrowning-unlessthereastrongsuggestion fatal drownings Drowning isarespiratoryincidentfollowingsubmersioninliquid,andarecalledfatalornon- Aboriginal andTorresStraitIslanderchildrenadolescents Drowning isamajorcauseofdeathinAustralia.Deathratesfromdrowningarehigher precipitating events Trauma, alcoholanddrugintoxication,hypoglycaemiaseizuresmustbeconsideredas wheeze onreview,consultMO/NP if patientreturnsearlierbecausetheyneedsalbutamolmorethanevery4hoursOR if nowheezepresentthenextdayadvisetobereviewedatMO/NPclinic availablefrom: submersion The ChronicConditionsManual:PreventionandManagementofin 2,3 4,5 2 https://publications.qld.gov.au/dataset/chronic-conditions-manual -adult/child 4 73 54
2 tothebrain 1 3 andbodytissues
4 3 for Critical emergencies 129 54 they may be 6 3 Section 3: Emergency | Critical emergencies Hypothermia, page 229 page Hypothermia, See Child protection, page 760 2 5,6 5 via non-rebreathing mask. A Hudson mask is not sufficient. See Oxygen via non-rebreathing mask. 2 5,6 therapy, intubation may be required if patient is unconscious therapy, intubation may be required if patient is 2
where all attempts to increase temperature have failed consult with MO/NP before stopping with MO/NP before have failed consult to increase temperature where all attempts CPR CPR should continue if temperature is < 32°C. See continue if temperature CPR should – – delivery, page 64 core temperature (if possible) review in 6 hours in the company of a responsible adult start at the head and progress to the toes do not let the patient get cold keep patient warm with blankets and space blankets keep patient warm with consult MO/NP urgently and dry patient remove all wet clothing if breathing commences, place patient on their side with appropriate head tilt place patient on their side with appropriate head if breathing commences, give high flow O vomiting and regurgitation often occur during resuscitation - roll onto side to clear airway, then - roll onto side to clear during resuscitation regurgitation often occur vomiting and reassess condition attempt to expel or stomach by applying external pressure. Do not do not empty a distended during resuscitation fluid that may accumulate in the upper airway drain clear water or frothy do not stop CPR without consulting MO/NP: CPR without consulting do not stop – – DRS ABCD resuscitation/the collapsed patient, page collapsed life support. See DRS ABCD resuscitation/the commence basic – – – – – – – – – – – – –
allowed home in consultation with the MO/NP: – If the patient did not lose consciousness, is asymptomatic, chest findings are normal If the patient did not lose consciousness, is asymptomatic, – Any patient who has lost consciousness, has chest symptoms or signs, or was submersed in Any patient who has lost consciousness, has chest because of a risk of developing contaminated water will need evacuation/hospitalisation cerebral oedema respiratory distress syndrome (such as ARDS) and/or Encourage to cough and take deep breaths the stomach of swallowed water MO/NP may advise insertion of a NG tube to empty or presentation is inconsistent with history or is Always consider non-accidental injury where injury unexpected in children or other vulnerable people. Consult MO/NP Continue O – – Listen to chest for added sounds - crackles or wheezes Take chest x-ray if available for other injuries: Expose and examine the patient systematically Obtain a complete patient history including circumstances of submersion Obtain a complete patient history including circumstances Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – – – – – return of breathing post drowning: If coughing/has spontaneous – – – – Remove from water as soon as possible (do not endanger your safety) not endanger possible (do as soon as from water Remove normally: not breathing and If unconscious –
• • • • • • • • • • • • • • •
4. Management
3. Clinical assessment 2.management Immediate 5. Follow up • Advise to be reviewed the next day and in 2 days • Consult MO/NP if the patient has any symptoms, an increased HR, increased temperature or any chest findings
6. Referral/consultation • Consult MO/NP on all occasions Cardiovas c ular • Non-fatal drownings are a notifiable event in some Australian jurisdictions
Cardiovascular emergencies
Chest pain assessment
Recommend1 • The single most important consideration in assessment of people with chest pain, is to identify acute coronary syndrome (ACS) or another life threatening condition • Chest pain assessment is time critical • ECG Flash is available in some remote facilities to send difficult to interpret ECG traces directly to an on call cardiologist's mobile phone for interpretation and advice. See https://qheps.health. qld.gov.au/caru/networks/cardiac/ecg-flash • Physical examination is often not helpful in distinguishing patients with ACS from those with other causes of chest pain4 • There is no evidence to support the use of a gastro-intestinal (GI) cocktail to assist in ruling out coronary ischemia e.g. 'pink lady' (oral viscous lidocaine (lignocaine), antacid ± anticholinergic).5 GI cocktails should not be used6
Related topics Acute coronary syndromes, page 135
1. May present with • Chest pain or discomfort • Other symptoms may vary depending on cause, e.g: –– jaw pain –– arm pain –– dyspnoea –– diaphoresis –– syncope –– nausea –– irregular heart rhythm –– cough –– fever –– frothy sputum –– palpitations
130 | Primary Clinical Care Manual 10th edition | Cardiovas 2. Immediate management • Perform ECG - to be reviewed by MO/NP within 10 minutes of presentation –– send to cardiologist using ECG Flash, if available at facility • Obtain detailed history of the chest pain:2,3
–– Site - retrosternal, (L) chest, epigastric, interscapular, jaw, neck, arm c ular –– Onset - when did it start, sudden or gradual onset –– Characteristics - what is the pain like: discomfort, pressure, tightness, heaviness, cramping, band like, burning, ache, sharp, dull, stabbing, fullness, squeezing, tearing, ripping –– Radiation - does it spread anywhere else - neck, jaw, shoulder, one or both arms, into hands and wrists, back –– Associated symptoms - breathlessness, nausea, vomiting, sweating, dizziness/light headedness, syncope, fever, cough with purulent or pink frothy sputum or blood –– Timing - is it still there, constant or intermittent, ever had this pain before, how often does it occur, how long did it last –– Exacerbating or relieving factors - what brought on pain e.g. activity, foods, cold, stress, trauma. What makes it better/worse e.g. rest, medicines (GTN, antacids), eating, position changes, deep inspiration. Any analgesia taken –– Severity - scale of 0-10, with 0 being none and 10 being the worst • Always consider acute coronary syndromes with anyone who presents with chest pain.1 See Acute coronary syndromes, page 135 • In the absence of ECG evidence of STEMI, always consider potentially life threatening conditions1 e.g. aortic dissection, pulmonary embolism and tension pneumothorax 3. Clinical assessment • Obtain past history, including:2,4 –– heart disease, previous myocardial infarction –– hypertension –– diabetes –– lung disease, kidney disease, cancer –– dyslipidaemia • Prior diagnostic studies e.g. stress test or coronary CT angiography • Current medicines + ask if taking aspirin, warfarin • Allergies • Recreational drug use e.g. cocaine, amphetamines2 • Smoking status • Exercise e.g. sedentary lifestyle • Alcohol intake • Diet • Recent events e.g. pregnancy, trauma, major surgery or medical procedures, periods of immobilisation, long distance travel • Family history of coronary artery disease2 • Perform physical examination, including:3,4 –– standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools)
–– SpO2 –– BP on both arms - if concern for aortic dissection –– respiratory and cardiovascular examination. See History and physical examination - adult, page 20
Section 3: Emergency | Cardiovascular 131 –– palpate the abdomen - acute abdominal problems can present as chest pain and vice versa. See Acute abdominal pain, page 238 • Chest x-ray may be ordered by MO/NP to assist in differential diagnosis2 e.g. pneumonia, pneumothorax, pericardial effusion • Use differential diagnosis table as a general guide - this is not exhaustive of all causes of chest pain
Cardiovas c ular Differential diagnosis - chest pain: Life threatening causes - may include: Cause Symptoms
• Usual presentation: –– pressure-type chest pain –– originating in retro-sternal area - may radiate to arms, neck, jaw –– occurs at rest or with minimal exertion –– duration ≥ 10 minutes • May be triggered by exertion, emotional stress, temperature extremes • Characteristics of pain: –– heaviness 2 Acute Coronary Syndromes –– pressure (ACS). See Acute coronary –– tightness syndromes, page 135 –– squeezing –– burning • Atypical presentations - more common in older patients, women and patients with diabetes: –– discomfort in jaw, neck, or arm –– dyspnoea –– vomiting –– diaphoresis –– unexplained fatigue (continued)
132 | Primary Clinical Care Manual 10th edition | Cardiovas
Differential diagnosis - chest pain: Life threatening causes - may include: (continued) Cause Symptoms • Sudden onset
• Dyspnoea - most common symptom c
• Pleuritic chest pain ular • Cough • Symptoms of deep vein thrombosis (DVT) 3 Pulmonary embolism. See • Consider PE in:7,8 Deep vein thrombosis (DVT), page –– pregnant/postnatal women 155 –– hospitalised within previous 3 months –– a period of inactivity e.g. long-haul travel –– history of cancer - other than skin cancer –– bone fracture –– HRT • Sudden onset of severe chest and/or back pain • Sharp, ripping, tearing, or stabbing • Can radiate anywhere in chest or abdomen • Pulse deficits i.e. impaired or absent blood flow to peripheral vessels Aortic dissection2,3 (rare) • Commonly associated with hypertension or connective tissue disorder • May have syncope, hypotension, shock3 • May display difference between left and right arm systolic BP of > 20 mmHg3 Spontaneous pneumothorax2,3 • Sudden onset unilateral pleuritic chest pain • Dyspnoea Tension pneumothorax - life • Tachycardia (common), tachypnoea, and hypoxia threatening. See Chest injuries, • Haemodynamic instability suggests tension pneumothorax page 171 • Mild to severe symptoms Pericardial tamponade4 • Cardiogenic shock
Section 3: Emergency | Cardiovascular 133 Non-immediate life threatening causes may include: Cause Symptoms Musculoskeletal causes e.g. costochondritis, cervical radiculopathy, fibrositis3 • Chest pain reproducible with palpation Trauma3 e.g. rib fractures • Pain on inspiration or movement of chest or upper body
Cardiovas c ular from repetitive strain of • Localised tenderness coughing, stress fracture, stress fractures from sports
• Typically, sharp and pleuritic pain • Improved by sitting up and leaning forward Pericarditis4 • Pericardial friction rub - superficial scratchy or squeaking sound: - heard best with the stethoscope over the left sternal border • New wide spread ST elevation or PR depression • Localised pleuritic chest pain 2,3 Pneumonia • Fever, crackles, productive cough • Increased RR See Pneumonia - adult, page 329 • Night sweats, persistent sputum
Acute bronchitis • Cough
• Acute respiratory symptoms See Upper respiratory tract infection (URTI) - adult, page 324 • No signs of pneumonia • Chest pain, typically on side of tumour • Cough, haemoptysis Lung cancer2,3 • Dyspnoea, hoarseness • Smoking history Gastrointestinal causes2,3 e.g. gastro-oesophageal reflux disease (GORD), • Heartburn, regurgitation, dysphagia, precipitated by meal, fatty oesophageal pain, peptic foods, bending down, or lying down ulcer, pancreatitis • Retrosternal without radiation • Prolonged epigastric pain, relieved by antacid or food See Acute abdominal pain, page 238 • GORD may mimic angina See Alcohol related epigastric pain, page 247
4. Management • For all patients with suspected cardiac causes of chest pain. See Acute coronary syndromes, page 135 • Urgently contact MO/NP If severe or life-threatening symptoms • Consult with MO/NP for all other presentations of chest pain 5. Follow up • Be guided by MO/NP
134 | Primary Clinical Care Manual 10th edition | Cardiovas c ular 6. Referral • Always consult with MO/NP
HMP Acute coronary syndromes (ACS) Possible cardiac chest pain, unstable angina and myocardial infarction
Recommend1,2 • Have local cardiac clinical pathways readily available • Queensland Health cardiac clinical pathways include: – suspected acute coronary syndrome – thrombolysis for STEMI – acute coronary syndrome (ACS) – see https://clinicalexcellence.qld.gov.au/resources/clinical-pathways/cardiac-clinical- pathways • Ensure ECG reviewed within 10 minutes for early detection of ST elevation myocardial infarction (STEMI), to enable early reperfusion:1 – ECG Flash is available in some remote facilities to send difficult to interpret ECG traces directly to an on call cardiologist's mobile phone for interpretation and advice • Elevated troponin levels alone (without cardiac symptoms) should not trigger the urgent treatment of ACS. Troponin will also be elevated in cases of sepsis6 (for example) Background1 • ACS includes myocardial infarction or unstable angina2 • Myocardial infarction can be ST elevation (STEMI) or non-ST elevation (NSTEMI) • Patients without ST elevation are initially described as having NSTEACS (non-ST elevation acute coronary syndrome) - until investigated further • In the acute management of patients with ischaemia, the use of oxygen, nitrates, beta blockers and opioid analgesia may have a role in short term symptom relief only - they are not an alternative to early re-vascularisation where clinically appropriate1
Acute coronary syndrome
STEMI NSTEACS
NSTEMI Unstable angina
Related topics Chest pain assessment, page 130
1. May present with4 • Usual presentation: – pressure-type chest pain – originating in retro-sternal area - may radiate to arms, neck, jaw – occurs at rest or with exertion – duration ≥ 10 minutes
Section 3: Emergency | Cardiovascular 135 • May be triggered by exertion, emotional stress, temperature extremes • Characteristics of pain: –– heaviness –– pressure –– tightness –– squeezing –– burning
Cardiovas c ular • Atypical presentations e.g. older patients, women, diabetes, renal failure, Aboriginal and Torres Strait Islander people: –– discomfort in jaw, neck, or arm –– dyspnoea –– vomiting –– diaphoresis –– unexplained fatigue
2. Immediate management1,2,3 • Obtain rapid history of chest pain if not already completed as per Chest pain assessment, page 130 –– site, onset, characteristics, radiation, associated symptoms, timing, exacerbating or relieving factors, severity • Do ECG - send for review by MO/NP within 10 minutes of first patient contact –– send to cardiologist using ECG Flash if available at facility • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) - monitor frequently +
–– SpO2 • Give aspirin as soon as possible - if not contraindicated/already given • Give sublingual glyceryl trinitrate (GTN): –– repeat GTN every 5 minutes if no contraindications e.g. hypotensive –– up to 3 doses • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Take blood: –– troponin levels - use point of care testing • If symptoms not relieved with GTN or for ongoing chest discomfort at any time during initial management: –– give IV fentanyl or morphine - titrate to pain. See Acute pain management, page 35 –– consider fentanyl as 1st option, as morphine may delay absorption of clopidogrel and ticagrelor5 • Give antiemetic if needed.7 See Nausea and vomiting, page 48 • Continuous cardiac monitoring
• If SpO2 ≤ 93% or evidence of shock give O2 –– use with caution if COPD - aim for 88-92%. See Oxygen delivery, page 64 • Repeat ECG every 10-15 minutes until pain free1 • Continue to liaise with MO/NP • MO/NP may order chest x-ray • At any time, commence CPR if indicated. See DRS ABCD resuscitation/the collapsed patient, page 54
136 | Primary Clinical Care Manual 10th edition | Cardiovas
Extended authority Schedule 2 Aspirin ATSIHP/IHW ATSIHP, IHW, RN and RIPRN can proceed Route of Recommended
Form Strength Duration c administration dosage ular Dispersible 300 mg 300 mg Oral stat tablet Chewed or dissolved
Provide Consumer Medicine Information: May cause GI irritation or bleeding Contraindication: Allergy to aspirin or NSAID’s, aspirin sensitive asthma, with or at risk of severe active bleeding Use in pregnancy: Avoid doses > 150 mg in pregnancy and breastfeeding Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 8
Extended authority Schedule 3 Glyceryl trinitrate ATSIHP/IHW ATSIHP, IHW, RIPRN and RN may proceed Route of Recommended Form Strength Duration administration dosage 600 stat Tablet 300-600 microgram microgram Repeat every 5 Sublingual 400 minutes up to 3 doses Spray microgram/ 400-800 microgram providing patient not spray hypotensive Provide Consumer Medicine Information: May cause headache, flushing, palpitations, hypotension and fainting. Patient should get up gradually from sitting or lying Note: Ensure patient sitting down prior to giving. Do not use tablets from bottles that have been opened > 3 months. Prime the spray until an even spray is obtained before administering Contraindication: If patient has taken phosphodiesterase-5-inhibitors e.g. sildenafil (e.g. Viagra®), vardenafil (Levitra®) in the last 24 hours or tadalafil (e.g. Cialis®) in the last 48 hours Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,9
3. Clinical assessment3 • Obtain past history and perform physical examination as per Chest pain assessment, page 130 • Early identification of STEMI or new left bundle branch block (LBBB)OR possible NSTEACs is required to guide management • Other critical causes of chest pain e.g. aortic dissection, pulmonary embolism must always be considered3 • MO/NP will make differential diagnosis • MO/NP will assess for indications for reperfusion - see following flow chart
Section 3: Emergency | Cardiovascular 137 Assessment of indications for reperfusion
If STEMI or presumed new LBBB If possible NSTEACS
MO/NP to assess for indications for reperfusion3 MO will risk stratify ACS • Chest pain > 30 minutes and < 12 hours See Option 3: Reperfusion NOT Cardiovas c ular indicated under Management • Persistent ST-elevation ≥ 1 mm in 2 continuous limb leads OR persistent ST-elevation ≥ 2 mm in 2 continuous chest leads OR new or presumed new LBBB • Myocardial infarction likely from history
If NO to ANY indications for If reperfusion IS indicated reperfusion
• A decision will need to be made to either: –– give thrombolysis in the rural or remote facility OR –– if there is time for an urgent evacuation for pPCI See Options for reperfusion on next page
138 | Primary Clinical Care Manual 10th edition | Cardiovas Options for reperfusion
• MO/NP to confirm reperfusion is indicated • Options for reperfusion will depend on accessibility to cardiac catheter laboratory c ular
Able to access appropriately equipped cardiac catheter laboratory within 90 Yes Urgent evacuation for Primary Percutaneous minutes of first medical contact Coronary Intervention (pPCI) - see OPTION 2: Urgent evacuation for pPCI under Management No
Thrombolysis - at rural or remote facility
Check for contraindications for thrombolysis10 if yes to ANY or unsure, MO/NP to seek specialist advice Absolute contraindications Relative contraindications • Active bleeding or bleeding diathesis • Current anticoagulants, including (excluding menses) novel anticoagulant agents • Suspected aortic dissection • Non-compressible vascular puncture • Significant closed head or facial trauma within • Recent major surgery ( < 3 weeks) 3 months • Traumatic or prolonged ( > 10 min) CPR • Any prior intracranial haemorrhage • Recent internal bleeding (within 4 weeks) • Ischaemic stroke within 3 months /active peptic ulcer • Known cerebral vascular lesion • Suspected pericarditis • Known malignant intracranial neoplasm • Advanced liver disease/advanced metastatic cancer • History of chronic, severe, poorly controlled hypertension • Severe uncontrolled hypertension on this presentation (systolic BP > 180 mmHg or diastolic > 110 mmHg) • Ischaemic stroke > 3 months ago, known intracranial abnormality (not covered in absolute contraindications)/dementia • Pregnancy or within 1 week postpartum
If NO contra-indications • Immediately proceed to OPTION 1: Thrombolysis at rural or remote facility • Aim to give ≤ 30 minutes of initial presentation1
Section 3: Emergency | Cardiovascular 139 4. Management • Management must be in consultation with MO/NP, who may seek specialist cardiology advice • See Queensland Government Acute coronary syndrome clinical pathway (or local pathway as relevant)
Queensland Government clinical pathways available at https://clinicalexcellence.qld.gov.au/resources/clinical-pathways/cardiac-clinical-pathways Cardiovas c ular
OPTION 1: Thrombolysis at rural or remote facility10 • Aim to give ≤ 30 minutes of initial presentation1 • See Queensland Government Thrombolysis for STEMI clinical pathway (or local pathway as relevant) • Informed verbal consent required • Ensure 2 x IV access still in situ • Record baseline: –– standard clinical observations –– circulation observations i.e. for bleeding –– neurological observations (GCS). See Glasgow Coma Scale/AVPU, page 785 • Weigh patient • Medications10 - give on MO/NP order ONLY: –– aspirin 300 mg - if not already given –– clopidogrel 300 mg - orally –– tenecteplase - IV bolus as per weight adjusted dose guide - consider ½ dose if ≥ 75 years old –– enoxaparin - if < 75 years old - loading dose 30 mg IV (if renal failure, use unfractionated heparin): –– omit loading dose if > 75 years old –– 15 minutes after loading dose, give 1 mg/kg subcut - maximum 100 mg
140 | Primary Clinical Care Manual 10th edition | Cardiovas
Schedule 4 Tenecteplase Prescribing guide
RIPRN and RN only. Must be ordered by an MO/NP Route of Recommended
Form Strength Duration c administration dosage ular Body 40 mg weight units mg mL (8,000 units) (kg) stat with IV < 60 6,000 30 6 8 mL diluent Inject over 10 Injection ≥ 60 to Reconstitiute 7,000 35 7 seconds (powder for 50 mg < 70 with diluent reconstitution (10,000 units) provided ≥ 70 to Flush line with diluent with 8,000 40 8 < 80 before and provided) 10 mL diluent Swirl to ≥ 80 to after with dissolve 9,000 45 9 sodium Reconstituted < 90 do not shake chloride 0.9% strength ≥ 90 5 mg/mL 10,000 50 10 1,000 units/mL Provide Consumer Medicine Information: May cause bleeding at injection sites, intracerebral bleeding, internal bleeding e.g. GI, genitourinary, and transient hypotension Note: If ≥ 75 years old, consider ½ standard dose to reduce risk of intracranial bleeding: MO/NP to consult cardiologist. Patient should be monitored by staff trained in advanced life support and where there is access to a defibrillator. Significant arrhythmias including VF can occur after reperfusion. Incompatible with glucose solutions Contraindication: Severe active bleeding disorders or disease states with an increased risk of bleeding. Allergy to gentamicin Management of associated emergency: Contact MO/NP. See Anaphylaxis, page 102 10,11,12,13
Section 3: Emergency | Cardiovascular 141 Schedule 4 Enoxaparin (Clexane®) Prescribing guide
RIPRN and RN only. Must be ordered by an MO/NP Route of Recommended Form Strength Duration administration dosage Adults < 75 years stat 30 mg Cardiovas c ular Loading dose Injection 60 mg/0.6 mL IV Expel the air bubble and Flush line before and excess enoxaparin before after injection with injecting sodium chloride 0.9% Provide Consumer Medicine Information: May cause bleeding at injection sites, intracerebral bleeding, internal bleeding (e.g. GI, genitourinary) and transient hypotension Note: If renal impairment or > 75 years seek MO/NP advice. Use Microbore® extension set (or similar) to administer enoxaparin using the pre-filled syringe (has a Y-injection port to put needle in). See QAS Procedure Priming of a Microbore extension set https://www.ambulance.qld.gov.au/CPPtable.html Contraindication: Severe hepatic impairment Management of associated emergency: Contact MO/NP. See Anaphylaxis, page 102 14,15,16
• Management post thrombolysis:10 – keep under direct observation until evacuated – continuous cardiac monitoring – be alert to reperfusion arrhythmias, including VF13 – monitor frequently - standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – circulation and neurological observations - to detect bleeding1 – repeat ECGs at 30 minutes, 60 minutes and 90 minutes10 - to be reviewed by MO/NP • Continuously liaise with MO/NP • Will require evacuation to pPCI capable hospital1 • If failed reperfusion i.e. unresolved pain and ST elevation has not reduced > 50% at 60-90 minutes:1 – MO/NP will urgently consult on-call interventional cardiologist for further advice
OPTION 2: Urgent evacuation for pPCI • If STEMI + reperfusion indicated + ABLE to access cardiac laboratory within 90 minutes • MO/NP will urgently: – contact on-call interventional cardiologist – arrange urgent evacuation + – order antithrombotic therapy as per Queensland Government Suspected acute coronary syndrome clinical pathway (or local pathway as relevant) • MO/NP may order: – aspirin 300 mg - if not already given – ticagrelor 180 mg - or alternative if advised by interventional cardiologist – enoxaparin OR unfractionated heparin - to confirm with interventional cardiologist
142 | Primary Clinical Care Manual 10th edition | Cardiovas c ular • Continuous cardiac monitoring • Frequent monitoring of standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) • Continue to liaise with MO/NP for further management until evacuation
OPTION 3: Reperfusion NOT indicated • If NSTEACS or STEMI + does not meet criteria for reperfusion:3,7 – MO/NP will risk stratify as per the Queensland Government Suspected acute coronary syndrome clinical pathway (or local pathway as relevant) – if MO/NP determines patient is high risk refer to Queensland Government Acute coronary syndrome pathway (or local pathway as relevant) • Be guided by MO/NP for further management, which may include:7 – evacuation to cardiac interventional facility – continuous cardiac monitoring – repeat ECGs – repeat troponin + ECG 6-8 hours after presentation (if using point of care testing) + chem20, FBC, COAGs, HbA1C – BGL – frequent monitoring of: – standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + circulation and neurological observations – SpO2 • If assessed as low risk, MO/NP may advise patient can be discharged home if:3 – repeat ECG normal – troponin negative at 6-8 hours (using point of care testing) – no further chest pain
5. Follow up • As directed by MO/NP 6. Referral/consultation • Consult MO/NP on all occasions of chest pain • May require further investigations e.g. angiography, echocardiogram, stress test
Section 3: Emergency | Cardiovascular 143 HMP Acute pulmonary oedema - adult Left ventricular failure/heart failure
Recommend1 • Rapid assessment and stabilisation Background2
Cardiovas c ular • GTN is very beneficial in severe pulmonary oedema even if no chest pain because it reduces blood pressure, which is often raised, reduces the work of the heart and dilates vessels
Related topics Chest pain assessment, page 130
1. May present with3 • Breathlessness - may start suddenly waking up at night, worse when lying down • ↑ HR • Ischaemic chest pain • Cough, ± wheeze • Pink frothy sputum in severe cases • Crackles especially in lung bases • Cyanosis • Lethargy, confusion, anxiety • Oedema of the ankles or sacrum and an enlarged liver may co-exist as a sign of right heart failure 2. Immediate management4 • See DRS ABCD resuscitation/the collapsed patient, page 54 • Sit the patient upright • Consult MO/NP urgently
• Give O2 for all patients (except known COPD). See Oxygen delivery, page 64
–– 15 L/minute via non re-breather mask to maintain SpO2 > 94% –– If known COPD:
–– give O2 28% via venturi mask to maintain SpO2 88-92%
–– if no venturi mask available, give O2 via Hudson mask 5 L/min, or nasal prongs 2 L/min • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) • Assess conscious state. See Glasgow Coma Scale/AVPU, page 785 • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Take bloods for UE and troponin level • Do ECG - send to MO/NP within 10 minutes • Cardiac monitor - continuously • Administer sublingual GTN provided the systolic BP is greater than 100 mmHg
144 | Primary Clinical Care Manual 10th edition | Cardiovas Extended authority Schedule 3 Glyceryl trinitrate ATSIHP/IHW ATSIHP, IHW, RIPRN and RN may proceed Route of Recommended Form Strength Duration administration dosage c ular 600 stat Tablet 300-600 microgram microgram Repeat every 5 Sublingual 400 minutes up to 3 doses Spray microgram/ 400 microgram providing patient not spray hypotensive Provide Consumer Medicine Information: May cause headache, flushing, palpitations, hypotension and fainting. Patient should get up gradually from sitting or lying Note: Ensure patient sitting down prior to giving. Do not use tablets from bottles that have been opened > 3 months. Prime the spray until an even spray is obtained before administering Contraindication: If patient has taken phosphodiesterase-5-inhibitors e.g. sildenafil (e.g. Viagra®), vardenafil (Levitra®) in the last 24 hours or tadalafil (e.g. Cialis®) in the last 48 hours Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 9,10,11,12
3. Clinical assessment3,5 • Obtain patient history - include in history this episode and previous heart trouble: –– angina, heart attack, heart failure –– has patient had heart palpitations • Look for evidence of acute ischemia, ST elevation (STEMI) • If hypotension/shock or irregular HR (fast or slow) consult MO/NP urgently • Current medicines • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + –– note HR and rhythm –– weight • Perform physical examination: –– general appearance - colour e.g. ashen, cyanosed, sweaty –– auscultate the chest for air entry and added sounds - crackles or wheeze –– are peripheries cool –– inspect and palpate the ankles, front of legs, sacrum - for oedema
4. Management6 • Consult MO/NP urgently who may advise: –– furosemide (frusemide) IV –– transdermal GTN patch –– GTN IV infusion –– administer analgesia as clinically indicated. See Acute pain management, page 35 • Prepare for evacuation • MO/NP may consider CPAP/BiPAP 7 • Intubation and ventilation may be needed if above not available or not successful
Section 3: Emergency | Cardiovascular 145 Extended authority Schedule 4 Furosemide (frusemide) ATSIHP/IHW ATSIHP, IHW, RIPRN and RN must consult MO/NP Route of Recommended Form Strength Duration administration dosage Adult stat Injection 20 mg/2 mL IV/IM 20-80 mg Give over 2-5 minutes Cardiovas c ular Provide Consumer Medicine Information: May cause dizziness, fainting and dehydration. Patient should get up gradually from sitting or lying position Note: High doses given at a rate faster than 4 mg/min can cause tinitus, vertigo and deafness Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 8,9,13
Extended authority Schedule 4 Glyceryl trinitrate ATSIHP/IHW/IPAP ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP Route of Recommended Form Strength Duration administration dosage 1 x Minitran 5 OR 5 mg = 1 x Nitro-Dur 5 Adult only OR 5-15 mg 1 x Transiderm Nitro 25 stat Patch Transdermal 1 x Minitran 10 Applied for a maximum OR of 14 hours in a 24-hour 10 mg = 1 x Nitro-Dur 10 period OR 1 x Transiderm Nitro 50 Provide Consumer Medicine Information: May cause headache, flushing, palpitations, orthostatic hypotension, fainting and peripheral oedema. Apply to clean, dry skin on the chest area or upper arm. Dispose of patches safely Contraindication: If patient has taken phosphodiesterase-5-inhibitors e.g. sildenafil (e.g. Viagra®), vardenafil (Levitra®) in the last 24 hours or tadalafil (e.g. Cialis®) in the last 48 hours Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 10,11
5. Follow up • As per MO/NP instructions 6. Referral/consultation
• Consult MO/NP on all occasions
146 | Primary Clinical Care Manual 10th edition | Cardiovas Cardiac arrhythmias - adult/child
Recommend1 • Anyone who presents with an arrhythmia should be investigated for cause c
• Opportunistically screen patients aged ≥ 65 for atrial fibrillation (AF) by pulse palpation, followed ular by ECG if irregular Background2 • Aboriginal and Torres Strait Islander people have increased incidence of stroke, AF, rheumatic heart disease and other cardiovascular diseases • Sinus tachycardia (increased HR with a normal ECG) can occur secondary to most injuries and illnesses: anxiety, fever, infection, blood loss/shock, dehydration • Algorithms for bradyarrhythmia and tachyarrhythmia are available from the Australian Resuscitation Council Guideline 11.9 - Managing Acute Dysrhythmias available at http://resus. org.au/guidelines/
Related topics Acute coronary syndromes, page 135
1. May present with3,2,4 • Symptoms may vary depending on cause - may include: –– asymptomatic - incidental finding –– chest pain –– fast, slow or irregular HR/palpitations –– heart failure –– hypotension/shock –– dizziness or lightheadedness –– vertigo –– syncope –– fatigue –– anxiety –– shortness of breath
2. Immediate management2 • See DRS ABCD resuscitation/the collapsed patient, page 54 • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools)
• Give O2 to maintain SpO2 ≥ 94%. See Oxygen delivery, page 64 • Attach cardiac monitor • Do ECG - send to MO/NP promptly • If chest pain. See Acute coronary syndromes, page 135 3. Clinical assessment5 • Perform rapid assessment • Obtain history of presenting concern
Section 3: Emergency | Cardiovascular 147 • Ask about: –– contributing factors to this episode –– previous episodes –– current medications –– illicit drug use • Obtain past history including: –– history of heart trouble
Cardiovas c ular • Perform physical examination: –– listen to the chest for air entry and added sounds - crackles or wheeze –– inspect and palpate the ankles, front of legs and sacrum for oedema
4. Management2,4 • Urgently contact MO/NP if: –– haemodynamically unstable –– history of heart problems –– chest pain –– drowsiness, confusion –– altered level of consciousness –– shortness of breath –– systolic BP < 90 mmHg –– HR < 40/min or > 150/min • If symptomatic: –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status –– collect blood for FBC, UE and troponin levels • Always consult MO/NP who may advise: –– atropine for slow ± irregular heart beat –– patients with bradyarrhythmia who do not respond to medicines, or who are at high risk of asystole, may require electrical pacing –– other drug treatment for fast ± irregular heart beat –– evacuation/hospitalisation –– management of any underlying cause
5. Follow up • If patient not evacuated/hospitalised advise to be reviewed next day • Advise to see MO/NP at next clinic 6. Referral/consultation • Consult MO/NP on all occasions
148 | Primary Clinical Care Manual 10th edition | Cardiovas HMP Electrocution/electric shock - adult/child
Recommend1 • The extent of burn after electric shock should not be underestimated. Skin findings can be
misleading and significantly underestimate the degree of underlying tissue damage c • Always consider the possibility of cardiac arrhythmias ular • Ears, eyes and mouth should always be checked Background1,2,3,4 • The electrical charge causes an entry wound (burn) that is often full thickness. There may be a similar exit (earthing) burn • Arrhythmias can occur - including ventricular arrhythmias up to 8 hours following electrocution • The severity of the injury and risk of death is greatest with: –– high voltage electricity e.g. lightning and power lines –– low resistance e.g. wet skin, sweating, immersion in water –– electrical pathway across the heart - can cause cardiac arrest –– prolonged exposure electrical current –– electrical pathway crossing the brain - unconsciousness may occur
Related topics Traumatic injuries, page 163 DRS ABCD resuscitation/the collapsed patient, page 54 Burns (general), page 217
1. May present with1 • History of: –– exposure to high or low voltage electricity - household or industrial –– lightning strike • Burns - major or minor • Extensive/deep tissue damage - can lead to rhabdomyolysis and kidney failure • Seizures • Confusion, drowsiness • Loss of consciousness • Cardiac arrest • Fractures/shoulder dislocation - due to falls or violent muscle contractions • Cervical spinal cord injury • Eye/ear complications • Sublingual haemorrhage e.g. in children with burns at the mouth • Compartment syndrome - if bone in path of the current, significant heat is generated and causes thermal injury to surrounding muscle 2. Immediate management3,4 • Only approach patient or surroundings after power is turned off at mains • See DRS ABCD resuscitation/the collapsed patient, page 54 • Assess conscious state. See Glasgow Coma Scale/AVPU, page 785 • Obtain rapid history:
Section 3: Emergency | Cardiovascular 149 –– circumstances of injury –– type of electrical exposure - high or low voltage –– any CPR measures implemented • Urgently consult MO/NP
• Give O2 to maintain SpO2 ≥ 94% or > 95% child. See Oxygen delivery, page 64 • Connect cardiac monitor • Do ECG Cardiovas c ular • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • IV fluid resuscitation may be required in high voltage injuries and significant underlying tissue destruction. See Shock, page 77 3. Clinical assessment1,2,3,4 • Inspect skin for entry wound (burn) and exit (earthing) burn • Examine the eyes. See Assessment of the eye, page 358 • Look for: –– fixed or dilated pupils –– cataracts, corneal burns, hyphema (pooling or collection of blood at front of eye) –– fundoscopy examination (if skilled) - retinal detachment • Check visual acuity • Assess the ears: –– using otoscope look for bloody drainage –– ask about hearing loss, vertigo, tinnitus • Examine the mouth: –– look for sublingual haemorrhage - particularly in a child who may have put an electrical cord in mouth - may be delayed • Examine extremities - look for: –– fractures –– muscle swelling • Evaluate peripheral circulation • Be alert to compartment syndrome (may occur over a few hours). See Compartment syndrome, page 197 • Urinalysis - checking for proteinuria/haematuria • Check troponin + CK if available 4. Management2,3 • Contact MO/NP urgently who will guide management • Monitor and act on any changes in conscious state • Continue to monitor urine for proteinuria/haematuria • Continue cardiac monitoring • Treat obvious burns. See Burns (general), page 217 • Administer analgesia as clinically indicated. See Acute pain management, page 35 • Prepare for evacuation • If there has been no history of altered consciousness or cardiac arrhythmia, the ECG is normal and
150 | Primary Clinical Care Manual 10th edition | Cardiovas the patient sustained only minor burns, the patient need not be evacuated/hospitalised and can be allowed home after a few hours of observationafter consultation with MO/NP
5. Follow up • If not evacuated, advise patient to be reviewed daily for 2-3 days for general assessment and c
wound care ular • Advise to see MO/NP at next clinic
6. Referral/consultation • Consult MO/NP on all occasions • MO/NP will refer patients with suspected deep tissue electrical injury to specialist burns unit • All survivors of high-voltage electrical injury need referral for ophthalmic and otic follow-up within 2-3 days to assess ocular and audio-vestibular complications
HMP Acute hypertensive crisis - adult
Recommend1 • Aim to reduce BP by no more than 25% within the first 2 hours, then towards 160/100 mmHg within 2-6 hours • Avoid lowering BP too rapidly as this can cause decreased blood supply (ischaemia) to kidney, heart or brain Background2 • Severe hypertension, often defined as systolic BP of ≥ 180 mmHg and/or diastolic blood pressure ≥ 120 mmHg, can produce life threatening complications such as encephalopathy, acute pulmonary oedema, acute myocardial ischaemia, aortic dissection, subarachnoid haemorrhage, retinal haemorrhages, papilloedema, Preeclampsia and acute kidney injury. These are hypertensive emergencies • BP cuff size is critical and must be appropriate to the arm size
Related topics Hypertension in pregnancy, page 526 Preeclampsia/eclampsia, page 530 Irukandji syndrome, page 306 Subarachnoid haemorrhage, page 157
1. May present with3 • Dizziness/feeling faint • Nausea and vomiting • Confused, drowsy, unconscious, fitting • Focal neurological symptoms e.g. weakness in a limb, facial paralysis • Headache, visual disturbance • Chest discomfort (angina/heart attack, or aortic dissection) • Breathlessness/heart failure • Papilloedema, retinal haemorrhages on looking into the back of the eyes (fundoscopy) • Haemorrhagic stroke. See Transient ischaemic attack (TIA) and stroke, page 158 • Acute head injury or trauma
Section 3: Emergency | Cardiovascular 151 • Asymptomatic • Pregnancy • Illicit drug use e.g. amphetamine, cocaine • Irukandji jellyfish sting. SeeIrukandji syndrome, page 306 2. Immediate management2 • See DRS ABCD resuscitation/the collapsed patient, page 54
Cardiovas c ular • If symptomatic (visual disturbance, heart failure) or BP > 220 mmHg systolic, consider immediate transfer - consult with MO/NP urgently • If pregnant, see Hypertension in pregnancy, page 526 or Preeclampsia/eclampsia, page 530 3. Clinical assessment3 • Obtain emergency patient history - previous medical history, including previous BP readings and episodes of acute hypertensive crisis and current medications • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + –– note BP (with correct size cuff), record with patient lying and standing and on both arms –– height and weight (if possible) –– urinalysis –– perform point of care testing for pregnancy for women of reproductive age –– ECG - send to MO/NP –– take blood for creatinine, electrolytes and troponin • Perform physical examination: –– auscultate the chest for air entry and added sounds (crackles or wheeze) –– palpate the abdomen for enlarged liver –– inspect and palpate the ankles, shins and sacrum for oedema
4. Management3
Asymptomatic or minimally symptomatic patient e.g. mild headache • Contact MO/NP who may order: –– regular monitoring of BP –– oral therapy such as ACE-Inhibitor e.g. Ramipril 2.5-10 mg OR –– a calcium channel blocker (dihydropyridine) e.g. amlodipine 2.5-10 mg
Symptomatic patient1 e.g. visual disturbance, heart failure or BP > 220 mmHg systolic • Urgently contact MO/NP • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • MO/NP may order: –– maximising of oral medicines as per asymptomatic patient above –– IV GTN –– note: sublingual or transdermal GTN can be considered in remote areas/low resource areas where IV GTN not available/practical, but strong evidence does not exist for efficacy • MO/NP will determine target BP, but no more than 25% reduction in first 2 hours • If significant concerns about aortic dissection, IV beta-blocker may be considered with or without IV GTN • Urgent evacuation
152 | Primary Clinical Care Manual 10th edition | Cardiovas • Hypertension may be due to other conditions e.g. intracranial haemorrhage, raised intracranial pressure, chronic kidney failure - manage as per MO/NP instructions
Schedule 4 Glyceryl trinitrate Prescribing guide c
RIPRN and RN only. Must be ordered by an MO/NP ular Route of Recommended Form Strength Duration administration dosage Commence at IV 10 microgram/minute As advised Dilute to 500 mL in Increase infusion by Injection 50 mg/10 mL by MO/NP sodium chloride 0.9% to 5 microgram/minute every 5 make a concentration of minutes until target BP reached, 100 microgram/mL up to a max. of 100 micrograms/minute Provide Consumer Medicine Information: May cause headache, flushing, palpations, orthostatic hypotension, fainting, peripheral oedema. Caution if patient moving from lying to sitting or to standing position. Ensure patient sitting down prior to giving Note: GTN is adsorbed onto some plastics, eg PVC. Use glass infusion bottle and polyethylene giving set. Do not stop infusion abruptly. Patient must have continuous cardiac monitoring during infusion Contraindication: Hypovolaemia, raised intracranial pressure, recent treatment with phosphodiesterase-5-inhibitors e.g. sildenafil (Viagra ®), vardenafil (Levitra ®) in the last 24 hours, or tadalafil (Cialis ®) in the last 48 hours Management of associated emergency: Contact MO/NP. See Anaphylaxis, page 102 1,4,5
Extended authority Schedule 3 Glyceryl trinitrate ATSIHP/IHW ATSIHP, IHW, RIPRN and RN may proceed Route of Recommended Form Strength Duration administration dosage 600 Tablet 300-600 microgram microgram stat Sublingual 400 Further doses on Spray microgram/ 400 microgram MO/NP order spray Provide Consumer Medicine Information: May cause headache, flushing, palpitations, hypotension and fainting. Patient should get up gradually from sitting or lying Note: Ensure patient sitting down prior to giving. Do not use tablets from bottles that have been opened > 3 months. Prime the spray until an even spray is obtained before administering Contraindication: If patient has taken phosphodiesterase-5-inhibitors e.g. sildenafil (e.g. Viagra®), vardenafil (Levitra®) in the last 24 hours or tadalafil (e.g. Cialis®) in the last 48 hours Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 4
Section 3: Emergency | Cardiovascular 153 5. Follow up • Ask patient to return for review next day if not evacuated/hospitalised • Advise to see MO/NP at next clinic on all occasions where BP ≥ 140/90 mmHg • Offer advice and information about lifestyles factors contributing to hypertension. SeeThe Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://publications.qld.gov.au/dataset/chronic-conditions-manual
Cardiovas c ular 6. Referral/consultation • Consult MO/NP on all occasions BP ≥ 160/110 mmHg
HMP Acute lower leg ischemia - adult
Recommend1,2 • Urgent evacuation for vascular assessment/surgery Background • Acute peripheral arterial occlusion is caused by a blockage (blood clot/foreign body) of an artery cutting off blood supply to a limb. The blockage can be partial or complete • Usually occurs in patients without a history of atherosclerosis3
Related topics Cellulitis, page 401 Deep vein thrombosis (DVT), page 155 Compartment syndrome, page 197
1. May present with2 • In affected limb - pain, pallor, lack of pulse, paraesthesia, paralysis • Intense pain 2. Immediate management • Contact MO/NP immediately to arrange evacuation for surgical management • Administer analgesia as clinically indicated. See Acute pain management, page 35 • Rest the affected limb 3. Clinical assessment • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + –– note regularity of HR • Neurovascular observations comparing affected limb with the other limb: –– colour and warmth –– active and passive movement –– sensation –– pulses 4. Management • Consult MO/NP urgently who will:
154 | Primary Clinical Care Manual 10th edition | Cardiovas –– advise ongoing analgesia –– advise on heparinisation • Ensure patient is nil by mouth • Rest affected limb c
5. Follow up ular • As advised by discharging MO/NP
6. Referral/consultation • MO/NP will notify the referring hospital of situation
HMP Deep vein thrombosis (DVT) - adult
Recommend1,2 • Early initiation of anticoagulant medicine to lower risk of pulmonary embolism (PE) and death Background1,2,3 • Deep vein thrombosis is caused by a clot which obstructs blood flow in a deep vein, most often a leg • DVT presents high risk for the development of thromboembolisms and subsequent PE • Hospitalised patients are 100 times more likely to develop a DVT/PE than the rest of the community. 59-75% of DVT/PE occur as a result of hospital admission • Most DVT/PE cases are not identified until up to 3 months after the patient is discharged
Related topics Cellulitis, page 401 Acute lower leg ischemia, page 154 Compartment syndrome, page 197
1. May present with1,4 • Often asymptomatic • Symptoms include: –– leg swelling, leg pain, tenderness in calf –– unilateral leg tenderness –– prominent superficial veins • A DVT in the upper leg may have symptoms including: –– swelling in thigh –– severe pain in buttocks or groin –– collateral superficial veins –– discolouration and redness in leg –– leg warm to the touch • Symptoms of a pulmonary embolus (PE) including:5 –– rapid onset dyspnoea, tachypnoea –– coughing up blood
–– low SpO2 –– chest pain
Section 3: Emergency | Cardiovascular 155 –– tachycardia –– low blood pressure –– collapse
2. Immediate management • Contact MO/NP urgently to discuss anticoagulation and to arrange evacuation • Rest the affected limb
Cardiovas c ular • Administer analgesia as clinically indicated. See Acute pain management, page 35 3. Clinical assessment1,5 • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + –– note if any signs of respiratory distress, haemoptysis or chest pain. If present, perform ECG • Compare affected limb with the other limb by inspection and measuring circumference, checking particularly for colour, warmth, swelling • Obtain history, checking for risk factors for DVT including: –– prolonged immobility such as bed rest, air travel, spinal cord injury, disabling stroke –– hospitalisation in previous 3 months –– recent surgery, including joint replacement surgery –– bone fractures –– previous history of DVT/PE, other venous disease –– pregnancy –– hormone replacement therapy –– cancer 4. Management • Prepare for evacuation • Take blood for FBC and coagulation studies prior to anticoagulation • The MO/NP will: –– arrange evacuation/hospitalisation –– order initial anticoagulation:6,7 –– enoxaparin at 1.5 mg/kg daily or 1 mg/kg BD –– patients with BMI > 35 or with renal impairment may require heparin infusion 5. Follow up • As advised by discharging MO/NP • May require anticoagulation for 6 weeks to 3 months, and longer for those at high risk of recurrence of DVT/PE 6. Referral/consultation • As advised by discharging MO/NP
156 | Primary Clinical Care Manual 10th edition | Neurological 157
2 73 158 Neurological emergencies 64 - adult/child 785 Section 3: Emergency | Oxygen delivery, page Transient ischaemic attack (TIA) and stroke, page Transient ischaemic attack of consciousness, page Unconscious/altered level 3 336 ≥ 94%. See 2 sudden onset. Immediately consult MO/NP Immediately consult sudden onset. 4 Glasgow Coma Scale/AVPU, page 2,3 and reassure
0 3 91 1 conscious state. See
It is usually due to an aneurysm on an intra-cerebral artery. It is important to suspect SAH as a on an intra-cerebral artery. It is important It is usually due to an aneurysm is often associated with a poor outcome subsequent recurrent bleed BP if there is any neurological deficit Beware of lowering an elevated Any awake patient who complains of the most severe headache they have ever had must be complains of the most severe headache they Any awake patient who haemorrhage regarded as having a subarachnoid Suspect spontaneous subarachnoid haemorrhage (SAH) in all patients presenting with a in all patients presenting haemorrhage (SAH) subarachnoid Suspect spontaneous severe and of headache, if – Consult MO/NP urgently Insert 2 x IV cannula - use the largest possible gauge given age and vascular status Check neck for stiffness (put hand under the patient's head and gently flex neck or ask patient to Check neck for stiffness (put hand under the patient's put chin on chest) Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) and pupillary responses to identify deficits Continue neurological examination including GCS Take rapid patient history Avoid hypoxia. Maintain SpO Perform rapid clinical assessment + – Altered level of consciousness or unconscious Lie patient at 30 Nausea/vomiting Stiff neck neurology, especially of the cranial nerves A short period of loss of consciousness and focal Sudden onset severe headache, often occipital - patient may feel they have been hit in the back of Sudden onset severe headache, often occipital the head (described as a 'thunder clap' headache) May have a history of headache, 7-10 days earlier
• • • • Meningitis, page Related topics page Acute and chronic headache, • • • • • • • • • • • • • • •
Background Recommend
4. Management 3. Clinical assessment
2. Immediate management 1. May present with
Subarachnoid haemorrhage (spontaneous) (spontaneous) haemorrhage Subarachnoid Neurological emergencies Neurological 158 Neurological Transient ischaemicattack( 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 1. Maypresentwith Recommend Background • • • • • • • Related topics Acute andchronicheadache,page • • • • • • – – Common: Neurological symptomsaresudden andoftenlocalised Consult MO/NPurgentlyinallcases As advisedbydischargingMO/NP – Arrange urgentevacuation/hospitalisation: MO/NP mayadviseinsertionofurinarycatheter Nil bymouth – – – – – – – gov.au/resources/clinical-pathways/tia-stroke-clinical-pathways – community. FASTstandsfor: Inform aboutwarningsignsandneedforimmediatemedicalattentionstrokeinthe reduce disabilityandmortality Acute strokeisamedicalemergency.Appropriateinitialmanagementandrapidinterventioncan See Aboriginal andTorresStraitIslanderpeopleareatgreaterriskofcardiovascular disease appropriate facilityforfurtherassessmentandtreatment vascular cause.Rapidassessmentshouldbeperformedandpatients beevacuatedtoan cerebral functionthatcompletelygoawaywithin24hoursandhave nootherapparentnon- A transientischaemicattack(TIA)isdefinedasrapidlydevelopedclinical signsofdisturbed brain tissue infarction) orrupture(haemorrhagicstroke),resultingindisruptedbloodsupplyanddeathof A stroke occurs when the arteries to the brain become blocked (ischaemic stroke/cerebral – – – investigations mayincludenon-contrastCTand/orlumbarpuncture difficulty walking, lossofbalanceorcoordination trouble seeinginone orbotheyes,doublevision difficulty speaking andunderstandingspeech side oftheface,clumsyhand unilateral weakness/clumsinessor altered sensationoflimbsand/orfacee.g.droopingonone – – – – T S A F -Facialweakness -Timetoactfast -Armand/orlegweakness -Speechdifficulty Transient IschaemicAttack(TIA)/StrokeClinicalPathway 1,2 3 3 3 336 TIA) and Unconscious/altered levelofconsciousness,page stroke 2 - adult : https://clinicalexcellence.qld. 73 Neurological 159
Neurological emergencies 64 54 Section 3: Emergency | Oxygen delivery, page 2 > 95%. See 2 1,2 4 to maintain SpO 2 4 1 is > 95% on room air then DO NOT give O is > 95% on room air then 2 DRS ABCD resuscitation/the collapsed patient, page DRS ABCD resuscitation/the
ataxia: did the patient walk in. Describe their gait. Do they have difficulty walking, loss of balance or have poor coordination dysarthria - can the patient speak normally. Speech slurred/altered in any way dysarthria - can the patient speak normally. Speech commands does the patient understand questions and obey any weakness or altered sensation of limbs and/or face, usually on one side of the body, e.g. drooping on one side of the face, clumsy hand. Does the patient have a symmetrical smile current medicines including anticoagulant/antiplatelet medications current medicines including anticoagulant/antiplatelet risk factors e.g. hypertension, diabetes, smoker, obesity, dyslipidaemia, illicit drug use risk factors e.g. hypertension, diabetes, smoker, physical activity atrial fibrillation any double vision TIA/stroke when the patient was last known to be well do they or did they have a headache any dizziness has their vision changed in one eye or both date and time when signs/symptoms were first noted date and time when signs/symptoms were first how long symptoms lasted BGL collapsed nausea or vomiting stupor or coma swallowing difficulty severe headache with no known cause no known headache with severe confusion vertigo sudden onset dizziness – – – – – – – – – – – – – – – – – – – – – – – – –
– – – – – Do ECG Perform full clinical assessment: – – – – Any past history of: – – – – – This presentation: – – Consider stroke mimics such as hypoglycaemia, meningitis, encephalitis, postictal state, migraine, Consider stroke mimics such as hypoglycaemia, hypotension friends if needed: Obtain a complete history as able - ask family and Insert 2 x IV cannula - use the largest possible gauge given age and vascular status the largest possible gauge given age and vascular Insert 2 x IV cannula - use as possible Consult MO/NP as soon Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) + – See If SpO If hypoxic, give O – – – – – Less common: – – – • • • • • • • • • • • • •
3. Clinical assessment 2. Immediate management 160 Neurological 4. Management | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5.Followup week oflastsymptoms territory symptoms,orwhopresentwithinone territory symptomsorcrescendoTIA ClinicalPathway Assess RiskStratificationusingclinicalhistory/examinationandtheQueenslandTIA/Stroke *'Urgent' meansimmediatelyifimagingfacilitiesavailablebutatmost within 24hrs Patients classifiedas Patients at Assessing urgencyoftransferTIA/strokepatient • • • • • • • • • • • • • • Consult MO/NPonalloccasionsofsuspected TIA/stroke conditions-manual Conditions inAustralia See thecurrenteditionof Community andcarersupportisessentialduringtherecoveryperiod ongoing May requirerehabilitationprogramandpoststrokecareplan As advisedbyMO/NP If ↓BGLsee Antihypertensive therapyisrecommendedforpatientswithischaemic/haemorrhagicstroke have anischaemicstroke Antiplatelet therapy(unlesscontraindicated)andstatinsarerecommendedforpatientsfoundto Do notgiveaspirinuntilCT/MRIhasruledoutahaemorrhage Keep nilbymouth – Collect blood: – Arrange evacuation/hospitalisation: Consult MO/NPassoonpossible resources/clinical-pathways/tia-stroke-clinical-pathways Stroke ClinicalPathway Assess thestrokeriskofTIAsusingtoolonQueensland – – FBC, UE,cholesterollevels for urgentCTorMRI(assoonaspossibleandwithin24hours) the patientshouldbetransferredtoasuitablyequippedandstaffedfacilityassoonpossible moderate/high 1 Hypoglycaemia, page 1 low
Risk
risk riskorAFcarotid availablefrom: 1 (orlocalstrokepathway).See 2 : withoutAForcarotid The ChronicConditionsManual:PreventionandManagementof and/or AF
115 https://publications.qld.gov.au/dataset/chronic- 1 possible (within48hours) and carotidimaging(ifindicated)assoon Need transfertoappropriatefacilityforbrain possible thrombolysis urgent imagingandmanagement,including Urgent* transfertoappropriatefacilityfor
https://clinicalexcellence.qld.gov.au/ Transient IschaemicAttack(TIA)/ Recommended action
1 Neurological 161
467 259 Neurological emergencies https://www. Behavioural and psychological
Section 3: Emergency | 2,3 Acute severe behavioural disturbance, page Toxicology (poisoning and overdose), page 478 494 80 490 2 - adult 1 1 a change in cognition e.g. memory deficit or disorientation or the development of a memory deficit or disorientation or the development a change in cognition e.g. perceptual disturbance during the over a short period of time and tends to fluctuate the disturbance develops course of the day a disturbance of consciousness with a reduced ability to focus, sustain, or shift attention with a reduced ability to focus, sustain, a disturbance of consciousness hip fracture age ≥ 65 years ( ≥ 45 years for Aboriginal and Torres Strait Islander people) and Torres Strait Islander ( ≥ 45 years for Aboriginal age ≥ 65 years or dementia history of cognitive impairment severe medical illness – – – – – – –
Delirium Delirium Patients with delirium may be confused with patients with dementia Patients with delirium may be confused with patients Drug toxicity is a major cause of delirium – – Delirium is characterised by: Delirium is characterised – – Delirium Clinical Care Standard available at: Recommended resource: safetyandquality.gov.au/our-work/clinical-care-standards/delirium-clinical-care-standard/ following risks: – – – Distinguish delirium from psychosis and dementia where the patient is alert and does not have a patient is alert and does and dementia where the delirium from psychosis Distinguish of consciousness disturbance more of the thinking and one or altered behaviour and where patients have Consider delirium Delirium is a medical emergency and needs investigation for a medical cause needs investigation for medical emergency and Delirium is a Hyperactivity, hypoactivity Disturbance of sleep wake cycle Variations in vital signs Emotional disturbance e.g. fear, anxiety, irritability, anger, apathy, euphoria, perplexity Clouding of consciousness poor short-term memory Impaired ability to concentrate, disorientation, levels of arousal Hallucinations and illusions, reduced or increased Agitation and restlessness (hyperactive delirium) Quiet and withdrawn (hypoactive delirium) fluctuate during the day Symptoms develop over a short period of time and See Signs and symptoms of delirium, dementia and depression in See Signs and symptoms of delirium, dementia symptoms of dementia (BPSD), page
• • • • • • • Sepsis/septic shock, page Alcohol withdrawal, page Other drugs/substances, page Related topics • • • • • • • • • • • Background Recommend
HMP HMP 1. May present with 162 Neurological 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 4. Management • • • • • • • • • • • • • • • • • effects includingphotosoffamily;low levellightingandstaffconsistency If possibleprovideorientatingenvironmental cuessuchasclocks,windowsandfamiliarpersonal Avoid treatingpatientinhighorvery lowstimulusenvironments Administer analgesiaasclinicallyindicated. See Attend tohydration,nutrition,ventilation, temperaturecontrol,skincare If atallconcerneddonotleavethepatientalone Maintain SpO Consult MO/NP ECG Urinalysis (dipstick) Collect bloodincludingBGL,FBC,UE,LFTs – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – – – – – – Obtain history,includingrecentbehaviouralchangessuchas: – See – – – – – – – – Recognised triggersinclude: be morethanonecause,particularlywitholderpeople The aimofclinicalassessmentistodeterminethemedicalcausefordelirium. Ensure safetyofpatient,selfandothers behaviour, perceptual disturbanceorsleep/wakecycle abnormalities The MO/NPmayconsider pharmacologicaltreatment for symptomsofagitatedanddisturbed – – – – – – – – – – – – – – – – – BGL alterations inmood difficulty meetingreasonablerequests less communicativeorresponsivethanusual sleepiness, alteredlevelsofconsciousness agitation, restlessness worsened concentration confusion including eyedrops medication historye.g.recentchangesinmedicine,newmedicines,todosage, pain cardiac events-myocardialinfarction,arrhythmias,heartfailure neurological events-cerebralhaemorrhage,stroke,seizures kidney failure,liverfailureandrespiratory(hypoxia) alcohol andotherdrugintoxicationwithdrawal(especiallybenzodiazepines) medicines includingillicitdrugs dehydration fluid andmetabolicdisturbances-hypoglycaemia,hyperglycaemia,electrolyteabnormalities, infections -urinary,respiratory,skin/softtissueandCNS Acute severebehaviouraldisturbance,page 2 ≥94%.See 1,4 1,4 Oxygen delivery,page 467 64 Acute painmanagement,page inparticular: 35 Note : theremay Traumatic injuries 163 https://resus.org.au/ Acute severeAcute Section 3: Emergency | Traumatic injuries Head injuries, page 175 Spinal injuries, page 180 Shock, page 77 185 11 1,2 1
For further information on application of tourniquet for a traumatic injury, see the Australian For further information on application of tourniquet Bleeding’ of Management Aid Resuscitation Council Guideline ‘First The potential benefits of using a semi-rigid cervical collar in the pre-hospital setting do not The potential benefits of using a semi-rigid cervical pressure, pressure injuries or pain and outweigh harms such as increased intracranial and applying the collar. Initial management unnecessary movement that can occur with fitting in a natural, neutral position, limiting angular should include manual support of the head movement Always consider non-accidental injury where injury or presentation is inconsistent with history or injury where injury or presentation is consider non-accidental Always is unexpected. See Child protection, page 760 Prevent further damage caused by hypoxia and hypotension and rapidly treat life-threatening Prevent further damage caused by hypoxia and pneumothorax complications such as airway obstruction and tension Keep all trauma patients warm ring, key e.g. accessory other or jewellery normal like look may jewellery: alert medic for Check USB stick, shoe tag, anklet, watch, tattoo Consider DRS CABCD where the 'C' stands for life-threatening catastrophic haemorrhage which the 'C' stands for life-threatening catastrophic Consider DRS CABCD where Disability, and before proceeding to Airway, Breathing, Circulation, should be controlled Exposure Criteria for early notification of trauma for interfacility transfer See Criteria for early notification Assess early for evacuation. (inside front cover) are needed Ideally one or more assistants guidelines/
History of trauma behavioural disturbance, page 467 disturbance, behavioural delirium on all occasions of suspected Consult MO/NP As per MO/NP instructions and medical cause of delirium medical cause and MO/NP instructions As per Commence regular observations (physical and level of consciousness). See See of consciousness). level and (physical observations regular Commence
• • • • • • • • •
Abdominal injury, page 183 Related topics Chest injuries, page 171 Fractures, dislocations and sprains, page • • • •
Background Recommend 5. Follow up 5. Follow
- adult/child Traumatic injuries HMP 1. May present with
Traumatic injuries 6. Referral/consultation 164 Traumatic injuries 2. Immediatemanagement- | Primary Clinical CareManual 10th edition | B -Breathing A - C - S -Sendforhelp R -Response D -Danger • • • • • • • • • • Catastrophic haemorrhage Airway andcervicalspineprotection – If openorsuckingchestwound: – Be awareofsignstensionpneumothorax: – – Assess effortandefficacyofbreathing: Check forwounds/signsofinjuryandtracheaposition-centralordeviating – – If suspected – – – – Establish clearairway: – Listen forsoundsofanobstructedairway: – Assess airwaypatency: – – – – If flailsegment: Consider needledecompression/needle thoracentesis. – – – – – – – – – – – – – – – – ↑respiratory distress unequal chestmovement,tracheadeviatedawayfromtheaffectedside, ↑HR,↓BP, auscultate -airentryequal muscles, diaphragmaticbreathing,trachealdeviation respiratory rate,rhythm,chestmovements,useofaccessorymusclesand/or abdominal as needed QAS recommendusinga manually supporttheheadinanatural,neutralposition,limitingangularmovement suction ifindicated-avoidstimulationofthegagreflex use chinlift/jawthrustasneeded,removelooseorforeignbodies snoring, gurgling,stridor objects, bleeding,vomitus/secretions,oedema observe forvocalisation,obstructedairwayinanunresponsivepatient,looseteethorforeign sodium chloride0.9%andsecure do notremoveanypenetratingforeignbodye.g.knife.Packaroundwithgauzesoakedin – if unabletocontrolcatastrophicbleedingconsiderapplyinga use directpressure provide adequate analgesia andpositionpatientforcomfort three sides. apply aproprietarychestsealdressing -ifnotavailableapplyanocclusivedressing,tapedon consider performingneedlecricothyroidotomyifunabletoobtainairwayusingabovemeasures if unabletosecureairwayconsideradjunct – and tightenedtocontrollife-threateningbleeding.Recordapplicationtime a constrictingdevice(preferablywide)appliedfirmlytolimbaboveaninjuryoramputation - e.g.bodyfluids,traffic,perpetratorsofcrime cervical spineinjury: Tension pneumothoraxisalife-threatening emergency 4,5 See Chest injuries,page 3 soft collar. - controlbeforeproceedingtoairway primary surveyandresuscitation- 12 Follow localpoliciesorseekMO/NPadviceforcollaruse 171 3 3 See 3
Chest injuries,page tourniquet: 7 171 DRS CABCD 11 Traumatic injuries 165
2 69 Criteria for early 171 have been - unresponsive U 8 Chest injuries, page (LMA or bag-valve mask may be mask may or bag-valve (LMA 3 Intraosseous infusion, page Intraosseous infusion, page 64 Section 3: Emergency | Traumatic injuries See 3 77 - responds to painful stimuli, - responds to painful stimuli, P lifesaving interventions/management Shock, page Oxygen delivery, page delivery, page Oxygen , see 6 secondary survey secondary survey ≥ 94% 2 haemorrhage by direct pressure/pressure bandaging by direct pressure/pressure haemorrhage central capillary refill > 2 secs and/or tachycardia): central capillary refill > - responds to verbal statement, - responds to verbal statement, V It may be beneficial for the patient to have adjuncts at this stage e.g. ECG, NG tube, or IDC It may be beneficial for the patient to have adjuncts Begin secondary survey only after any initiated in the primary survey consider needle decompression/needle thoracentesis. urgently contact MO/NP as able provide appropriate interventions as injuries are identified provide appropriate interventions as injuries are give fluid bolus of sodium chloride 0.9% or Hartmann’s solution 10-20mL/kg chloride 0.9% or Hartmann’s solution 10-20mL/kg give fluid bolus of sodium use intraosseous route if unable to obtain IV access. See use intraosseous route if airway burn bleeding to upper airway, rib tenderness or visible flail segments, circumferential burns or circumferential burns or visible flail segments, upper airway, rib tenderness bleeding to
- alert, • • – – – – – – A life-threatening tension pneumothorax: – – Be alert, and respond, to abnormal observations/signs of shock - ↑ HR, ↓ BP, ↑ RR, ↓ SpO Be alert, and respond, to abnormal observations/signs and central capillary refill > 2 secs. See Increasing respiratory distress and ↑ HR, with falling BP and falling GCS may indicate at this stage and Response Tools Full Q-ADDS/CEWT score or other local Early Warning Remove all clothing as you move down, maintaining privacy. Prevent hypothermia - cover patient Remove all clothing as you move down, maintaining with blanket after examination pelvic fracture which may require a pelvic binder Search for and control sites of bleeding including The secondary survey is a brief systematic process to identify ALL injuries: The secondary survey is a brief systematic process – Assess against criteria for early notification of trauma for interfacility transfer. See Assess against criteria for early notification of trauma front cover) notification of trauma for interfacility transfer (inside Check pupil size, equality, and reactivity Check pupil size, equality, continue to monitor for airway compromise If decreased level of consciousness there is concern over as possible on completion of primary survey if Consult MO/NP as early ongoing bleeding
If shock evident ( – Attach cardiac monitor Control any external Control any time central capillary refill Check HR, and status: the largest possible gauge given age and vascular Insert 2 x IV cannula - use – Give O₂ to maintain SpO to maintain Give O₂ required) breathing: threats to Assess – If unable to achieve effective breathing commence bag-valve mask ventilation or CPR as indicated or CPR ventilation mask bag-valve commence breathing effective to achieve If unable
• • • • • • • • • • • • • • • • • • • F - Perform full standard clinical observations F - Perform full standard clinical observations E - Expose and examine - identify life-threatening injury/injuries E - Expose and examine - identify life-threatening D - Disability - basic neurologic evaluation D - Disability - basic neurologic C - Circulation 3. Clinical assessment - 166 Traumatic injuries | Primary Clinical CareManual 10th edition | H - H -obtainhistoryfrompatient/witnessesuse G -Givepainrelief.Getresuscitationadjunctsuse F -Familyconsidertheneedsandinvolvementofpatient’sfamily • • • • • • • • • Head totoeassessment – – General appearance: – – – – – – head injuriesafterdiscussionwithMO/NP See P O N M blood gases,lactate,electrolytes,BGL,FBC,LFTs,groupandhold L trained, equipmentavailable,andclinicallyindicated Perform eFAST(FocusedAssessmentwithSonographyforTrauma)ultrasoundscanifsuitably – – – – – Continue tomonitor: – Perform neurologicalexamination: – aboratory studies/pointofcaretestingasclinicallyindicatedandavailable:arterialorvenous -considerNasoororogastrictube – – – – – – – – – – – – – – – -OxygentomaintainSpO - assessPainandadministeranalgesiaasclinicallyindicated. onitor cardiacrateandrhythm E L P M A S conscious state.See BGL central capillaryrefill SpO BP, HR,RR/effortandefficacyofbreathing incontinence strength/movement oflimbs,numbness/sensation,andevidenceurinaryorfaecal unusual odours:alcohol, petrol,chemicals,vomitus, urine orfaeces position oflimbs(flexion orextension),trunk,andhead body position,posture,anyguarding orself-protectionmovements -Lastoralintake/fastingstatus -Eventsandfactorsrelatedtotheinjury: -Pastmedicalandsurgicalhistory: -Symptoms Acute painmanagement,page - Allergiescheckformedicalertjewellery:maylooklikenormaljewelleryorotheraccessory e.g.keyring,USBstick,shoetag,anklet,watch,tattoo - Medications+anyanticoagulation/antiplatelettherapy – – – – – – – – – – – – – – – – – – 2 last menstrualperiodandpossible pregnancy social issuese.g.domesticviolence alcohol ordrugconsumption anterograde orretrogradeamnesia,anddurationofanyrelatedamnesia from witnesses any posttraumaticlossofconsciousness/durationalteredlevel of consciousness mechanism ofinjury-bluntorpenetrating,velocitypatientobjects time ofinjury surgery any conditionscontributingtocoagulopathy,alcoholmisuse,previous hospitalisations or check tetanusvaccinationstatus.See 3 Glasgow ComaScale/AVPU,page 3 2 ≥94%,pulseoximetryandcapnographyasindicated 35 . Opioidanalgesiashouldonlybegiventopatientswith 3
Tetanus immunisation, page SAMPLE mnemonic: LMNOP mnemonic: 785
773 3 Traumatic injuries 167 369 191 Blunt eye injury, page 180 191 Section 3: Emergency | Traumatic injuries Fractured mandible/jaw, page Fractured mandible/jaw, 171 Spinal injuries, page 175 Chest injuries, page Fractured mandible/jaw, page Fractured mandible/jaw, Head injuries, page page Head injuries, see signs of tenderness crepitus indicating subcutaneous emphysema step in spine weakness, numbness, or pins and needles in arms or legs – – – – if any findings indicate spinal injury, see – – – – neck while maintaining the inline immobilisation of the patient's cervical spine e.g. neck while maintaining the inline immobilisation immobilised by an assistant Any: deformity (if sufficient assistants available) trachea midline or deviated, see the appearance of the external jugular veins ask patient if any neck pain or midline tenderness bruising, swelling, wounds, impaled objects orbit - is there a palpable step, or numbness under the eye, see orbit - is there a palpable step, or numbness under ask patient to follow your moving finger in all directions (if conscious) - any restriction of eye ask patient to follow your moving finger in all directions movements - check light perception, hand motion, and gross visual acuity, any double or blurred vision counting fingers at one metre pupils - size, equality and reactivity to light haemorrhage, and/or oedema any periorbital bruising (raccoon's eyes), subconjunctival is patient wearing contact lenses jaw fracture/mobility/pain, see jaw fracture/mobility/pain, emphysema) crepitus (subcutaneous depressions, deformity, boggy swelling of scalp, and areas of tenderness depressions, deformity, or teeth numbness of the cheek asymmetry of facial expression drowsiness, vomiting nausea ask patient about headache, properly on closure or unable to open mouth wide, see closure or unable to open properly on and (indicating skull fracture bleeding or CSF leakage mouth for any signs of ears, nose, or - do NOT pack to stop drainage laceration of the dura mater) fracture behind the ear indicating base of skull 'Battle sign' - bruising/haematoma position of the nasal septum, flattening or angulation of the nose, occlusion of nostrils, septal nose, occlusion of nostrils, or angulation of the nasal septum, flattening position of the haematoma do not meet jaw fracture e.g. teeth wounds, signs of loose teeth, foreign material, oral cavity for for deformities, wounds, abrasions, bleeding, bruising , swelling, haematomas, impaled impaled haematomas, , swelling, bruising bleeding, abrasions, wounds, for deformities, object(s) – – – – – – – – – – – – – – – – – – – – – – – – – – – Palpate: – – – – – – Inspect for: – Palpate: – Neck, trachea and cervical spine – – Inspect: – – – – – Eyes Palpate: – – – – – – – – – Head and face Head and Inspect: – • • • 168 Traumatic injuries | Primary Clinical CareManual 10th edition | • • • • • • • • If anyfindings,see Urinalysis: testforbloodifpossible – – – Palpate: – Auscultate (beforepalpating)for: – Inspect: Abdomen/flanks – Move to: – Palpate for: – Inspect: Shoulders > 10-15mmHg If significantchestinjurysuspectedauscultateBPinbotharmsandnoteifdifference If anyfindings,see – – Auscultate for: – Percuss: – – Palpate clavicles,sternumandribsfor: – – – – – Inspect: Chest – Inspect: Pelvis – – – – – – – – – – – – – – – – – – – bowel sounds-present/absent any wounds,bruising-'seat-beltsign',distension,oedema,impaledforeign body,scars identify painorrestrictedrangeofmotion tenderness, deformity,swelling,bonycrepitusor(subcutaneous emphysema) any deformities,wounds,bruising,swelling,impaledforeignbody heart sounds-murmurs,frictionrubs,muffled bilateral/equal airentry,abnormalsounds(wheezesandcrackles) assess resonance-dull,resonantorhyper-resonant – – – tenderness, deformities,bonycrepitus: crepitus (subcutaneousemphysema) assistants available) final partofthesecondaryassessmentwhenallposteriorsurfacesareinspectedifsufficient check anteriorandlateralchestwallsincludingaxillae(leavetheposteriorwallfor deformity, wounds,bruising,swelling,impaledforeignbody,andscars pain associatedwithbreathing paradoxical breathing movement onrespiration rate, depth,effort,useofaccessoryand/orabdominalmuscles,diaphragmaticbreathing,chest any wounds, bruising, deformity, swelling, impaled foreign body, scars, and irregular angulation perform eFASTultrasoundscanifsuitably trainedandequipmentavailable any tendernessincludingreboundtenderness, guarding,rigidity,masses all 4quadrantsgently.Startinanarea wherethereisnocomplaintofpainorobviousinjury – – – and consultMO/NP if tendernessofsternum,considerunderlyinglungorcardiacinjury-performECGavailable, do NOTspringribcage the presenceoflocaltendernessribsisadequatetodiagnosepossiblefractured
9 Chest injuries,page Abdominal injury,page 9 171 183
Traumatic injuries 169 190 3,10 185 Section 3: Emergency | Traumatic injuries Fractured pelvis, page Fractured pelvis, 180 Spinal injuries, page page injuries, Spinal
Fractures, dislocations and sprains, page if there is evidence of head/cervical spine injury/pelvic fracture: if there is evidence of head/cervical spine injury/pelvic
along the cervical, thoracic, and lumbar spine all posterior surfaces for log roll technique, see extremities with suspected injuries and maintain cervical spine in-line immobilisation. Support extremity do not log roll the patient onto a side with an injured – – – – document findings of assessment fully report abnormal findings to MO/NP bilateral/equal air entry, abnormal sounds (wheezes, crackles, or friction rubs) bilateral/equal air entry, abnormal sounds (wheezes, – posterior chest for crepitus (subcutaneous emphysema) squeeze buttocks and feel for tightening. assess sensation at the perineum. Ask patient to with MO/NP Perform PR exam if indicated after discussion any tenderness and deformity: – – foreign body, and scars deformity, wounds, bruising, swelling, impaled log roll patient if clinically indicated with adequate assistance to inspect back log roll patient if clinically indicated with adequate – neurovascular function is intact assess movement and strength motion check joints for range of not remove if appropriately applied and check previously applied splint(s) if present. Do tenderness, deformity, bony crepitus tenderness, deformity, bony in all four limbs pulses, warmth, sensation any open or closed wounds, bruising, deformity, swelling, impaled foreign bodies bruising, deformity, swelling, impaled foreign any open or closed wounds, colour of limb faecal or urinary incontinence faecal or urinary ability to void assess any pain and/or evidence of trauma - blood at the vagina, penis, urethra, and rectum penis, urethra, and trauma - blood at the vagina, evidence of tenderness and instability over the iliac crests and the symphysis pubis symphysis and the the iliac crests over and instability tenderness should be and log roll be applied binder should a pelvic is suspected, pelvis if a fractured bleeding, see as it may exacerbate avoided if possible, of the legs of the – – – – – – – – – – – – – – – – – – – – – – Auscultate posterior chest for: – as available in consultation with MO/NP Use other diagnostic tools such as x-ray and ultrasound – – Palpate: – Inspect back, flanks, buttocks, and posterior thighs for: Inspect back, flanks, buttocks, and posterior thighs – Use caution – If any findings, see Move to: – – – Palpate for: – – Inspect: – – – – Limbs Perineum/genitalia Inspect for: – Palpate for: Palpate – – • • • • • I - Inspect posterior surfaces J - Jot it down 170 Traumatic injuries 4. Management | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • • • • • • Consult MO/NPassoonpossiblewithanyfindingsfromexamination Be guidedbyMO/NP this responsibility until non-affectedorbedischargedintothecareofaresponsibleadultwhoaccepts Patients whoareaffectedbydrugsand/oralcoholshouldbeencouragedtostayunderobservation trauma andinjuriesincollaborationwithMO/NP.See Prepare patientforevacuationasindicatedviaairorroadtofacilitywithcapabilityaddress Give tetanusboosterifindicated.See Consider gastrictubeindiscussionwithMO/NP available: arterialorvenousbloodgases,lactate,UEC,BGL,FBC,LFTs,group,holdandcrossmatch If bloodsnotalreadytaken-laboratorystudies/pointofcaretestingasclinicallyindicatedand Perform ECG Provide appropriateinterventionsasperfindingsofsecondarysurvey Administer antiemeticasclinicallyindicated,see MO/NP 35 If notalreadygiven-administeranalgesiaasclinicallyindicated.See – urethral injuryand/orbloodpresentatmeatus-ifuncertainconsultMO/NP: Insert indwellingurethralcatheterifclinicallyindicated.Cautionorcontraindicatedsuspected Response Tools) Continue tomonitorclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand primary survey Reassess primarysurveyandmanageanylifesavinginterventions/managementinitiatedinthe Keep patientnilbymouthandwarm – . measure urineoutputhourly Opioidanalgesiashouldonlybegiventopatientswithheadinjuriesafterdiscussion 1 Tetanus immunisation,page Nausea andvomiting,page Patient retrieval/evacuation,page 773 Acute pain management, page Acute painmanagement,page 48 29 Traumatic injuries 171 Section 3: Emergency | Traumatic injuries
if suitably trained and equipment available 1
rib fractures including flail segments rib fractures including flail including costal cartilage closed soft tissue injuries or without foreign body penetrating injuries with open wounds and lacerations – – – –
– – injuries include damage to the chest wall from: damage to the chest Chest injuries include – – Suspect tension pneumothorax in all patients where there is unexplained respiratory distress or distress respiratory unexplained is there where patients all in pneumothorax tension Suspect shock Do not remove any object sticking out of wound e.g. knife any object sticking out Do not remove
Perform eFAST ultrasound scan (on following page) See Differential diagnosis table for potential injuries Follow EFGHIJ. See Traumatic injuries, page 163 Perform chest x-ray if available Criteria for early notification of trauma for interfacility transfer (inside front cover) Assess against Criteria for early notification of trauma for interfacility 163 Follow DRS CABCD. See Traumatic injuries, page interventions/management initiated in the Begin secondary survey only after any life saving primary survey History of chest injury secondary to blunt or penetrating trauma History of chest injury secondary
• • •
Related topics Traumatic injuries, page 163 • • • • • • • •
Background Recommend
Chest injuries - adult/child injuries Chest HMP 3. Clinical assessment - secondary survey
2. Immediate management - primary survey and resuscitation 2. Immediate management - primary 1. May present with 172 Traumatic injuries | Primary Clinical CareManual 10th edition | 4. Management Differential diagnosis Non-penetrating causes(noopenwounds) disruption, oesophagealdisruption Other possiblecomplicationsincludecardiactamponade,aorticdisruption, tracheo-bronchial • • • • Penetrating (open)causesincludinggunshotandstabwounds • • • • • • • • • • • • • • Symptoms • • • • SOB Pain SOB Pain SOB -Nil coughing inspiration and Pain worseon movement ofchest Paradoxical SOB Pain SOB Pain SOB Coughing upblood Pain SOB –notworsening Pain of breath(SOB) Worsening shortness Pain Administer antiemeticasclinicallyindicated. See Administer analgesiaasclinicallyindicated. See Insert IVcannulaifnotalready Consult MO/NPinallcases 3 2 • • • • • • • • Clinical observations dressing withopeningonbottom sucking in.Coverwiththreesidedocclusive Chest wallopeningthroughwhichairis or withoutanobjectstickingout An obviouswoundtothechestwith Localised chestwall,swellingandtenderness in, andoutwhenpatientbreathes chest wallmovesinwhenthepatientbreathes paradoxical movementiswherepartofthe Respiratory distress.Inflailchestthe air entryanddullpercussiononaffectedside be unequalchestmovement,maydecreased Respiratory distress.Hypotension/shock.May with haemothoraxandpneumothorax Hypoxaemia and↑HR.Oftenassociated Respiratory distressandcracklesinchest. onaffectedside movement, ↓airentryand↑percussionnoted Respiratory distress.Maybeunequalchest on affectedside,distendedneckveins and hyperresonanceonpercussionnoted away fromtheaffectedside,↓airentry unequal chestmovement,tracheadeviated Increasing respiratorydistress,↑HR,↓BP, Acute painmanagement,page Nausea andvomiting,page
48 pneumothorax Tension Consider Open chestwound pneumothorax haemothorax or Possible Broken rib Flail chest Haemothorax Lung contusion pneumothorax Simple 35 Traumatic injuries 173 Rib
Neurovascular bundle 3 Section 3: Emergency | Traumatic injuries intercostal space, midclavicular line) into midclavicular line) intercostal space, nd rib below (see diagram) rib below (see rd Thoracic cavity sucking chest wound and is a treatable cause of potential death in the severely injured injured in the severely death cause of potential a treatable and is 2 open pneumothorax/ ambulatory chest drainage system ambulatory chest drainage ® Needle thoracentesis site life threatening emergency life threatening perform immediate decompression by needle thoracentesis by needle decompression immediate perform allow as soon as circumstances consult MO/NP or Portex if patient has only partly improved, or gets worse, check the cannula has not kinked or the improved, or gets worse, check the cannula has if patient has only partly on the have recurred, or there may be a tension pneumothorax tension pneumothorax may as may need to try again on the other side other side. Consult MO/NP to Heimlich valve intercostal catheter prior to evacuation and attach MO/NP will insert a formal thoracic cavity just above the upper edge of the 3 just above the upper thoracic cavity pleural space under is present, air will escape with a rush from the if tension pneumothorax of respiratory distress pressure with an easing insert a 14 G IV cannula through upper chest wall (2 IV cannula through upper insert a 14 G – – Cover sucking chest wounds with a sterile occlusive dressing taped securely on three sides (opening at bottom) to provide a flutter-type valve effect or proprietary device designed for this purpose Do not remove any object sticking out of wound e.g. knife. Pack around with gauze soaked in sodium chloride 0.9% and secure Monitor and await transfer to evacuation MO/NP will insert a formal intercostal catheter prior Is a patient: – – Needle thoracentesis • • • • • • • • • Tension pneumothorax Tension Penetrating injuries/ Simple pneumothorax
174 Traumatic injuries | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup Flail chest Tenderness ofsternum Broken rib Haemothorax • • • • • • • • • • • • • • • • • In allcasesconsultMO/NP MO/NP willadviseongoingmanagement Prepare patientforevacuationasindicat If largeflailsegment,mayrequireintubationandventilationbyMO/NPpriortoevacuation Continue toprovideairway Pr Give highflowoxygen.See Consider unde Consult MO/NPwhowilllikely The MO/NPwillinsertaformalintercostalcatheterpriortoevacuation If respiratorydistressdevelopsthentreatastensionpneumothorax MO/NP willadvisetype,volume,andratesoffurtherIVfluids Treat hypovolaemia.See Keep patientwarm Keep patientnilbymouth MO/NP willinsertaformalintercostalcatheterpriortoevacuation Consult MO/NPwhomayadviseantibioticsandarrangeevacuation ovide adequateanalgesiaandpositionpatientforcomfort 1,4 rlying lungorcardiacinjury.PerformECGandconsultMO/NP Shock, page Oxygen delivery,page a nd ventilationsupportasperMO/NPinstructions adviseoralanalgesia,andreviewnextdayifno 77 ed. See 64 Patient retrieval/evacuation,page otherinjury 29 Traumatic injuries 175
8 Traumatic injuries for assessment and 191 flowchart Section 3: Emergency |
163 163 Fractured mandible/jaw, page Fractured mandible/jaw, Follow local policies or seek MO/NP advice for collar use Follow local policies or seek MO/NP advice for 9 Traumatic injuries, page - adult/child 163 Traumatic injuries, page . See Criteria for early notification of trauma for interfacility transfer (inside front cover) Criteria for early notification of trauma for interfacility
. See Decision making for escalation and CT scanning EFGHIJ DRS CABCD medical history - any previous neurological conditions or signs follow the classification of severity of head injury any altered level of consciousness or concerns of significant head injury any altered level of consciousness or concerns of open/penetrating head injury QAS recommend using a soft collar. as needed manually support the head in a natural, neutral position, limiting angular movement manually support the head in a natural, neutral
A significant brain injury can occur without loss of consciousness A significant brain injury Head injuries injuries Head the care of a responsible non-affected adult who accepts this responsibility adult who accepts this responsible non-affected the care of a on the outside damage to the brain without signs of injury Blows to the head can cause Consult MO/NP before administering opioids to patients with head injuries opioids to patients with before administering Consult MO/NP not assume injury may co-exist. Do to be intoxicated - a head patient who appears Be wary of the drugs and/or who are affected by alone. Patients signs are caused by intoxication that physical into non-affected or be discharged under observation until be encouraged to stay alcohol should Assume all head injuries have an associated neck injury an associated have all head injuries Assume – – – – – – Ask specifically about: – – Begin secondary survey only after initiating any life saving interventions/management in the Begin secondary survey only after initiating any primary survey Follow Assess against Consult MO/NP urgently if: – – Assume cervical spine injury: – – Follow Altered level of consciousness, confused, drowsy pupil signs, lack of coordination Neurological symptoms - weakness or numbness, Seizures History of injury to head - could be blunt or penetrating trauma History of injury to head visual disturbances Headache, nausea and vomiting,
•
• • • • Traumatic injuries, page Related topics • • • • • • • • • • • •
Background Recommend
HMP HMP 3. Clinical assessment - secondary survey 3. Clinical assessment - secondary
2. Immediate management - primary survey and resuscitation 2. Immediate management - primary 1. May present with 176 Traumatic injuries | Primary Clinical CareManual 10th edition | 4. Management • • • • • • • • • •
and Nauseavomiting,page48 Administer analgesiaandantiemeticasclinicallyindicated.SeeAcutepainmanagement,page 35 Keep patientwarm-preventhyperthermiaandhypothermia – – – In collaborationwithMO/NPmanageany: – Consult MO/NP: – – – – Urgently contactMO/NPif: immunisation, page773 If theskinisbroken,checktetanusvaccinationstatusandgiveboosterifindicated.SeeTetanus – – Children withclosedheadinjuryareassessedashighrisk,intermediate,orlowrisk: – Assess patientforriskfactorsandneedurgentCTscan: – – head-injury ifQueenslandHealth,orlocalpathwaysavailable: Recommend useofclinicalpathwayshttps://qheps.health.qld.gov.au/caru/clinical-pathways/ – – – If GCS≤8,patientwillneedintubationandventilationbyMO/NPpriortoevacuation:
see DecisionmakingforescalationandCTscanningflowchart Head Injury(Children)clinicalpathway≥14years Closed HeadInjuryAdultclinicalpathway consult MO/NPbeforeadministration ofopioidsinheadinjuries compound orbasalskullfracture-theMO/NPwillorderantibiotics.See alteration incondition fall inBP-maintainsystolic>90mmHg if GCS<15(orfallingGCS) provide airway,breathingandcirculationsupportuntilMO/NParrives these patientsareunabletoprotecttheirairwayandatriskofobstructionaspiration – suggestive ofexpandingintracranialhaemorrhage: if thereisarapiddeteriorationinGCSof>2/15,and/oronepupilbecomesfixedanddilated, a dropof≤2inGCSsincethelastassessmentinterval scanning flowchart if assessedasintermediateorhighriskpertheDecisionmakingforescalationandCT open/penetrating headinjury-willneedurgentevacuation for assessmentofhighandintermediateriskseetableonpage178 – – – – – assessed aslowriskorminorif:
MO/NP mayorderIVmannitol20%orsodiumchloride3% normal examinationotherwise may havescalpbruisingorlaceration stable, alertconsciousstate up tooneepisodeofvomiting no lossofconsciousness 1 2,3 10 Meningitis, page91
Traumatic injuries 177 to any evacuation Yes Medical emergency CT scan is required Open/penetrating head injury Open/penetrating next page Section 3: Emergency | Traumatic injuries Consult MO/NP immediately to arrange immediately to arrange Consult MO/NP 4,6 to organise evacuation Consult MO/NP immediately deteriorates HEAD INJURY HEAD abnormal or patient Observations become
Assess patient for RISK FACTORS Assess patient for RISK GCS = 15 Are there any high or intermediate risk factors present? Are there any high or Closed head injury Closed head GCS < 15 on arrival GCS < 15 on to all No consult MO/NP immediately consult MO/NP next clinic perform routine clinical assessment perform routine clinical neuro observations Arrange MO/NP review with head injury advice into care of responsible person patient may be discharged – – – – – – using minimum of half hourly using minimum of half hourly If observations remain in post injury: normal range for 6 hours Decision making for escalation and CT scanning and escalation for making Decision Monitor for minimum of 6 hours Monitor for minimum of 178 Traumatic injuries | Primary Clinical CareManual 10th edition | Injury Focal neurologicalabnormality Glasgow comascale Force Fall occupant) Motor vehicleaccident(pedestrian,cyclistor Headache Co-morbidities previous intracranialsurgery History ofcoagulopathy,bleedingdisorderor history inconsistentwithinjury Non-accidental injuryissuspected/parental Seizure innon-epilepticpatient Episodes ofvomitingwithoutothercause Behaviour assessable) Anterograde orretrogradeamnesia(where Witnessed lossofconsciousness Age Dangerous mechanismofinjury Post traumaticseizure Intoxicated (alcoholand/orotherdrugs) Significant mechanismofinjury Unwitnessed headinjury behaviour and/orcognition Persistent abnormallevelofalertness, Persistent vomiting Focal neurologicaldeficit Persistent GCS<15at2hourspostinjury deficiency Known coagulopathye.g.liverdisease,factor Age >65years Head injury'highrisk'factors-adult Head injuryclinicalfeatures-child 7 4 6 factors Multiple co-morbiditiesorcombinationofworrying Delayed onsetofsymptoms Delayed presentationorre-presentation Multi-system trauma impairment Known previousneurosurgeryand/orneurological Persistent severeheadache Clinical suspicionofskullfracture Deterioration inGCS Loss ofconsciousness>5minutes On anticoagulant/antiplatelettherapy Haematoma, swellingor Mild agitationoraltered unclear mechanism Intermediate risk Moderate impactor laceration >5cm Impact only < 5minutes 1-3 metres behaviour 3 ormore Possible < 60kph factors Present < 1year 14-15 Yes No No Nil Persistent orincreasing children <1yearofage Suspected depressed Abnormal drowsiness Tense fontanellein projectile orobject High riskfactors High speed/heavy Penetrating injury skull fracture > 5minutes > 5minutes > 3metres > 60kph Present Present < 14 Yes Yes Yes
Traumatic injuries 179 1 4 Section 3: Emergency | Traumatic injuries the patient/you: 5 1 4 - advice sheet - wake every 2 hours for the first 24 hours to check condition and reaction to familiar - wake every 2 hours for the first 24 hours to check
- wake several times during the first night after the injury. Set the alarm. Ensure the - wake several times during the first night after no significant persistent symptoms/signs no significant persistent injury no concerns of non-accidental and parental/carer concerns no other clinical concerns tolerating oral fluids full CEWT score (or other local paediatric Early Warning and Response Tools) Early Warning and (or other local paediatric full CEWT score GCS and reactivity pupillary size, equality, limb strength pain assessment sedation score – – – – – – – – – – has continual fluid or bleeding from the ear or nose carer is concerned has a seizure (fit) or any jerking of the body or limbs cannot move parts of body or has lack of coordination develops blurred vision or slurred speech ‘black out', faint, is drowsy, cannot be woken or is not responsive ‘black out', faint, is drowsy, cannot be woken or or places, or has increased confusion cannot remember new events, recognise people things that don’t make sense acts strangely (has change in behaviour) or is saying be left alone for 24 hours vomits more than twice have a headache that gets worse play sports for at least 24 hours drugs for at least 48 hours drink alcohol or take sleeping pills or recreational take sedatives or other medication unless instructed drive for at least 24 hours and only once you can concentrate properly drive for at least 24 hours and only once you can – – – – – – or as clinically indicated observe for up to 6 hours advice sheet if: into the care of parent/carer with head injury the child may be discharged – – – responsible person, with head injury advice sheet advice sheet person, with head injury responsible observations including: do hourly clinical – monitor clinical observations including GCS at a minimum of half hourly for 6 hours hourly for 6 of half at a minimum including GCS clinical observations monitor of a in the care be discharged patient may normal the remain observations if clinical – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Return to the clinic immediately if – – – – – Children things DO NOT: – Use paracetamol for any headache. Do NOT use aspirin or anti-inflammatory pain reliever e.g. Use paracetamol for any headache. Do NOT use of complications ibuprofen or naproxen which may increase risk Adults - can they walk and talk patient walks (e.g. to the toilet) to assess their coordination Rest quietly for at least 24 hours ice cubes, or ice pack in a towel first Use 'ice packs' over swollen or painful areas. Wrap Consider a longer period of observation if anti-emetics have been given Consider a longer period or any other concerns consult MO/NP If any signs of deterioration – – Children: – Adults: Adults: – – • • • • • • • • • • • Head injury If assessed as low risk closed head injury head risk closed low as If assessed 180 Traumatic injuries 6. Referral/consultation 5. Fol | Primary Clinical CareManual 10th edition | 1. Maypresentwith HMP Recommend • • • • • • Traumatic injuries,page Related topics • • • • • – – Symptoms andsignsdependonlocation of,andextentofinjury.Mayinclude: – – – – – – – – History oftrauma-mostcommoncausesare: Consider referraltooccupationaltherapistforposttraumaticamnesiatest(PTA) Consult MO/NPasabove If patientnotevacuatedadvisetobereviewedthenextdayandatMO/NPclinic file/0021/648012/mild-head-injury-advice.pdf Give writteninformation:e.g. – – low up – – – – – – – – – – – – In apatientwiththoracolumbarinjuriessuspectspinalandtreatthewholespine needles) ofarms/legsnomatterhowtransient elderly, anyonewithaheadorneckinjury,whohashistoryofparaesthesia(e.g.pinsand accident, adivein Suspect cervicalspine(neck)injuriesinanyoneinvolvedamotorvehicleorbike Padded spineboard,airmattressorbeadfilledvacuummaybemorecomfortable breathing, andshouldbeloosenedifneeded are athigherriskofpressurenecrosisduetolackpainsensation.Strappingcanrestrict patients mayattempttomovearoundimprovecomfort.Paralysedandunconscious Do notleavepatientsonrigidspinalboards.Cancauseneck,back,shoulderpainandconscious and oftenmissedwhichcanhaveseriousconsequences Treat asthoughthereisacervicalspineinjuryifanypossibilityofone,theyareeasily Spinal injuries nausea weakness orinability tomovethelimbs(paralysis) tingling, numbness inthelimbsandareabelowinjury pain ininjuredregion severe penetratingwounde.g.gunshot significant blowtohead fall intheelderly fall fromgreaterthanstandingheighte.g.ladder,roof sporting accidente.g.rugby,fallingfromahorse dive orjumpintoshallowwaterbeing“dumped”inthesurf industrial accidenti.e.workplace motor vehicleorbikeaccident(occupant,riderpedestrian)
to shallowwater,fallfromheight,suddenacceleration/deceleration,inthe 163 1 - adult/child https://www.health.qld.gov.au/__data/assets/pdf_ 1
1
or aslocallyavailable 1 1 Traumatic injuries 181 Section 3: Emergency | Traumatic injuries 3
1
2 - follow local policies or seek MO/NP advice for collar use - follow local policies or seek MO/NP advice for 6 manually support the head in a natural, neutral position, limiting angular movement manually support the head in a natural, neutral QAS recommend using a soft collar avoid moving the remainder of the spine 2 cm) may optimise neutral position in healthy adults, padding under the head (approx. as needed – – – –
– – – lie flat on back on a firm supportive surface lie flat on back on a firm maintain cervical spine in-line immobilisation: – loss of function in limbs loss of function control loss of bladder or bowel priapism (erection in males) breathing difficulties shock or stiff tone, either flaccid change in muscle altered or absent skin sensation or absent skin altered position neck in abnormal head or head injury signs of state altered conscious headache or dizziness headache – – – – – – – – – – – – –
Obtain a thorough history of the traumatic incident the body level numbness or altered sensation Check for numbness/sensation and note where starts determining if imaging is required Apply NEXUS Low-Risk Criteria rules to assist in Only begin secondary survey after initiating any life saving interventions/management in the Only begin secondary survey after initiating any primary survey Follow EFGHIJ. See Traumatic injuries, page 163 Consult MO/NP as soon as possible on completion of primary survey Consult MO/NP as soon as possible on completion – – Criteria for early notification of trauma for interfacility transfer (inside front cover) of trauma for interfacility transfer (inside front Assess against Criteria for early notification sufficient assistants absolutely necessary or on MO/NP orders and Do not move patient unless spine and log roll patient. See How to log roll on following page available to immobilise scene: Stabilise patient at the Traumatic injuries, page 163 Follow DRS CABCD. See – – – – – – – – – – –
• • • • • • • • • •
3. Clinical assessment - secondary survey 3. Clinical assessment - secondary 2. Immediate management - primary survey and resuscitation 2. Immediate management 182 Traumatic injuries | Primary Clinical CareManual 10th edition | injury. ConsultMO/NPforclearanceofthecervicalspine If noneofthese5criteriaarepresentthepatientisconsideredtobeat lowriskofcervicalspine NEXUS Low-RiskCriteria 2 3 4 5 1 • • • back and/ortoplaceorremoveaspineboard Used tomovepatientfromasupinepositionontotheirside,andthenflat again,toexaminethe How to
– – – Three people(ifavailable)performthe roll: stabilisation tothecervicalspine.Thispersongivesinstructions rest oftheteam One persontakesthelead.Theyarepositionedatpatient'sheadto providemanualin-line Minimum ofthree,preferablyfivepeoplearerequired – – – Painful distractinginjury Evidence ofintoxication Focal neurologicdeficit Altered mentalstatus Midline cervicaltenderness rotation, keepingthepatient'snose inlinewiththeumbilicusatalltimes perform therollslowlymaintaining spinal alignment,especiallyavoidingflexionand legs one personpositionedattheshoulders/chest; oneatthehips;andincontrolof position alongthepatient'sbodyopposite tothedirectionthatpatient'sheadisfacing • • • • • • • • • • • log roll – – – – – – – – – – Tests ofbodilysecretionsarepositivefordrugs(includingbutnotlimitedtoalcohol) Behaviour consistentwithintoxication speech, ataxia,dysmetria,orothercerebellarfindings Evidence ofintoxicationonphysicalexamination,suchasodouralcohol,slurred ingestion Recent historyreportedbythepatientoranobserverofintoxicationintoxicating Any patient-reportedorexaminer-elicitedneurologicdeficit Delayed orinappropriateresponsetoexternalstimuli Inability torememberthreeobjectsat5minutes Disorientation totime,place,personorevents Glasgow ComaScale≤14 of anycervicalspinousprocess ridge totheprominenceoffirstthoracicvertebra,orifpainisreportedonpalpation Present ifpainiselicitedonpalpationoftheposteriorcervicalmidlinefromnuchal patient fromacervicalspineinjury.Examplesmayinclude: Any conditionthoughtbythecliniciantobeproducingpainsufficientdistract affecting any otherinjuryproducingacutefunctionalimpairment extensive burns a largelaceration,deglovinginjury,orcrushinjury a significantvisceralinjury any longbonefracture 1,5 mental alertness 3,4
Traumatic injuries 183
2 35 Acute pain management, page management, Acute pain 171 Section 3: Emergency | Traumatic injuries 1 Chest injuries, page - adult/child 48
midline cervical spine pain or tenderness following injury requires midline cervical spine pain 163 any 190
MO/NP with any findings above or if at risk of serious injury because of circumstances above or if at risk of serious injury because of MO/NP with any findings or non-penetrating abdominal trauma e.g. after a fall from a horse, seat belt injury or punch or non-penetrating abdominal trauma e.g. after Nausea and vomiting, page Nausea and serious bleeding from ruptured spleen, liver or kidneys serious bleeding from ruptured spleen, liver or kidneys bowel infarction serious injury to abdominal viscera e.g. bowel perforation, – –
Abdominal injuries The absence of abdominal pain does not rule out the presence of significant abdominal injury The absence of abdominal pain does not rule out If mechanism of injury indicates high forces - closely monitor for abdominal injuries. Be aware If mechanism of injury indicates high forces - closely by distracting injuries or more apparent external that abdominal injuries are often overshadowed and orthopaedic injuries and can be missed eFAST ultrasound scan can assist if available and staff suitably trained eFAST ultrasound scan can assist if available and wounds, can also perforate the bowel and Penetrating wounds, including gunshot and stab the above wound any with occur can chest the to damage Associated infection. serious cause umbilicus to the abdomen can cause: – – facility with appropriate surgical capability, as abdominal bleeding may be the cause facility with appropriate surgical capability, as abdominal Blunt Urgently evacuate all patients with hypotension/shock and evidence of abdominal injury to a Urgently evacuate all patients with hypotension/shock
Consult As advised by MO/NP Any patient who has radiological clearance Insert IDC as ordered by MO/NP Insert IDC as under patient straighten bedding and remove debris from If extended immobilisation, Keep nil by mouth Keep warm for evacuation Prepare patient Consult MO/NP Consult See indicated. as clinically and antiemetic analgesia Administer and
• • • • • • Traumatic injuries, page Fractured pelvis, page Related topics • • • • • • • • • •
Background Recommend
HMP 6. Referral/consultation
5. Follow up 4. Management 4. 184 Traumatic injuries 3. Clinicalassessment-secondarysurvey 2. Immediatemanagement-primarysurveyandresuscitation 1. Maypresentwith | Primary Clinical CareManual 10th edition | 5. Followup 4. Management Penetrating woundincludinggunshotandstabwounds Blunt ornon-penetratinginjury • • • • • • • • • • • • • • • • • • • • • • •
are concernedaboute.g.increasein pain,increasedheartrate,orswellingofabdomen Advise thepatientandcarer(s)toreturn totheclinicimmediatelyiftheyhaveanysymptoms observation inconsultationwithMO/MP If notforevacuationthepatientmay bedischargedafteraclinicallyappropriateperiodof Consult MO/NPwhowilladviseonanyfurtherIVfluidsandantibiotics, andarrangeevacuation Do notreplaceexposedboweloromentum.Coverwithsodiumchloride 0.9%soakedpacks Pack openwoundwithsodiumchloride0.9%soakedpack sodium chloride0.9%andsecure,asmaydislodgehaematomaordamage vessels Do notremoveanyobjectstickingoutofwounde.g.knife.Packaround withgauzesoakedin Consult MO/NPwhowilladviseonanyfurtherIVfluids drainage andaspirateperiodically MO/NP mayadvisetopassNGtubeifeasyandnosignsoffacialorbasal skullfractures.Allowfree Keep warm Keep nilbymouth and Nauseavomiting,page48 Administer analgesiaandantiemeticasclinicallyindicated.SeeAcutepainmanagement,page35 Perform eFASTultrasoundscanifsuitablytrainedandequipmentavailable assessment assoonpossible abdominal injuriesareathighriskfromplacentalabruptionandshouldhaveanobstetric Perform pointofcaretestingforpregnancywomenreproductiveage.Pregnantwith Follow EFGHIJ.SeeTraumaticinjuries,page163 primary survey Only beginsecondarysurveyafterinitiatinganylifesavinginterventions/managementinthe Assess againstCriteriaforearlynotificationoftraumainterfacilitytransfer(insidefrontcover) Consult MO/NPassoonpossible Follow DRSCABCD.SeeTraumaticinjuries,page163 Abdominal pain Back orshoulderpain Increased HR,RR,hypotension/shock trauma History ofisolatedabdominalinjurysecondarytobluntorpenetratingtrauma,aspartmultiple – Advise patienttobe reviewedthenextday – consult MO/NPifthe patienthasanysymptoms,anincreased HR,increasedtemperature orany
Fractures, dislocations and sprains 185 Fractured pelvis, page 190 Sprains, page 195 Section 3: Emergency | Fractures, dislocations and sprains 1 1
1 1
skin is broken) abdominal finding abdominal Significant blood loss into tissues can occur with pelvic or long bone fractures Significant blood loss into tissues can occur with following direct or indirect injury e.g. twisting Fractures (buckle or break in the bone) often occur skin is intact), or compound (where the overlying Clinically fractures are either closed (where the The aim of management is adequate splinting and immobilisation to avoid long term disability is adequate splinting and immobilisation to avoid The aim of management 760 abuse or domestic violence. See Child protection, page abuse in children, elder the elderly and other injuries thoroughly after a fall in Always examine for fractures or nerve supply may and sensation distal to limb fractures, as blood Repeatedly monitor pulses be damaged by the fracture Always consider non-accidental injury where injury or presentation is inconsistent with history, is history, with inconsistent is presentation or injury where injury non-accidental consider Always that may suggest a high index of suspicion with signs and symptoms unexpected or there is
Assess against Criteria for early notification of trauma for interfacility transfer (inside front cover) Immobilise the affected area Administer analgesia as clinically indicated. See Acute pain management, page 35 If long bone fracture, insert IV cannula. Commence sodium chloride 0.9% or Hartmann's solution. MO/NP will advise quantities and rate any external haemorrhage by pressure bandaging or direct pressure Stop any external haemorrhage by pressure bandaging Loss of function Tenderness, swelling, bruising and deformity Asymmetry with the other side of the body History of injury Pain circumstances MO/NP with any findings as above or if at high risk of serious injury because of or if at high risk of serious any findings as above Consult MO/NP with
• • • • • • •
Compound fractures, page 189 Dislocations, page 194 Fractured mandible/jaw, page 191 Related topics • • • • • • • • • • •
Background Recommend limbs - adult/child Simple fracture of HMP
2. management Immediate 1. with May present
Fractures, dislocations and sprains dislocations Fractures, 6. Referral/consultation 186 Fractures, dislocations and sprains .Clinicalassessment 3. | Primary Clinical CareManual 10th edition | Management 4. • • • • • • • • • • • • • • • •
and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning – are notoftenseenonwristx-rays, and maynotbevisiblefor7-10days: After afallonanoutstretchedhand, thescaphoid(ofwrist)isparticularlyatrisk.Fractureshere Consider sprain(softtissue)injury if nofracture.SeeSprains,page195 – – – X-rays (ifavailable): two dosesofanalgesia-consultMO/NP.SeeCompartmentsyndrome,page 197 Consider compartmentsyndromewherepainissevereandunrelievedby splintingandelevationor If patientrequiressurgicaltreatmentkeepnilbymouth Elevate thelimb-aslingforarminjuries,onpillowsleginjuries plaster backslabonfollowingpage Splint thesiteoffracture/dislocationtoreducepain.SeeSplintingforlimbinjuriesusing – – Consult urgentlyif: Consult MO/NPonalloccasionsofsuspectedfracture Check colour,pulsesandsensationbeforeafterdoinganythingtotheinjuredlimb Remove anyconstrictionsonthelimb,suchasringsandwatches – – – – – – – – – – Perform physicalexamination-carefullyexamine: limb(s) Examine andrecordcolour,warmth,movementsensationdistaltothefracturesiteofinjured – Obtain patienthistoryincludingcircumstancesandmethodofinjury+ In childrennormal growthplatescanmimicfractures or bedamagedandassociatedfractures – – – – – – – – – – – – – – – – – – – x-rays ofcrushorimpactedfractures maybedifficulttoidentifyonplainfilms only performx-raysifitwilllikelychangethediagnosisortreatment unless beingtreatedatthelocalfacility,receivinghospitalwillperform allx-rays pulses orsensationareabsent,weakdisappear straightening ortheskinwillbreakdownandmakefracturecompound the limbisdeformedandskinoverfracturesitestretchedpale.Thewillneed fracture. Thisisafracturethroughdiseasedareaofbone,e.g.osteoporosisorcancer if thereisafracturebutthemechanismofinjuryseemsminorortrivial,suspectpathological may feelpain joint function,aboveandbelowtheinjurysite-compressgentlyfromendtopatient range ofmovement if theperipheralpulsesarepalpable.Islimbwarm if thelimbisswollen,itthrobbingorgettingbigger skin overthefracture.Doesitlooknormalordamaged,isstretchedandpale colour ofthewholelimb,especiallypalenessorblue any woundsorswelling if thelimbisoutofshape.Compareonesidewithother all placeswhereitispainful medication history-askaboutanticoagulantusee.g.Warfarin immobilisation of limb shouldbeconsidereduntilcheck x-rayisdone the MO/NPanda follow upx-rayarranged after suchafall,anytendernessof the wristatbaseofthumbshouldbediscussedwith 1 1 Fractures, dislocations and sprains 187 ® , Velband ® 1,2 ® Section 3: Emergency | Fractures, dislocations and sprains back slab plaster used: and fit a length of non-compression cotton stockinette from half way up the middle and fit a length of non-compression cotton stockinette : short arm plaster back slabs are for injuries to the wrist or the very end of the forearm. slabs are for injuries to the wrist or the very end : short arm plaster back long leg plaster back slabs are for injuries involving the part of the lower leg above the ankle are for injuries involving the part of the lower long leg plaster back slabs and the knee note Discuss with MO/NP hand may require a modified short arm plaster. Any injuries involving the long arm plaster back slabs are for injuries involving the elbow and forearm except for the end are for injuries involving the elbow and forearm long arm plaster back slabs near the wrist are for injuries to the ankle and foot short leg plaster back slabs in acute trauma to immobilise an injured part of an arm or leg while also accommodating while also accommodating part of an arm or leg to immobilise an injured in acute trauma applied subsides or new splint tightened when swelling bandage should be swelling. Crepe for some soft tissue injuries as a temporary splint, usually for < 10 days splint, usually for < 10 as a temporary – – – – – – Place arm in a sling prominences if applicable slab. Fold back cotton padding and non- Wrap crepe bandage firmly around plaster back the plaster back slab compression cotton stockinette over the end of Immerse the layered plaster in a bowl of room temperature tap water holding on to each end, Immerse the layered plaster in a bowl of room temperature gently squeeze out the excess water and hand in a neutral position Lightly mould the slab to the contours of the arm padding can be placed over bony Do not apply pressure over bony prominences. Extra Wrap cotton padding over top for the full length of the stockinette - 2 layers, 50% overlap Wrap cotton padding over top for the full length padding/stockinette at each end. Fold the roll Measure a length of plaster 1 cm shorter than the in about ten layers to the same length Ensure rings and jewellery are removed from injured limb Ensure rings and jewellery are removed from injured Measure cm more than the width of the distal forearm finger to just below elbow. Width should be 2-3 Sling Non-compression cotton stockinette e.g. Protouch Webril Undercast cotton padding of appropriate size e.g. Crepe bandage Plaster of Paris of appropriate width e.g. 7.5 or 10 cm, for short arms/wrists, 15 or 20 cm for long width e.g. 7.5 or 10 cm, for short arms/wrists, Plaster of Paris of appropriate limb arm/long leg. Plaster must not fully encircle the – – Discuss positioning with MO/NP. Back slabs include: Discuss positioning with – – – A back slab is A back slab – Advise patient that fractures take at least 4-6 weeks to heal 4-6 weeks to at least fractures take patient that Advise sheet information advice with plaster patient/carer Provide missed • • • • • • • • • • • • • • • • • • Technique Materials Splinting of limb injuries using Splinting of 188 Fractures, dislocations and sprains | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • Plaster castinstructionsforpatient physiotherapist wherepossible Stiffness ofjointsisacommonproblem withimmobilisationinplaster/slings.Referto Consult Advise patientswithfractureswhoarenotevacuated/hospitalisedtosee MO/NPwithinaweek – Advise tobe Short armplasterbackslab Long armplasterbackslab – Keep plastercleananddrycoverwithplasticbagduringbathorshower to plaster Plaster doesnotdryfor24-48hours,sotopreventbreakingduringthistimedoapplyforce – – – – – Return forinjuryandplasterreviewin24hoursorimmediatelyif: Do notinsertanythingunderplastertorelieveitching Elevate limbtotheleveloforaboveheartwhenresting,duringfirst24hours Apply arminaslingforatleast24hours if painhasnotimproved,acomplicationshouldbeconsidered-consult MO/NP – – – – – plaster becomescrackedorwet,loosebadlydamagedforreapplication severe painthatcannotberelievedbyelevation numbness orlossofsensationafterelevation unable tomovefingersortoesafterelevation swelling orbluenessoffingerstoes MO/NPasabove 1 reviewed in24hours.Checkcolour,sensationandpainlimb: 1 Short legplaster back slab
Long legplaster back slab
Fractures, dislocations and sprains 189 Fractured Traumatic injuries, page 163 Section 3: Emergency | Fractures, dislocations and sprains - adult/child - adult/child
1,2,3 1,2,3 1,2,3 1,2,3
IV antibiotics (all compound fractures) evacuation to an appropriate facility with surgical capability X-ray if in doubt if there is a fracture underlying a wound cover with a sodium chloride 0.9% soaked dressing insert 2 x IV cannula - use the largest possible gauge given age and vascular status insert 2 x IV cannula - use the largest possible gauge solution MO/NP may advise sodium chloride 0.9% or Hartmann's Compound or open fractures are those with direct communication between the fracture and the between the fracture with direct communication open fractures are those Compound or soft tissue and skin of the intervening due to traumatic disruption environment compound fracture visible from the wound to be classified as a There does not have to be bone Provide antibiotic cover to prevent infection in the bone cover to prevent infection Provide antibiotic fracture as soon as possible Reduce fracture as soon – – – – – – Compound fractures Compound
– – Consult MO/NP who will advise: – Do not suture any wounds chloride 0.9% Clean wound(s) by irrigating copiously with sodium – if indicated. See Tetanus immunisation, pageCheck tetanus vaccination status and give booster 773 See Simple fracture of limbs, page 185 for general management of fractures pelvis, page 190 Assess as for Simple fracture of limbs, page 185 – – transfer (inside front cover) Assess against Criteria for early notification of trauma for interfacility Immobilise the affected area. Apply pelvic binding if required for pelvic fracture. See Immobilise the affected area. Apply pelvic binding If pelvis or long bone fractures: any external bleeding by external pressure/pressure bandage Stop any external bleeding by external pressure/pressure Acute pain management, page 35 Administer analgesia as clinically indicated. See Broken bone with break in the overlying skin Broken bone with break Pain and swelling History of injury
• • • •
Simple fracture of limbs, page 185 Simple fracture of limbs, Related topics • • • • • • • • • • • • • •
Background Recommend HMP
4. Management 3. Clinical assessment
2. Immediate management 1. May present with 190 Fractures, dislocations and sprains 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Fracturedpelvis-adult/child Recommend Background • • • • • • • • • • • • • • • • Related topics Simple fractureoflimbs,page185
• • • • Assess againstCriteriaforearlynotification oftraumaforinterfacilitytransfer (insidefrontcover) potential forfurtherdisplacementand mayreduceriskofhaemorrhage safety pins,spongeholdingforceps. Applyearly.Thiswillhelpwithpainonmovement,decrease If unstablepelvicfracture,wrapsheet orbinderaroundpelvis,tightenandsecuresheete.g.with Administer analgesiaasclinicallyindicated. SeeAcutepainmanagement,page35 – Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascular status: Give O₂tomaintainSpO Follow DRSCABCD.SeeTraumaticinjuries,page163 Blood outoftheurethraorinurine Hypotension/shock Abdominal painandtenderness Abnormal neurology(unilateral) Abnormal positioningoflegs Pain aroundthehips,especiallyonmoving,orwhenpressingbonypartsofhipsandgroin History oftraumaorfall,especiallyintheelderly As perTraumaticinjuries,page163 Consult MO/NPonalloccasions As perMO/NPadvice
– Fractures to the pelvis are either stable (a single fracture) or unstable (break at two sites) or leading toshockandlossofconsciousness Patients with unstablepelvicfractures may experience internal bleedingof over 2 L of blood If unstablepelvicfracture,bindingshouldbeappliedassoonpossible external injuries;examinethoroughly Fractures ofthepelvistakealargeamountforce,andtherearelikelytobeotherinternal MO/NP mayadvisesodiumchloride 0.9%orHartmann'ssolution associated withotherfractures 1,2,3, 4 2,3,4 2 >94%.SeeOxygendelivery,page64 1,2,4 Traumatic injuries,page163 Fractures, dislocations and sprains 191 Trauma to teeth, page 338 Section 3: Emergency | Fractures, dislocations and sprains - adult/child
1,2,3,4 MO/NP may advise:
1,2
1,2,3,4 1,2
Shock, page See Shock, poor capillary refill. i.e. ↓ BP, ↑ HR, attention to signs of shock pay particular catheterise patient if no bladder injury confirmed apply pelvic binding if not already done attempt walking with aid as soon as comfortable attempt walking with aid x-ray if available evacuation bed rest as pain symptoms dictate bed rest as pain symptoms if experienced, perform a rectal examination if indicated if experienced, perform palpate for signs of pelvic instability - tenderness of iliac crests, greater trochanters, symphysis greater trochanters, - tenderness of iliac crests, of pelvic instability palpate for signs angulation of legs pubis and irregular opening especially in males inspect for blood at urethral and check for obvious blood and blood on dipstick if possible collect urine 77
Multiple fractures of the jaw are common e.g. bilaterally after a blow to one side only Multiple fractures of the jaw are common e.g. bilaterally associated cervical spine injury with all jaw injuries Consider associated cervical spine injury with all jaw injuries or extensive swelling from fractures to the Be aware of risk of airway obstruction from bleeding jaw – – – – – – – – – –
As per Traumatic injuries, page 163 History of punch/fight Urgent consult with MO/NP as above As per MO/NP advice – – – MO/NP may advise: If unstable pelvic fracture. – – MO/NP urgently if fractured pelvis suspected Consult MO/NP urgently if fractured If stable pelvic fracture – – – – – Perform physical examination: Perform physical complete patient history including circumstances of injury circumstances history including patient complete Obtain and Early Warning or other local score Q-ADDS/CEWT (full clinical observations standard Perform + Response Tools) –
• • •
Head injuries, page 175 Related topics • • • • • • • • • •
Recommend
HMP Fractured mandible/jaw HMP 1. May present with
6. Referral/consultation 5. up Follow
4. Management 3. assessment Clinical 192 Fractures, dislocations and sprains .Clinicalassessment 3. Immediatemanagement 2. | Primary Clinical CareManual 10th edition | Management 4. • • • • • • • • • • • • • • • • • • • •
and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning Administer analgesiaasclinicallyindicated.SeeAcutepainmanagement,page 35 – – – Check cervicalspineforpainortenderness.SeeSpinalinjuries,page180 considered acompoundfracture.SeeCompoundfractures,page189 Any lacerationsorbleedinginsideoutsidethemouthassociatedwithafractureshouldbe teeth ontheinside Inspect foravisibleand/orpalpablestepinthejaw.Thismaybeonoutside,oras – – – Perform physicalexamination: Obtain completepatienthistoryincludingcircumstancesofinjury Assess airway.SeeForeignbodyairwayobstruction(choking),page Broken/loose teeth Teeth donotcloseproperlyorlineupasusual(malocclusion) Unable toopenmouthwidely Pain andmovementoffragmentsonopeningthemouth Bleeding fromthemouth Pain, swellingandtendernessalongthejaw Any blowortraumatothejaw – – swelling, pain,rednessandwarmth, theMO/NOmayorder: If patientpresentsdaysafterahistory oftraumatojawAND/ORaconfirmedfracturewithfacial 773 Check tetanusvaccinationstatusand giveboosterifindicated.SeeTetanusimmunisation,page page If possiblereplacepermanentteeth/tooth,washifdirtywithouttouching root.See Consult MO/NPwhowilladvise: tooth/teeth. SeeTraumatoteeth,page338 Are thereavulsed(tornaway),displacedorbrokentooth/teethsecondary toinjury.Neverdiscard – – – – – – – – amoxicillin orallyPLUS metronidazoleorally benzylpenicillin IVPLUSmetronidazole orallyOR antibiotic choice evacuation/surgery diet -eitherniltoeatordrink,clearfluidsonly,dependingonseverity andurgencyof evacuation forsurgery are likelytohaveafracture if patientisunabletomaintainbiteontonguedepressor(orsimilarobject)whilsttwisted,they not, thisismalocclusion,andafracturelikely ask thepatienttoclenchtheirteethtogetherandobservewhetherthey'fittogether'asusual.If check thepatient'sairwayandbite 338 1,2,3 1,2 99 Trauma to teeth, Trauma toteeth, Fractures, dislocations and sprains 193 3,5
3,4,7
Duration Max. 3 days Duration commenced. Until surgical management is Max. 3 days commenced. Until surgical management is
ATSIHP/IHW/IPAP Extended authority Extended 102 102 ATSIHP/IHW/IPAP Extended authority Adult Child
30 min dosage 1.2 g qid Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis,
30 mg/kg qid Recommended Recommended concentration of Adult dosage 400 mg bd to a max. 1.2 g/dose qid Dilute the dose to a max Dilute the dose to a max mL of water for injections mL of water for injections Child > 2 years Recommended then dilute with a further 10 then dilute with a further 10 mL of water for injections 10 mL of water fluid and infuse over at least fluid and infuse over at 400 mg/dose bd 60 mg/mL with a compatible 60 mg/mL with a compatible Reconstitute the 1.2 g vial with Reconstitute
10 mg/kg/dose bd to a max. of Section 3: Emergency | Fractures, dislocations and sprains Benzylpenicillin Benzylpenicillin Metronidazole Avoid alcohol while taking and for 24 hours thereafter. Take Avoid alcohol while taking and for 24 hours thereafter. May cause diarrhoea and nausea May cause diarrhoea and IV Consult MO/NP. See Consult MO/NP. See :
Route of administration Oral Route of administration 4 4 3 g
1.2 g 600 mg Strength Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity Severe or immediate allergic reaction to a penicillin. 400 mg 200 mg Strength 200 mg/5 mL Rapid IV injection of large doses may cause seizures Form : Injection Schedule Oral Form (powder for liquid Tablet Schedule reconstitution) Management of associated emergency Provide Consumer Medicine Information: liquid 1 hour before food for better absorption. May tablet with food to reduce stomach upset. Take oral diarrhoea, metallic taste, dizziness or headache cause nausea, anorexia, abdominal pain, vomiting, ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP Contraindication: between penicillins, carbapenems and cephalosporins Management of associated emergency: Provide Consumer Medicine Information: Provide Consumer Medicine Note ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, 194 Fractures, dislocations and sprains | Primary Clinical CareManual 10th edition | 1. Maypresentwith 6. Referral/consultation 5. Followup HMP Recommend Management ofassociatedemergency: between penicillins,carbapenemsandcephalosporins Contraindication Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution • • • • • • • to oralliquid Related topics Schedule Simple fractureoflimbs,page Powder for • • • Capsule Pain, swellingand deformityofthejoint History ofinjury wiring orinternalfixation Dental orfaciomaxillaryassessmentisusuallynecessary,andthepatientoftenrequiresrepairby Consult MO/NPonalloccasionsofsuspectedfracturedmandible/jaw Advise tobereviewedthenextday 24 hoursduetothepotentialriskairwayfrombleedingandswelling If notevacuated/hospitalised,thepatientshouldbewitharesponsibleadultforatleastfirst joint In upperlimbdislocations, thepatientoftenpresents supportingthelimb,unwillingto move the Form joint e.g.elbowdislocationafterfallingonanoutstretchedhand Dislocation isacompletedisruptionofjoint.Itoftenresultsfrominjuries awayfromtheaffected Minor dislocationsmayberealignedlocally Realign/reduce dislocationassoonpossiblethelimbwillbecome compromised Dislocations 1,2 : Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity 500 mg/5mL 250 mg/5mL Strength 4 500 mg 250 mg
- adult/child 185 administration Route of Oral ConsultMO/NP.See Maycauserash,diarrhoea,nauseaandcandidiasis Amoxicillin
to amax.500mg/dosetds Adult andchild≥12years 15-25 mg/kg/dosetds Child <12years Recommended 500mgtds Anaphylaxis, page dosage ATSIHP/IHW/IPAP/RIPRN Extended authority 102
management is Until surgical commenced. Max. 3days Duration
3,6
Fractures, dislocations and sprains 195 Section 3: Emergency | Fractures, dislocations and sprains - adult/child
1,2,3 1,2,3 examine and record colour, pulses, sensation and temperature of the limb sensation and temperature record colour, pulses, examine and examine pulses and sensation before and after manipulation and continue to monitor examine pulses and sensation before and after circulation over deltoid muscle prior to reduction, for shoulder dislocations, specifically check sensation as this nerve can be damaged during reduction x-ray before and after manipulation. Look for associated fractures x-ray before and after manipulation. Look for associated inspect and palpate for other injuries inspect and palpate for inspect and palpate movement of joints above and below the affected joint of joints above and below the affected inspect and palpate movement fracture below the joint for tenderness that may suggest examine bones above and
Distal fibula fractures are the most common ankle fractures in children. They are often Distal fibula fractures are the most common ankle misdiagnosed as an ankle sprain or are missed of a joint Sprain is a partial disruption of a ligament or capsule – – – – – –
Refer to Physiotherapist for dislocation exercise sheets/advice Refer to Physiotherapist for dislocation exercise If realigned locally advise to follow up as per MO/NP instructions If realigned locally advise to follow up as per MO/NP MO/NP clinic Dislocations will require full review - refer to next After realignment patient's pain will lessen dramatically. This may accentuate sedation and After realignment patient's pain will lessen dramatically. respiratory depression caused by analgesics – – Insert IV cannula locally: If dislocation is to be realigned – Support the dislocated area using pillows, sling or bandaging if possible using pillows, sling or bandaging if possible Support the dislocated area advise if dislocation can be realigned locally Consult MO/NP who will until reduction is achieved Keep patient nil by mouth – Perform physical examination: Perform physical – – Obtain complete patient history, including circumstances of injury circumstances of patient history, including Obtain complete Warning score or other local Early (full Q-ADDS/CEWT clinical observations Perform standard Tools) + and Response – 35 page management, See Acute pain indicated. as clinically analgesia Administer
• •
Simple fracture of limbs, page 185 Related topics • • • • • • • • • • • • •
Recommend
HMP Sprains/soft tissue injury HMP 6. Referral/consultation
5. up Follow 4. Management
3. Clinical assessment 2.management Immediate 196 Fractures, dislocations and sprains .Clinicalassessment 3. Immediatemanagement 2. Maypresentwith 1. | Primary Clinical CareManual 10th edition | Referral/consultation 6. Followup 5. Management 4. • • • • • • • • • • • • • • • • • •
– and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning For severesprainsrefertoMO/NP/Physiotherapist For allsprainsrefertosprainexercise sheetsoradvice If painandswellingpersistinapatient withasprainbeyondweekthensuspectfracture progress. ConsultMO/NPifrequired For mild/moderatesprainsadvisetobereviewedin48hoursandagain inoneweektocheck Avoid HARM(Heat,Alcohol,Running,Massage)for48hours – – – For severesprain: painful, thenencouragefullweightbearingandrangeofmovement For anklesprain,usepartialweightbearingcrutchesfor48hoursoruntil standingisnolonger Strap/bandage Administer analgesiaasclinicallyindicated.SeeAcutepainmanagement,page35 – – – – – For mildandmoderatesprains: Perform physicalexamination.SeeSimplefractureoflimbs,page185 Obtain patienthistory No fractureseenonx-ray Unable toweightbear Swollen joint Pain History ofinjury – – – – – – – – examine andrecordcolour,warmth,movementsensationofhandsfeetinjured consult Physiotherapistifavailable MO/NP mayadvisetemporarysplinte.g.plasterofparisuntilreview as above R Referral.ForseveresprainsrefertoMO/NP/Physiotherapist E C I R limb(s)
Elevate tohiplevelminimiseswelling(anklesprain) Compression bandagee.g.crépe Ice packfor20minutesevery2-4hourswhenawakethefirst48thencease Rest theinjuredpartfor48hours,dependingondisability 1,2,3 1,2,3 Notapplicable
Fractures, dislocations and sprains 197 185 163 Simple fracture of limbs, page Simple fracture of limbs, Traumatic injuries, page Section 3: Emergency | Fractures, dislocations and sprains - adult/child
185 1,2,3 1,2,3 189 1,2,3 217 1,2,3 1,2,3 altered level of consciousness altered level tense compartments whose contralateral limb can not be clinically compared limb can not be clinically whose contralateral tense compartments distracting injuries Simple fracture of limbs, page – – – unable to actively extend the great toe severe pain on passive stretching of muscles within the compartment by examiner in the arm, movement of any finger causes severe pain muscle compartment feels tense gluteal region
Compartment syndrome Compartment Most common in the forearm or leg compartments but can also occur in the foot, thigh and or leg compartments but can also occur Most common in the forearm closed muscle compartment. The syndrome can lead to muscle necrosis, limb amputation, acute amputation, limb necrosis, muscle to lead can syndrome The compartment. muscle closed and death renal failure, nerve ischaemia electric shock, can be caused by crush injuries, fractures, snakebite, Compartment syndrome burns, exercise and hyperthermia – increased pressure in a is caused by bleeding or oedema leading to Compartment syndrome Be suspicious of compartment syndrome in patients with: of compartment syndrome Be suspicious – – Urgent evacuation to facility with appropriate surgical capability to facility with appropriate Urgent evacuation – – – – – – – See Look for any signs of compartment syndrome which may include: – Insert IV cannula Consult MO/NP urgently casts, splints or dressings that may increase Splint limb without applying any circumferential compartment pressure Rest, ice and elevate the limb Remove any items encircling the limb e,g, bracelets, socks, clothing, watch band Remove any items encircling the limb e,g, bracelets, Persistent deep ache or burning tingling, prickling, itching. Onset within 30-120 Paraesthesia i.e. numbness, burning sensation, min of injury Severe pain on distal movement of limb e.g. great toe Severe pain on distal movement of limb e.g. great Crush injury to arm or leg Lower limb (tibial) fractures Pain disproportionate to injury
• • • • • Burns (general), page Compound fractures, page Related topics • • • • • • • • • • • • •
Background Recommend
HMP HMP 3. Clinical assessment
2. Immediate management 1. May present with 198 Acute wounds 6. Referral/consultation 5. Followup 4. Management | Primary Clinical CareManual 10th edition | Acute wounds HMP Recommend Background • • • • • Bat bite/scratch,page Related topics Cellulitis, page Burns (general),page • • • • • • • • • Consult MO/NPonalloccasions As perMO/NPadvice Arrange urgentevacuationforsurgicalrelease Administer analgesiaasclinicallyindicated.See Consult MO/NPurgently – –
– – present scalpel orscissors.Thelongerthedelay beforerepair,thegreateramountofdeadtissuewillbe Debridement this methodisrequired There isnoformalclosureofthewounde.g.withsutures.Scarringmay bemoreextensivewhen would bepropercleaning,appropriatedressingsand/orantibioticsif indicatedforinfection. Healing bysecondaryintention Any necrotictissueinawoundwilldelayitshealing seen indirtyorcomplexwounds.Delayedprimaryclosureinvolvesdebridement beforeclosure. Delayed primaryclosure leads tothebestoutcome,withleastscarring Primary closure The aimofwoundcareistoachievehealingwithoutinfection,scarring and deformity Never shave/cuteyebrowwhenrepairingwound Strait Islandersandpeoplewithadiagnosisofdiabetes patients with,oratriskof,peripheralvasculardisease. Lidocaine (lignocaine)withadrenaline(epinephrine)shouldnotbeusedonfingersortoesin Do notremoveanylargepenetratingobjects and forinjurytosurroundingstructures Examine allwoundsforforeignbodies,bonyinjuries,damagetovessels,nervesandtendons, Acute altered sensationdistaltoinjuredarea peripheral pulsesmayornotbepalpable 2 wounds 401 istheremovalofdeadanddyingtissue frominandaroundawound,usuallywith isthecleaningandrepairofwoundswithin6-8hoursafterinjury.This usually 217 215
- adult/child isthedelayofrepairfor3-5daystoallowpropercleaning,usually of suspectedcompartmentsyndrome isleavingthewoundtohealnaturally,whereonlyintervention Water relatedwounds, page Human (tooth-knuckle) andanimalbites,page Chronic wounds,page Acute painmanagement,page 1 ThisincludesAboriginalandTorres 427 209 35 212 Acute wounds 199 Acute wounds
163 Section 3: Emergency | 773 Traumatic injuries, page
See
4 Tetanus immunisation, page 3 for further management 3
77 Shock, page
aspirin, warfarin/other anticoagulants tetanus vaccination status. See diabetes history of smoking healing history of taking steroid medicines which may affect bleeding disorder where did the injury occur - dirt, oil, water, other environmental hazards where did the injury occur - dirt, oil, water, other peripheral vascular disease when did the injury happen type of injury/wound and healing of the wound) time until presentation (will impact on the management mechanism of injury commence sodium chloride 0.9% or Hartmann's solution 10-20 mL/kg commence sodium chloride and rate MO/NP will advise quantities see scalp wounds status the largest possible gauge given age and vascular insert 2 x IV cannula - use consider using a tourniquet in cases of uncontrolled, catastrophic limb haemorrhage and limb haemorrhage of uncontrolled, catastrophic a tourniquet in cases consider using as possible after applied. consult MO/NP as soon especially small hair as a tie is very effective at stopping bleeding, suturing the wound or using – – – – – – – – – – – – – – – – – –
Is there visible damage or division of structures e.g. tendons, nerves, bone Is there any skin or tissue loss How long and how deep is the wound Is it still bleeding. Oozing dark blood suggests venous bleeding. Spurting blood is from a severed artery Site of injury help track the wound Try to determine the direction of entry. This will Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) Perform physical examination In medication history ask about: – – – – – – – Does the patient have: – – – – Take patient history including: – – – – If blood loss is heavy or continuing or there is hypotension/shock: If blood loss is heavy or – Control any major bleeding by applying direct pressure and/or pressure bandaging: direct pressure and/or major bleeding by applying Control any – – Secondary to blunt or sharp trauma Secondary to Laceration tissue defect Large Burns
• • • • • • • • • • • • • • • • •
Assess wound 3. Clinical assessment
2. Immediate management 2. Immediate 1. May present with present May 1. 200 Acute wounds | Primary Clinical CareManual 10th edition | 4. Management • • • • • • • • • • • – – – If indicated,instillocalanaesthesia, usuallyafterbasicwoundcleaning: Administer analgesiaasclinicallyindicated. See need evacuation/surgery Consult MO/NPifdamagedordividedtendons,nervesandvessels,fracture suspected.Will immunisation, page If woundtetanusprone,checkvaccinationstatusandgiveboosterifindicated. See Document findingscarefully injury, page possible, oryouareconcerned,consultMO/NP.See If woundtothechestandabdomen,bewaryofpenetrationthrough bodywall.Ifthisis – – – X-ray maybeindicatedif: – will needtobedoneafterlocalanaesthetic: Explore thewoundwithasmallprobeorforceps-canoftenfeelforeignbodybeforeseeingit.This – – – – Could therebeaforeignbody.Suspectoneiftheinjuryinvolved: – Clean woundthoroughly: – – – – – damage totendons,nervesandvesselswhichwillaffectfunctionfurtherdownthelimb: Inspect thelocalstructuresandsurroundingarea.Withwoundsonlimbsthereisriskof – – – – – – – – – – – – – – – – – – – if available,considerUSSwithasmallpartsprobe foreign bodyinthewound,unlessyouaresureitwouldberadio-opaque glass, wood,grass,plasticorstonemaynotbe.'Noforeignbodyonx-ray'doesexcludea to helplocaliseaforeignbody.Metal,bonesandmostglassareradio-opaque.However,some fracture, see in doubtwhetherthereisafractureunderlyingthewound.Iffracture,treatascompound do notexploredeepwoundswithspurtingbloodornearlargevesselse.g.neck,groin,armpits a limbgoingthroughglasssuchaswindscreeninjuries assault e.g.knives,bottles,glass,spears,arrows projectiles thrownbymachinery stepping onanythinge.g.glass,wood/sticks,metal,fishbarbs,bones,somegrasses very effective use sodiumchloride0.9%.Ifthereisalotofdirt,grassorcontamination,runningtapwater is thereincreasingswellingtosuggestbleedingintothetissues is therebonytendernesstosuggestanunderlyingfracture the handthroughrangeofmovementanyunderlyingtendons: muscles suggeststendonormuscleinjury.Witharmandhandinjuries,assessthetendonsof get thepatienttomovejointsaboveandbelowwound.Paininwoundor check sensationaroundandbelowthewound(dothisbeforeputtinginanyanaesthetic) check colour,warmthandpulsesbelowthewound at riskofperipheral vasculardisease longer andtheadrenaline cutsdownbleeding.Donot useonfingersandtoesofpeople with or 1% lidocaine(lignocaine) withadrenaline(epinephrine) isusefulastheanaesthesialasts inject viathewoundandunderskin e.g.don'tgothroughnormalskin,ithurtsmore warn thepatientitwillhurtasgoes in 1% lidocaine(lignocaine)isusedin mostwounds – – – – – – against resistance thumb: raiseittotheceiling(palmup),andalsomakean'O'withlittlefinger,both flexors: makeafist extensors: straightenthefingersagainstresistance 183 5 Compound fractures,page 773 1 189 Acute painmanagement,page Chest injuries,page 171 and/or 35
Abdominal Abdominal Tetanus Tetanus Acute wounds 201
6,7,8 stat Acute wounds Duration in this topic Water related wounds, Extended authority
ATSIHP/IHW/IPAP/RIPRN Section 3: Emergency | 212 dosage 200 mg in this topic in this Adult and 189 Recommended Child < 12 years 215 up to max. of 3 mg/kg child ≥ 12 years or > 50 kg in this topic in this up to 3 mg/kg to a total max. of 401 Report any drowsiness, dizziness, blurred vision, vomiting Report any drowsiness, dizziness, blurred vision, Ensure resuscitation equipment readily available. Consult
Lidocaine (lignocaine) Cellulitis, page 3 Compound fractures, page Compound fractures, Bat bite/scratch, page page bite/scratch, Bat Subcut Route of 102 Subungual (under the fingernail or toenail) haematoma the fingernail or Subungual (under administration Removal of a tight ring of a tight Removal Removal of small embedded fish hook embedded fish of small Removal 4 Human (tooth-knuckle) and animal bites, page Human (tooth-knuckle) and 1% Strength Anaphylaxis, page page Anaphylaxis, 50 mg/5 mL 209 sodium chloride 0.9% into the wound. Repeat this a number of times sodium chloride 0.9% into the wound. Repeat this use PPE before you do this the patient will need local anaesthetic or pain relief surrounding skin without the stylet, or a 20 mL syringe and squirt use a blunt drawing up needle or 18 G cannula, use sodium chloride 0.9% or tap water if a lot of contamination. Antiseptic can be used for the or tap water if a lot of contamination. Antiseptic use sodium chloride 0.9% established infection. See established infection. See page bites. See compound fractures. See compound fractures. sustained in sea water, fresh water or mud. See wounds that have been – – – – – – – – Use the lowest dose that results in effective anaesthesia If prophylactic antibiotics are required give at time of wound closure If prophylactic antibiotics are required give at time – – Deeper wounds need irrigation to get dirt out: Deeper wounds need irrigation – Remove rings, watches etc. from the affected limb Remove rings, watches etc. Use a sterile field (as described above): Clean the wound thoroughly – – – – – Are not needed for recent clean wounds, especially if cleaned properly especially if cleaned for recent clean wounds, Are not needed for: Should be used If fish hook, see If fish removal, see For ring nail, see If blood under If a result of a bat bite, see see bite, of a bat result If a Form • • • • • • • • • • • Schedule Injection Note: Management of associated emergency: MO/NP. See Provide Consumer Medicine Information: or tremors ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed Preparation for wound repair Preparation for wound Antibiotics 202 Acute wounds | Primary Clinical CareManual 10th edition | Options forwoundtreatmentandclosure Raynaud’s Use Note: MO/NP. See Management ofassociatedemergency Provide ConsumerMedicineInformation:Report tremors, anxiety,pallor,tachycardia,hypertension,sweatingorarrhythmias RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Injection Schedule • • • • • • • Form
– – – Sutures: – – – Adhesive skinstripse.g.Steristrips – Simple dressings: Leave itopentotheair-forgrazesandverysuperficialcutsincleandryareasofbody After repairingthewound,elevationwilllessenpain,swellingandrisk of infection – – – – – Do notclosewoundsthatare: Skin glue
3M Cavilon Suture instead very mobilepartsofthebodye.g.joints.Don'tusethemiftheyarelikely togetwetorruboff. don't workwellinlargerwounds>2-3cmorgapingwounds,thoseunder tension,orwoundsin the elderlyandespeciallyforwoundsovershin,evenlargeones good forchildren,smalllacerations,somefacialwoundsandfinger skintearsin getting dirty for grazesandsmallcutsinmoistareas(groins,armpitsetc.) ofthebodyproneto page marine orhaveoccurredinwatere.g.coralcuts,stingraywounds.SeeWaterrelatedwounds, bite/scratch, page215 tooth/knuckle injuriesorbites.SeeHuman(tooth-knuckle)andanimalbites,page over compoundfractures dirty, contaminatedorinfected over 8-12hoursold.ConsultMO/NP tissue loss.Clean and consultMO/NP do notsutureawound thatneedsalotoftensiontobring ittogethere.g.wheretherehas been with syntheticsutures sutures causeanormalpinkforeign bodyinflammationaroundthewound.Thisislessened use forlargerwoundsandareaswith highskintensionormobilepartsofbodye.g.overjoints with phenomenon orperipheralvasculardisease lidocaine (lignocaine)1% 209 adrenaline (epinephrine) Anaphylaxis, page 102 11 (tissueadhesive) e.g. Dermabond 1:100,000 /5mL caution ® skinbarrierwipeonthehelps them stick 4 Strength (5o mg) + near terminal arteries terminal near Lidocaine (lignocaine)+Adrenaline : Ensureresuscitationequipmentreadilyavailable.Consult ® administration : (epinephrine) Route of Subcut 3 in ® drowsiness, dizziness,blurred vision, vomiting, or orHistoacryl fingers, toes, fingers, Use thelowestdosethatresults in effectiveanaesthesia ® : ears
child >12years Recommended up to7mg/kg Adult and dosage and ATSIHP/IHW/IPAP/RIPRN nose; avoid in avoid nose; Extended authority 212 andBat Duration stat 8,9 Acute wounds 203 Acute wounds Section 3: Emergency | after removal ® , can be used for deeper layers, mucosa of the mouth , can be used for deeper layers, mucosa of the mouth ® in this topic see Image 1. Suturing sutures 10 peripheral vascular disease diabetes use prolonged corticosteroid a sensitivity to formaldehyde : Application of skin glue – – – – areas where wound is under tension areas where or dense hair or prolonged moisture areas of high have: in patients who – – – – 5/0 or 6/0 non-absorbable sutures are used e.g. face, torso and extremities e.g. face, are used sutures 6/0 non-absorbable 5/0 or held together edges easily length with than 3 cm in is less the wound around eyes joints hands, feet, or mucocutaneous junctions, mucosal surfaces, and vagina 4/0 or 5/0 for hands calf 3/0 for the back, soles and sometimes scalp and absorbable sutures e.g. Vicryl rapide 5/0 or 6/0 for the face – – – – – – – – – – – used for rapid closure particularly in extensive wounds. Align wound edges, staple across in extensive wounds. Align wound edges, used for rapid closure particularly needed to extract for face, neck, hands or feet. Staple remover wound. Not recommended staples see – – – – – typically used in areas where: used in areas typically – – used in the following: should not be can be used successfully to close superficial, smooth and clean wounds clean and smooth superficial, close to successfully be used can Some or all sutures may come out sooner if the wound becomes infected and later if the wound Some or all sutures may come out sooner if the wound becomes infected and later if the wound does not look and feel firm yet. Consider Steristrips Scalp 6 days, face 3-5 days Hands, arms 7-10 days, trunk and legs 10-14 days If the wound crosses wrinkles or skin creases, these must be lined up as well as possible If the wound crosses wrinkles or skin creases, these are in the wrong place Don't be afraid to take sutures out again if they do it. Consult MO/NP If you are not happy repairing any wound, don't all the rest in, but it may lose tension when the others are completed. If so, take it out and all the rest in, but it may lose tension when the re-insert suture point of the 'V' first When suturing a 'V' or 'Y' shaped wound, align the straight up and exit the skin about 5 mm from the wounds other edge straight up and exit the skin about 5 mm from the and continue to divide the wound in half with Place the first suture halfway along the wound, well. The first suture makes it easier to put the other sutures. This will bring the edges together Clean and debride the wound first using sodium chloride 0.9% Clean and debride the wound first using sodium scissors or a scalpel blade, but keep it to a Hair can be removed from the wound edges with minimum - approximately 1 cm. Never remove eyebrows the wound edge. Go straight down, across, then Enter the skin with the needle about 5 mm from The aim is to eliminate dead space in the wound, evert the skin edges (like puckered lips) and The aim is to eliminate dead space in the wound, bring skin edges together with the minimum of tension – – – Nylon or silk sutures are used for the skin: Nylon or silk sutures are – – – – – – – – Staples – – – Suturing • • • • • • • • • • • • • • Removal of 204 Acute wounds | Primary Clinical CareManual 10th edition | Special sites Image 1.Suturing • • • • • – – – – – Fingers: – Eyelid: – – Lips: – Inside themouth: – Face: – – – – – – – – – – – – Alternatively, useSteristrips sutures willpulloutofthetissueasfingerenlarges,sokeep toaminimum. fingers swellafterinjurysoensureringsaretakenoff finger lacerations-checkfortendonandnervedamage if thesearefullthicknesstheyneedspecialisedrepair,consultMO/NP to berealignedexactlyavoidanunsightlycosmeticresult note: ifthewoundcrossesedgeoflipontonormalskin(thevermilion border)itneeds mouth displacement oflargeflaps.Smalllacerationswillhealwithoutsutures asforwoundsinsidethe lips swellenormouslywhenwounded.Lipsoftenonlyneedsuturingif there isgross within aweek few days,butmouthrinsesaftereachmealwillhelptokeepitcleanandshouldbehealed which casetheyneedspecialisedrepair,consultMO/NP.Itwilllookgreyandsloughyaftera these healverywellwithoutsutures,unlessthereisfullthicknesspenetrationofthecheek,in always necessary.Beawarethattheremaybedamagetofacialnerves They shouldberepairedwithin6-8hoursofinjury.Adressingonthewoundisnot only repairifyouareconfidentofgettingagoodresult,ascosmeticoutcomeisveryimportant. review in2-3days together anditwill heal) functional positionofminimalflexion (ifthefingerisinthisposition,woundedgeswillstay apply anon-adherentdressinge.g.Melolin occlusion edges approximated.Circumferential ortightlytensionedSteristrips most fingerlacerationscanbetreated withoutsutures.UseSteristrips 10 Correct andincorrectmethodsofmakingasimplesuture Making averticalmattresssuture ® ® , andbandagethewholefingersothat itstaysina 2 ® cancausevascular ® carefullytokeepwound Acute wounds 205 Acute wounds ® Section 3: Emergency | simple sodium chloride 0.9% dressing to keep it moist simple sodium chloride . See Image 2. Skin glue skin glue 12 : skin glue should never be placed in the wound or subcutaneously as it can cause necrosis : skin glue should never be placed in the wound fingers regenerate skin very well, especially in children. Clean the wound and apply a vaseline the wound and apply in children. Clean skin very well, especially fingers regenerate foam dressing or a non-adherent that with an absorbent If possible follow gauze type dressing. the finger. Review daily dressing, then bandage cm) consult MO/NP if large wounds (over 1 sq. cover with a non adherent dressing, and bandage the finger to keep it straight and bandage the finger non adherent dressing, cover with a More often graft onto the wound. will 'take' and act as a days. Hopefully the flap review in 2-3 it heals the wound well until die off, but at least it covers the flap will reapply the flap over the wound and secure it loosely with Steristrips it loosely and secure the wound the flap over reapply – – – – – put the amputated part in a clean plastic bag and seal it. Put this bag in a mix of crushed ice in a clean plastic bag and seal it. Put this bag in put the amputated part The amputated part should not get wet or frozen and water for transport. arrange evacuation to an appropriate facility consult MO/NP who will patient don't forget to send the amputated part with the surgical repair may be possible a clean the stump, and apply e.g. finger caught in a door, the finger is often lacerated. Leave the nail on if at all possible. the finger is often lacerated. Leave the nail e.g. finger caught in a door, and review daily Clean and dress the finger, x-ray to look for an underlying fracture consult MO/NP and consider – – skin flap lost: – cuts to the finger tips often leave a flap of skin, which may or may not come off not come may or may of skin, which a flap tips often leave the finger cuts to not lost: skin flap – – If gluing the forehead or in the vicinity of the eye, the eye should be padded to avoid any glue If gluing the forehead or in the vicinity of the eye, dripping into the eye or onto eyelashes in 5-10 days Skin glue does not require removal - sloughs off Continue to hold the wound edges together for at least 30 seconds after applying the glue. This Continue to hold the wound edges together for at method prevents pooling or running of the glue the initial layer Subsequent layers can be applied over the top of application. Skin glue generates heat and may be uncomfortable if applied too thickly application. Skin glue generates heat and may be yourself (including gloves or equipment) to the Avoid introducing any glue into wound or gluing patient glue reduce painful stinging by skin glue in Topical application of lidocaine (lignocaine) can children allowing time for drying between each Apply the glue in multiple thin layers (at least 3), or foreign body reaction and tattooing. Avoid contact around eyes. Eye should be padded to or foreign body reaction and tattooing. Avoid contact lashes avoid any glue dripping in the eye or onto the eye paint the wound line with a small amount of Approximate the skin edges (no dead space) and Note – – – – – – – – – – – – – Amputations: – – Crush injuries: – – – – – Finger tips: Finger Application of • • • • • • • • • • • • 206 Acute wounds | Primary Clinical CareManual 10th edition | Image 3.Digitalnerveblock Image 2. Digital • • – – Technique: nerves, thedigitisanaesthetised.Thumbsandgreattoescanbemoredifficulttoanaesthetise Digital nervesrunalongeachsideofthephalanx.Byinfiltratinglidocaine(lignocaine)around – – – – – Clean anddrywound – – – – – – – wait atleast5minutesfortheanaesthetictotakeeffect draw backregularlytoavoidinjectingintoabloodvessel require more) use approximately1-2mLoflidocaine(lignocaine)oneachside(thumbsandgreattoesmay finger, avoidingthejoint.Keepinfiltrationasclosetobonepossible infiltrate thelidocaine(lignocaine)neardigitalnerveoneachsideofdorsum clean thedigitwithalcoholantiseptic use asterilefield (epinephrine) use 1%plainlidocaine(lignocaine).Never(lignocaine)withadrenaline nerve block. Skin glue 13 SeeImage3.Digitalnerveblock precisely opposed Ensure edgesare allowing timefordryingbetween Apply glueinmultiplethinlayers, each application
Acute wounds 207 Acute wounds Section 3: Emergency | 1 fish hook fish encircled by the bend in the hook making encircled by the bend in placement of the loop difficult in most cases local anaesthesia is in most cases local anaesthesia unnecessary necessary if the local anaesthesia may be e.g. the finger is hook is awkwardly placed – – Grip the barbed end of the hook with needle holding forceps and guide the hook out Cut the eye off the hook with a pair of wire cutters. Always protect the eyes of patients/staff and others before cutting the hook Grip the hook with needle holding forceps advancing the hook through the tissue until the barb end of the hook penetrates through the skin at a separate location Always have needle holding forceps holding at least one end of the hook, so as not to lose the hook – – looped around the bend in the hook as shown the bend in the hook looped around loop of string is A quick, firm tug on the hook: necessary to dislodge the A length of string or fishing line tied in a loop is or fishing line tied A length of string hook curve upwards until the needle and hook are removed through the original wound inside of the hook’s curve Then push the needle gently downwards until its hole locks over the barb Rotate the hook shank slightly downward and the part of the point towards the inside of the hook’s part of the point towards the inside of the hook’s curve Pull gently on the shank to disengage the barb Insert a hypodermic needle (18 G or larger) along Insert a hypodermic needle the barbed side of the hook, with the bevelled Large hooks may require surgical intervention. Consult MO/NP Consult intervention. surgical hooks may require Large immediately consult MO/NP involvement If ocular • • • • • • • • • • • • Method 3 Method 1 Method 2 Removal of small embedded embedded of small Removal 208 Acute wounds 6. Referral/consultation | Primary Clinical CareManual 10th edition | 5. Followup Subungual (underthe Removal of • • • • • • • • • • • • • • • • Subungual haematoma-proceduretoreleasebloodrelievepain Consult MO/NPasaboveandif Advise tohavewoundreviewedafter1-2days(orasclinicallyindicated) andagainafter5-7days NP whomayorderx-rayifavailable may haveasignificantlacerationtothenailbedwithfractureofunderlyingbone.ConsultMO/ A largehaematomae.g.almostthewholenailarea,isusuallycausedbymuchgreaterforce,and the nail,throbsandisverypainful Usually causedbyadirectblowtotheendoffinger/toe.Bloodcollectsunderpressurebeneath If unsuccessfuluseringcutter Several repetitionsoftheprocessmayberequired threaded undertheringtowardsendoffinger Unwind thefibreorelasticbypullingendthatwas Keep tensiononthefibreorelastic the finger the restoffibreorelasticfirmlyandcloselyaround Holding theendthatwasthreadedunderring,wind makes agoodhook) Feed oneendoffibreorelasticunderring(apaperclip string, dentalflossorthinelastic Using 3/0nylonsuturematerialorotherstrongfibree.g. dressing forafewdays The nailshouldbepaintedorirrigatedwithBetadine The bloodseparatesthenailfromsensitivebedunderneath,so processwillbepainless blood seepsupthroughthehole back andforthbetweenthumbforefingeruntilitdrillsthroughthebaseofnail Attach alarge(18G)needleto3mLsyringeandusinggentledownwardpressurerotateit Administer analgesiaasclinicallyindicated.See penetration ofnailbed and thebed(andmoreeffectivedrainage)whilereducingchancesofaccidental(painful) The punctureisperformedatthebaseofnailwheretheregreaterspacebetween tight ring fingernailortoenail)haematoma 2 any woundisnothealing Acute painmanagement,page ® daily,thencoveredwithasimple 1
1 35 Acute wounds 209 292 Acute wounds 292 3 314 312 Section 3: Emergency | Toxinology (bites and stings), page Toxinology (bites and stings), page Toxinology (bites and stings), Sea urchin injuries, page page injuries, urchin Sea page injuries, Stingray - adult/child - adult/child 1,2,3 for assessment
198 2,4 1,2 198 1,2 310 401 1,2
Acute wound(s), page patient has liver disease, cancer, diabetes or is immunocompromised suspected tendon or joint involvement wounds over chest or abdomen wound not healing large wounds any marine lacerations, stings or wounds that cannot be adequately cleaned - which may any marine lacerations, stings or wounds that cannot require excision of tissue or foreign body recent sporting activity on muddy field recent travel industry occupational exposures to water and mud e.g. fishing/aquaculture ponds, aquariums home exposure such as hobbies, surfing, fish Water related wounds wounds related Water fish bites, fish spines, boat propellers, or from animals and objects that have been immersed and objects that have or from animals fish spines, boat propellers, fish bites, aquarium objects shells, crocodile bites, such as shellfish/prawn/crayfish 75-90% of wounds liver disease are more likely to develop an infection. People with cancer and related activities is not explained by predominance in water occur in men and this prevalence water in swimming pools and aquariums, are prone to complicated infections by a wide range of infections by a wide are prone to complicated pools and aquariums, water in swimming organisms coral cuts, in water or mud e.g. plants or inanimate objects be caused by animals, Wounds can Wounds sustained in fresh, brackish (estuaries, mangrove swamps) or salt water, including swamps) or salt water, (estuaries, mangrove in fresh, brackish Wounds sustained – – – – – – – – – –
– – – – – Consult MO/NP if: – – Patient history to include: – – – See Wound with bleeding, multiple puncture sites, severe pain, redness and swelling may be an Wound with bleeding, multiple puncture sites, severe See envenomation, which may require resuscitation. Foreign body - embedded stingray barb, fish spine (from bullrout, catfish, stonefish), glass Foreign body - embedded stingray barb, fish spine Fever, cellulitis, abscess, ulceration, necrosis Cut/laceration(s) from objects in water and mud or that have been in water Cut/laceration(s) from objects Fish stings
• • • Acute wound(s), page Cellulitis, page Fish stings, page Related topics • • • • • • • • Background
HMP
2. Immediate management 1. May present with
4. Management 3. Clinical assessment 210 Acute wounds | Primary Clinical CareManual 10th edition | ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: Use inpregnancy: Children <8yearsofage.After18weeks ofpregnancy Contraindication: calcium, zinc,orantacidswithin2hours oftaking.Avoidsunexposure and photosensitivity.Takewithfoodormilk.Donotliedownforanhour aftertaking.Donottakeiron, Provide ConsumerMedicineInformation: • • • • • • • • • Tablet Form of infection-redness,swelling,increaseinpain Close supervisionisrequiredasinfectionmayspreadrapidly.Instructpatienttoreturnifanysigns – For acontaminatedwoundinfectionandifpathogenisidentified: – For more – For mildinfectionofotherwaterrelatedwounds: – For mildinfectionof 773 Check tetanusvaccinationstatusandgiveboosterifindicated.See – – – Thorough woundcleaningandcareisessential.See Collect woundswabforMCS.Fortechniquesee – Administer analgesiaasclinicallyindicated.See – – – – – – – – Schedule – – – consult MO/NPwhomayorder: – – consult MO/NPwhomayorder: treat withantibioticsaspercellulitis. treatwithantibioticsasperimpetigo. do notsuture,allowtohealbysecondaryintention may requireincisionofwoundandremovalforeignbody irrigate, clean,debrideasneeded Stingray injuries,page for painassociatedwithpenetratingwoundsfromwatercreatures,see – – – – – other antibioticsaspersensitivitiesfrompathology ± doxycycline ciprofloxacin PLUSclindamycin doxycycline ifwoundoccurredinbrackishorsaltwater more thanoneantibiotic
severe infectionsinwaterrelatedwounds: Strength 100 mg Severe or immediate allergic reaction to tetracyclines or treatment with oral retinoids. 50 mg Safeinthefirst18weeksofpregnancy coral cuts: 4 312 administration and 3 Route of Sea urchininjuries,page Oral ConsultMO/NP.See 3
Maycausediarrhoea,nausea,vomiting,epigastricburning Doxycycline
1 See 1 See Cellulitis, page Impetigo, page
Chronic wounds,page to amax.100mg/dosebd Acute painmanagement,page 200mgfirstdosethen Recommended dosage Child >8-18years Acute wound(s),page 2 mg/kg/dosebd 100 mgbd 314 Anaphylaxis, page Adult
401 for alternativeoptions 392 Tetanus immunisation, page Tetanus immunisation,page 427 Extended authority ATSIHP/IHW/IPAP 102 Fish stings,page 198
: 35 Duration 14 days
310 1,8,9 , Acute wounds 211 1,6,7 1,4,5
Acute wounds
14 days Duration 14 days Duration 102 102 ATSIHP/IHW/IPAP IHW/IPAP/RIPRN Extended authority authority Extended / Extended authority ATSIHP Section 3: Emergency | dosage Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, 500 mg bd dosage Recommended Recommended Child < 12 years 450 mg tds 12.5 mg/kg/dose bd Recommended Child < 12 years Adult and child ≥ 12years Adult and child of 450 mg/dose tds
up to a max. of 500 mg/dose bd up to a max. of 500 mg/dose Adult and child ≥ 12 years If renal impairment seek MO/NP advice If renal impairment seek 10 mg/kg/dose tds to a max.
Ciprofloxacin Take 1 hour before, or 2 hours after meals. Drink plenty of Take 1 hour before, or
: May cause rash, diarrhoea, nausea, vomiting and abdominal : May cause rash, diarrhoea, nausea, vomiting and Clindamycin Consult MO/NP. See Consult MO/NP. See Cl. difficile. Cl. difficile Oral Oral Route of Route of administration administration 4 4 Allergy to clindamycin or lincomycin : Severe or immediate allergic reaction to to ciprofloxacin or other quinolones : Severe or immediate allergic 150 mg 750 mg 250 mg 500 mg Strength Strength : Not recommended. Reserve for severe or life-threatening infections : Not recommended. Reserve Can cause severe colitis due to
: Can cause severe colitis due to : Can cause severe colitis Form Schedule Form Tablet discard any excess solution so that the correct dose remains in the syringe discard any excess solution so that the correct dose taste before giving it mix the dose in juice or soft food to disguise the dissolve contents of 1 capsule in 2 mL water up to 3 mL (if necessary) draw this solution into a syringe and make the volume Capsule Schedule Contraindication Pregnancy Management of associated emergency: heavy machinery if affected. Stop taking and notify health professional if any tendon soreness or soreness tendon any if professional health notify and taking Stop affected. if machinery heavy sun exposure or tingling in your fingers or toes occurs. Avoid inflammation, or numbness Note Provide Consumer Medicine Information: Provide Consumer Medicine 2 hours of taking dose as they zinc, iron or calcium supplements within fluids. Avoid dairy products, pain, dyspepsia and cause rash, itch, nausea, vomiting, diarrhoea, abdominal reduce absorption. May Avoid driving or operationg and alcohol. May cause dizziness or faintness. increase effects of caffeine ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP Management of associated emergency: • • Contraindication: There is no oral liquid for children. A 50 mg/mL solution can be made: There is no oral liquid for children. A 50 mg/mL • • Provide Consumer Medicine Information pain. Take with a full glass of water Note: 212 Acute wounds 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • Related topics Acute wound(s),page • • • • – Low riskwounds: See Attend toanybleeding.See Bat bite/scratch.See Evidence ofhumanoranimalbitetosomepartpatient'sbody Injury tohand/knuckles History offight/punch/bite Consult MO/NPasabove necessary Ask patienttoreturnforreviewataminimum1-2daysandagainafter5-7days,orearlierif patient toreturnifanysignsofinfectione.g.redness,swelling,increaseinpain All marinelacerationsshouldbemonitoredcloselyasinfectionmayspreadrapidly-instruct – – High riskwounds: – – – osteomyelitis orsepticarthritisamputation If thereisadamagetobones,jointsortendonsthenhighriskofinfectioncausing A tooth-knuckleinjuryisusuallyabitefrompunchinthemouth bites woundingthehands Consider dogandcatbitestobeusuallyinfected.Humanare MO/NP If thereistendoninvolvementorbonytendernessconsiderafracturetobepresentandconsult Human – – – antibiotics maynotbenecessaryfor: wounds having ahighrisk of infectioninclude: consult MO/NPfor allhighriskwounds – – – Acute wound(s),page that areseenwithin 8hours wounds thatcanbeadequatelydebrided andirrigated mild woundsnotinvolvingbones,joints, tendons 1 ( tooth-knuckle) and 1 198 Bat bite/scratch,page 198 Acute wound(s),page
for assessment 1 Bat bite/scratch,page 215
animal
198 bites - adult/child 215 always infectedespecially Acute wounds 213
773 1,2,3,4 5 days Acute wounds Duration 102 Extended authority ATSIHP/IHW/IPAP/RIPRN 427 Tetanus immunisation, page Tetanus immunisation, 198 ® Section 3: Emergency | dosage to < 12 years Recommended Anaphylaxis, page page Anaphylaxis, Child > 2 months bd up to a max. of 875 mg + 125 mg bd amoxicillin component) Adult and child ≥ 12 years 875 mg + 125 mg/dose bd 22.5 mg + 3.2 mg/kg/dose (Calculate dose based on the 1 Chronic wounds, page
Acute wound(s), page Cl. difficile Oral Take with food. May cause rash, diarrhoea, nausea and Take with food. May cause rash, diarrhoea, nausea Route of Amoxicillin + clavulanic acid : Consult MO/NP. See administration
4 OR 125 mg Strength 875 mg + 57 mg/ 5 mL 125 mg/5 mL + 31.25 mg/5 mL 400 mg/5 mL + : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity : Severe or immediate allergic reaction to a penicillin. wounds with delayed presentation (8 hours or more) or (8 hours presentation delayed with wounds debrided adequately unable to be wounds puncture feet or face on hands, wounds joints, tendons e.g. bones, involved structures with underlying wounds patient immunocompromised wounds in the – – – – – Schedule if allergic to penicillin, treat with metronidazole plus doxycycline if allergic to penicillin, treat with metronidazole amoxicillin + clavulanic acid amoxicillin + clavulanic treat with IM or delay in commencing oral antibiotics if lack of adherence is anticipated + clavulanic acid as above procaine benzylpenicillin followed by amoxicillin patient may need IV antibiotics e.g. ceftriaxone and oral metronidazole, and likely evacuation/ and likely ceftriaxone and oral metronidazole, need IV antibiotics e.g. patient may surgical drainage – – – – – Form Tablet – – – – – – – Larger wounds may need delayed primary closure. Consult MO/NP Larger wounds may need non-adherent dressing e.g. Melolin Review daily and dress with risk wounds or mild infections with: If not allergic treat high Debride dead tissue and irrigate copiously Debride dead tissue and by secondary intention Do not suture. Allow to heal affected limb Elevate and immobilise Check tetanus vaccination status and give booster if indicated. See give booster if indicated. vaccination status and Check tetanus MCS. For technique see Collect wound swab for is essential. See Thorough wound cleaning Consult MO/NP if presentation is delayed or infection established - swelling, decreased range of - swelling, decreased or infection established if presentation is delayed Consult MO/NP pus: movement, or – Powder for to oral liquid reconstitution • • • • • • • • • • Contraindication Avoid in women with premature rupture of the between penicillins, carbapenems and cephalosporins. membranes as there may be an increased risk of neonatal necrotising enterocolitis Management of associated emergency Provide Consumer Medicine Information: candidiasis. Can cause severe colitis due to ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed 214 Acute wounds | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: between penicillins,carbapenemsandcephalosporins Contraindication benzylpenicillin, page Note Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: cause nausea,anorexia,abdominalpain,vomiting,diarrhoea,metallic taste, dizzinessorheadache tablet withfoodtoreducestomachupset.Takeoralliquid1hourbefore food forbetterabsorption.May Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Tablet liquid Form Oral (pre-filled Schedule Injection syringe) : Stopinjectionimmediatelyifpatientshowssignsofseverepain.See Schedule Form 200 mg/5mL Strength 200 mg 400 mg : Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity 1.5 g/3.4mL 787 Strength
4 4 administration Route of Oral administration Route of
Procaine benzylpenicillin ConsultMO/NP.See ConsultMO/NP.See Maycausediarrhoea,nauseaandpainatinjectionsite IM Avoidalcoholwhiletakingandfor24hoursthereafter.Take (procainepenicillin) Metronidazole 10mg/kg/dosebdtoamax.of
400 mg/dosebd Child >1month Recommended 50 mg/kgtoamax.of1.5g 400 mgbd dosage Adult Recommended Anaphylaxis, page Anaphylaxis, page dosage Adult Child 1.5 g ATSIHP/IHW/IPAP/RIPRN Administration tips for benzathine ATSIHP/IHW/IPAP/RIPRN Extended authority 102 Extended authority 102 Duration 5 days Duration stat
1,7,8 1,5,6 Acute wounds 215 1,9,10
Acute wounds 5 days Duration 2 1
102 Extended authority authority Extended ATSIHP/IHW/IPAP/RIPRN Section 3: Emergency | Adult Anaphylaxis, page page Anaphylaxis, 100 mg daily 100 mg daily Child > 8 - 18 years to a max. 100 mg daily Recommended dosage Recommended 200 mg first dose then 200 mg first dose then 2 mg/kg daily 4 mg/kg (to max. 200 mg) first 4 mg/kg (to max. 200 mg)
May cause diarrhoea, nausea, vomiting, epigastric burning epigastric nausea, vomiting, diarrhoea, cause May Doxycycline Consult MO/NP. See Oral Route of administration - adult/child Lyssavirus and other rabies virus exposures/infection Lyssavirus and other rabies virus 4 Safe in the first 18 weeks of pregnancy Safe in the first 18 weeks 50 mg Severe or immediate allergic reaction to tetracyclines or treatment with oral allergic reaction to tetracyclines or treatment Severe or immediate 100 mg Strength Rabies' refers to disease caused by any of the known Lyssavirus species as the clinical disease Rabies' refers to disease caused by any of the known
Bat bite/scratch Australian Bat Lyssavirus has an incubation period of 20 days to 27 months caused by classic rabies virus and other Lyssaviruses is indistinguishable caused by classic rabies virus and other Lyssaviruses Be aware that Lyssavirus infection can arise in overseas travellers who have returned to Australia from countries with rabies in animals such as monkeys and dogs - this includes Bali, Indonesia requires an urgent medical response ' Any possible/or suspected history of bat scratch/bite, or direct contact with the mucous Any possible/or suspected history of bat scratch/bite, with the saliva or neural tissues of a bat membrane (e.g. nose, eyes, mouth) or broken skin, Consult MO/NP for all bites that are not healing Consider referral to Physiotherapist for hand therapy Advise to be reviewed daily, especially tooth-knuckle injuries. If swollen, decreased range of Advise to be reviewed daily, especially tooth-knuckle movement or pus, consult MO/NP Form
Tablet • • • • Schedule • • •
Background retinoids. Children < 8 years of age. After 18 weeks of pregnancy retinoids. Children < 8 years Use in pregnancy: Management of associated emergency: and photosensitivity. Take with food or milk. Do not lie down for an hour after taking. Do not take iron, with food or milk. Do not lie down for an hour and photosensitivity. Take within 2 hours of taking. Avoid sun exposure calcium, zinc, or antacids Contraindication: Provide Consumer Medicine Information: Provide Consumer Medicine ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed Recommend
HMP HMP Australian Bat
6. Referral/consultation 5. Follow up 216 Acute wounds 2. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup 4. Management • • • • • • • • • • • • • conditions.health.qld.gov.au/HealthCondition/condition/14/217/10/Australian-Bat-Lyssavirus based onpathologicaldiagnosisto your localPublicHealthUnitbytelephone Report anysuspectedrabiesvirusor LyssavirusincludingAustralianBatinfection, See Referral/consultation 773 Check tetanusvaccinationstatusandgiveboosterifindicated.See Do notsuturewound – – prophylaxis (PEP)assoonpracticable,preferablywithin48hoursof exposure: MO/NP willcontactPublicHealthUnitwhoadviseabouttheadministrationofpostexposure Contact MO/NPurgently Public HealthUnit and trainedpeople,wearingprotectiveglovesclothing,shouldhandlebats.Seekadvicefrom Testing ofthebatisdoneoccasionallywhereitsafetodoso. have beenvaccinated What istherabiesvaccinationstatusofpatiente.g.overseastravellersorbathandlersmay – – – – Record asmuchinformationpossibleincluding: alcohol (ethanol)ifavailable Apply virucidalantisepticsuchaspovidone-iodine,iodinetincture,aqueoussolutionor possible afterexposure Wash, don'tscrub,wound(s)withsoapandcopiouswaterforatleastfiveminutesassoon neural tissuesofawildordomesticterrestrialmammalincountrieswhererabiesisprevalent Direct contactwiththemucousmembranee.g.nose,eyes,mouthorbrokenskin,saliva Suspected historyofbatscratch/biteorcontactwithsalivaneuraltissue – – – – – – injury was thebatdisplayingunusualbehaviourandcurrentdispositionofthatcaused did theinjurydrawblood is itabite,scratch,ordirectcontactwithbrokenskinmucousmembrane when, where,how gov.au/ the PEP comprisesrabiesvaccinecourse±humanimmunoglobulin. See currenteditionof PEP regimendependsonrabiesvaccinationstatus,exposureandtiming Australian ImmunisationHandbook 1 availableat: https://immunisationhandbook.health. Note: Tetanus immunisation, page Tetanus immunisation,page onlyappropriatelyvaccinated See: http:// Burns 217
Burns 07 03 0976 2000 who will Section 3: Emergency | [email protected] up to 6 hours following burn. If up to 6 hours following 1 [email protected]
224 222 1 Minor burns, page Major burns, page 760 149 02 9767 5000 and page the Burns Registrar who will provide further 02 9767 5000 and page the Burns Registrar who - adult/child 225 Child protection, page Child protection, general) general) 1,2 provide further direction 3646 8111 and ask for Registrar on call and email burns photos to 3646 8111 and ask for Registrar on call and email in New South Wales direction Hospital on in Victoria contact the Adult Burns Unit at the Alfred in North Queensland, for children email photos of burns to in North Queensland, for and Women's Hospital switchboard in Queensland, for adults contact Royal Brisbane – – – –
Burns ( Burns If chemical burn flush with copious amounts of water If chemical burn flush with chemical prior to irrigation If dry chemical first remove for initial dressing for major burns Cling wrap should be used Keep the patient with major burns warm with space blanket, especially children burns warm with space blanket, especially Keep the patient with major burning, effective up (never ice or iced water) for 20 minutes to stop Use cool running tap water burn to 3 hours following the violence. See violence. See feet or hands in children and with defined lines around perineum, Burns with no splash marks injury may indicate non-accidental Always consider non-accidental injury where presentation is inconsistent with history, is is inconsistent with where presentation non-accidental injury Always consider or domestic children, elder abuse may suggest abuse in or signs and symptoms unexpected, – – For immediate assistance with burns: For immediate assistance – – transfer is delayed beyond this then change to an antimicrobial dressing this then change to an antimicrobial dressing transfer is delayed beyond
• • • • • • • • Electrocution/electric shock, page Chemical burns, page Related topics Recommend
HMP HMP Burns 218 Burns | Primary Clinical CareManual 10th edition | • • • • • • Do thepatient's circumferential limborchestburns genitalium, perinerum,majorjointsand Burns ofspecialareas-face,hands,feet, Non-accidental injury Burns associatedwithmajortrauma Burns withpre-existingillness Full thicknessburns>5%TBSA Burns >10%TBSA • • • Queensland Children'sHospitalBrisbane OR Contact PaediatricSurgeononcall children withupto35%TBSA) The TownsvilleHospital(forNorthQueensland and Women'sHospital Queensland AdultBurnsCentreRoyalBrisbane MO/NP refertoappropriateBurnsUnit 0730681111 Yes burns meetreferralcriteria See Assessmentof%totalbodysurfacearea(TBSA)-'Rulenines' Obtain clearhistoryofburninjury: – – – – – – – – were clothesremoved any firstaid-what,howlong mechanism ofinjury-howandwhenburnt continue coolingfor20minifwithin3hoursofburn Apply coolrunningwaterforatleast20minutes Keep restofbodywarmtopreventhypothermia Administer analgesiaasclinicallyindicated 0736468111 Perform primaryandsecondarysurveys Assess totalbodysurfaceareaburnt On presentationofburnpatient Stop, drop,coverandrollifonfire Remove clothingandjewellery
First aid 0744331111 3
for burns • • • • • •
children andtheelderly Burns attheextremeofage-young Burn injuryinpregnantwomen Chemical burns Electrical burns Burns withinhalationinjury Burns inchildren>5%TBSA Minor burn: • • • • Give analgesiaasrequired review Arrange followupdressingand Apply appropriatedressing Assess burnwound No Burns 219
Burns
weeks scarring scarring Within a few days ulceration Within 2-3 No healing high risk of elements in weeks by re- hypertrophic Healing time from epidermal Longer than 2-3 granulation and leads to chronic dermis, minimal epithelialisation wound contraction
1% 1 or Section 3: Emergency | Yes and Early hours (hours) None or Blisters Palmar 1% Patient's palm + fingers = destroyed) (epidermis later (days) No blistering Usually large rupture within desquamation % 'Rule of nines' of 'Rule 9 Nil Present 14% sensation Painful ++ Sensation Decreased 18% hypersensitive Back 18% Front 18% 14%
% 9 Nil absent Normal increased Circulation Sluggish to Hyperaemic Paediatric 1% from the head and add of life after 12 months take For every year when adult proportions leg, until the age of 10 years 0.5% to each % 9 red Red Pink Colour White/ blotchy charred to touch) Pale pink/ (and warm
18% total body surface area (TBSA) - (TBSA) area surface body total % 1 9% 1 Back 18% Front 18% 18% and only most intact intact part of dermis, dermis, adnexal adnexal destroyed Epidermis Epidermis Epidermis structures structures structures and upper Pathology significant Epidermis, dermis and % only deeper cell adnexal 9
assessment Assessment of % of Assessment Full burn burn Adult Depth partial partial thickness Epidermal Burn thickness) thickness) Mid - deep (erythema) (superficial mid dermal (mid - deep Superficial - dermal burn 220 Burns | Primary Clinical CareManual 10th edition |
Burns dressings4 Type of Product/what Function/why Indication/when Application/how Note/precaution dressing Silver • Anti-microbial • Superficial or mid dermal wounds, likely • Apply 2-3 mm cream onto wound • Use with caution in children/ sulfadiazine • Maintains to heal without the need for surgical • Smear cream on, no need to rub it in pregnant women near term cream - moist wound intervention i.e. < 2 weeks to close • Ensure all broken areas and blisters • Do not use on face Flamazine environment that • Transfer/retrieval are covered • Daily dressing changes may cream® promotes healing• Applicable to all areas of the body • Cover cream with Melolin® and secure be associated with more pain • Easy to apply except the face with bandage • Daily dressing allows for daily • Easy for patient • Switch to simple paraffin based • Change dressing daily checking of wound for signs of to mobilise dressing once the wound is pink and infection • Penetrates there is no eschar (dead dermis), and eschar risk of infection is reduced Acticoat® • Anti-microbial • Epidermal/dermal burns with a layer of • Cut Acticoat to size of raw area • Must be kept moist with water • Maintains hydrogel e.g. Solosite® • Wet Acticoat in water to moisten • Can cover final dressing with moist wound • Switch to simple paraffin based • Spread hydrogel e.g. Solosite® Glad Wrap® to retain moisture environment dressing once the wound is pink and onto blue side of dressing if required • Contraindicated for patients in the presence there is no eschar (dead dermis), and • Acticoat blue side down on wound hypersensitive to silver of exudate that risk of infection is reduced • Cover Acticoat areas with hyperfix • Do not use normal saline to promotes healing • Can shower and lightly wet the moisten Acticoat® as it alters affected areas, then pat dry the silver compound Antimicrobial/antiseptic • DO NOT saturate Acticoat • Do not use where compliance • Dressing changed every 3-7 days is a concern
Mepilex Ag® • Anti-microbial • Epidermal/dermal burns • Cut to cover burn area and approx. • Foam must be in contact with • Soft/comfortable • Switch to simple paraffin based 2 cm around wound wound at all times • Over mobile dressing once the wound is pink and • A generous layer of paraffin or • Dressing must be kept dry areas e.g. joints there is no eschar (dead dermis), and hydrogel e.g. Solosite® under and hands risk of infection is reduced Mepilex Ag® helps keep wound moist • Absorbs exudate • Secure foam (with hyperfix or cohesive bandage) and change every 3 days
(continued) Burns 221
Burns
changed daily changed
and Silver sulfadiazine cream are are cream sulfadiazine Silver and Bactigras •
®
Cover with melolin and heavy crepe bandage. crepe heavy and melolin with Cover •
top of the Bactigras the of top
®
Smear Silver sulfadiazine cream over the the over cream sulfadiazine Silver Smear •
on wound. wound. on Bactigras Place •
®
Section 3: Emergency | scissors. scissors.
to size of wound with clean clean with wound of size to Bactigras Cut •
eschar/pseudo membrane eschar/pseudo Paraffin baseddressing ®
sulfadiazine to lift lift to sulfadiazine formation chlorhexidine) sulfadiazine
0.5% 0.5% In conjunction with Silver Silver with conjunction In • exudate membrane in conjunction with Silver Silver with conjunction in membrane
containing containing Decreases Decreases • When used to help lift eschar/pseudo eschar/pseudo lift help to used When •
OR paraffin paraffin environment
OR with white white with moist wound wound moist
impregnated impregnated of infection is reduced is infection of Maintains • wound wound
(gauze (gauze (dead dermis), and the risk risk the and dermis), (dead Non-adherent • Change dressing second daily second dressing Change • open wound as it may stick to to stick may it as wound open
and there is no eschar eschar no is there and anti-septic 1 week) cover with Bactigras with cover week) 1 Vaseline gauze directly to an an to directly gauze Vaseline
®
Bactigras Once the wound is pink pink is wound the Once • Slow-release • Once wound is pink and no eschar (after about about (after eschar no and pink is wound Once • Do not apply coarse weave weave coarse apply not Do •
®
action
infection is reduced is infection eodorizing D •
gauze) about 1 week and the risk of of risk the and week 1 about environment
impregnated impregnated (dead dermis) - after after - dermis) (dead wound moist ) Xeroform
®
(fine mesh mesh (fine and there is no eschar eschar no is there and Maintains • of soft white paraffin first then cover with with cover then first paraffin white soft of
Xeroform • • Non-adherent • Once the wound is pink pink is wound the Once over with Xeroform with over C • (can apply thick layer layer thick apply (can
® ® ®
dressing
Product/what Function/why Indication/when Application/how Note/precaution
Type of of Type
Burns dressings Burns 4 222 Burns 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | HMP • • • • • • • • • • • • • • • • • • • • • • • – – – – – – Obtain emergencypatienthistoryincluding: – unburnt skinifpossiblebutnecessarythroughaburntarea: Insert 2xIVcannula.Usethelargestpossiblegaugegivenageandvascular status,through Consult MO/NPassoonpossiblepatientmayrequireintubationand fluidresuscitation circumferential burns Keep affectedlimbselevatedtominimiseswellingandmaintainperfusion, especiallyin burns unit.Limbscanbewrappedlooselywithanon-adherentdressing andaloosebandage Use clingwrapforinitialdressingaskeepsburnmoistandallowseasier assessmentonarrivalat Administer analgesiaasclinicallyindicated.See If cervicalspinecleared,raiseheadofbedtoreduceswelling – – – and alteredvoice: If yoususpectinhalationburnse.g.blacksootaroundthenose,mouthorface,burntnasalhairs O Give to avoidhypothermia.Keepnon-affectedareaswarmanddry Immediately coolburntareafor20minutesunderrunningwater(canbetapwater).Becareful Remove clothing,rings,watches,jewelleryandbelts Perform primaryandsecondarysurveys.See If clothingstillsmoulderingputoutwithlargeamountsofcoolwater Put outburningclothinge.g.rollingpatientonthegroundcoveredwithablanket R See Associated traumaticinjuriesfromfall,blast,structurecollapse Altered levelofconsciousnessfromhypotension,headinjuryorinhalationburn Shock Hypotension Associated respiratoryburns,distresswithstridorand/orwheeze Visible and/orhiddenburns(checkunderhair) Pain orpainless-patientwithfullthicknessburnsmayhavenopain emove patientfromdanger(withoutendangeringyourself) – – – – – – – – – – Major burns page if IVaccessisunabletobeestablisheduseintraosseousinfusion.See consider intubationearlyasswellingmayoccurandcompromiseairway contact MO/NPurgently give O any first aid measurestaken is thereariskofother injuriessuchasfallfromheight, roadaccident,explosion whether inenclosed oropenspace-ifenclosedgreater riskofinhalationburn how longpatientwas exposedtoenergysource the timeburnoccurred circumstances andmechanismofburn e.g.electrical,flame,contact,chemical,scald DRS ABCDresuscitation/thecollapsedpatient,page 2
to maintainSpO 69 2 viaanon-rebreathingmask-Hudsonisnotsufficient
- adult/child 1,2,3 2 >94%.See 1,2,3 1,2,3 Oxygen delivery,page
Traumatic injuries,page Acute painmanagement,page 54
64
163 Intraosseous infusion, Intraosseous infusion, 35 1
Burns 223
Burns Burns
Section 3: Emergency |
- is used for the first 24 hours after burns. MO/NP will advise - is used for the first 24 1 773 1,2,3 217
half the fluid replacement is given in the first 8 hours, and the rest over the next 16 hours. The is given in the first 8 hours, and the rest over half the fluid replacement out from the time of the burns, not the time the fluid replacement requirement must be worked patient presents for treatment modified Parkland formula: 3-4 mL x weight (kg) x % TBSA, given in first 24 hours (over and 3-4 mL x weight (kg) x % TBSA, given in first modified Parkland formula: for children) above maintenance fluids Tetanus immunisation, page Tetanus immunisation, page – – contamination extensive burns may cause ileus (bowel obstruction) in which case MO/NP may advise to pass a extensive burns may cause ileus (bowel obstruction) periodically nasogastric tube. Allow free drainage and aspirate there is evidence of cellulitis or gross antibiotics are not indicated for clean burns unless MO/NP may request that the patient be catheterised measure urine output hourly – – commence IV Hartmann's solution commence IV Hartmann's fluid replacement as below: quantities and rate. Calculate – – – – –
Consult MO/NP as above https://metronorth.health.qld.gov.au/rbwh/healthcare-services/burns Transfer to Burns Unit of patients with respiratory burns Speech Pathologist is required for ongoing management exercise and full range of movement of burned Physiotherapy support is required to encourage at: body area. Physiotherapy exercise sheets available Additional management issues: – – – – Fluid resuscitation in patients with 10-15% burns and above: Fluid resuscitation in patients – Consult MO/NP who will arrange retrieval Consult MO/NP who will determine if respiratory tract burns determine if MO/NP discussed with relevant and send by email once burn wounds If able to, photograph give booster if indicated. wounds. Check tetanus vaccination status and Burns are tetanus prone See For patchy burns in an adult and paediatric patients, the area of patient's hand is about 1% of patient's hand is about patients, the area in an adult and paediatric For patchy burns the burnt area covers) out how many 'hands' (roughly work sounds to for air entry and added auscultate the chest the mouth, nose and Carefully inspect Response Tools) Response Do by burns. depth affected surface and of body the percentage and work out burnt area Inspect See or loss of skin. blisters (red) without are only erythematous areas that not count (general), page Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Warning Early local or other score (full Q-ADDS/CEWT observations clinical standard Perform
• • • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management 224 Burns 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | 4. Management HMP Management ofassociatedemergency: Contraindication: Note: Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP • • • • • • • • • • • • Cream Form See Xeroform Switch toasimplelowadhesiveparaffindressingoncetheriskofinfectionisreduced – – For superficialormid-dermalburnsuse: Debride blistersif>2.5cmoroverjoints Remove allforeignmatter,looseandnonviableskintissue Clean withsodiumchloride0.9% See Administer analgesiaasclinicallyindicated.See Cool withrunningwaterforatleast20minuteswithinthefirst3hoursofinjury or deep Note: scald, minorflamecontact Superficial tomiddermalburns-blistered,painful,palepink/red,raw,briskcapillaryreturn Epidermal burns-painful,skinintact,redsun,flash,minorscald Discardtube7daysafteropening – – Minor burns moist asperdirections) an antimicrobial/antisepticbaseddressinge.gMepilexAg silver sulfadiazinecreambaseddressingwherewoundcareadherenceisaconcernOR Schedule
Burns (general),page Burns (general),page thedepthofapartialthicknessburnmaytakeupto7-10daysdeclareitselfassuperficial ® orBactigras Strength Prematureinfants,babies<2months, orinlastmonthofpregnancy 1% 2,3 1,2 - adult/child ®
administration 4 217 217 Route of Topical
and 1,2
Major burns,page or cleanwaterandmildsoap
Consult MO/NP.See Maycauseburning,itch,rash.Avoidcontactwitheyes Silver sulfadiazine Apply a3-5mmthicklayer Adult andchild>2month Acute painmanagement,page Recommended 222 dosage Anaphylaxis, page ® orActicoat ATSIHP/IHW/IPAP/RIPRN Extended authority
102 ® (ifdressingcanbekept 35 max. afterburn Duration 3 days
e.g.
4,5 Burns 225
Burns Consult MO/NP
Section 3: Emergency | 224 for technique.
427 54 Minor burns, page Chronic wounds, page Chronic wounds, 1
- adult/child 2 217 222 1 DRS ABCD resuscitation/the collapsed patient, page
Chemical burns Hydrofluoric acid is a chemical compound used in electroplating, stain removal, glass etching, Hydrofluoric acid is a chemical compound used refining and light bulbs detergents cleaners, battery fluid, fertiliser Acid substances include: toilet bowl cleaners, metal chemicals, rust proofing manufacturing, swimming pool cleaners, laboratory Alkali substances are found in: drain cleaners, oven cleaners, denture cleaners, cement, found in: drain cleaners, oven cleaners, denture Alkali substances are in cleaners and detergents and dishwashing household bleach, pool chlorine, ammonia Irrigate with copious amounts of water Irrigate with copious amounts produce heat and will the chemical as most resultant reactions Do not attempt to neutralise in the case of hydrofluoric acid) exacerbate the injury (except burns, especially for those involving eyes Consult MO/NP for all chemical
Any dry chemical e.g. cement or lime should be brushed away and contaminated clothing removed Any dry chemical e.g. cement or lime should be brushed away and contaminated clothing removed before irrigating with copious amounts of water See Irrigate with copious amounts of water Cardiac arrest may follow absorption of hydrofluoric acid by the skin (with little or no skin changes) Cardiac arrest may follow absorption of hydrofluoric concentrated 70% hydrofluoric acid solution from as little as a 2% body surface area burn with or high serum potassium) (due to low serum calcium, low serum magnesium Visible burns appearance due to deeper tissue toxicity Pain may be extreme and out of proportion to burn Hypotension/shock History of exposure to chemical agent Consult MO/NP as above Consult MO/NP collect wound swab for MCS. See collect wound 10 days any burns not healed in next MO/NP clinic for Advise to see Advise patient to have wounds reviewed depending on the appropriate regime for the dressing for the dressing regime the appropriate on reviewed depending wounds patient to have Advise used exudate, swelling and purulent in pain, redness, a fever, wound increases If patient develops
• • • • • • Burns (general), page Major burns, page Related topics • • • • • • • • • • • •
Background Recommend HMP HMP
2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up Follow 5. 226 Burns .Management 4. Clinicalassessment 3. | Primary Clinical CareManual 10th edition | Followup 5. Bitumen burns Hydrofluoric acidburns • • • • • • • • • • • • • • • • • • • • • • •
and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning See Orange oil(De-Solv-It Specialist burnunitmayadviseremoval ofsmallbitumenareasusingahydrophobicsolvente.g. medical assessmentandtreatment Bitumen burnstotheeye-donotattemptremovebitumen.Refer urgentlyforspecialist consultation withtheburnsunitsoftenand/orsplittopreventbloodflow restriction Circumferential burns-wherehardenedbitumeniscausingconstriction, elevatethelimbandin should becarriedoutbyaspecialistinanoperatingtheatre Extensive andfullthicknessbitumenburns-refertoaBurnsUnit.Active removalofbitumen Seek specialistadvicebeforeactivelyremovingbitumen burn fromdryingout Do notremovebitumen.Coldbitumenwillformawaterproof,sterilelayer whichwillpreventthe Irrigate withcopiousamountsofwater Contact PoisonsInformationCentre(PIC)131126(24hours) normal serumcalciumconcentrationcanbedischarged All patientsshouldbeinitiallyobservedfor6hoursafterexposure.Asymptomaticwitha If pointofcaretestingavailable,checkpotassium,calciumandmagnesium Calcium chloridesolutionshouldnotbeusedasitmaycausetissuenecrosis with 30mLofwatersolublegele.g.KY neutralise theacid.Alternativelycombine10mLofcalciumgluconate2.2mmolinsolution Covering theburnwithgauzesoakedincalciumgluconate2.2mmol10mLsolutionwill Weak acidthatpenetratestissuesverywellandbindstocalciummagnesium Burns of3-4%TBSAhavecauseddeaths.MaintainPPEstandards and <10%upto24hours) Time fromexposuretosymptomsaredependentonconcentrationofagent(>40%withinanhour Consult MO/NPforallhydrofluoricacidburns exacerbate theinjury(exceptincaseofhydrofluoricacid) Do notattempttoneutralisethechemicalasmostresultantreactionsproduceheatandwill MO/NP Consult See Burns(general),page217,Majorburns,222andMinor224 Include inhistorycircumstancesofchemicalburn,agentifknown,andtimeinjuryoccurred. Administer analgesiaasclinicallyindicated.SeeAcutepainmanagement,page35 Use PPEi.e.gloves,plasticapronandgogglestopreventcontactwithchemical Major burns,page222andMinor 224 3,4 ® 2 ), paraffin,orotheroil ® jellyandapply Environmental 227 728 - adult/child - adult/child 54 are controversial and should only be 3 Section 3: Emergency | Environmental emergencies bends) Traumatic rupture of the eardrum, page DCI/ 4 128 4 , glucocorticoids and lidocaine (lignocaine) 2 1 1 ate management 2 3 DRS ABCD resuscitation/the collapsed patient, page
speech, visual or hearing disturbances irritability, confusion or reduced consciousness weakness, paralysis, physical collapse rash extreme fatigue numbness/tingling or altered sensations joints headache or other body pain, especially at or around poor balance or coordination Decompression illness ( Decompression ordered by a Hyperbaric Consultant on specialist advice ordered by a Hyperbaric Consultant on specialist (road or helicopter) or by an aircraft capable of pressurising the cabin to the equivalent of sea an aircraft capable of pressurising the cabin (road or helicopter) or by level Assume DCI until proven otherwise with all symptoms occurring during or up to 48 hours after hours 48 to up or during occurring symptoms all with otherwise proven until DCI Assume fit and healthy person SCUBA diving in an otherwise ft metres/1,000 300 < of altitude an at transported is evacuated patient any that important is It Always keep patient flat if decompression illness (DCI) suspected Always keep patient flat Early onset of symptoms or altered level of consciousness indicates serious decompression indicates consciousness altered level of or symptoms of onset Early illness Aspirin DCI is caused by nitrogen bubble formation in the blood or tissues due to the changes in pressure in changes the to due tissues or blood the in formation bubble nitrogen by caused is DCI while diving Recompression (in a hyperbaric chamber) is the universally accepted standard for the treatment chamber) is the universally accepted standard Recompression (in a hyperbaric of DCI – – – – – – – –
See Remove patient from water Expired air resuscitation (EAR) should never delay the recovery of a diver to a platform or the shore – – – – – – – – Signs and symptoms may occur during, immediately after a SCUBA dive, or develop up to 48 hours Signs and symptoms may occur during, immediately afterwards Signs and symptoms include: Consult MO/NP as above MO/NP as Consult
• • • • • • • Drowning/submersion, page Related topics • • • • • •
Background Recommend HMP HMP
Environmental emergencies Environmental 6. Referral/consultation 6.
2. Immedi 1. May present with 228 Environmental 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 5. Followup 4. Management • • • • • • • • • • • • • • • • • • • • • Other conditionsneedconsideration suchasbarotraumaofthemiddleear,includingruptured illnesses assooncanbearranged evenifDCIhasbeenexcludedinconsultationwithMO/NP All patientswithsymptomsafterSCUBA divingshouldseeaMO/NPfamiliarwithinjuries/ If seizureoccurssee Indwelling catheter(IDC)ifrequired Aminister antiemeticasclinicallyindicated.See – Administer analgesiaasclinicallyindicated.See Oral clearfluidsasadvisedbyMO/NP,ifnoalteredlevelofconsciousness – – – If tobeevacuated: Available from: Examine thenervoussystemincludingmini-mentalstateexaminationtoassesscognitivefunction. – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand symptoms of dive(s),surfaceintervalbetweendives,timecompletingthediveandonset descent tobeginningdirectascent),depth,decompressionstops,speedofascent,dateandtime Recent divehistory:numberoverrecentdays,duration,bottomtime(thefrombeginning Obtain rapidpatienthistory Consult MO/NPurgently Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand instruction. Avoidusingsolutionscontainingglucose If required,giveIVsodiumchloride0.9%atleast10-20mL/kgover30minutesonMO/NP Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus NP. See Give highflow100%O The patient'sairwaymayneedtobemanagedastheyunableprotecttheir bubble travellingtothebrain Lie patientflat. See Assess andtreatassociatedproblems See eardrum andinner ear,whichcanleadtopermanentdeafness ifnotdiagnosedearlyand treated. – – – – – nitrous oxide/O keep warm,correcthypothermiaifpresent. hours. MO/NPmayadviseairbreaks high flowO otherwise the patientwillneedtobekeptflatuntilreacheshyperbaricchamber,unless MO/NPadvises BGL Drowning/submersion, page Traumatic ruptureof theeardrum,page Oxygen delivery,page
2 mustcontinueuntilpatientreacheshyperbaricchamber,unlessthistakes many 4 3 https://qheps.health.qld.gov.au/mentalhealth Raisingtheheadmaycausesuddendeteriorationanddeathduetoalargegas 2 mix(Entonox Fits/convulsions/seizures, page 2 andcontinueuntilpatientreacheshyperbaricchamberororderedbyMO/ 3,4 64 128 ® ) mustNOTbeusedforDCI and/or 728 Traumatic injuries,page 3 See Nausea andvomiting,page Acute painmanagement,page Hypothermia, page 109 3 formedication 163 229 48 35 Environmental 229 73 259 4 07 4433 2080 or 07 4433 2095 or after hours or 07 4433 2095 or after 07 4433 2080 Section 3: Emergency | Environmental emergencies Toxicology (poisoning and overdose), page Unconscious/altered level of consciousness, page http://www.danap.org/emergency/hotline_numbers.php
128 4 163 1,2,3 - adult/child - adult/child 1800 088 200. 1800 088 200. 1 oral 36.8 ± 0.7°C lower axilla generally 0.5-1.0°C rectal generally 0.5-1.0°C higher
– – – increasing muscle stiffness progressive decrease in consciousness confused or apathetic absence of shivering environmental exposure - wet, windy patient - shivering, pale, skin cool to touch impaired coordination slurred speech tachycardia, tachypnoea The hypothermic heart is very sensitive to movement therefore rough handling of the patient may patient the of handling rough therefore movement to sensitive very is heart hypothermic The (VF) or asystole precipitate arrhythmias including ventricular fibrillation Hypothermia may occur in any setting or season. The elderly are more susceptible to Hypothermia may occur in any setting or season. the most common precipitants of hypothermia environmental hypothermia, while in non-elderly immersion include injury, systemic illness, drug overdose and during the warming process) Observe for hypotension (resulting from reflex vasodilation – – – Hypothermia is when a body's core temperature falls below 35°C Hypothermia is when a body's (adult): Normal temperature ranges Do not remove wet clothing if there is no dry blanket or other suitable cover Do not remove wet clothing in a warm bath Do not place the patient are at greatest risk of hypothermia Infants and elderly people – – – – – – – – –
– – – Moderate to severe hypothermia - rectal temperature 29-32°C: – – – – – considering hypothermia Mild hypothermia - rectal temperature 32-35°C: – The clinical condition of the patient is more important than the measured temperature when The clinical condition of the patient is more important Hyperbaric Medicine Unit, The Townsville Hospital Unit, The Townsville Hyperbaric Medicine on 07 4433 1111 Consult MO/NP on all symptoms occurring up to 48 hours after SCUBA diving after SCUBA up to 48 hours occurring all symptoms MO/NP on Consult Alert - Divers and retrieval management advice on facility or hyperbaric of nearest For location Network
• • • • • • • • Traumatic injuries, page Drowning/submersion, page Related topics • • • • • •
Background Recommend 1. May present with
Hypothermia Referral/consultation 6. 230 Environmental 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment • • • • • • • • • • • • • • – – External warming: If consciousandtolerated,givewarmcaloricoralfluids(notalcohol) MO/NP Consult – – Perform physicalexamination: Bloods forUE – – Response Tools)+rectaltemperatureifprobeavailable: Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – Obtain completepatienthistory: Provide headcovering Apply insulationbetweenbodyandtheenvironmente.g.blanket,spaceblanket Dry patientifwet contact withcoldsurfaces,windyenvironment Remove fromcoldenvironment,wetclothing(ifthereisadryblanketorwarmcoveravailable), See – – – – – – – Very severehypothermia-rectaltemperature<29°C: – – Aim towarm0.5-2°C/hour – – – – – – – – – – – – – – – – – – – examine forinjuriesandsignsofinfection,malnutrition,pressureareas is skincold,patientshivering BGL ECG andongoingmonitoring period oftimesinceexposure exposure toalcohol/otherdrugs/sedatives trauma immersion/submersion, exhaustion recent environmentalhistory/exposuretocold,wetandwindyconditions,coldwater loss ofreflexes weak slowpulse patient appearsdead fixed dilatedpupils cardiac arrest severe hypotension cardiac arrhythmias hypotension slow irregularpulse-atrialfibrillationorjunctionalbradycardia – – active externalwarmingformoderate toseverehypothermia(rewarming2°C/hourachieved): – – – passive (rewarmingrate0.5-2°C/hour achieved): – – – – – DRS ABCDresuscitation/thecollapsedpatient,page mild hypothermia requirespassivewarmingwithblankets, headcovering,spaceblanket use heatsourcessuch asBairHugger avoid burnsbyensuringanyheatsource iswarmortepidbutnothot place inawarmenvironment cautiously applyexternalheatsuch asheatpack,bodytocontact,warmblankets 1,2 2 2 1,3,4
® orWarmTouch 54 ® blanketswhereavailable 4 Environmental 231
73 259 1,2 - adult/child 1 Heat stroke Section 3: Emergency | Environmental emergencies C and the body's capacity to dissipate heat is lost, C and the body's capacity to dissipate heat is lost, 0 hyperthermia Cardiovascular collapse (cardiac arrhythmias, clotting disorder) Muscle weakness, cramps and pain Bruising and haemorrhage Core temperature of ≥ 4o⁰C Confused, drowsy, seizures, altered consciousness, altered neurological signs Hot dry skin. May have sweating in exertional form Abnormal glucose level • • • • • • • Toxicology (poisoning and overdose), page Unconscious/altered level of consciousness, page 109 heat stroke/ 2,3 115 - a heat-related disorder often known as exercise associated collapse (EAC) and - a heat-related disorder often known as exercise - the core body temperature is > 40
Heat exhaustion
1 axilla generally 0.5-1.0°C lower rectal generally 0.5-1.0°C higher oral 36.8 ± 0.7°C – – – Heat exhaustion/
thermoregulation or hot environment) or exertional (exercise in high ambient temperatures and thermoregulation or hot environment) or exertional humidity) is associated with dehydration. The body's normal heat dissipation capacity is maintained is associated with dehydration. The body's normal Heat stroke non-exertional (occurs as a result of an impaired and results in organ failure. Heat stroke can be – – Heat exhaustion Normal ranges of temperature - adult: Normal ranges of temperature – organ failure is common as this will result in heat gain Do not induce shivering, can develop. Fluids with caution in heat stroke as pulmonary oedema IV fluids should be used should not be withheld Immediate management for heat stroke. True heat stroke is a medical emergency and multi- for heat stroke. True heat stroke is a medical Immediate management Consult MO/NP as avove Consult MO/NP Consult with MO/NP prior to discharge, despite temperature MO/NP prior to discharge, Consult with through large peripheral vein - aim for BGL between 5.5-11 mmol/L between 5.5-11 - aim for BGL vein large peripheral through unit is necessary dependency to a high admission hypothermia, In severe MO/NP may order glucose 10% IV commenced at 100 mL/hour (3-5 mL/kg/hour for children) for children) (3-5 mL/kg/hour mL/hour at 100 commenced 10% IV glucose order may MO/NP
• • • • • •
Profuse sweating Postural dizziness Pale cool/moist skin Muscle cramps Temperature typically < 40⁰C Headache, nausea or vomiting Collapse Fits/convulsions/seizures, page Hypoglycaemia, page Related topics • • • •
Background Recommend • • • • • • •
HMP HMP 1. May present with
6. Referral/consultation 5. Follow up 5. Follow 232 Environmental .Immediatemanagement 2. | Primary Clinical CareManual 10th edition | Clinicalassessment 3. Heat stroke-coretemperatureof≥4o Management ofassociatedemergency:ConsultMO/NP.See Note: Cautioncalculatingandmeasuringlowdose.Monitorforsedationrespiratorydepression Provide ConsumerMedicineInformation:Maycausedrowsinessorrespiratorydepression RIPRN mayproceed RN mustconsultMO/NP Injection • • • • • • • • • • • Form
– – – and ResponseTools)+ Perform standardclinicalobservations (fullQ-ADDS/CEWTscoreorotherlocalEarly Warning – Obtain completepatienthistory: Insert indwellingcatheter Check BGL-if<3mmol/L.SeeHypoglycaemia,page115 – – Control shivering-cancauseanincreaseincoretemperature: Connect tocardiacmonitor Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus Maintain adequateoxygenationi.e.SpO Consult MO/NP – – – – Rapidly reducecoretemperature: See DRSABCDresuscitation/thecollapsedpatient,page – – – – – – – skin -moistandcool orhotanddry BGL take coretemperature(ifequipment available) midazolam IV(0.01mg/kgforadultandchild). treat bycoveringpatientwithasheetuntilitstops aim tocoolatleast0.1⁰C/minute spray orspongethetorsoandlimbswithtepidwaterthenfan place icedirectlyagainstskin place wrappedicepacksoverlargebloodvesselsofaxillae(armpits),neckorgroin.Donot place patientinacoolplace,withfullcirculatingair,removeunnecessaryclothing poisoning/overdose ornewpsychiatric medications,otherillnesses recent environmentalhistory/exposure, levelofexerciseandambienttemperature,snakebite, adult Schedule 5 mg/5mL Strength administration 4 Route of 1,5 IV 1,4 H 1,3,4 Adult andchild Recommended ⁰ C 0.01 mg/kg 2 >94% dosage Midazolam 3 Note:thisisasmalldoseofonly0.5-1mgforan 1,3,4 54 Anaphylaxis, page 102 MO/NP mayorderfurtherdosesat5 minutely intervalsuntilshiveringis suppressed Extended authority Duration stat RIPRN 3,5,6 Environmental 233 4 if available, unless vomiting is present if available, unless vomiting C ® O Section 3: Emergency | Environmental emergencies but rarely needed 4 /Hydralyte ® 2,3 1,5
observe colour of urine and urinalysis for blood and/or myoglobin. If positive could be red be could positive If myoglobin. and/or blood for urinalysis and of urine colour observe (muscle breakdown) or rhabdomyolysis cells (bleeding) blood – Consult MO/NP as above As per MO/NP advice Consult with MO/NP prior to discharge, despite temperature Consult with MO/NP prior to discharge, despite illness Give patient education on prevention of heat-related Aim to reduce core body temperature to around 38 Aim to reduce core body temperature to around are ineffective as antipyretics in heat-related Avoid paracetamol, ibuprofen, and aspirin as they illness See Immediate management of heat stroke See Immediate management Consult MO/NP - arrange evacuation/hospitalisation MO/NP may order IV fluids if dehydrated, MO/NP may order IV fluids Monitor temperature Consult MO/NP Lie in supine position, ideally with legs elevated Lie in supine position, ideally Specific cooling is not required or Gastrolyte Give oral fluids e.g. water Remove patient from hot environment/trigger Remove patient Remove excess clothing Perform ECG and monitor Perform ECG Perform physical examination Perform blood for LFT take UEC if possible, testing for point of care Perform –
• • • • • • • • • • • • • • • • • • •
Heat stroke - Core temperature of ≥ 4o⁰C Heat stroke - Core temperature Heat exhaustion - Temperature < 40⁰C - Temperature Heat exhaustion 6. Referral/consultation
5. up Follow 4. Management 234 Ears, nose and throat Ears, noseandthroat(ENT)emergencies | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • • Related topics Head injuries,page • • • • • Medicines -isthepatientonantiplatelets and/oranticoagulants back oftheneck,oranteriorlyin nose tract infection,historyofbleedingdisorders. Itisimportanttoascertainifthebleedingbeganin Obtain completepatienthistory-include pastepisodesofepistaxis,historyupperrespiratory – – If bloodlossisheavyorcontinuing,thereincreasedHRhypotension/shock Instruct patienttobreathethroughmouth point for10-15minutes Wear gloves,holdnosefirmlybetweenthumbandforefingertoapply pressure onthebleeding Clear clotsbyblowingnose Sit patientup,leaningforward See Increased HR,hypotension/shockifheavyorcontinuingloss Swallowing orspittingupbloodiffromposteriorpartofthenose Nose bleed – Response Tools)+ Perform standard clinical observations(fullQ-ADDS/CEWT scoreorotherlocalEarlyWarning and – – – hypertensive crisis,page condition. IfapatientisveryhypertensiveconsiderreducingBPtodecreasebleeding.See In adults,occursmoreposteriorlyandmaybeassociatedwithhighbloodpressureorableeding Usually spontaneousinchildren,occurringfromtheanteriorpartofnose Most casesoccurinchildren<10years vasodilatation andtrauma(nosepicking) Most common reasonsforepistaxisis upper respiratory infection, withmucosal congestion and hypotension/shock, especiallyintheelderly Provide immediatemanagementifnosebleed is profuseornotstopped.Itcaneasilyleadto Nose bleed/ rate. See commence IVsodiumchloride0.9%orHartmann'ssolution.MO/NPwill advisequantitiesand insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascular status central capillaryrefill DRS ABCDresuscitation/thecollapsedpatient,page
Shock, page 175 epistaxis 77 151 -adult/child 1 54
Acute Acute Ears, nose and throat 235
1 35 pack can also be used ® Ears, nose and throat emergencies Acute pain management, page Acute pain management,
However a Kaltostat 3 Section 3: Emergency | nasal tampons are the easiest to use. ® nasal packing
if discharged with nasal packing, MO/NP will order a penicillin or first-generation cephalosporin packing, MO/NP will order a penicillin or first-generation if discharged with nasal to prevent sinusitis with fresh day. If bleeding recurs, consult MO/NP and replace remove anterior pack next packing patients should only be discharged with nasal packing following advice from the MO/NP discharged with nasal packing following advice patients should only be all epistaxis post surgery all epistaxis disease haemophilia, von Willebrand’s bleeding disorders e.g. patients with measures not stop with simple bleeding does – – – – – – Tape the string to the nose and trim ends Remove nasal tampon after 24 hours contact with blood or other liquid After the nasal tampon is inserted it may be necessary to drip sodium chloride 0.9% or water into the nostril to achieve full expansion of the tampon if the bleeding has decreased at the time of insertion Apply lubricant jelly to the nares to facilitate placement. Do not apply to tampon as it will cause the Apply lubricant jelly to the nares to facilitate placement. tampon to expand floor of the nasal cavity, where it expands on The nasal tampon is inserted carefully along the Merocel A nasal tampon may be used. Always wear gloves, mask and goggles A nasal tampon may be used. Always wear gloves, tampon. Lidocaine (lignocaine) + phenylephrine Consult MO/NP before proceeding to insert nasal spray may be used to anaesthetise the nasal cavity Consult MO/NP if on these medicines for cardiac disease or TIA Consult MO/NP if on these is necessary if the bleeding does not stop Evacuation/hospitalisation When bleeding has stopped instruct the patient not to sniff, blow or pick their nose for 10 days instruct the patient not to sniff, blow or pick When bleeding has stopped clinically indicated. See Administer analgesia as NSAID for analgesia. using aspirin, aspirin-containing products, and Advise patients to avoid – – If bleeding continues or you suspect blood is coming from the posterior part of the nose, consult posterior part of the blood is coming from the or you suspect If bleeding continues posterior nasal packing: MO/NP who will likely advise – Consult MO/NP for: Consult MO/NP – – – Encourage patient to spit blood out and not swallow - swallowing blood often results in nausea results in blood often swallowing swallow - out and not to spit blood patient Encourage Perform physical examination physical Perform
• • • • • • • • • • • • • • • • Nasal tampon Anterior 4. Management 236 Ears, nose and throat | Primary Clinical CareManual 10th edition | Posterior nasalpacking • • • • • • • • • • nostril the epistaxis,itmaybenecessarytoremovecatheterandinsertanother catheterintotheother If itisunclearwhichsideaposteriorepistaxiscomingfrom,orthesinglecatheterfailstoarrest The cathetercanbeheldinplacebyaclip An anteriorpackistheninserted There shouldbeenoughtensiononthecathetertoarrestbleeding is nowlodgedintheposteriornose and pullthecathetergentlyforwarduntilresistanceisfelt.Injectanother3-5mLofair.The Once thetippassesbeyondpalateintooropharynx,blowupballoonwith5mLofair Lubricate thecatheterandadvancefarbackalongfloorofnose Foley catheterifavailable the nostril.Sedationmaybenecessary.ARapidRhino Rapid temporarycontrolofposteriornosebleedisgainedbyinsertingaFoleyurinarycatheterinto phenylephrine spraymaybeusedtoanaesthetisethenasalcavity Consult MO/NPbeforeproceedingtoinsertposteriornasalpacking.Lidocaine(lignocaine)+ neurogenic syncopeduringpacking,andpressurenecrosissecondarytoexcessivelytightpacking Complications includeseptalhaematomasandabscessesfromtraumaticpacking,sinusitis, Moisten thenasaltamponwithsodiumchloride0.9%beforeremoving
4 ® inflatabletamponadeisanalternativetoa 3 Ears, nose and throat 237
2
stat Duration ATSIHP/IHW/IPAP Extended authority authority Extended
102 12 years ≥ 2 years Ears, nose and throat emergencies ≥ dosage Child Recommended Recommended Anaphylaxis, page page Anaphylaxis, 2-4 years 1 spray/nostril 4-8 years 2 sprays/nostril Adult and child Adult and child 8-12 years 3 sprays/nostril 8-12 years 3 sprays/nostril up to a max. 5 sprays/nostril up to a max.
Section 3: Emergency | Numbness of tongue or mouth; risk of trauma from hot drinks Numbness of tongue or Consult MO/NP. See Route of Intranasal administration Lidocaine (lignocaine) + phenylephrine (lignocaine) Lidocaine 2 + Strength : Pregnancy and children < 2 years : Pregnancy and children Lidocaine (lignocaine) 5% (lignocaine) phenylephrine 0.5% : Use a new nozzle attachment for each patient. : Use a new nozzle attachment
Schedule heavy or continuing or there is increased HR or hypotension/shock Nose bleeds in adults may need further investigation or posterior nasal packing or where blood loss is Consult MO/NP for all cases that require anterior anticoagulation and/or antiplatelet therapy consult MO/NP anticoagulation and/or antiplatelet therapy consult non-recurring nose bleeds in children Advise to see MO/NP at next clinic except minor nitrate cautery Recurrent nose bleeds in children can warrant silver Advise to be reviewed the next day or as clinically indicated Advise to be reviewed the next day or as clinically until review Advise patients to avoid alcohol and hot drinks products and NSAID. If patient is on regular Advise patients to avoid aspirin, aspirin-containing
Form Spray • • • • • • • ATSIHP, IHW, IPAP, RIPRN and RN may proceed RIPRN and IHW, IPAP, ATSIHP, Notes Contraindication emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine for two hours after. Bitter taste for 1-2 minutes or biting. Do not eat or drink
6. Referral/consultation 5. Follow up 238 Gastrointestinal Gastrointestinal emergencies | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1.Maypresentwith HMP Recommend Background • • • • • • • • • • • • • • • Related topics Ectopic pregnancy,page Bowel obstruction,page APSGN, page Acute retentionofurine-adult,page • • • • – If hypotension/shock: Perform rapidclinicalassessment Hypotension/shock Increased HR Vaginal bleeding Inability topassurine Abdominal distensionormass Scrotal pain.See Abdominal wallpain/lump Jaundice Fever, sweats,rigors gastrointestinal bleeding,page Vomiting blood(haematemesis)orpassingtar-like(melaena)bowelmotions.See Can't passwind,constipation No appetite,nausea,vomiting Abdominal pain – – – – – recognise caseswhicharesignificant,andtobeablepresentthehistoryfindingsinan It isnotnecessaryfortheRN/IHW/ATSIHPtomakeadefinitivediagnosis.moreimportant diagnosis anddoesnotconcealsignsofacuteabdomen Patients withabdominalpainshouldbegivenadequateanalgesia.Adequateanalgesiacanaid ( >12years) Consider testiculartorsioninpre-pubescentboys(8-12years)andpost-pubescent and/or vaginalbleeding Consider ectopicpregnancyinallwomenofchildbearingagewhopresentwithabdominalpain Acute ordered mannertotheMO/NP consult MO/NPurgently whowilladvisefurthermanagement andarrangeevacuation rate commence IVsodium chloride0.9%orHartmann'ssolution. MO/NPwilladvisequantities and page insert2xIVcannula-usethelargest possiblegaugegivenageandvascularstatus.See 77
700 abdominal pain 2 Testicular/scrotal pain,page 252 511 4 1 249 256 and -adult/child Rectal bleeding,page 257 Renal colic,page Low abdominalpaininfemale,page Upper gastrointestinalbleeding,page Testicular/scrotal pain,page 3 251 254 257
635 249 Upper Upper Shock, Shock,
Gastrointestinal 239
Bowel obstruction, obstruction, Bowel 35 Gastrointestinal emergencies Acute pain management, page Acute pain management, Section 3: Emergency | and consider possibility of tubal/ectopic and consider possibility
513 511 5 Ectopic pregnancy, page 252 assessment hernial areas scrotum in a male – –
colour and pigmentation – – for bowel sounds. Absence or faint tinkling suggests bowel obstruction. See page jaundice arthralgia recent weight loss distension symmetry scars no appetite, nausea, vomiting and tar-like stools (melaena) last bowel movement, any blood observed or black diarrhoea, constipation fever, sweating, rigors on passing urine blood, cloudy or offensive urine, burning or pain – – – – – – – – – – – – – – inspect the: auscultate (listen with stethoscope): – – – – inspect abdomen for: – – – – – are there any associated signs or symptoms: – – – the degree of pain at onset and over time e.g. colic such as renal, biliary or bowel colic does the patient get some relief by moving about irritation/peritonitis from any cause or does relief come from lying very still e.g. peritoneal check pain scale (0-10), how severe is the pain e.g. shoulder-tip pain where is the pain. Does it radiate, if so, where to, is the pain sharp or dull, cramping Vaginal bleeding in early pregnancy, page Vaginal bleeding in early pregnancy. See BGL urinalysis If positive see for pregnancy for women of reproductive age. perform point of care testing woman taking any contraception and past alcohol intake - current history of recent trauma past medical and surgical history past medical history current medicines and family it normal, is the are periods regular, when was the last, was menstrual history in women: previous history of similar episodes previous history – – – – – – – – – – – – – – – – – –
– – Perform physical examination: – – – – – – – – Assessment of the pain: Response Tools) + – – – – local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical – – – Administer analgesia as clinically indicated. See as clinically indicated. Administer analgesia evidence will provide enough history and examination patient history - a detailed Obtain complete with the likely diagnosis: management to contend an appropriate course of to establish – If severe acute abdominal pain, assessment may be easier after analgesia is given analgesia is after may be easier assessment pain, acute abdominal If severe Give nil to eat or drink eat or nil to Give • • • • • • • Clinical Clinical 3. 240 Gastrointestinal | Primary Clinical CareManual 10th edition | • shock todetectmelaena.See abdominal painbutitisessentialincasesofhaematemesisorunexplainedhypotension/ Rectal examination-itisnotnecessaryforNurses/HealthWorkerstoperformincasesofacute – – – – – – – – – – palpate: – – – percuss (tap): – – – – – – – – – – – loins: sitthepatientupandpalpateoverrenalanglesfortenderness palpate thescrotuminamale palpate thehernialareasaboveandbelowinguinalligaments – – – any: where isthemaximaltenderness gently commencingatasitefarremovedfromtheindicatedofpain ask thepatienttositupifpossibleandcheckkidneyarea is theredullnessoverliver,stomach,intestines,spleen,bladder. left lowerquadrant) all fourquadrants(rightlowerquadrant,rightupperleftquadrantandthen attack canpresentwithabdominalpain to thechestforairentryandaddedsounds(wheezescrackles).Pneumoniaheart – – – rebound tenderness masses guarding quadrant Right upper quadrant Right lower Upper gastrointestinalbleeding,page quadrant Left upper quadrant Left lower 249 Gastrointestinal 241
Urinary tract infection Renal colic Left lumbar • • Left iliac Gastrointestinal emergencies Testicular torsion Diverticulitis Tubal/ectopic pregnancy Ovarian cyst PID Irreducible or strangulated hernia Pneumonia Pancreatitis Ruptured spleen Left iliac Left hypochondriac Left Left lumbar Left hypochondriac • • • • • • • • •
m Section 3: Emergency | Umbilical Epigastric Hypogastric PID Tubal/ectopic pregnancy Testicular torsion Irreducible or strangulated umbilical hernia Ruptured aortic aneurysm Gastroenteritis Small bowel obstruction Inflammatory bowel disease Early appendicitis Urinary tract infection Large bowel obstruction Acute retention of urine Uterine fibroid complication Gastritis or gastric/ Gastritis duodenal ulcer Pancreatitis Heart attack aneurys Ruptured aortic Umbilical Hypogastric Epigastric • • • • • • • • • • • • • • • • • 4 re Right lumbar
Right iliac Right hypochondriac Irreducible or strangulated hernia (usually men) Testicular torsion Appendicitis Tubal/ectopic pregnancy Ovarian cyst PID Urinary tract infection Renal colic Hepatitis - alcoholic or infective Hepatitis - alcoholic Pneumonia - ra Liver abscess/tumour Gall bladder - biliary - biliary Gall bladder colic or cholecystitis Right iliac Right lumbar Right hypochondriac Right Causes of acute abdominal pain abdominal acute of Causes • • • • • • • • • • • • 242 Gastrointestinal 4. Management | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • Consult MO/NPinallcasesofacuteabdominalpain Advise toseeMO/NPatnextclinic reviewed nextday If inconsultationwithMO/NP,patientnotevacuated/hospitalisedandallowedhome,advisetobe Administer antiemeticasclinicallyindicated.See – – MO/NP mayadvise: Give niltoeatordrink only tworeasonstoperformplainabdominalx-rays supine abdominalx-raylookingfordilatedbowelloopsandair-fluidlevels.Theseareprobablythe If availableMO/NPmayordererectchestx-raylookingforairunderdiaphragmand Do ECGinallcasesofupperabdominalpaincaseischaemicchestpain:angina/heartattack – – – If board-likerigidityofabdomen,orpulsatileabdominalmass: Consult MO/NPinallcasesofacuteabdominalpainusingdiagramsasaguide – – – – – catheter NG tube.Allowfreedrainageandaspirateperiodically surgical capability MO/NP willadvisefurthermanagementandarrangeevacuationtoafacilitywithappropriate consult MO/NPurgently insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus Nausea andvomiting,page 48 Gastrointestinal 243
738 Gastrointestinal emergencies 77 Shock, page Giardiasis, page 1,2 adult Section 3: Emergency | - 231 730 3 increased fluid losses (diarrhoea, vomiting, fever, exertion, heat exposure, (diarrhoea, vomiting, fever, exertion, heat exposure, increased fluid losses uncontrolled diabetes) for inadequate oral intake. The elderly in particular can be at risk reduced/inadequate oral intake gastroenteritis/dehydration – –
– – Be alert that a presentation of diarrhoea and vomiting could be sepsis Be alert that a presentation in adults include: Risk factors for dehydration patient's condition and/or life threatening electrolyte imbalances and/or life threatening patient's condition with hyperglycaemia Dehydration may be associated Be alert for acute renal impairment Rehydration is the most important aspect of management is the most important aspect Rehydration imbalance Be alert for electrolyte in the lead to a further deterioration (oral and IV) can fluids for rehydration Use of inappropriate Reduced skin turgor/sunken eyes Delayed capillary return Tachycardia/tachypnoea Weakness/light-headedness/altered level of consciousness Headache Thirst Dry mucous membranes Reduced urine output/concentrated urine Cramping abdominal pain Fever Acute diarrhoea - passing of three or more abnormally loose or watery stools in the preceding 24 Acute diarrhoea - passing of three or more abnormally hours Vomiting Electrolyte imbalance Acute renal failure Hypovolemic shock
• • • • • • • Acute gastroenteritis/dehydration - child, page Heat exhaustion/heat stroke/hyperthermia, page Related topics • • • • • • • • • • • • • • • May present with
Background Recommend Dehydration signs and symptoms Gastroenteritis signs and symptoms Possible Complications 1.
Vomiting and diarrhoea and Vomiting Acute Acute 244 Gastrointestinal 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 3. Clinicalassessment • • • • • • • • • – – – – – – For gastroenteritisalsoinclude: – – – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDSscoreorotherlocalEarlyWarningand temperature andhighhumidity history ofpresentingconcernandanyenvironmentalexposuree.g.exertioninhighambient Obtain acompletepasthistoryinparticularnotecurrentdiabetesstatusandmedications.Include – – – If severedehydration: – – – – – – – Consult MO/NPimmediatelyif: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Decreased pulsepressure Postural hypotension/hypotension Hyperthermia – – – – – – – – – – – – – – – – – – – collect afaecesspecimenforMCSand OCP,PCRandviralstudiesif: household membersorsocialcontacts epidemiological cluese.g.recenttravel,eatingofshellfish,similar illnessinother abdominal pain vomiting presence ofbloodinstool onset, stoolfrequency,typeandvolume in casesofhyperthermiaperformurinalysisobservingforblood BGL following page assessment ofdehydrationstatus.See following page commence sodiumchloride0.9%asper dehydration. See risk factorsand/orsigns&symptomsofmoderate/severe – – – – – – consider intraosseousaccessifunabletoobtainIVaccess.See insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus visible bloodinstool high-output diarrhoea(frequentandsubstantialvolumes) decreased urineoutput(oliguria) tachycardia hypotension altered levelofconsciousness – – – – – – history offeveror blood instoolincludetestfor test for recent overseastravel history suggestiveoffoodpoisoning e.g.clusterpresentation severe orprolongeddiarrhoea>7days history ofbloodinstool 1,2 -see Clostridium difficile Hyperglycaemia, page Management ofadultdehydrationflowchart toxinsifhistoryofrecentantibiotic use orhospitalisation 113 or Management ofadultdehydrationflowchart Hypoglycaemia, page Management ofadultdehydrationflowchart Salmonella
115 , on followingpage Shigella
Intraosseous infusion,page , and Campylobacter on on 69 4
Gastrointestinal 245
7 Gastrointestinal emergencies to guide rehydration Management of adult dehydration dehydration of adult Management 3,5 3 7 Section 3: Emergency | 6 8 Management of adult dehydration flowchart Management of adult dehydration for complicated gastroenteritis for complicated Use the 1 level teaspoon of salt, 8 level teaspoons of sugar, 1 L of clean drinking water 8 level teaspoons of sugar, 1 L of clean drinking 1 level teaspoon of salt, use oral rehydration solutions (ORS) use oral rehydration solutions tolerated 24 hrs - frequent small volumes may be better recommend 2-3 litres over not preclude use of ORS intermittent vomiting does and potato (mashed, hot chips, or crisps) and potato (mashed, hot and lactose containing products to avoid caffeine, milk to eat foods with sodium and/or potassium such as canned soups, salted crackers, bananas, and/or potassium such as canned soups, salted to eat foods with sodium prior to discharge in cases of moderate/severe dehydration in cases of moderate/severe prior to discharge for all cases of moderate/severe dehydration and as per and as per dehydration cases of moderate/severe for all flowchart
– – – – – – – – Offer advice and education as applicable such as: safe food handling; avoidance of extreme Offer advice and education as applicable such high ambient temperatures; and adequate fluids environmental heat exposure/limited exertion in Consult MO/NP who may order Hartman's Solution for response to treatment Monitor fluid intake and urine output as a key indicator - severe dehydration MO/NP may arrange evacuation in cases of moderate energy drinks, cordials and fruit juice required. Commence sodium chloride 0.9%. See If unable to rehydrate orally then IV fluids may be Management of adult dehydration flowchart If commercial ORS not available use the following recipe: If commercial ORS not available – with high sugar content e.g. soft drinks, sports and Avoid drinking either diluted or undiluted fluids Initiate rehydration (oral whenever possible): Initiate rehydration (oral – – – – Continue normal diet as tolerated, or clear fluids if vomiting diet as tolerated, or Continue normal Advise: – – Maintain hydration/rehydrate Consult MO/NP: Consult –
• • • • • • • • • • • • If dehydrated. For gastroenteritis 4. Management 4. 246 Gastrointestinal | Primary Clinical CareManual 10th edition | Management ofadult • • • • • • • Consult MO/NP ± antiemetic Trial oralfluids Ketones 0-+ Concentrated urine Dry mucousmembranes Mild thirst 2-3 litresover24hours Mild <5%=2.5Ldeficit dehydration flowchart • • • • • • • • • • • • • • • • • • • Assess dehydrationstatus 2-3 litresover24hours ± antiemetic Faecal specimen Electrolytes MSU Reduced skinturgor mmHg Postural hypotension>20 Tachycardia Light-headed Weakness Dry mucousmembranes Sunken eyes Oliguria Moderate thirst Encourage oralfluids Monitor intake/losses Review dailyfor3days IV Fluids ± antiemetic Moderate 5-8%=4Ldeficit Investigations toconsider If failureoforalfluids Consult withMO/NP Trial oralfluids 8,9,10 • • • • heartfailure * • • • • • • • • • • • • • • • • • • Cool extremities Low pulsevolume Tachycardia Significant thirst Prepare forevacuation – Estimate thefluiddeficit: Initial bolusof10mL/kg* chloride 0.9% Give IVsodium access notobtained - orintraosseousifIV Insert 2xIVcannula hypovolaemic shock Symptoms of Ketones +++ Oliguria <400mL/24hours Confusion Marked hypotension pressure Decreased eyeball Reduced skinturgor – Severe >9%=≥6Ldeficit Signs ofevolvingillness Persisting fluidlosses Deterioration ofsymptoms Inadequate response Ketosis Signs ofoverload as directedbyMO/NP 16 hours±potassium- remainder overthenext in thefirst8hoursand 0.9% -halfthisvolume give sodiumchloride Consult withMO/NP caution inpatientswith Give IVfluids Watch for:
Gastrointestinal 247
249 Gastrointestinal emergencies 130 - adult Section 3: Emergency | Chest pain assessment, page Upper gastrointestinal bleeding, page 4 135 epigastric pain epigastric 238 77 1 2 Shock, page http://disease-control.health.qld.gov.au/Condition/704/gastroenteritis
commence IV sodium chloride 0.9% or Hartmann's solution. MO/NP will advise quantities and commence IV sodium chloride 0.9% or Hartmann's rate. See consult MO/NP urgently who will advise further management and arrange evacuation Alcohol related Alcohol There is no evidence to support the use of a gastro-intestinal (GI) cocktail to assist in ruling out ruling in assist to (GI) cocktail gastro-intestinal a of use the support to evidence no is There lidocaine (lignocaine), antacid ± anticholinergic) coronary ischemia e.g. 'pink lady' (oral viscous GI cocktails should not be used The diagnosis of gastritis can only be made on endoscopy or biopsy The diagnosis of gastritis isn't necessarily reflux disease (GORD) Epigastric pain from gastritis/gastro-oesophageal or adults associated with alcohol. GORD can occur in children Alcohol can cause epigastric and/or right and/or left upper quadrant pain secondary to gastritis, and/or right and/or left upper quadrant pain Alcohol can cause epigastric bowel obstruction or hepatitis, gastric or duodenal ulcer, small acute pancreatitis or alcoholic biliary tract disease heavy alcohol intake with alcohol usually occurs during or soon after Epigastric pain associated Don't jump to conclusions as to the cause of the epigastric pain in a person who drinks alcohol as to the cause of the epigastric pain in a person Don't jump to conclusions – –
– – Perform rapid clinical assessment the largest possible gauge given age and vascular If hypotension/shock, insert 2 x IV cannula - use status: Increased HR Hypotension/shock Epigastric and/or right upper quadrant and/or left upper quadrant pain Epigastric and/or right upper quadrant and/or left Lack of appetite, nausea, vomiting bowel motions (melaena) Vomiting blood (haematemesis) or passing tar-like Consider notification to your Public Health Unit; refer to the Communicable Diseases Communicable Diseases Health Unit; refer to the to your Public Consider notification website: Advise patient to be reviewed the next day reviewed patient to be Advise and treat appropriately and OCP results of MCS Review
• • • • • • Acute coronary syndromes, page Acute abdominal pain, page Related topics • • • • • • • • • • May present with
Background Recommend HMP HMP
2. Immediate management 1.
6. Referral/consultation 5. Follow up Follow 5. 248 Gastrointestinal 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 4. Management Moderate Mild Severe • • • • • • • • • • • • • • • • Normal BP,HR,RR,T aggravating ordistressing Annoying painbutnot If paindoesnotrespondregardassevere – – – – – Consult MO/NPwhomayadvise: If doesn'trespondtoantacidand/orantiemeticwithin30minutes,consider asmoderateorsevere Take bloodsforLFTifnotdoneinthelast3months indicated. See Give antacide.g.Gastrogel Check BGL Do ECG management subjective, howeverobjectiveindicationssuchasvitalsignsandclinicalfindingswillalsoguide pancreatitis maycausehypotension/shockandrespiratorydistress.Theseverityofpainis The severityofthepainandotherfindingspatientwillguidemanagement,e.g.acute Determine ifpresentationismild,moderateorsevere – – Perform physicalexamination: – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – Include inhistorytaking: See – Consult MO/NPwho mayadvise: – – – – – – – – – – – – analgesia asclinicallyindicated.See clear fluidsonly other causes/associatedpain inspect andpalpatefortendernessoverliverarea,upperabdominalpain,leftquadrant pain scale problems, stressandmoneyworries,sexualproblems assess otheralcoholrelatedproblemsincludinginjuries,mentalhealthstatus,relationship is thepatientconcernedabouttheiralcoholintake current alcoholuse-havetherebeenchangesrecently give niltoeatordrink observe andconsultMO/NPwithin4-6 hoursofprogression take bloodforLFT,lipase(morespecific forpancreatitisthanamylase) ranitidine, omeprazole,hyoscinebutylbromide (Buscopan
Acute abdominalpain,page
Mild
Nausea andvomiting,page ® or Mylanta • • • 238 BP slightly↑ HR slightly↑ aggravating pain about, restlesswith Patient moving
to guideassessment ®
Acute painmanagement,page (doseaccordingtolabel)and/orantiemeticasclinically 48 Moderate ® ) • • • (hypotension /shock) BP ↑or↓ HR ↑ very distressedwithpain Patient keepingstilland 35 Severe
Gastrointestinal 249
251 64 Gastrointestinal emergencies 35 3 490 Rectal bleeding, page Oxygen delivery, page page delivery, Oxygen - adult Section 3: Emergency | Alcohol withdrawal, page Alcohol withdrawal, page Acute pain management, page Acute pain management,
680 238 2 via non-rebreather mask. See See mask. non-rebreather via 2 gastrointestinal bleeding 1 analgesia as clinically indicated. See analgesia as inhibitor (PPI) proton pump evacuation/hospitalisation insert 2 x IV cannula - use the largest possible gauge given age and vascular status given age and gauge largest possible - use the 2 x IV cannula insert IV fluids may advise MO/NP UE, LFT, lipase for FBC, take blood test urine apply high flow O flow high apply
Upper Patient may vomit blood, which was swallowed from a nose bleed Patient may vomit blood, which was swallowed Use of NSAID can predispose to bleeding Most common causes are gastric or duodenal ulcer, oesophageal varices/erosion Most common causes are gastric or duodenal ulcer, blood Can range from small bleed to very large loss of upper GI bleed to manage. Apart from IV fluids, including early Upper GI bleeds can be dramatic and are difficult to evacuate urgently blood if available, the best treatment option is usually Endoscopy is needed urgently for unstable patients, and within 24 hours for other patients with Endoscopy is needed urgently for unstable patients, – – – – – – – – Vomiting up blood (haematemesis) Passing black tar-like bowel motions (melaena) Burning pain in epigastrium or retrosternally Consider referral for chronic alcohol misuse Consult MO/NP as above Offer advice and information regarding the harmful effects of excessive alcohol intake. There is regarding the harmful effects of excessive Offer advice and information be influential in an MO/NP or Health Care Worker's advice can good evidence to show that modifying drinking patterns next clinic Advise to see MO/NP at Be aware of the potential over the following days to develop withdrawal symptoms in a heavy over the following days to develop withdrawal Be aware of the potential abruptly. See drinker who ceases drinking patient to return for review next day If allowed home, request If chronic alcohol misuse patient to have oral thiamine 300 mg daily If chronic alcohol misuse – – – – – – – –
• • • • • • Acute abdominal pain, page Button battery ingestion/insertion, page Related topics • • • • • • • • • • May present with
Background Recommend
HMP HMP 1.
6. Referral/consultation 5. Follow up 250 Gastrointestinal 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 5. Followup 4. Management 3. Clinicalassessment • • • • • • • • • • • • • • • If notevacuated,advisepatienttobe reviewedthenextday MO/NP mayconsiderreferralforendoscopy – – – Consult MO/NPwhomayadvise: Take bloodsforFBC,UE,INR Rectal examinationasappropriate – – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – – – – See – – – If hypotension/shockorlarge Administer analgesiaasclinicallyindicated.See Give O Perform rapidclinicalassessment See Hypotension/shock Fresh bloodinthebowelmotion(haematochezia) Advise toseeMO/NP atnextclinic – – – – – – – – – – – – – evacuation/hospitalisation oncehaemodynamically stable a ProtonPumpInhibitor(PPI)suchasomeprazole,esomeprazoleorpantoprazole metoclopramide -Ifhaematemesissmallor'coffeeground'onlyinvomitus cardiac monitoring continue tomonitor current medicinesespeciallyaspirinorNSAID,anticoagulants – – – is there: determine thecharacterofbleeding:isitlargeorsmall,darkbright past historyofliverdiseaseorrenal oesophageal varices past historyofgastric(stomach)orduodenalulcerpreviousepisodesbleeding – – – – MO/NP mayadviseIVfluids.Inanadulttheaimistokeep: insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus consult MO/NPurgently – – – – – – – Acute abdominalpain,page DRS ABCDresuscitation/thecollapsedpatient,page bright blood,withorwithoutbowelmotion melaena rectal bleeding see urine output>0.5mL/kg/hour systolic BP>90-100mmHg HR <120/min 2 tomaintainSpO Shock, page
1 77 2 ≥94%.See haematemesisormelaena: 238
to guideassessment,notinginparticular: Oxygen delivery,page Acute painmanagement,page 54 64 35 Gastrointestinal 251
249 35 Gastrointestinal emergencies 249 Acute pain management, page Section 3: Emergency | Upper gastrointestinal bleeding, page Upper gastrointestinal bleeding, to guide assessment, noting in particular: 238 77 - adult 238 Upper gastrointestinal bleeding, page 2 Shock, page 1 Acute abdominal pain, page
change in bowel habits (mucoid diarrhoea or constipation) insert 2 x IV cannula - use the largest possible gauge given age and vascular status insert 2 x IV cannula - use the largest possible gauge MO/NP may advise IV fluids will require blood replacement, in most cases blood loss that causes hypotension/tachycardia if available. See Rectal bleeding to blood loss have been excluded to haemorrhoids unless more serious causes Do not attribute rectal bleeding and anticoagulants bleeding are underlying colonic/rectal cancer Serious causes for rectal years leading bleeding is determined by the location of disease/condition The characteristic of rectal Screening for 50-75 year olds for colorectal cancer with faecal occult blood test (FOBT) every 2 occult blood test (FOBT) cancer with faecal 50-75 year olds for colorectal Screening for – – – –
See – Consult MO/NP urgently who will advise further management and arrange evacuation/ Consult MO/NP urgently who will advise further hospitalisation in an appropriate facility – – – Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See If passing melaena. See HR or hypotension/shock: If blood loss is heavy or continuing, or there is increased Diarrhoea/constipation Abdominal pain Fever Obvious worm infestation Anorexia/vomiting Weight loss Ineffective urge to pass a bowel motion Bright red clots or burgundy clots Melaena Anaemia Bright red blood from rectum Consult MO/NP on all occasions MO/NP on Consult
• • • • Acute abdominal pain, page Acute abdominal pain, page Related topics • • • • • • • • • • • • • • • • • May present with
Background Recommend HMP HMP
3. Clinical assessment 2. Immediate management
1. 6. Referral/consultation 6. 252 Gastrointestinal 4. Management | Primary Clinical CareManual 10th edition | 1. 6. Referral/consultation 5. Followup HMP Recommend Background May presentwith • • • • • • • • • • • • • • • • Related topics Acute abdominalpain,page • • • • Cramping orcolicky abdominalpain Vomiting mayornotbepresent -maysmelllikefaeces Nausea All patientswithrectalbleedingneedtobereviewedbyanMO/NP If notevacuated,advisetobereviewedatnextMO/NPclinic,orearlierifconcerned Treat forwormswhereclinicallyindicated.See examination/proctoscopy ±sigmoidoscopy Need tobeassessedbyanMO/NPatnextavailableopportunityincludingdigitalrectal haemorrhoids ±shorttermlaxative If bleedingnotheavyorcontinuingconsultMO/NPwhomayadvisetopicaltreatmentfor If heavybloodloss-patientwillrequireevacuation.SeeImmediatemanagement Collect bloodsforESR,C-reactiveprotein(CRP),UE,FBC Digital rectalexaminationmayberequired Note nutritionalstatus Collect astoolspecimentocheckOCP – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – Abdominal distension -softorrigid Cannot passwind orstool(obstipation) – – – – narrowing oftheopeningduetodiverticulitis Common causesoflargebowel/colonobstructionarecancer,twisting ofthebowel(volvulus), Common causesofsmallbowelobstructionarepost-operativeadhesions, herniasandcancers Bowel obstructioncanoccurinthesmallorlargeintestine,itbepartial orcomplete Metoclopramide iscontraindicated Bowel obstruction weight check forbowelsounds external examinationofanuslookingforevidencehaemorrhoidsandbleeding sense ofrectalurgencyorunsatisfieddefecation 2,3 238 -adult/child 1 Intussusception, page Intestinal worms,page 747 740 Gastrointestinal 253
35 Gastrointestinal emergencies Acute pain management, page Acute pain management,
77 Section 3: Emergency | if available ® Shock, page to guide assessment, noting in particular: to guide assessment, noting 238
Acute abdominal pain, page Acute abdominal pain, page and erect chest x-ray looking for gas under the diaphragm keep nil by mouth indwelling urinary catheter and monitor urine output evacuation/hospitalisation NG tube. Allow free drainage and aspirate periodically for dilated bowel loops and air fluid levels if available erect and supine abdominal x-ray looking absent or tinkling bowel sounds abdominal tenderness, guarding presence of vomiting or diarrhoea any abdominal mass past surgical history, previous bowel obstruction past surgical history, previous history of bowel habit abdominal distension MO/NP may advise IV fluids. See MO/NP may advise IV fluids. – – – – – – – – – – – – –
Refer to Dietitian treated conservatively or surgically Consult MO/NP. All cases of suspected bowel obstruction will need to be evacuated/hospitalised When back in the community: bowel obstruction has a high likelihood of recurrence whether When back in the community: bowel obstruction – – MO/NP may advise: – – – If a patient looks unwell, has persistently abnormal vital signs or rigidity of the abdomen, then If a patient looks unwell, has persistently abnormal suspected ischaemic bowel or perforated viscus should be Consult MO/NP urgently Take bloods for UE and lactate - iStat – – – – – – – See Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) If hypotension/shock: – Consult MO/NP urgently Consult MO/NP See as clinically indicated. Administer analgesia status the largest possible gauge given age and vascular Insert 2 x IV cannula - use Hypotension/shock with perforation and sepsis with perforation Hypotension/shock Fever - may be indicative of peritonitis, late sign late of peritonitis, may be indicative Fever - diarrhoea Liquid and elderly especially in children ↑HR, dehydration, Bowel sounds may be increased or absent increased be may sounds Bowel
• • • • • • • • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management
3. Clinical assessment 2. Immediate management 2. Immediate 254 Genitourinary Genitourinary emergencies | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. HMP Recommend Background May presentwith • • • • • • • • • • • • • Related topics Acute abdominalpain,page • • • – – – – – Noting inparticular: Obtain historyandcompletephysicalexamination.See Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascular status – – Administer analgesiaasclinicallyindicated: – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand Restless/agitated Haematuria -visibleoronurinalysis Fever Nausea andvomiting Pain inthetipofpenis-maybeduetoastonebladder to thelowerabdomenandinguinalregions Acute anddebilitatingpain-colicky,sharp,burningoriginatingintheflankarearadiating Perform pointofcare testingforpregnancysexually activewomenofreproductiveage Urinalysis +MSUfor MCS – – – – – – – – bladder Renal colicisthepaincausedbykidneystonespassingthroughureterfromto Fever mayindicateaninfectedobstructedkidneywhichisaurologicalemergency Provide earlypainrelief.NSAIDandopioidsareeffectiveforrenalcolic Renal colic management, page if ketorolactrometamolcontraindicated,morphineisthepreferredopioid. give ketorolactrometamol check painscale consider rupturedaorticaneurysmin patients>45yearsandfirstpresentationofthispain fever renal angletenderness blood visibleinurineorpositiveon testing past historyofkidneystonesorprevious episodes 1,2 3
- adult 3 35 238 1 if notcontraindicated Acute abdominalpain,page 2 See
Acute pain Acute pain 238 Genitourinary 255
1
stat Duration 48 ATSIHP/IHW/RIPRN Extended authority Genitourinary emergencies 102 Inject slowly and deeply Further doses on MO/NP order Further doses on MO/NP Anaphylaxis, page page Anaphylaxis, 10 mg dosage Adult only Nausea and vomiting, page and vomiting, Nausea Section 3: Emergency | Recommended
May cause pain at the injection site, itching, sweating and May cause pain at the injection site, itching, sweating Ketorolac trometamol Consult MO/NP. See IM use Route of approved for IV
administration Not 4 Seek specialist advice for use in the second half of pregnancy; do not use during the Seek specialist advice for use in the second half : : Dehydration, hypovolaemia, probenecid use, GI bleeding, renal or hepatic : Dehydration, hypovolaemia, probenecid use, GI Strength 10 mg/mL
fever (an infected obstructed kidney is a urological emergency) - MO/NP may order IV antibiotic(s) a urological emergency) obstructed kidney is fever (an infected than 24 hours or persists for more pain not controlled Use with caution in the elderly, patients with history of hypertension, asthma, coagulation Use with caution in the elderly, patients with – – : Advise to see MO/NP at next clinic and likely referral for IVP, CT scan, and/or renal USS Advise to see MO/NP at next clinic and likely referral Consult MO/NP on all occasions Request patient to return for review the next day If the pain settles, the patient should be advised to maintain hydration, and to strain all urine (for hydration, and to strain be advised to maintain the patient should If the pain settles, stones) at home Evacuation/hospitalisation required if: required Evacuation/hospitalisation – – Administer antiemetic as clinically indicated. See indicated. as clinically antiemetic Administer and pain scale clinical observations to monitor Continue MO/NP in all cases Consult with
Form Schedule • • • • • • • • Injection
last few days before expected birth. May increase rate of miscarriage last few days before expected birth. May increase Management of associated emergency: Contraindication to NSAIDs impairment, heart failure and hypersensitivity reaction Use in pregnancy Provide Consumer Medicine Information: purpura Note disorders, or other NSAID use RIPRN may proceed ATSIHP, IHW and RN must consult MO/NP ATSIHP, IHW and RN must 6. Referral/consultation
5. Follow up 4. Management 4. 256 Genitourinary 1. | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement HMP May presentwith Background • • • • • • • • • • • • • • Related topics Acute abdominalpain,page • • • Measure andrecordallurineoutput – – If doesnotpassurinespontaneously, MO/NPwillrequestpatientbecatheterised: A reasonableeffortshouldbemade toallowforspontaneousurination Adequate analgesiamayrelieveurethralspasmenoughtobeablepass urinespontaneously Consult withMO/NP Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – – – – guide, notinginparticular: Obtain history,andcompletephysicalexamination.See Administer analgesiaasclinicallyindicated.See Constipation thigh (obstructionofureter) Severe suprapubicandflankpainthatradiatestothepenis,scrotum,orinneraspectofupper Dull suprapubicpain(obstructionofurinarybladder) Inability topassurineorpassingdribblesofonly Send MSUorcatheter catchurineforMCS Perform urinalysis – – – – – – – It isusuallyprecededbyahistoryofhesitancyanddribblingduetoprostaticenlargement herpes orspinalinjury occur secondarytodelayinpassingurine,UTI,medicines,severepaine.g.primarygenital Most commoninmiddleagedorelderlymenduetobenignprostatichyperplasia,butcanalso extraurinary, orpsychogenic Causes maybeobstructive,neurogenic,infective,post-operative,trauma,pharmacologic, Acute perform bladderscanifavailable palpable bladder,dullpercussion(palpationandisassociated withurgetourinate) medical andsurgicalhistoryincludingcurrentmedications preceding historyofurinaryretention,hesitancyanddribbling any flankpain,orpainradiatingtoscrotum catheter instead if unabletocatheteriseeasily,MO/NP willattemptonevacuationandmayinsertsuprapubic DO NOTuseexcessiveforcetopush thecatheterthroughobstructedurethra 1
retention ofurine 1,3 2,3 2 238 - adult
Acute painmanagement,page Acute abdominalpain,page 35 238
as a Genitourinary 257
35 as a 238 to save testes Genitourinary emergencies 632 Acute pain management, page
Acute abdominal pain, page Section 3: Emergency | Epididymo-orchitis, page - adult/child 48 238 1,2,3 scrotal pain
torsion 1,2 Nausea and vomiting, page
esticular/ history of minor physical trauma/sport, rapid movement, previous history of scrotal/testicular T Other less common causes of acute scrotal pain include mumps, strangulated inguinal hernia, of acute scrotal pain include mumps, strangulated Other less common causes epididymo-orchitis, traumatic haematoma Testicular torsion is an emergency requiring urgent surgery (within 4-6 hours) emergency requiring urgent surgery (within 4-6 Testicular torsion is an swelling, the diagnosis presenting with abdominal/and scrotal pain or In male paediatric patients be considered of testicular torsion must –
Obtain history, and complete physical examination. See guide, noting in particular: – and Complete rapid history Consult MO/NP urgently indicated. See Administer analgesia and antiemetic as clinically History of rapid movement, physical trauma Nausea and vomiting Impaired gait pain Right iliac fossa (RIF) or left iliac fossa (LIF) referred Fever Symptoms may be vague testicle(s) Gradual or acute onset of pain and/or swelling of Abdominal pain +++ Consult MO/NP on all occasions Consult MO/NP Advise to see next MO/NP clinic Advise to see the catheter be removed or left insitu or left be removed the catheter and consult MO/NP to be reviewed next day advise If not evacuated/hospitalised, Depending on the clinical circumstances, and the volume of urine drained, the MO/NP may advise may advise the MO/NP drained, of urine the volume and circumstances, clinical on the Depending
• • • Acute abdominal pain, page Related topics • • • • • • • • • • • • • • • • May present with
Background Recommend HMP HMP
3. Clinical assessment 2. Immediate management
1. Testicular
6. Referral/consultation 5. Follow up 5. Follow 258 Genitourinary 4. Management | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup Epididymo-orchitis Torsion testicles Effect ofelevating Examination Associated symptoms Fever Severity ofpain Onset Age • • • • • • • • • Differential diagnoses – – If MO/NPdecidestotreatasacuteepididymo-orchitis andnottoevacuate/operate: See Rare inpre-pubescentboys-alwaysexcludetesticulartorsionfirst Ultrasound imagingisgenerally Keep nilbymouth Urgent evacuation Testicular torsionisanemergencyrequiringurgentsurgery table Testicular torsionmustbeexcluded,particularlyinboys.Usethefollowingdifferentialdiagnoses – – – – – Consult MO/NPon alloccasionsoftesticular/scrotalpain – – – – – – – obtain urinalysis urethral discharge,burningonpassingurine(dysuria) examine thescrotumfortendernessandcomparelocationofeachtesticle any associatednausea,vomitingorfever pain location,onset(suddenorgradual),onebothtesticles pain if thepatientisnotsignificantlybetter, consultMO/NP advise tobereviewedthenextday 1 Epididymo-orchitis, page
as aguideinconsultationwiththeMO/NP
2 2 Usually suddenbutcanbegradual Any agebutmostcommonlyinthe Swollen, redandtender,affected testicle maysithigherthanthe other andbelyingtransversely 632 Abdominal pain,vomiting Absent orslight,<37.5°C No changeorworsepain 10-25 yearsagegroup NOT Very severe indicated(unacceptablefalsenegativerate) Torsion Abdominal pain,occasionalurethral the elderlywhomayhaveprostatic Young adultswhoaresexually trouble, rarebeforepuberty 1 Swollen, redandtender Epididymo-orchitis discharge/dysuria Relief ofpain Significant Moderate Gradual active, 1 poisoning and overdose 259
73 www.
Organophosphates, , https://tgldcdp.tg. 274 Cyanide, page 13 11 26 (24 hours): 13 11 26 (24 54 general approach general Section 3: Emergency | Poisoning and overdose Unconscious/altered level of consciousness, page Unconscious/altered level of consciousness, page overdose) - overdose)
,2,3,4 1 286 109 1,2,3,4 115 Paraquat, page Poisons Information Centre (PIC) for any poisoning, and/or for information on for information on any poisoning, and/or Centre (PIC) for Poisons Information poisoning and and poisoning and 1,2,3,4 1,2,3,4 282 org.auguideLine?guidelinePage=Toxicology+and+Wilderness&frompage=etgcomplete Queensland PIC - first aid treatment and prevention of poisonings. Available at: Queensland PIC - first aid treatment and prevention childrens.health.qld.gov.au/chq/our-services/queensland-poisons-information-centre/ Available at: Therapeutic Guidelines (eTG) 'Toxicology and Wilderness'. if possible, the MO/NP should contact PIC MO/NP should contact if possible, the advice is required poisoning where specific expert medical in cases of severe or complex to a Clinical Toxicologist PIC can refer health practitioners DRS ABCD resuscitation/the collapsed patient, page DRS ABCD resuscitation/the collapsed patient, page – – – – if CPR required continue until discussed with Poisons Information Centre/Toxicologist if CPR required continue until discussed with Poisons
– – There is no evidence that the use of sorbitol or other cathartic agent provides any benefit over the use of sorbitol or other cathartic agent provides There is no evidence that and they are no longer indicated activated charcoal alone Recommended resources: The use of ipecac syrup or any other methods to induce vomiting are no longer recommended due any other methods to induce vomiting are no longer The use of ipecac syrup or and lack of effectiveness to the risk of aspiration Use PPE (gloves, plastic gown and mask), in particular for Use PPE (gloves, plastic page could still be in the early is conscious and talking after taking a poison Remember, someone who stages of severe poisoning – – Contact the Contact the in the PCCM not specifically mentioned agents/drugs – See – If breathing, turn on to side in recovery position while obtaining more information. Some poisons may cause both vomiting and sedation resulting in aspiration accidental poisoning Gastrointestinal tract toxicity e.g. nausea, vomiting Gastrointestinal tract toxicity e.g. nausea, vomiting bradycardia or tachycardia, arrhythmias Cardiovascular system toxicity e.g. hypotension, circumstances suggestive of deliberate or Conscious and fully orientated with a history or Confusion, drowsiness, altered level of consciousness or fitting (always consider poisoning) Confusion, drowsiness, altered level of consciousness Respiratory failure Hyperthermia, hypothermia
• • • • • • Fits/convulsions/seizures, page Hypoglycaemia, page Related topics • • • • • • • • May present with
Background Recommend
2. Immediate management 1.
Toxicology ( Toxicology Toxicology (poisoning and overdose) and (poisoning Toxicology 260 poisoning and overdose 3. Clinicalassessment | Primary Clinical CareManual 10th edition | • • • • • • • • • • • • – – MO/NP mayadvisefurtherinvestigations e.g: – – – If intentionalpoisoning,alwaysperform: – – – – Obtain: assessment Undertake a'Poisoning/overdoseriskassessment'toobtainhistory, details ofpoisoningandrisk risk assessmenthasbeencompleted Note – – – – – – ensure safetyofself,staff,familyandvisitors: If patientisconfusedorwithdrawn,strange,aggressivedisplayingacutelydisturbedbehaviour MO/NP mayconsiderantidotese.g.naloxoneforopioidpoisoning Hypothermia, page If hyperthermiaorhypothermiatreat.See If BGL↓treat.See Insert IVcannula – – – Do notadministerO – – – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – – – – – – – – – – – – – – – – – – – – – – ECG -see paracetamol level.See paracetamol levelifavailable arterial orvenousbloodgasifavailable blood forUE urinalysis (forpH) disturbance, page for additionalinformationonensuringsafetyandmanaginganger.See use de-escalationtechniquestomanageaggression.See explain whatishappeningalways.Reassurethepatientandavoidconfrontation where youcouldbetrappedbythepatient do notapproachthepatientiftheyhaveaweaponanddon'tputyourselfinposition have themvisiblyclosebyandreadytohelp,butnotfurtherfrightenorintimidatethepatient you mayneedtogethelpfromthepoliceorothers in poisoning,donotassumehypoxiaisaresultofthepoisoningalone CO patients withongoingabnormalO page if required,giveO conscious state.See BGL SpO further urinetesting spirometry chest x-ray – blood tests: + mentalhealthreviewrequired.See – : Donotundertakeanygastrointestinaldecontamination(e.g.activatedcharcoal)untilafull renal andliverfunction,FBC,coagulation tests(rarely) 2 monitoringviaabloodgasanalysis 2 64 Specific ECGchangesforfurtherinformation 229 Hypoglycaemia, page 2 467 2 routinely: tomaintainSpO Glasgow ComaScale/AVPU,page
1 ,2,3,4 Paracetamol, page 2 saturationsrequireanassessmentoftheirventilatione.g. 2 saturation>94%adultor95%child.See
Mental healthassessment,page 115 Heat exhaustion/heatstroke/hyperthermia,page 283 785 on followingpage De-escalation techniques,page 450 Acute severe behavioural Acute severebehavioural Oxygen delivery, Oxygen delivery, 231 789
or poisoning and overdose 261
13 11 26 (24 hours): Section 3: Emergency | Poisoning and overdose , conscious state 2 Accidental or deliberate skin been washed, eyes irrigated etc Has substance been diluted, pre-existing illness, heart Does the patient have any etc disease, patient weight, BGL, suicidal behaviour to poison/ What symptoms has the patient noticed since exposure dose and time medicine. This can then be correlated with the agent, since ingestion to strengthen the risk assessment BP, HR, RR, T, SpO Look for container if possible Look for container or witnesses Ask relatives than one substance drugs often involve more Overdoses of as it may taken in all instances if alcohol has been Inquire specifically the toxicity of other exposures greatly affect and any other specifically about paracetamol Also inquire over-the-counter products injected Oral, topical, eye, inhaled, much was taken Try to work out exactly how counting out the amount remaining in the This may require manually initially thought to be there container from the amount consider the worst-case scenario It is important to always Exact time if possible Name of product, its ingredients/components, manufacturer its ingredients/components, of product, Name • • • • • • • • • • • • • • • • risk assessment 1,2,3,4 still in the gastrointestinal tract, usually within an hour of ingestion still in the gastrointestinal tract, usually within an is able to be removed by chosen method – – – – secured the patient's airway is self protected or has been the risk assessment indicates severe or life threatening toxicity the risk assessment indicates severe or life threatening not ensure a good outcome supportive care or antidote treatment alone may the poison is: – – – –
– – – – the PIC can help determine the contents and other characteristics of the agent involved in the the PIC can help determine the contents and other and appropriate management exposure, and advise on the likely clinical effects most of the time good supportive care and monitoring is sufficient – – MO/NP may consider gastrointestinal decontamination (e.g. activated charcoal) only when a risk MO/NP may consider gastrointestinal decontamination assessment has been undertaken and: – Following stabilisation of the poisoned patient: – Consult MO/NP urgently if suspected poisoning PIC MO/NP will contact Poisons Information Centre
• • • • Poisoning/overdose Clinical status of patient Clinical course Has any treatment been Has any treatment been attempted Patient factors Time of exposure Intent of exposure Dose Route of exposure Agent 4. Management 262 poisoning and overdose | Primary Clinical CareManual 10th edition | Activated charcoal(ifrequired) Specific • • • • • • Reproduced andadaptedfromAustralianPrescriber: line isassociatedwithanincreasedriskoftorsadesdepointes The QTnomogramisaplotoftheintervalversusheartrate.AQT-heart ratepairabovethe QT interval (msec) – – – – Administration points: Clinical Toxicologistforinformationbeforeuseinpaediatrics MO/NPs areadvisedtoconsultthePoisonsInformationCentre(PIC) Give onMO/NPadviceonly – – Evacuation/hospitalisation mayberequiredforpatients whoare: abnormal QTHRpairshouldbemonitoreduntiltheisbelowline use theQTnomogramwhereuncorrectedisplottedagainstHR.Patientswithan prolonged QTinterval.Amoreaccuratemethodofassessingtheintervalintoxicologyisto formula usedisBazett'sformula.ThisovercorrectswhentheHR>70,leadingtoabnormally machines correcttheQTintervalforHRbuttheseareproblematic.Themostcommoncorrection antiarrhythmics, antidepressants,antihistamines,antibioticsandantipsychotics.AllECG torsades depointes.MedicinesassociatedwithQTprolongationincludesomeofthe QT prolongation-thisissecondarytopotassiumchannelblockadeandcanbeassociatedwith (0.12 seconds)isconsideredpathological ingestions e.g.tricyclicantidepressants,antihistamines,antiarrhythmics.AQRS>120msecs QRS widening-thisissecondarytosodiumchannelblockadeandseeninanumberof 200 300 400 500 600 – – – – – – unconscious orfitting drowsy, orareatrisk ofbecomingdrowsy there maybeadvantageinadministering activatedcharcoalafterthistime,orinrepeatdoses is usuallyineffectiveifgivenmorethan 1hourpost-ingestion.Howeverwithsomemedicines alkalis orpetroleumproducts is noteffectiveforcyanide,alcohols, iron,lithium,potassiumandotherelectrolytes,acids, protection andintubationpriortoadministration all patientswhoare,orareatriskof becomingdrowsy,unconsciousorfittingwillneedairway only giveifthepatientcanself-administerwithoutanyassistancefrom treating staff 20 406080100120140160 Dashedlineisextrapolatedtoallowassessmentoffasterheartrates Solidlineindicatesheartratesthatarenottachycardic ECG changes (bindstopoisonsinthegutpreventingabsorption) QT IntervalNomogram Heart rate(bpm) www.australianprescriber.com/magazine/38/1/20/4 131126(24hours)or poisoning and overdose 263
1,5 . 464 Stat Prescribing guide Duration elimination ( 25-50 g 4-6 hourly) quinine, colchicine and digoxin, aspirin) to enhance Repeat doses may be ordered carbamazepine, theophylline, for overdose of some drugs (e.g. phenobarbital (phenobarbitone), Suicide risk assessment, page risk assessment, Suicide for advice Section 3: Emergency | Poisoning and overdose 50 g Child Adult dosage 1 g/kg/dose to max. of 50 g Recommended Activated charcoal 13 11 26 (24 hours)
Improve palatability by chilling; it may be easier to take if take to easier be may it chilling; by palatability Improve
Consult MO/NP Oral Route of Orogastric Nasogastric administration Strength 50 g/250 mL Unscheduled Poisons Information Centre e.g. feed and toilet themselves simple mental tasks to time, place and person and perform the patient should be orientated down from 100) e.g. serial sevens (counting physical and mental state to have returned, or be close to their pre-morbid state to have returned, or be close to their pre-morbid physical and mental state of daily living to mobilise independently, perform simple activities the patient should be able violent self-harm attempt such as jumping, hanging or shooting attempt such as jumping, violent self-harm misuse or drug dependency chronic alcohol single, male a baby after having mental illness including depression and schizophrenia depression illness including mental or who may require specific management or antidotes or management specific require may or who : Offer orally to conscious patients who are able to protect their airways. Should never be : Offer orally to conscious patients who are
– – – – – – – – – give on advice of PIC/MO/NP Form Consult MO/NP on all occasions if the substance taken is known or suspected to be toxic As advised by MO/NP – Medical clearance of a patient with deliberate self-poisoning or accidental ingestion requires: or accidental ingestion deliberate self-poisoning of a patient with Medical clearance – – – – – – Before allowing any patient home assess suicidal intent, see suicidal intent, assess patient home allowing any Before factors: other high-risk Consider – –
• • • • • Schedule Suspension Contact the administered in unconscious patients without intubation to protect airway. Rarely indicated in children: administered in unconscious patients without intubation a good outcome is unlikely with supportive care only consider when risk assessment suggests that Management of associated emergency: Provide Consumer Medicine Information: or drunk with eyes shut served in a covered container with a large straw, Notes Only
6. Referral/consultation 5. Follow up 264 poisoning and overdose Specific poisons | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Recommend For informationregardingagents/drugsnotspecificallymentionedinthissectionpleasecontactthe Background • • • • • • • • • – – – – – Consult MO/NPwhowilladvisefurthermanagementwhichmayinclude: Delirium, page patient inadarkandquietroomthecompanyoffamiliarperson,friend orrelative.See The patientmaybeinahyperstimulatedstatee.g.delirium.Itcanuseful toattendthe page See Poisoning/overdoseriskassessmentin See Effects maybedelayedandcyclical urinary retention,reducedbowelsounds,tachycardiaandhyperthermia Peripheral nervoussystemeffectse.g.dilatedpupils,red,dryskin,mouthandaxilla Central nervoussystemeffectse.g.hallucinations,delirium,sedationandoccasionallyseizures – – – – – activity aspartoftheirtoxicity,suchtricyclicantidepressantsandantihistamines notably angel'strumpetordatura( benzatropine, atropine,trihexyphenadylhydrochloride(benzhexol),anticholinergicplants, Anticholinergic toxicitycanbeduetoingestionofpureanticholinergicagentse.g. Consult MO/NPfirstforallpatientswithanticholinergicoverdose.PIC Anticholinergic agents IV fluidstomaintainhydration active coolingforhyperthermia.See diazepam forsedationorseizures.See deep veinthrombosisprophylaxisif patientisbedboundforanextendedperiodoftime IDC forurinaryretention Toxicology (poisoningandoverdose)-generalapproach,page 259
161 1 Poisons InformationCentre(PIC) Brugmansia - adult/child Heat exhaustion/heatstroke/hyperthermia,page Fits/convulsions/seizures, page Toxicology (poisoning and overdose) - general approach, Toxicology (poisoningandoverdose)-generalapproach, species)orbydrugsthathaveanticholinergic 13 1126(24hours) 259 109 13 1126(24hours)
231 poisoning and overdose 265
259 259 1
Section 3: Emergency | Poisoning and overdose
13 11 26 (24 hours) - adult/child Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach,
2 1 - adult/child
1 Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach,
dose adjustments and/or medicine interactions behaves in a similar fashion dose adjustments and/or Ingestion of anticonvulsants other than sodium valproate and carbamazepine is rarely associated carbamazepine is rarely sodium valproate and anticonvulsants other than Ingestion of liver metabolism However, toxicity can be prolonged due to saturable with life threatening toxicity. Chronic toxicity from Most patients will do well with supportive care. with long half-life > 24 hours. and carbamazepine are more toxic in overdose in comparison with the new agents e.g. lamotrigine with the new agents e.g. overdose in comparison are more toxic in and carbamazepine and levetiracetam with > 3 g total, can be associated dose: > 50 mg/kg or toxicity is related to Carbamazepine significant toxicity This is a diverse group of drugs with differing toxicities. The older agents e.g. sodium valproate older agents e.g. sodium differing toxicities. The group of drugs with This is a diverse
Toxicity can be delayed and prolonged due to erratic absorption and the anticholinergic properties Toxicity can be delayed and prolonged due to erratic absorption and the anticholinergic properties of carbamazepine Haemodialysis may be required in a patient with life threatening toxicity Haemodialysis may be required in a patient with Poisons Information Centre (PIC) Large ingestions will require intubation and ventilation. Activated charcoal 50 g should be given Large ingestions will require intubation and ventilation. post intubation treated with IV fluid. On rare occasions inotropes Hypotension (systolic BP < 90 mmHg) should be will be required to maintain blood pressure The risk assessment is based on the dose ingested, serum valproate levels (if available) and the The risk assessment is based on the dose ingested, depression status of the patient, especially the level of CNS Evacuation/hospitalisation may be required Consult MO/NP who will advise further management. High serum sodium level may indicate a significant ingestion High serum sodium level may indicate a significant See See Risk assessment under Bone marrow depression e.g. thrombocytopenia Central nervous system depression: ranges from mild sedation to coma Central nervous system e.g. hypotension and QT prolongation Cardiovascular effects (lactic acidosis), hypernatraemia (sodium load) Metabolic abnormalities e.g. metabolic acidosis Gastrointestinal toxicity e.g. nausea and vomiting Gastrointestinal toxicity
• • • • • • • • • • • • • • • • • • Background
1. May present with Carbamazepine 4. Management
3. Clinical assessment 2. Immediate management 1. May present with Sodium valproate Anticonvulsants (general) (general) Anticonvulsants 266 poisoning and overdose 4. Management 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith oxcarbazepine e.g. Other anticonvulsants • • • • • • • • • • • • • • • • • • • • • • phenytoin, lamotrigine,gabapentin,pregabalin,levetiracetum, Most patientsdowellwithsimplesupportive care See Riskassessmentunder See phenytoin (>50mg/min)arenotseenwithoral Cardiovascular effectse.g.bradycardia/hypotension,associatedwithrapid infusionofIV GIT toxicitye.g.nauseaandvomiting coma andseizures More severeingestionsmayshowworseningnystagmus,ataxia, dysarthriaandsedation, Early neurologicalsymptomsmaybenystagmus,ataxiaandmildsedation Poisons InformationCentre(PIC) Take bloodforcarbamazepineconcentrationevery3-6hoursinseverecases ( >120msec) Rarely sodiumbicarbonateforpatientswithcardiovascularinstabilityandwidenedQRS IV fluidsforhypotension(systolicBP<90mmHg),inotropesrarelyrequired Multi doseactivatedcharcoal(50gevery4hours)forintubatedpatients(ifbowelsoundspresent) Intubation andventilationforpatientswithadecreasedlevelofconsciousness Consult MO/NPwhowilladvisefurthermanagement.Evacuation/hospitalisationmayberequired See Riskassessmentunder See ventricular arrhythmias Cardiovascular effectse.g.tachycardiaandhypotensionrarelyQRSprolongationwith progressing tocoma,seizures(rare) Central nervoussystemdepression:cerebellareffectse.g.nystagmusanddysarthria,sedation GIT toxicitye.g.bowelobstruction(ileus) Multi-dose activatedcharcoal (50g4hourly) toincreaseclearance inseveretoxicity maybe IV fluidsforhypotension (systolicBP<90mmHg) Intubation andventilation israrelyrequired Toxicology (poisoningandoverdose)-generalapproach,page Toxicology (poisoningandoverdose)-generalapproach,page
2 3
3
Toxicology (poisoningandoverdose)- generalapproach,page Toxicology (poisoningandoverdose)-generalapproach,page 131126(24hours) 259 259 259 259 poisoning and overdose 267
259 259
Section 3: Emergency | Poisoning and overdose 13 11 26 (24 hours) 13 11 26 (24 hours) 13 11 26 - adult/child - adult/child
Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach, 1 1 13 11 26 (24 hours) Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach,
mental status effects e.g. anxiety, agitation and confusion (rare) mental status effects e.g. anxiety, agitation and neuromuscular effects e.g. hyperreflexia, clonus, tremor, hypertonicity, seizures (rare) neuromuscular effects e.g. hyperreflexia, clonus, flushing, tachycardia autonomic effects e.g. hyperthermia, diaphoresis, ingestions ( > 8 g) there is also a risk of cardiac toxicity ingestions ( > 8 g) there modified or extended release so onset of toxicity can be delayed ( > 6 hours post ingestion). so onset of toxicity can be delayed ( > 6 hours modified or extended release including seizures with toxicity, and sympathomimetic toxidrome Toxicity consists of serotonin In large venlafaxine the seizure risk increases with ingested dose. venlafaxine. With venlafaxine SSRIs rarely cause significant toxicity. Citalopram and escitalopram can cause QT prolongation toxicity. Citalopram and escitalopram can SSRIs rarely cause significant may be required and prolonged cardiac monitoring only available as Both venlafaxine and desvenlafaxine are SNRIs have varying toxicities. Consult MO/NP first for all patients with antidepressant overdose. Poisons Information Centre Poisons Information with antidepressant overdose. first for all patients Consult MO/NP (PIC) – – –
Poisons Information Centre (PIC) Most ingestions of SSRIs require only observation. Some may need symptomatic treatment for any Most ingestions of SSRIs require only observation. symptomatic serotonin toxicity e.g. benzodiazepines be managed in consultation with MO/NP and Ingestions of citalopram and escitalopram should See Risk assessment under See – QT prolongation with citalopram and escitalopram Serotonin toxicity, which is rarely life threatening, is best described as: Serotonin toxicity, which is rarely life threatening, – – Serial phenytoin levels (no more than daily) (no more phenytoin levels Serial Centre (PIC) Information Poisons indicated
• • • • • • • • • • •
Background Recommend 4. Management
3. Clinical assessment 2. Immediate management
1. May present with escitalopram e.g. fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram, e.g. fluoxetine, paroxetine, fluvoxamine, Selective serotonin reuptake inhibitors (SSRIs) reuptake inhibitors (SSRIs) Selective serotonin Antidepressants (general) Antidepressants 268 poisoning and overdose 1. Maypresentwith e.g. venlafaxine,desvenlafaxine,duloxetine,tramadol Serotonin andnoradrenalinereuptakeinhibitors(SNRIs) | Primary Clinical CareManual 10th edition | 1. Maypresentwith imipramine, nortriptyline, trimipramine e.g. amitriptyline,clomipramine, dosulepin(dothiepin),doxepin, 4. Management 3. Clinicalassessment 2. Immediatemanagement HMP • • • • • • • • • • • • • • • Neurological effectse.g.rapiddeterioration inlevelofconsciousnessandseizures fluids Seizures andthosewithsympathomimeticsymptomsmayneedbenzodiazepines andintravenous ECG, cardiacmonitoring Activated charcoalshouldbeconsideredwithvenlafaxineingestions>5 g Most ingestionsofSNRIsrequireonlyobservation Consult MO/NP/ClinicalToxicologistandPoisonsInformationCentre(PIC) See Riskassessmentunder Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus See See – – – – Seizures: – – – – Sympathomimetic toxidromesymptoms: – – – Serotonin toxicity,whichisrarelylifethreatening,bestdescribedas: Anticholinergic toxicityisoften seenwithsmaller ingestionsor afterrecoveryfrom alarge ventricular arrhythmias. Bradycardiaisapreterminal sign ofcardiovascularcollapse Cardiovascular effects e.g.tachycardia,hypotension progressing tobroadcomplextachycardia and – – – – – – – – – – – Tricyclic antidepressants(TCAs) can bedelayedupto24hoursbutmostareseenwithin16 have notbeenrecordedwithdesvenlafaxine are rarewithduloxetine 10%, 3-5g10-20%,5-820-50%,>8almostuniversal) are commonwithvenlafaxine,dosedependentandcanbedelayedupto24hours(0-3g with venlafaxinehypotensionandarrhythmias(rare)maybeseenlargeingestions(>8g) hyperthermia mild hypertension tachycardia mental statuseffectse.g.anxiety,agitationandconfusion(rare) autonomic effectse.g.hyperthermia,diaphoresis,flushing,tachycardia neuromuscular effectse.g.hyperreflexia,clonus,tremor,hypertonicity Fits/convulsions/seizures, page Toxicology (poisoningandoverdose)-generalapproach,page 1 5 Toxicology (poisoningandoverdose)-generalapproach,page
109 259 131126(24hours) 2,3,4 259 poisoning and overdose 269
259
259 Section 3: Emergency | Poisoning and overdose Toxicology (poisoning and overdose) - generalToxicology (poisoning and 109 109
Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and - adult/child Fits/convulsions/seizures, page 1 259 1,2 1 Toxicology (poisoning and overdose) - general approach, page and overdose) - Toxicology (poisoning page Fits/convulsions/seizures, intranasal. See activated charcoal post intubation via an NGT consideration should be given to administering QRS widening associated with haemodynamic compromise should receive IV sodium QRS widening associated with haemodynamic compromise bicarbonate (1-2 mmol/kg) e.g. midazolam 5 mg IM/IV/buccal or seizures should be managed with benzodiazepines fluid load with sodium chloride 0.9% if hypotensive (BP < 90 mmHg) fluid load with sodium chloride 0.9% if hypotensive urinary retention urinary dry mucosa sounds bowel diminished
Many antihistamines are available combined with analgaesia and decongestants, and the Many antihistamines are available combined with combined medicine may be more significant toxicologically Consider ingestion of both sedating antihistamines e.g. promethazine and doxylamine, and non-sedating antihistamines e.g. loratadine, desloratadine, cetirizine and fexofenadine cyproheptadine cetirizine, desloratadine, fexofenadine and Antihistamines with no sedative effect include loratadine Antihistamines with sedative effects available in Australia include promethazine, alimemazime Antihistamines with sedative effects available in (only available combined with (trimeprazine), doxylamine, diphenhydramine, dimenhydrinate brompheniramine and hyoscine hydrobromide), pheniramine, dexchlorpheniramine, Consider paracetamol toxicity if a combination cough and cold preparation has been ingested Consider paracetamol toxicity if a combination cough – – – – – – – to the above treatment should be discussed with a Clinical Toxicologist to the above treatment should be discussed with – and/or ongoing seizures and/or not responsive Patients with hypotension, ventricular arrhythmias – – If unconscious see Immediate management under If unconscious see Immediate approach, page advise further management which may include: Consult MO/NP who will – ECG See Risk assessment under See Risk assessment under Patients who arrive with a decreased level of consciousness will often require intubation and will often require intubation level of consciousness arrive with a decreased Patients who ventilation monitoring Commence continuous cardiac See See – – – ingestion, including: ingestion,
• • • • • • • • • • • • • •
Background Recommend
Antihistamines 4. Management
3. Clinical assessment 2. Immediate management 2. Immediate 270 poisoning and overdose 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Background • • • • • • • • • • • • • • • • • • 259 See Immediatemanagementunder consciousness doesnotoccur Risperidone in largeingestions Quetiapine delirium andotheranticholinergictoxicitye.g.tachycardia Olanzapine Cardiovascular effectse.g.hypotension,tachycardiaandQTprolongation Neurological effectse.g.decreasedlevelofconsciousness,dystonicreactions – – Consult MO/NPwhowilladvisefurthermanagementwhichmayinclude: an excellentprognosiswithgoodsupportivecare Close attentiontoairways,breathingandcirculationisessential,asthemajorityofpatientshave See Riskassessmentunder See QT prolongationandveryrarelytorsadesdepointeswithnon-sedatingantihistamines Rarely arrhythmias,myocardialdepressionandrhabdomyolysise.g.doxylamine Tachycardia, orthostatichypotension mucosa andrarelyseizures.See Central nervoussystemdepression,anticholinergicsymptomse.g.delirium,urinaryretention,dry ventilation Patients whoarrive withadecreasedlevelofconsciousness willoftenrequireintubation and – – Atypical antipsychoticsmayinclude,butnotlimitedtoquetiapine,olanzapine andrisperidone periciazine Typical antipsychoticsmayinclude,butnotlimitedto,chlorpromazine, haloperidoland Although groupedasaclass,theseagentshavedifferenttoxicitiesinoverdose Antipsychotics have resolved,buttheanticholinergenicdeliriumremains sedation mayberequired12-24hoursaftertheingestionwhenantihistaminicsedativeeffects considered iningestionsofparticularantihistaminese.g.promethazine activated charcoal.Thisisrarelyrequiredduetotherapidonsetofsedation,butmaybe Toxicology (poisoningandoverdose)-generalapproach,page
-tachycardiaandhypotension,decreasedlevelofconsciousnessprogressing tocoma -mildtomoderatedecreasedlevelofconsciousnessrarelyleadingcoma, sedated -tachycardiaanddystonicreactions, rarelyhypotension.Decreasedlevelof 6 1 1,3 - adult/child Toxicology (poisoningandoverdose)-generalapproach,page 6
Anticholinergic agents,page Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoningandoverdose)- generalapproach,page 264 259 259 poisoning and overdose 271
259 259 Acute severe behavioural disturbance, page behavioural disturbance, Acute severe Section 3: Emergency | Poisoning and overdose . See 2 Toxicology (poisoning and overdose) - general approach, pageToxicology (poisoning and overdose) - general approach, 1 Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach, Toxicology (poisoning and overdose) - general approach, page approach, - general and overdose) (poisoning Toxicology - adult/child 1,2 1,2 1 1,2,3 patients with QT prolongation should have ongoing cardiac monitoring should have ongoing cardiac monitoring patients with QT prolongation
300-500 mg/kg - severe toxicity e.g. hyperthermia, metabolic acidosis, coma and seizures 300-500 mg/kg - severe toxicity e.g. hyperthermia, > 500 mg/kg - potentially fatal < 150 mg/kg - minor toxicity hyperventilation, vomiting 150-300 mg/kg - mild to moderate effects e.g. tinnitus, extrapyramidal effects e.g. dystonic reactions, should be managed with IV benzatropine - adult managed with IV benzatropine reactions, should be effects e.g. dystonic extrapyramidal (max. 1 g) children 0.02 mg/kg 1-2 mg and for 467 fluid load with sodium chloride 0.9% if hypotensive (systolic BP < 90) if hypotensive (systolic sodium chloride 0.9% fluid load with of age Ingestion of small amounts of topical salicylates can result in severe toxicity in children < 5 years of topical salicylates can result in severe toxicity Ingestion of small amounts Clinically all salicylate poisoning presents and is managed in a similar manner Clinically all salicylate poisoning containing topical products and methylsalicylate of aspirin containing May be due to ingestion antacids, and vaporiser fluids preparations, effervescent – – – – – –
Consult MO/NP who will advise further management which may include activated charcoal for salicylate doses > 150 mg/kg when the time of ingestion is within 6 hours In addition, patients with salicylate toxicity require an arterial blood gas (ABG), repeated salicylate In addition, patients with salicylate toxicity require levels and biochemistry e.g. electrolytes, renal function See Risk assessment under See Immediate management under 259 – – Hypovolaemia Toxicity is related to ingested dose – – ears), vertigo. Coma and seizures are rare and associated with severe poisoning ears), vertigo. Coma and seizures are rare and associated metabolic acidosis Metabolic effects e.g. respiratory alkalosis and Pulmonary oedema Gastrointestinal effects e.g. nausea, vomiting restlessness, hyperventilation, tinnitus (ringing in Neurological effects e.g. confusion, drowsiness, – If unconscious the patient will often require intubation and ventilation require intubation and the patient will often If unconscious may include: management which who will advise further Consult MO/NP – See Risk assessment under assessment See Risk
• • • • • • • • • • • • • • • • Background
4. Management
3. Clinical assessment 2. Immediate management
1. May present with Aspirin/salicylates Aspirin/salicylates
4. Management 3. Clinical assessment assessment Clinical 3. 272 poisoning and overdose Carbon monoxideinhalation | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Recommend Background • • • • • • • • • • • • • • • • • • • • – ongoing clinicaleffects.See High flowO Consult MO/NPorclinicaltoxicologist viathePoisonsInformationCentre(PIC) Carboxyhaemoglobin levelsareapoormarkerofexposureandhenceprognosis See Riskassessmentunder delivery, page Apply highflowO 259 See Immediatemanagementunder Metabolic effectse.g.lacticacidosis,rhabdomyolysis,hyperglycaemia Cardiovascular effectse.g.tachycardia.InseverepoisoningsECGchangesandarrhythmias Respiratory effectse.g.respiratoryarrest,Cheyne-Stokesbreathing Gastrointestinal effectse.g.nausea,vomiting state ofconsciousness(maybetransient),seizures Neurological effectse.g.headache,lethargy,confusion,drowsiness,weakness,ataxia,altered Clinical Toxicologist treatment inacriticalcarearea.Thismayrequireretrievaltolargercentreconsultationwith Patients whohaveingestedmorethan300 mg/kg,oranyevidenceofacidosis,mayrequire When theamountisunknown,bloodlevelsmaybetaken,althoughthisrequireevacuation The PoisonsInformationCentre(PIC)canassistwithcalculationsinvolvingsalicylateexposures. If conscious,reassure andkeepatresttominimizeoxygen needs In carbonmonoxide poisoning,apulseoximetercanrecord amisleadingnormalO – Poisoning causestissuehypoxiaandorgandamage exposures tocarbonmonoxidehaveoftentakenoverdosesofotheragents occupationally e.g.firefightersanddeliberately(carexhaustfumes).Patientwithdeliberate Poisoning canresultfromexposuretocombustioninaconfinedspace,bothaccidentally, by industrialprocesses room heaters,cigarettesmoke,fires(includingfromwoodburningheaters),andproduced Carbon monoxideisacommoncolourlessandodourlessgasfoundinvehicleexhaust,faulty Most commonagentusedinsuicidesbypoisoning Oxygen administrationincreasestheeliminationofcarbonmonoxide management with HighflowO 1 1
2 asaboveforatleast6hours.Ongoing O 64 1 2 viaanon-rebreathingmask.AHudsonmaskisnotsufficient. 1,2
Toxicology (poisoningandoverdose)-generalapproach,page Oxygen delivery,page 2 shouldbediscussed withaClinicalToxicologist Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoningandoverdose)-generalapproach,page - adult/child 64
2 therapymaybeconsideredinpatients with
2 1,2 131126(24hrs) See 2 saturation Oxygen Oxygen 259 poisoning and overdose 273
456 259 456 Suicidal behaviour, page page behaviour, Suicidal - adult/child - adult/child Section 3: Emergency | Poisoning and overdose Suicidal behaviour, page Suicidal behaviour,
680 Toxicology (poisoning and overdose) - general approach, page 1,2 2
1,2 1
Corrosive/caustic substance ingestion substance Corrosive/caustic injuries to the oesophagus cleaners, ammonia, detergents including automatic dishwashing detergent cleaners, ammonia, detergents tissue perforation, haemorrhage and necrosis of Major complications include and duodenum, whereas alkalis cause more Acids tend to cause more injuries to the stomach Known or suspected exposures to acids including: rust removers, some toilet bowl cleaners, to acids including: rust removers, some Known or suspected exposures drain cleaners, oven used in cleaning and industry or alkalis including: battery acids, other acids Early airway intervention can be lifesaving Early airway intervention from exposure to should be used to protect staff and bystanders Personal protective equipment corrosive substance
Consult MO/NP who will advise further management and arrange evacuation/hospitalisation if Consult MO/NP who will advise further management and arrange evacuation/hospitalisation if See Risk assessment under Initial management is to wipe out the mouth with a cloth, then rinse with water. No further fluids Initial management is to wipe out the mouth with should be given Hypoxia Signs associated with oesophageal inflammation: pain or difficulty with swallowing, excessive Signs associated with oesophageal inflammation: abdominal pain, haematemesis drooling, irritability, pulling at lips or tongue, vomiting, ingestion include chest pain, dyspnoea, Signs and symptoms indicating a possible life threatening of neck and chest fever, stridor, hoarse voice, subcutaneous emphysema Burns to the lining of the mouth, oesophagus and stomach. The lips and mouth should be Burns to the lining of the mouth, oesophagus and redness and swelling. However, a clear mouth does inspected for signs of burns, including blisters, not necessarily indicate a clear oesophagus psychiatric support see resulted from suicidal behaviour, If inhalation Patients with ongoing symptoms or pregnant patients should be discussed with a Clinical a Clinical with should be discussed patients or pregnant symptoms with ongoing Patients Toxicologist neuropsychiatric of potential for evaluation team to psychiatric poisoning, referral after 1-2 months and and for psychological memory loss, depression) cognitive impairment, injury (ongoing Consider suicide in deliberate inhalations of carbon monoxide. See monoxide. carbon of inhalations in deliberate suicide Consider
• • • • • Button battery ingestion/insertion, page Related topics • • • • • • • • • • •
Background Recommend HMP HMP
4. Management 3. Clinical assessment
2. Immediate management 1. May present with 274 poisoning and overdose Cyanide | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Recommend Background Take precautions(gloves,plasticgownandmask)topreventcontactwith cyanidedirectlyoroffthe • • • • • • • • • • • • • • • • • • See Riskassessmentunder intubation andventilation Patients withadecreasedlevelofconsciousnessand/orrespiratoryfailure willrequireearly 259 See Immediatemanagementunder Respiratory distressandcyanosisfromhypoxia Gastrointestinal effectse.g.nauseaandvomiting cardiorespiratory arrestcanoccur Cardiovascular effectse.g.hypotension,tachycardia,ECGchanges,arrhythmiasand Neurological effectse.g.headache,weakness,confusion,drowsiness,comaandseizures urgency andthespecificsofmanagement The PoisonsInformationCentre(PIC)canhelptoclarifytoxicityandgiveupdateadviceonthe Consult MO/NPonalloccasionsifthesubstancetakenisknownorsuspectedtobetoxic Administer analgesiaasclinicallyindicated.See Do notgiveactivatedcharcoal.Itisineffective cause furtherdamage Do notgiveanacidtoneutraliseingestedalkaliorviceversaastheheatofneutralisationmay Do notinducevomiting Close attentiontoairwaysandbreathingisessential required page Give highflowO Remove thepatient fromthesourceofcontamination tofreshair cellular respirationandresultsinlacticacidosis.Cyanideexposureisusuallyfrominhalation Cyanide bindstotheferricioninmitochondrialcytochromeoxidases,therebyinhibiting 11 26(24hours) Consult MO/NPfirstforallpatientswithcyanidepoisoning.PoisonsInformationCentre(PIC) supportive carewithouttheneedforantidotes Onset oftoxicityanddeathisrapid.Mostpatientswhosurvivetohospitalwilldowellwith from domesticorindustrialfiresoccupationalexposure(cyanideisusedingoldrefining). 64 - adult/child 1 2 viaanon-rebreathing mask.AHudsonmaskisnotsufficient. See patient, particularlyfromtheliquidformofcyanide
Toxicology (poisoningandoverdose)- generalapproach,page Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoningandoverdose)-generalapproach,page
Acute painmanagement,page 35 Oxygen delivery, Oxygen delivery, 259 13 poisoning and overdose 275
259 Section 3: Emergency | Poisoning and overdose 1,2 2
1,2
Ingestion of as little as 2-3 mL or more may produce signs of toxicity. Ingestion can also result in toxicity. Ingestion can may produce signs of as little as 2-3 mL or more Ingestion of that evolves over hours in a pneumonitis, aspiration resulting cough and essential oil, but also a common ingredient of non-prescription Available as a purified rubs and balms cold remedies, lice treatments,
Consult MO/NP who will advise further management and arrange evacuation/hospitalisation Consult MO/NP who will advise further management given the rapid onset of symptoms and the risk of The use of activated charcoal is contraindicated aspiration Toxicology (poisoning and overdose) - general approach, page See Risk assessment under Toxicology (poisoning and overdose) - general approach, Toxicology (poisoning and overdose) - general approach, page See Immediate management under Toxicology (poisoning and overdose) - general approach, 259 Onset can be rapid with severe toxicity developing within the hour Onset can be rapid with severe toxicity developing Gastrointestinal effects e.g. vomiting, nausea Gastrointestinal effects Eucalyptus odour on breath Cardiovascular effects e.g. tachycardia and hypotension Cardiovascular effects coughing, gagging, aspiration, which may result in pneumonitis, with Respiratory effects e.g. distress wheezing and respiratory Neurological effects e.g. ataxia, confusion, drowsiness, decreased level of consciousness and ataxia, confusion, drowsiness, decreased level Neurological effects e.g. coma MO/NP will arrange evacuation/hospitalisation to an appropriate facility appropriate to an evacuation/hospitalisation will arrange MO/NP Consult MO/NP who in consultation with the Poisons Information Centre (PIC) may recommend the the recommend may (PIC) Centre Information Poisons the with in consultation who MO/NP Consult available are several of which there an antidote, use of
• •
• • • • • • • • • • • • Background
4. Management
3. assessment Clinical 2. Immediate management
1. May present with oil - adult/child Eucalyptus 276 poisoning and overdose adult/child Petrol, fuelsandotheroils(hydrocarbons)-ingestion/aspiration | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Background • • • • • • • • • • • • • • Consult MO/NPifanychestsymptoms orsignsofincreasedHRtemperature symptoms Advise tobereviewedthenextdayandaftergivenpossibility ofdelayinrespiratory Staff mayneedpersonalprotectiveequipmentsuchasgown,glovesand goggles See followingtableTypesofhydrocarbons poisoning Do notinducevomiting.Activatedcharcoaladministrationiscontraindicated inhydrocarbon Give O (PIC) Consult MO/NPfirstforallpatientswithingestionofhydrocarbons.Poisons InformationCentre See Riskassessmentunder 259 See Immediatemanagementunder Cardiac arrhythmiascanoccurearlyandbefatal Rapid onsetofcentralnervoussystem(CNS)depressionandseizures occurred Respiratory symptomssuchasgagging,coughingandchoking,whichindicatesaspirationhas – – In general: hours) expected toxicity may be obtained from the Poisons Information Centre (PIC) Toxicity dependsontheparticularhydrocarbon.Clarificationoftypehydrocarbonand – – aspiration andsystemiceffectsduetoeasierabsorption.Onsetoftoxicityisoftenrapid with inhalationandaspiration.Theycancausechemicaldamagetothelungs,hypoxia, low viscosityhydrocarbonsareofteneasilyvaporisedoraerosolisedandassociated gastrointestinal effects high viscosityhydrocarbonsarethicksubstancesandgenerallyswallowedresultingin 2 tomaintainSpO 131126(24hours) 1 2 2
2 2 ≥94%.See
Toxicology (poisoningandoverdose)-generalapproach,page
Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoningandoverdose)-generalapproach,page Oxygen delivery,page 64 13 11 26 (24 259 - poisoning and overdose 277
Management pneumonitis. May be delayed 1 - 2 days Observe for nausea, vomiting, diarrhoea Consult MO/NP Observe for acute asthma- like features or pneumonitis. May be delayed 1 - 2 days. Observe for nausea, vomiting, diarrhoea Consult MO/NP who will organise evacuation/ hospitalisation if required Marked diarrhoea may Marked diarrhoea managed by occur, usually fluids increasing oral acute Observe for features or asthma-like Risk of Risk of toxicity systemic systemic Section 3: Emergency | Poisoning and overdose Particularly severe effects include cardiac arrhythmias and seizures Low Low can toxicity CNS occur, whether due to an asphyxia effect, or a direct hydrocarbon effect High Risk of Risk of pneumonitis Low High Toxicology (poisoning and overdose) - general approach, page
mixture contains 6 mg/mL of elemental iron. The Poisons Information mixture contains 6 mg/mL of elemental iron. The ® 1 Examples 13 11 26 (24 hours) can assist with calculations - adult/child potential for marked CNS effects similar to eucalyptus oil Camphor Chlorinated insecticides Benzene Toluene Other lubricating oils Other lubricating Kerosene Lighter fluid Mineral turpentine Petrol & diesel Pine oil - associated with Petroleum jelly Motor oil 1 > 120 mg/kg - potentially lethal < 60 mg/kg - asymptomatic or GIT toxicity 60-120 mg/kg - systemic toxicity
– – – It is unusual for children to ingest more than 40 mg/kg elemental iron It is unusual for children to ingest more than 40 – Toxicity depends on the weight of the patient and amount of elemental iron ingested: Toxicity depends on the weight of the patient and – – It is the elemental iron content that is used for the calculation of toxicity. The amount may vary It is the elemental iron content that is used for or ferric salt tablet depending on the between 80 mg and 105 mg in a 300 mg ferrous formulation. Ferro-Liquid Centre (PIC) Type See Immediate management under 259 Severe signs and symptoms after several hours may include coma, seizures, pulmonary oedema, Severe signs and symptoms after several hours hypotension, haemorrhage, metabolic acidosis and multi-organ failure Early signs and symptoms include vomiting, altered mental status, dehydration Early signs and symptoms include vomiting, altered Shock, seizures, haematemesis, bloody diarrhoea
• • • • • • • Background
toxicity Low-viscosity: known systemic Low-viscosity: systemic toxicity possible High-viscosity Types of hydrocarbons Types 2. Immediate management
1. May present with Iron ingestion 278 poisoning and overdose 4. Management 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background • • • • • • • • • • • • • • • • • • Serial lithiumlevels anddischargewhenlithiumlevel isbelow1mmol/L and vomiting,page Acute lithiumingestionsoftenonly require antiemeticsandIVfluids.MO/NPwillorder.See Clinical Toxicologist.ThePoisonsInformation Centre(PIC) All casesofchroniclithiumtoxicitywith neurologicaltoxicityshouldbediscussedwiththeMO/NP/ See Riskassessmentunder Cardiovascular effectse.g.hypotension/QTprolongationinseveretoxicity only Neurological effectse.g.tremor,hyperreflexia,clonus,ataxiaanddysarthria Gastrointestinal effectse.g.nausea,vomitinganddiarrhoea retrieval team Desferrioxamine isanantidotethatwillbeneededinseriouscases. (over 60mg/kg) Whole bowelirrigationmaybeorderedbytheMO/NP/ClinicalToxicologistforlargeexposures Activated charcoalisineffective IV fluids-toensureadequatecirculatingvolumeandreplacementoffluidloss – – – ingestion requireanumberofotherinvestigationsincluding: Iron levelsatthe4-6hourspostingestioncanpredicttoxicity.Inaddition,patientswithiron Consult MO/NPwhowillorganiseevacuation/hospitalisation inorganic mass) A plainabdominalx-rayifavailablemayshowresidualwholetabletsoraconcretion(ahardusually See Riskassessmentunder balance including anIDC Chronic lithiumtoxicity usuallyrequiresinpatientadmission andIVfluidwithattentionto fluid – – – impairment, isaseriousillnessrequiringinpatientcareandrarelydialysis Chronic lithiumtoxicity,whichoftenoccursinsidiouslyinthecontextofadvancedageandrenal usually regardlessofwhetherthepatientistakinglithiumregularlyorirregularly GIT toxicity only, as the lithiumisexcretedby kidneys prior to entry into the CNS. Thisis Acute lithiumingestionsinpatientswithnormalrenalfunctionarerelativelybenignminor Lithium blood gases full bloodcount UE, creatinine,LFT 1 - adult/child 1 2 3
48 1
Toxicology (poisoningandoverdose)-generalapproach,page Toxicology (poisoningandoverdose)-generalapproach,page Notapplicable 131126(24hours)canassist 4 Thiscanbebroughtwiththe 259 259 Nausea Nausea poisoning and overdose 279
259 - adult/ 283 NSAID) NSAID) Paracetamol, page Section 3: Emergency | Poisoning and overdose 271 Not applicable Aspirin/salicylates, page Aspirin/salicylates, Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach,
1,2
2 ) ® 1,2
e.g. diclofenac, ibuprofen, indometacin, ketorolac, naproxen, naproxen, ketorolac, indometacin, ibuprofen, diclofenac, e.g. For aspirin ingestions, see For aspirin ingestions, Most people with ingestions of NSAID do well with supportive care. Most ingestions are with care. Most ingestions do well with supportive with ingestions of NSAID Most people toxicity to result in major if < 400 mg/kg are unlikely ibuprofen and
MO/NP may order IV/oral proton pump inhibitors (PPI) MO/NP may order IV/oral proton pump inhibitors supportive care Most patients will do well with symptomatic and Consult MO/NP first for all patients with NSAID overdose. Consult MO/NP first for all patients with NSAID Insert IV cannula. MO/NP may order IV fluids See Risk assessment under See NSAID products often contain paracetamol or codeine. Neurological effects e.g. altered level of consciousness and seizures with ingestion of mefenamic altered level of consciousness and seizures with Neurological effects e.g. acid (Ponstan mg/kg ibuprofen) metabolic acidosis with large ingestions ( > 400 Metabolic effects e.g. Majority of cases are asymptomatic e.g. nausea, vomiting and upper GIT irritation Gastrointestinal effects impairment in patients who are dehydrated/hypovolaemic Renal effects e.g. renal
• • • • • • • • • • • • • Background
4. Management 3. Clinical assessment 2. Immediate management 1. May present with
mefenamic acid mefenamic Ingestion of non-steroidal anti-inflammatory drugs ( drugs anti-inflammatory of non-steroidal Ingestion child 280 poisoning and overdose morphine, heroin,oxycodone,pethidine,tramadol,Lomotil® e.g. buprenorphine,codeine,fentanyl,hydromorphone,methadone, | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • • • • • • • • • • respiratory depression Closely monitorrespiratoryrateasregular opioidusersmayhaveaGCS>14,butstill Hypoxia inpatientswithopioidingestion mandatesanassessmentofCO MO/NP. See May requireO Consult MO/NPfirstforallpatientswithopioidoverdose.ThePoisons Information Centre(PIC) Hypoglycaemia, page A headinjuryandhypoglycaemiacanmimicopioidtoxicity. See Riskassessmentunder Inspect forandremoveanytransdermalpatchesofopioidmedicineifpresent See QT prolongationandtorsadesdepointescanoccurwithingestionsofmethadone Miosis (smallpupils) Cardiovascular effectse.g.hypotension Respiratory depressionoftenmirrorsthedegreeofCNS Neurological depressionrangingfromdrowsinesstocoma complications couldinclude seizuresandarrhythmias whichmay befatal needs tobeconsidered priortoinducingwithdrawalin patientswhoareregularusersofopioids as Give naloxoneifdepressed levelofconsciousnessor respiratory rate.Careandclinicaljustification Lomotil® containsatropineanddiphenoxylate.Diphenoxylateischemicallyrelatedtopethidine form ofdecontamination onset ofsymptomsisalsousuallyrapid,makingairwayprotectionessentialifconsideringany A goodoutcomeisexpectedwithsupportivecareandantidoteadministrationasnecessary.The Activated charcoalisnotroutinelyindicated delay intheonsetofsymptomsthereforeneedlongerperiodobservation People whohaveoverdosedonslowreleaseopioidsandthosewithrenalimpairmentmay in opioiddependentpatients Toxicity fromopioidscannotbepredictedsolelythedoseingestedduetodifferingtolerance such asmethadone,oxycodoneandslow-releasemorphine Consider urgentevacuationandcriticalcareadmissionforanoverdosewithlong-actingopioids Opioids 131126(24hours) Toxicology (poisoningandoverdose)-generalapproach,page 1 1 Oxygen delivery,page 2 - adult/child tomaintainsaturation>94%adult or >95%child.IfSpO 115 1
Toxicology (poisoningandoverdose)-generalapproach,page Notapplicable 64 2 See 259 Head injuries,page 2 isnotmaintainedconsult 2 2 175 and 259 poisoning and overdose 281
3,4 stat of 2 mg Duration at intervals of Can be repeated 2-3 min to a max.
ATSIHP/IHW 102 Extended authority Adult Anaphylaxis, page page Anaphylaxis, 400 microgram Recommended dosage Section 3: Emergency | Poisoning and overdose Naloxone . Must then consult MO/NP . Must then consult MO/NP
Consult MO/NP. See IV/IM Route of (IV preferred) administration one dose only . Complete reversal of opioids is not required and can lead to required and can lead to of opioids is not . Complete reversal 3 400 Do not use in opioid dependent women; risk of withdrawal in fetus Do not use in opioid dependent women; risk of Strength microgram/mL : Use with caution in opioid dependance: may have an acute withdrawal syndrome e.g. anxiety, : Use with caution in opioid dependance: may have Schedule Form undesirable effects e.g. acute opioid withdrawal, agitation, pulmonary oedema withdrawal, agitation, effects e.g. acute opioid undesirable patient may relapse as the naloxone is metabolised. This is particularly relevant to patients with to patients relevant is particularly This is metabolised. as the naloxone may relapse patient renal impairment. easily minute and per > 12 respirations rate with a respiratory be a patient should The endpoint verbal stimuli responsive to MO/NP may order further doses or IV infusion of naloxone. Naloxone has a short half life and the and half life short has a Naloxone of naloxone. IV infusion or doses further order may MO/NP Injection • • Management of associated emergency: respiratory depression may return as the naloxone wears off. Continued observation and monitoring respiratory depression may return as the naloxone of respiratory function is required Use in pregnancy: Note severe effects e.g. seizures, pulmonary oedema or agitation, tachycardia, confusion, or rarely more 1 minute. Reconsider diagnosis if no response arrythmias. There should be an improvement within a longer duration of action than naloxone and after a total of 10 mg has been given. Opioids have Provide Consumer Medicine Information: ATSIHP and IHW may proceed for ATSIHP and IHW may proceed RIPRN and RN may proceed 282 poisoning and overdose Organophosphates/carbamates ( | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Recommend Background • • • • • • • • • • • • • • • • • PPE (gloves,gowns,eyeprotection)MUSTbeusedwhenassessingand managingpatientswith See Riskassessmentunder Decontamination ofthepatientisimportant butimmediatemanagementshouldnotbeimpeded 259 See Immediatemanagementunder Respiratory failureandunconsciousnessmayfollow Runny nose Muscle weaknessandtwitching poisonings Cardiovascular effects:arrhythmias,tachycardia,shockcanoccurwithsomeorganophosphate Gastrointestinal effects:nausea,vomiting,diarrhoea, urinary frequencyandincontinence,productivecough,bronchoconstriction Acute autonomicfeatures:sweating,miosis,bradycardia,hypotension,salivation,lacrimation, confusion, coma Central nervoussystem:headache,slurredspeech,blurredvision,restlessness,seizures, Consult MO/NPfirst. Mayadviseseveralstatdosesof atropineIVandaninfusion especially ifaspirated.See Organophosphates areoftenformulatedwithhydrocarbonswhichcancontributetothetoxicity, toxicity, butthisisrarelylifethreatening Occupational dermal,ophthalmicorinhalationalexposurewhicharemorecommoncancause encountered. Carbamatesincludecarbaryl,propoxur,bendiocarbandmethomyl severe. Somecarbamateproductsaremixedwithmethanol,whichcanbethemajortoxicity organophosphate ingestions.Thedurationofeffectsisusuallybrieferandsometimesareless Carbamates aremorerecentlydevelopedpesticidesandclinicalpresentationisidenticalto situations ofdeliberateoverdose Organophosphate toxicityisarareandpotentiallylethaltoxicity.Toxicityusuallyoccursin fenthion andmalathion industry andinthehomegarden.Organophosphatesincludechlorpyrifos,diazinon,dimethoate, Organophosphates areinmanyinsecticides,herbicidesandfungicidesusedagriculture, Oximes arenotgenerallyindicatedforthemanagementoforganophosphatepoisoning 276 suspected organophosphatepoisoningtoensuresafetyandavoidstaff beingaffected 1 2 1 Toxicology (poisoningandoverdose)- generalapproach,page Petrol, fuels and other oils (hydrocarbons) - ingestion/aspiration, page Petrol, fuelsandotheroils(hydrocarbons)-ingestion/aspiration,page Notapplicable Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoningandoverdose)-generalapproach,page pesticides) - adult/child 259 poisoning and overdose 283
13 11 26 (24 hours), should be Section 3: Emergency | Poisoning and overdose 64 https://www.mja.com.au/journal/2016/205/4/ Guidelines for the management of paracetamol poisoning in Guidelines for the management available at: 13 11 26 (24 hours) can assist (24 hours) 13 11 26 3 Oxygen delivery, page Oxygen delivery, - adult/child 2,3,4 1,2 according to clinical condition - at a minimum, use non-rebreathing mask. A Hudson mask mask. A Hudson minimum, use non-rebreathing clinical condition - at a according to 2 in all cases of deliberate self-poisoning regardless of stated dose, need to be managed in a self-poisoning regardless of stated dose, need in all cases of deliberate acute deliberate self-poisoning; acute accidental paediatric exposure; or inadvertent repeated supratherapeutic ingestion – – –
Management guidelines vary between ingestion of immediate release versus modified release Management guidelines vary between ingestion supratherapeutic ingestion formulations, and also between acute versus repeated Death due to liver failure may result Most paediatric exposures are to the liquid forms of paracetamol in children aged between 1-3 Most paediatric exposures are to the liquid forms years (10-15 kg) as well as other drugs capable of Some over the counter preparations contain paracetamol causing complicating symptoms – – – Mortality rates from paracetamol ingestion are low, and most patients recover from toxicity Mortality rates from paracetamol ingestion are low, Paracetamol poisoning can arise from: Intravenous paracetamol errors leading to toxicity are managed differently and are not discussed Intravenous paracetamol errors leading to toxicity Centre (PIC) in this topic. The MO/NP and Poisons Information administration consulted where there is an error in IV paracetamol facility where they can have serum paracetamol concentration measured 4 hours post ingestion serum paracetamol concentration measured facility where they can have (MJA): Medical Journal of Australia Australia and New Zealand summary-statement-new-guidelines-management-paracetamol-poisoning-australia-and All adults or children ≥ 6 years of age who have ingested more than 200 mg/kg of paracetamol, years of age who have ingested more than 200 All adults or children ≥ 6 or 24-72 hours after ingestion signs and symptoms of hepatic damage may emerge including right 24-72 hours after ingestion signs and symptoms of hepatic damage may emerge including right upper quadrant pain and increased INR 72-96 hours after overdose signs and symptoms of continuing hepatic damage include During the first 24 hours following acute overdose the patient may have few if any signs or During the first 24 hours following acute overdose symptoms but may include: malaise, pallor, diaphoresis, anorexia, nausea and vomiting. Persistent or late vomiting is common with hepatotoxicity History of paracetamol overdose (deliberate, accidental, or inadvertent) History of paracetamol overdose (deliberate, accidental, wash skin thoroughly with warm soapy water, and irrigate eyes if contaminated water, and irrigate eyes with warm soapy wash skin thoroughly absorption of the liquid is unlikely to be effective due to rapid Gastrointestinal decontamination formulations Manage the patient in a well-ventilated room. patient in a well-ventilated Manage the Give O See is not sufficient. disposal, and and seal in bags for and eyes. Remove clothing of skin Aggressive decontamination Advanced care, including intubation and suctioning of airways may be required be required airways may of and suctioning intubation care, including Advanced The Poisons Toxicologist. with a Clinical discussed should be ingestions All organophosphate (PIC) Centre Information MO/NP will organise urgent evacuation urgent organise will MO/NP
• • • • • • • • • • • • • • • • • • • • Background Recommend
1. May present with Paracetamol 284 poisoning and overdose 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 4. Management Children <6years Adult orachild≥6years Paracetamol dosingthatmaybeassociatedwithhepaticinjury • • • • • • • • • • • • • • – – – – Activated charcoal50gshouldbeoffered tocooperative,awake,adultpatientswhopresent: The patientmayrequireevacuation/hospitalisation with thePoisonsInformationCentre(PIC) All immediate-releaseingestions>30gandallmodified-release shouldbediscussed ingestion requireanurgentconsultwiththeMO/NPorPIC management ofparacetamolingestion.Allchildren<6yearspresenting withpossibleparacetamol Poisons InformationCentre(PIC) The managementofparacetamolingestioncanbechallenging.MO/NP advised tocontactthe weight, growthchartsareavailablefrom For obesechildrentheweightshouldbebasedonidealbodyweight.To determineidealbody – – – Supratherapeutic paracetamoldoseisingestionof: – Acute exposurerequiringinvestigation – – – Repeated supratherapeuticparacetamoldoseisingestionof: – Acute exposuresrequiringinvestigation: concentration, andclinical/laboratoryfeaturesofliverinjury(suchasALTmeasurement) Risk assessmentforparacetamoltoxicityencompassestheingesteddose,serum See Riskassessmentunder asymptomatic untilday2or3followingtheexposure Severe liverdamageabout2-4daysafteringestionifuntreated.Thepatientmaybemostly hypoglycaemia, metabolicacidosis,andjaundice,frequentlyrenalcomplications Risk assessments forparacetamoltoxicitymayusea nomogram todeterminetreatment. decontamination with activatedcharcoalorgastriclavage isnotindicated In children<6years ofagewithpotentialaccidentalparacetamol intoxication,gastrointestinal – – – – – – – – – – – – > 100mg/kgper24hourperiodformorethan48hours > 150mg/kgper24hourperiodforthepreceding48hours > 200mg/kginasingle24hourperiod ingestion of>200mg/kgoveraperiodlessthan8hoursrequireinvestigation also haveabdominalpainornauseaandvomiting > 100mg/kgor4g(whicheverislower)per24hourperiodformorethan48hoursinthosewho > 150mg/kgor6g(whicheverislower)per24hourperiodforthepreceding48hours > 200mg/kgor10g(whicheverislower)inasingle24hourperiod ingestion of>200mg/kgor10g,whicheverislowestoveraperiodlessthan8hours more than4hourspostingestionof amassiveoverdoseofmodified-releaseparacetamol paracetamol within 4hoursofingestionalarge/massive dosei.e.greaterthan30gimmediate-release within 4hoursofatoxicdosemodified releaseparacetamol within 2hoursofingestionatoxic doseofimmediatereleaseparacetamol 2,3,4 2
1
Toxicology (poisoningandoverdose)-generalapproach,page Notapplicable 13 1126wherethereareanyconcernsregardingthe http://www.rch.org.au/childgrowth/Growth_Charts 13 1126 1,2 259
2 poisoning and overdose 285
102 2,4,6 Give 3 21 hours Duration infusions over Anaphylaxis, page page Anaphylaxis, Prescribing guide
THEN THEN Adult dosage hour period . If being evacuated, the RFDS will bring this the RFDS will bring . If being evacuated, Recommended 2 100 mg/kg in 1 L 2,5 Section 3: Emergency | Poisoning and overdose 200 mL glucose 5% infused over 4 hours Initially 150 mg/kg in Max. 300 mg/kg in 21 Infuse over 60 minutes 50 mg/kg in 500 mL glucose 5% . Risk assessment is complicated and advice from and advice is complicated assessment . Risk glucose 5% infused over 16 hours 2 4 Acetylcysteine May cause flushing, urticaria and itch. Anaphylaxis is May cause flushing, urticaria and itch. Anaphylaxis
Stop the infusion. Contact MO/NP. See IV Route of administration ) given intravenously, is an effective antidote and ensures survival if survival and ensures antidote is an effective intravenously, ) given ® 4 Strength 200 mg/mL Calculation errors may lead to potentially fatal dosing errors. Calculate dose using actual body actual using dose errors. Calculate dosing fatal may lead to potentially Calculation errors ingestions is uncertain ingestions is the post ingestion is above the level at 4 hours paracetamol can be measured, where serum treatment nomogram recommended level on the where serum paracetamol level is not available within 8 hours of ingestion, or if time of of ingestion, or if time available within 8 hours paracetamol level is not where serum – – Form – medication with them medication include: Acetylcysteine administration Indications for – which is sent with the results from pathology the results is sent with which is needed Toxicologists MO/NP/Clinical (Parvolex Acetylcysteine ingestion within 8 hours of paracetamol administered Indications for acetylcysteine are based on the serum paracetamol level plotted on the nomogram, nomogram, on the plotted level paracetamol serum on the based are acetylcysteine for Indications Schedule Injection • • weight rounded up to the nearest 10 kg and to a maximum of 110 kg weight rounded up to the nearest 10 kg and to a Management of associated emergency: Provide Consumer Medicine Information: Medicine Consumer Provide common (1%) Note: RIPRN and RN only. Must be ordered by an MO/NP RIPRN and RN only. Must 286 poisoning and overdose | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • • • • • • • PPE (gloves,gowns,eyeprotection) MUSTbeusedwhenassessingandmanagingpatientswith Treatment mustbe rapid.Immediateevacuation.Delays willgreatlyincreaseriskoftoxicity and See Strong odourduetostenchingagentaddedParaquatbymanufacturer Profuse vomiting – – – – – – Severe life-threateningeffectsinclude: hypotension, respiratorydistress,acidosis Moderate effectsincludeGIhaemorrhage,corrosiveinjuriestooropharynxandoesophagus, and diarrhoea Mild effectsincludeoral,tongueandpharyngealburningpainand/orulceration,nausea,vomiting A ‘burningskin’sensation charcoal, e.g.isolatedpatients telephoningin, instructthemto eatsoilorfood- thiswillabsorb Give activatedcharcoal immediately.Ifthereisadelay withgettingapatienttoreceiveactivated death – – – – – – Resource bookletavailableat: pulmonary fibrosiscanoccurwithparaquatpoisoning Inflammation oftheheartmuscle(myocarditis),liver,pancreasandkidneydamage dysfunction ortopulmonaryfibrosis Paraquat ingestionshaveahighmortalityrate.Deathisearly,secondarytomulti-organ corresponds tolessthanamouthfulinanadult As littleas10-15mLofconcentratedliquidparaquat(herbicide-weedkiller)isfatal,which Paraquat isaverycommonandeffectiveherbicideusedworld-wideonmanyagriculturalcrops Immediate evacuationforrapidtreatmentisrequired a ClinicalToxicologist.ThePoisonsInformationCentre(PIC) Consult MO/NP first. All paraquat exposures, accidental and deliberate should be discussed with linen andothermaterialincontactwithpatientmustbebaggedsealed suspected paraquatpoisoningtoensuresafetyandavoidstaffbeingaffected.Patientclothes, PPE (gloves,gowns,eyeprotection)mustbeusedwhenassessingandmanagingpatientswith documents/paraquat-booklet.pdf Paraquat ingestion/inhalation/contact coma, seizures cardiac arrest hypotension hyperkalaemia kidney andliverinjury pulmonary oedema DRS ABCDresuscitation/thecollapsed patient,page suspected paraquatpoisoningtoensure safetyandavoidstaffbeingaffected 1 1 2 1 3
https://www4.syngenta.com/~/media/Files/S/Syngenta/ 54 - adult/child 13 1126(24hours)canassist poisoning and overdose 287
259 259 35 13 11 26 (24 hours) can assist Section 3: Emergency | Poisoning and overdose enhances pulmonary toxicity of paraquat enhances pulmonary toxicity 2 Acute pain management, page Acute pain management, - adult/child Toxicology (poisoning and overdose) - general approach, page approach, - general and overdose) (poisoning Toxicology Not applicable Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach, page and overdose) - Toxicology (poisoning
367
cocaine
1 initially unless ordered by MO/NP. O initially unless ordered 2 falls below 90% 2
1 if SpO 2 cardiovascular effects e.g. tachycardia, hypertension, arrhythmias and rarely hypotension cardiovascular effects e.g. tachycardia, hypertension, and metabolic acidosis metabolic effects e.g. hyperglycaemia, hypokalaemia CNS excitation e.g. agitation, delirium, seizures neuromuscular excitation e.g. hyperreflexia mydriasis autonomic effects e.g. hyperthermia, diaphoresis, UEC FBC O oximetry is of use for monitoring patient condition base line spirometry and
There are numerous derivatives of amphetamines available. Some are used therapeutically e.g. There are numerous derivatives of amphetamines via illicit means e.g. ecstasy (MDMA) or ice. dexamphetamine, while others are only available that toxicity of these agents can be variable Concentrations vary and patient tolerance means Consult MO/NP. Complicated amphetamine toxicity should be discussed with a Clinical Consult MO/NP. Complicated amphetamine toxicity Toxicologist. The Poisons Information Centre (PIC) – – – – – – – – – See Risk assessment under – – cerebral haemorrhage, aortic dissection Can be complicated by hyponatraemia, rhabdomyolysis, and myocardial infarction – – – Sympathomimetic and serotonin toxidromes characterised by: Sympathomimetic and serotonin toxidromes characterised Administer analgesia as clinically indicated. See Administer analgesia as 0.9% for 15 minutes. See eyes, irrigate copiously with sodium chloride If paraquat has contacted Chemical burn to eye, page Bloods, including: – – – – status the largest possible gauge given age and vascular Insert 2 x IV cannula - use Do not give O advise: Consult MO/NP who may See Risk assessment under See Risk assessment Remove, bag and seal all patient clothing and wash skin thoroughly with soap and copious water and copious with soap thoroughly and wash skin clothing seal all patient bag and Remove, under management See Immediate 259 the paraquat the
• • • • • • • • • • • • • •
Background Recommend
3. Clinical assessment 2. Immediate management
1. May present with Amphetamines and
4. Management 3. Clinical assessment 3. Clinical 288 poisoning and overdose 4. Management | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Cannabis (marijuana) Background • • • • • • • • • • • • Occasionally sedatione.g.oraldiazepam mayberequired Most patientstoxicitywillresolvewith timeandsimplesupportivecare Consult MO/NP See Riskassessmentunder Psychiatric e.g.euphoria,agitation,anxiety,delusionsandhallucinations Cardiovascular symptomse.g.tachycardia,hypotension(postural) Neurological symptomse.g.ataxia,uncoordination,sedationandrarelyCNSdepression Complicated amphetaminetoxicityshouldbediscussedwithaClinicalToxicologist – – – – In additiontoabove,specifictherapymayinclude: – – Consult MO/NPwhowilladvisefurthermanagementwhichmayinclude: – – – – – – Widely usedillicit drug with psychoactive properties whichingeneral cause benignsymptoms symptoms willresolvewithdecreaseduseorabstinence either athomeorinhospital.Patientswilloftenadmittoinfrequentuseonly.Allpatient's vomiting andcolickyabdominalpain.Thepatientmayreportimprovementwithhotshowers Chronic heavyusemayleadtocannabinoidhyperemesissyndrome,characterisedbynausea, only rhabdomyolysis -IVfluids,IDC,fluidbalance See hyperthermia (>39°C)-coldIVfluids,tepidspongingandicepackstothegroinaxillae. myocardial ischaemia-aspirin300mg,nitratese.g.GTN See hypertension -IVnitratese.g.GTNorphentolaminesodiumnitroprusside(ifavailable). and anotheragentshouldbeusedforsedatione.g.droperidol10mgIM/IV minimal responseand/orbriefdurationofactionstronglysuggestsbenzodiazepinetolerance up toamaximumof20-30mg. most patientssympathomimetictoxidromewillsettlewithsedatione.g.diazepam2.5-5mgIV
Acute hypertensivecrisis,page Hypothermia, page
2 229 - adult/child Toxicology (poisoningandoverdose)-generalapproach,page Notapplicable 151 259 poisoning and overdose 289
259 13 11 26 (24 13 11 26 (24 229 Hypothermia, page Section 3: Emergency | Poisoning and overdose - adult/child - adult/child Toxicology (poisoning and overdose) - general approach, pageToxicology (poisoning and Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach, aerosol
1,2,3
Rates of inhalation are high in some Aboriginal and Torres Strait Islander communities Inhalation can be associated with cardiac arrest known as sudden sniffing death syndrome Inhalation can be associated with cardiac arrest Substances inhaled include petrol, solvents/acetone in glues, paints, thinners, correction fluids. fluids. correction thinners, paints, glues, in solvents/acetone petrol, include inhaled Substances air fresheners. Presentations may be Others include propellants in aerosols such as deodorants, related to acute or chronic use Recreational sniffing of fumes can occur directly from the container of the substance ‘chroming’, Recreational sniffing of fumes can occur directly ‘bagging’ by or nose, and mouth the over substance the of cloth a saturated placing or ‘huffing’ by bag and breathing the fumes or pouring the substance into a plastic or paper e.g. date rape. Its use leads to a rapid onset of CNS and respiratory depression usually with respiratory depression onset of CNS and Its use leads to a rapid e.g. date rape. within 4 - 6 hours complete recovery hours) assault in a drug facilitated sexual and possibly precursors are used by bodybuilders GHB and its Consult MO/NP for all patients with GHB toxicity. Poisons Information Centre (PIC) GHB toxicity. Poisons Information for all patients with Consult MO/NP Most patients can be managed in the left lateral position to maintain an adequate airway as the Most patients can be managed in the left lateral is required duration of toxicity is brief. Rarely intubation/ventilation See IV fluids for hypotension and re-warming for hypothermia. Consult MO/NP See Risk assessment under See Immediate management under See Immediate management 259 may require intubation and ventilation Patients who arrive with a decreased level of consciousness Cardiovascular effects e.g. bradycardia and hypotension Cardiovascular effects hypothermia Other effects e.g. vomiting, Neurological effects e.g. rapid onset of CNS depression with coma and agitation/delirium on rapid onset of CNS depression with coma and Neurological effects e.g. waking
•
• • • • • • • • • • • • • • Background
Background Recommend
Sniffing petrol/glue/ 4. Management
3. Clinical assessment 2. Immediate management
1. May present with Gamma-hydroxybutyrate (GHB) (GHB) Gamma-hydroxybutyrate 290 poisoning and overdose 1. Maypresentwith | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement • • • • • • • • • • • • • • • • • • • • • Acute severebehaviouraldisturbance,page Acute asthma,page Related topics – Response Tools)+ Perform standardclinicalobservations (fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – Obtain completepatienthistory(ifpossible)includeintaking: – – – – – ensure safetyofself,staff,familyandvisitors: If patientisconfusedorwithdrawn,strange,aggressivedisplayingacutely disturbedbehaviour Treat inwellventilatedroomtoensuresafetyofself,staff,familyandvisitorsfromfumes If fittingsee 259 See Immediatemanagementunder Suicidal intent.See Lethargy Withdrawn, strange,aggressiveordisplayingacutelydisturbedbehaviour Euphoria, disinhibition,giddiness,confusion,agitation,stupor,hallucinations,delirium Odour ofagentthathasbeenusede.g.petrol,airfreshener,glue Tremor (shakes),nystagmus(eyetremor),ataxia(unsteadiness),blurredvisionandslurredspeech Eczema-like itchyrasharoundmouthandonface,stainingtofingershands Headache, nausea,vomiting,abdominalcramping Fitting Acidosis Epistaxis. See Fever Respiratory distress,aspiration Cardiac arrest,myocardialinfarction,increasedQTduration – Perform physicalexamination: – – – – – – – – – – alcohol and/orsubstanceintake past medical,surgicalandsocialhistoryincludingepisodesofsniffing page for additionalinformationonensuringsafetyandmanaginganger.See explain whatishappeningatalltimes.Reassurethepatientandavoid confrontation you couldbetrappedbythepatient do notapproachthepatientiftheyhaveaweaponanddon’tputyourself inapositionwhere have themvisiblyclosebyandreadytohelp,butnotfurtherfrighten orintimidatethepatient you mayneedtoenlistthehelpofpoliceorothers auscultate chestfor airentryandaddedsounds(crackles orwheezes) BGL presentation obtain informationonthetypeofhydrocarbon used,asthiswilldirectlyinfluencetheclinical 789
and see Fits/convulsions/seizures, page Nose bleed/epistaxis,page 119
Suicidal behaviour,page Acute severebehaviouraldisturbance,page 1,2,3,4 3
Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoningandoverdose)-generalapproach,page 467 234 109 456 Pneumonia -adult,page Fits/convulsions/seizures, page 467 De-escalation techniques, De-escalation techniques, 329 109 3 poisoning and overdose 291
467 259 760 Acute asthma, pageAcute asthma, Oxygen delivery, pageOxygen delivery, Child protection, page Section 3: Emergency | Poisoning and overdose See 1 Acute severe behavioural disturbance, page page disturbance, behavioural Acute severe saturation > 94% adult or > 95% child. See 94% adult or > 95% child. saturation > 329 2 Not applicable Toxicology (poisoning and overdose) - general approach, page Toxicology (poisoning and overdose) - general approach,
- adult/child 2,3
2,3 3,4 to maintain SpO to maintain 2 3 1,2 Pneumonia - adult, page Pneumonia -
and inspect for tremor, nystagmus or unsteadiness (finger-nose-finger test) (finger-nose-finger unsteadiness or nystagmus tremor, for inspect Most ingestions of these agents are in patients who are therapeutically taking this medication. agents are in patients who are therapeutically taking Most ingestions of these to moderate sedation only. Unconsciousness Regular use leads to tolerance and in overdose mild requiring intubation and ventilation is uncommon –
Consult MO/NP who will advise further management. Evacuation/hospitalisation may be required Flumazenil, a specific benzodiazepine antagonist is rarely indicated. It may be useful where facilities are not available to safely intubate and ventilate a patient. Flumazenil may be hazardous Close attention to airway, breathing and circulation is essential, as the majority of patients have an Close attention to airway, breathing and circulation is essential, as the majority of patients have excellent prognosis with good supportive care See Risk assessment under Be wary of hypotension (BP < 90 mmHg) and unsteadiness on waking Be wary of hypotension (BP < 90 mmHg) and unsteadiness commonly taken in deliberate overdose, often in combination with alcohol commonly taken in deliberate overdose, often in is combined with other sedatives or Unconsciousness is unusual unless the benzodiazepine and maintain adequate respiratory function alcohol. Most patients are sleepy, easily roused Benzodiazepine sedatives such as diazepam, oxazepam, nitrazepam and flunitrazepam are Benzodiazepine sedatives such as diazepam, oxazepam, Advise to see MO/NP at next clinic Advise to see MO/NP at If allowed home, patient should be discharged into the care of a responsible person should be discharged into the care of a responsible If allowed home, patient may be delayed for 2-3 days. Respiratory symptoms in particular Advise to be reviewed daily coordination, particularly following administration of sedation coordination, particularly with history or is injury where injury or presentation is inconsistent Always consider non-accidental other vulnerable people. unexpected in children or 64 is evacuated/hospitalised and GCS until either the patient recovers or Regularly assess vital signs effects on balance and with signs of petrol sniffing, be mindful of the When caring for patients Most cases can be managed by removing the substance and allowing patient to rest the substance and can be managed by removing Most cases treatment. See MO/NP may advise chest signs and symptoms If evidence of 119 O May require For management of behavioural disturbance see disturbance behavioural of For management –
• • • • • • • • • • • • • • • • • • Background
4. Management 3. Clinical assessment 2. Immediate management 1. May present with
e.g. benzodiazepines, zopiclone, zolpidem e.g. benzodiazepines, zopiclone, Sedatives/hypnotics
5. Follow up 4. Management 292 bites and stings Toxinology (bitesandstings) | Primary Clinical CareManual 10th edition | 2. Immediate management 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • • • • • – – – – – – Signs andsymptomsofenvenomation: swelling maybepresentbutisnotafeatureofAustraliansnakebites Obvious bitesiteoftenappearsasasinglemarkorsmallscratch.Pain, rednessandlocaltissue No obviousbitesite No symptoms,butahistorysuggestiveofbite flumazenil Contact thePoisonsInformationCentre(PIC) if givenwhenthereisaco-ingestionofpro-convulsantmedicine Aim todelay lymphaticspread ofvenomand possiblesystemic effectsthrough immobilisation, of See – – – – – – Toxicologist early MO/NP willarrangeevacuation/hospitalisationasrequired.isadvisedtocontactClinical other circumstances,usepolyvalentantivenom appropriate monovalentantivenomforthatsnake.Itislesslikelytocausesideeffects Outside ofTasmaniaandVictoria,ifthetypesnakeisaccuratelyidentified,use Antivenom isnotindicatedwithoutsignsofsystemicenvenomation if thepatientappearswell Snakebite isapotentialmedicalemergencyandshouldreceivehighpriorityassessment,even Every snakebiteshouldbetreatedaspotentiallyvenomous and acutekidneyinjury substances thatcausearangeofeffectssuchasmuscleparalysis,bleeding,damage Many Australiansnakeshavepotentiallylethalbites.Venomsareacomplexmixtureof Snakebite isrelativelycommoninregionalandremoteareas.Envenomationrare Expert adviceisavailablefromthePoisonsInformationCentre(PIC) Snakebite including myotoxicity: muscleandbackpain, tenderness, weakness breathing, gaitdisturbances,including weaknessorpoorcoordination double vision,difficultyinswallowing, breathingorspeaking,fatigueandirregularshallow neurotoxicity: progressiveparalysis -droopingofeyelids,uncoordinatedeyemovements, the biteorIVpuncturesite,bloodin urine coagulopathy: bleedingofgums,coughing,spittingorvomitingblood, prolonged bleedingfrom diarrhoea non-specific systemiceffectse.g.nausea,vomiting,abdominalpain, headache, sweatingand occasionally cardiacarrestorseizure sudden collapse(oftenpriortopresentation),hypotensionandaltered consciousness DRS ABCDresuscitation/the collapsedpatient,page 1,2,3,4 1,2,3,4 2,3,4 2,4 sea snake 131126(24hours)foradviceontheuseof -adult/child 5
54 3,4 5 13 1126
(24 hours) 1 . Inall bites and stings 293 Bites and stings 3,4,6 Section 3: Emergency | Procedure for pressure immobilisation pressure immobilisation Procedure for Indicate on bandage the location of the snakebite (as per illustration) If a snakebite occurs and only one other person is present and no vehicular transport is available, it is probably safest to apply a pressure bandage and splint, then leave the bitten patient to get help In isolated areas, if bitten when alone, apply local pressure if possible. The patient should move themselves to seek urgent help Never let the patient walk • • • • pressure immobilisation bandage pressure immobilisation Procedure for below antivenom administration has commenced if found to be envenomed antivenom administration the patient has a normal neurological examination and the first set of bloods and examination neurological examination and the first set of the patient has a normal are normal, or lack of any bite/fang marks does not exclude envenomation not exclude marks does any bite/fang lack of scratches like minor may look fang marks has occurred that massive envenomation fang marks may indicate multiple random – – – – – – Do not remove a pressure immobilisation bandage until either: Do not remove a pressure – Keep the patient at rest and as calm and still as possible, provide reassurance and still as possible, provide at rest and as calm Keep the patient Note time of snakebite sucking techniques such as tourniquets, ice, cutting, Avoid unproven and harmful If bandaged do not remove If bandaged See bandage with immobilisation. Apply a pressure bandage Check for evidence of bite if pre-hospital bandage not applied: not bandage of bite if pre-hospital for evidence Check – – – both the patient and the affected limb limb the affected and patient the both Apply a splint including joints on either side of the bite to restrict limb movement (see Apply a splint including joints on either side of the illustration) apply local pressure over the site and If the bite is on the trunk, MO/NP may request to Then apply a further bandage upwards from the lower portion of the bitten limb to cover as much Then apply a further bandage upwards from the This includes application of the bandage, over the of the affected limb as possible (see diagram). be kept calm and still. Firm pressure bandages top of the clothes if necessary. The patient should movement is not impeded can be applied to bites on the trunk provided respiratory Use a broad elastic bandage (15 cm) relevant to size of patient Use a broad elastic bandage unable to easily slide a the bite site using firm pressure (should be Apply a firm bandage over finger between the bandage and skin) • • • • • • • • • • • • 294 bites and stings 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 4. Management Indications forantivenom • • • • • • • • • • • • • • • • • • • • • Clinical evidenceof envenominge.g.neurotoxicity,sudden collapse,convulsions,myoglobinuria Laboratory evidenceofenvenoming e.g.coagulopathy stocks, monitoredresuscitationarea,onsitepathology MO/NP will arrange evacuation/hospitalisation if required to a facility thathas sufficient antivenom Nil bymouth 20 mL/kgstat.ConsultMO/NPwhowilladvisesubsequentvolumes/rate. See If hypotension/shockispresent,commencebolussodiumchloride0.9% orHartmann'ssolutionat Collect urineforurinalysis treatment of,possibleorconfirmedsnakebitepatients Do notusepointofcareanalysere.g.iSTAT,toassessthecoagulationstatus of,ortomonitorthe patient Collect bloodforFBC,UE,CKandcoagulationtests(INR,aPTT,DDimer). Thiscanbesentwiththe Monitor vitalsignsandurineoutput Insert 2xIVcannula–usethelargestpossiblegaugegivenageandvascularstatus the firstbandage Ensure limbisappropriatelybandagedandapplyfurtherbandagesasnecessarywithoutremoving Consult MO/NPimmediately Check forevidenceofrhabdomyolysis-muscletendernessandweakness Check forevidenceofabnormalbleeding-gums,urine(asabove),bitesiteandIV – – Check forevidenceofparalysis: Palpate thelymphnodesdrainingbitesiteforsignsoftenderness Do notremovebandage – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – – – – Include inhistorytaking: The recommended dosageofantivenomis1ampoule oftheappropriatemonovalent(species All caseswhereantivenom isconsideredshouldbediscussed withaClinicalToxicologist – – – – – – – – – – impaired respiratoryeffortorperipheralweakness double vision,lossoffullrangeeyemovements muscles ofeyesandfaceaffectedfirst-droopingeyelids,uncoordinatedeyemovements, breakdown, ormyoglobin(musclebreakdown) urinalysis forblood.Ifpositivecouldberedbloodcells(bleeding),haemoglobin(redcell time ofbandageapplication first aidmeasuresused number ofstrikes appearance ofsnakeifseen time ofbite(ifnotalreadynoted) location ofbite(s)onbody geographic areabiteoccurred Snake VenomDetectionKits(SVDK) arenolongerrecommendedforuse 4,7 1,3,5,7 Shock, page 8,9 77 bites and stings 295 773 1,10,11
11 Bites and stings stat
effects Duration over 20 minutes on MO/NP order Additional doses watching for adverse Begin infusion slowly, If no adverse reaction, increase rate and infuse stop the infusion and give Extended authority 102 and resuscitation equipment ATSIHP/IHW/IPAP/RIPRN Tetanus immunisation, page Tetanus immunisation, page Section 3: Emergency | dosage (epinephrine) Anaphylaxis, page or Hartmann's Recommended Adult and child In a small child, Dilute with 450 mL dilute with 200 mL 1 vial (40,000 units) sodium chloride 0.9% to avoid fluid overload, . Consult MO/NP 102
May commonly cause anaphylaxis, rash, urticaria. Serum May commonly cause anaphylaxis, rash, urticaria. IV Ensure adrenaline Polyvalent snake antivenom Route of 9 administration polyvalent antivenom must be used polyvalent antivenom Anaphylaxis, page page Anaphylaxis, 4 or 1 ampoule of polyvalent. More than 1 ampoule is usually not required not usually is 1 ampoule than More polyvalent. of 1 ampoule or 9 Fetal death is common in pregnant snakebite victims. Obvious benefits to mother Fetal death is common in pregnant snakebite Taipan : Strength Contains Tiger snake In any circumstance where unable to positively confirm snake species positively confirm snake where unable to In any circumstance Black snake Death adder Brown snake 5 monvalents: 40,000 units/50 mL in Tasmania (tiger snake monovalent) in Tasmania plus brown snake monovalent) snake monovalent in Victoria (tiger where laboratory testing confirms the species of snake the species confirms laboratory testing where snake or museum or zoo reptile handler by a licensed identified has been of snake the species expert – – – – Schedule : In life threatening emergency situations can be injected undiluted. Continue to monitor for : In life threatening emergency situations can be In cardiac arrest undiluted antivenom, administered as a rapid IV push, may be life saving antivenom, administered as a rapid IV push, In cardiac arrest undiluted status and give booster if indicated. See Check tetanus vaccination Draw up adrenaline (epinephrine) 0.5 mL of 1:1000 for adults. Keep close at hand in the event of an 0.5 mL of 1:1000 for adults. Keep close Draw up adrenaline (epinephrine) to the antivenom. See allergic reaction/anaphylaxis minutes while antivenom is being administered Check BP and HR every 5 Patients receiving antivenom should be in a resuscitation area where an allergic reaction can be should be in a resuscitation area where an Patients receiving antivenom managed – – Monovalent antivenom is used: antivenom Monovalent – – specific) antivenom specific) Form • • • • • • Injection Management of associated emergency: readily available. If patient develops a significant allergic reaction e.g itching of the skin, hives, angiooedema, hypotension/shock and loss of consciousness, immediately adrenaline (epinephrine). See adverse effects post administration: if these occur, treat promptly adverse effects post administration: if these occur, Use in Pregnancy and fetus outweigh potential risks of antevenom Provide Consumer Medicine Information: pain) may occur up to 14 days later sickness (symptoms of fever, rash, joint and muscle Note RIPRN must consult MO/NP unless circumstances do not allow, in which case notify MO/NP as soon RIPRN must consult MO/NP unless circumstances as circumstances allow ATSIHP, IHW, IPAP and RN must consult MO/NP 296 bites and stings 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP • • • • • • • • • • • • • • • • Related topics Funnel-web (bigblack)spiderbite,page Administer analgesiaasclinicallyindicated. See Apply icepacktobitesite Reassure thepatient Perform physicalexaminationofallsystems Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – – – – Include inhistory: – – Signs andsymptomsofsystemicenvenomationwhichinclude: Generalised spreadingpainnotassociatedwithbitesuggestsredbackspider Pain associatedwithbitewilldependontheageofspiderandsizeitspincers/fangs. Localised reactions-red,swelling,hot Fang marksornomarks,withwithoutbleeding A historyofbeingbittenbyaspider Consult MO/NPonalloccasionsofsnakebite Toxicologist reduce theincidenceofserumsicknessiscontroversialandshouldbediscussedwithClinical features arerash,feverandpolyarthralgiasorpolyarthritis.Theuseofprophylacticsteroidsto Be awareserumsicknesscanoccurwithinthefirsttwoweeksafterexposuretoantivenom.The If antivenomisused,completeandsendoffthequestionnairethatcomeswitheachampoule Necrotic lesions havenotbeen reportedfrom confirmedspider bitesinAustralia 773 Check tetanusvaccination statusandgiveboosterifindicated. See – – – – – – – Spider bites(general) site andfeatureofbite first aidmeasuresused geographical locationwherebiteoccurred time ofbite description ofspider(ifseen) general feelingofbeingunwell nausea, vomiting,headache,sweating,respiratorydistress 1 1,2 Notapplicable - adult/child 297
Acute painmanagement,page Redback spiderbite,page Tetanus immunisation, page Tetanus immunisation, page 299 35 1,2 bites and stings 297
Bites and stings 3 A/Prof. Julian White Section 3: Emergency | - adult/child 13 11 26 (24 hours) can assist 13 11 26 (24 hours) can 1 Distribution of funnel web spiders in Australia Distribution of funnel A Clinician's Guide to Australian Venemous Bites and Stings. A Clinician's Guide to Australian Venemous Bites and Stings. 3 1,2 ©2013
Funnel-web (big black) spider bite (big black) spider Funnel-web Funnel-web spiders are the most dangerous spiders in Australia. Their venom can cause a the most dangerous spiders in Australia. Their Funnel-web spiders are illness, but envenomation is rare rapidly developing life-threatening The Poisons Information Centre (PIC) The Poisons Information bandage Apply pressure immobilisation All cases of suspected funnel-web spider bite should be discussed with a Clinical Toxicologist. spider bite should be discussed with All cases of suspected funnel-web Lacrimation, piloerection (erection of the hair on limbs), sweating, hypersalivation Abdominal pain, nausea, vomiting, headache Hypertension, bradycardia or tachycardia History of witnessed painful bite by big black spider with large fangs History of witnessed painful bite by big black spider Severe pain at bite site, bleeding from site, but little local reaction - no swelling/redness Tongue and other muscle twitching, tingling of the lips If severe systematic envenomation occurs, it develops rapidly, usually within 30 minutes and If severe systematic envenomation occurs, it develops almost always within 2 hours Consult MO/NP if severe or persistent local or systemic symptoms if severe or persistent Consult MO/NP Advise daily wound care and review as required care and review daily wound Advise
• • • Referral/consultation Referral/consultation • • • • • • • • • Recommend
Background
HMP HMP 1. May present with
6. 5. Follow up up Follow 5. 298 bites and stings 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical CareManual 10th edition | 4. Management • • • • • • • • • • • • • • • • • • If notevacuated/hospitalisedobservefor4hours immediately availablefunnel-webantivenom(atleast4vials)shouldbe given Note Check tetanusvaccinationstatusandgiveboosterifindicated.See Complete anECG administered the patientissymptomaticandantivenomavailableand/orafter2-4 vialshavebeen Do notremovethepressureimmobilisationbandageunlesspatient iseitherasymptomaticorif severe envenomation If antivenomisrequiredaninitial2vialsarerecommended.Furtherdosesmaybein Consult MO/NPwhomayarrangeevacuation/hospitalisationforadministrationofantivenom Nil bymouth Insert 2xIVcannula-usethelargestpossiblegaugegivenageandvascularstatus Perform physicalexaminationobservingforanysignsofenvenomation Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – – Include inhistorytaking: Apply asplinttoimmobilisethelimb Apply pressureimmobilisationbandage.See cardiorespiratory andresuscitationequipmentifpossible See inconsolable crying,salivation,vomitingorcollapse In youngchildren,thefirstindicationofenvenomingmaybesuddensevereillnesswith Anxiety Breathlessness, pulmonaryoedema – – – – – first aidmeasures geographical locationwherebiteoccurred site locationandfeaturesofthe time ofbite description ofspider(ifseen) DRS ABCDresuscitation/thecollapsedpatient,page : incardiacarrest,antivenom,administeredasarapidIVpush,may belifesaving.All 1,3 2
1,2
Snakebite includingseasnake,page 1 54 -managedinanareawith Tetanus immunisation,page773 6 292 bites and stings 299
3,4,5,6 stat minutes Duration Bites and stings in 15 minutes Inject over 2-5 on MO/NP order May be repeated Extended authority authority Extended stop the injection and give and injection the stop ATSIHP/IHW/IPAP/RIPRN and resuscitation equipment dosage Section 3: Emergency | Recommended Recommended envenomation) Adult and child (4 vials if severe Initial dose 2 vials (epinephrine)
IV . Consult MO/NP Route of 102 ) bite is not life-threatening, even to children. No deaths administration May cause anaphylaxis, rash, urticaria and serum sickness and urticaria rash, anaphylaxis, cause May Ensure adrenaline - adult/child
Funnel web spider antivenom web spider Funnel may take Anaphylaxis, page page Anaphylaxis, : dissolve Strength injections 125 units Latrodectus hasseltii 10 mL water for Reconstitute with 4 up to 10 minutes to Limited data available. Benefits to mother and fetus may outweigh potential risks Benefits to mother and fetus may outweigh potential Limited data available. Gently swirl : 2 1 1
Redback spider bite Red-back spider ( have been reported in the past 60 years Do not apply pressure immobilisation bandage Treatment is symptomatic Form : Dissolved solution should appear slightly opalescent to colourless. Anaphylaxis can occur appear slightly opalescent to colourless. : Dissolved solution should
Consult MO/NP on all occasions of suspected funnel-web spider bite Consult MO/NP on all occasions of suspected funnel-web If not evacuated/hospitalised advise to be reviewed the next day If not evacuated/hospitalised advise to be reviewed after exposure to responsible agent. The Be aware serum sickness can occur one to two weeks features are rash, fever and polyarthralgias or polyarthritis
Injection • • • (powder for Schedule • • •
reconstitution) Background Management of associated emergency: allergic reaction e.g itching of the skin, hives, readily available. If patient develops a significant immediately consciousness, of loss and hypotension/shock angiooedema, adrenaline (epinephrine). See Note rapidly Use in Pregnancy Provide Consumer Medicine Information: Provide Consumer Medicine joint and muscle pain up to 14 days later) (symptoms of fever, rash, soon as circumstances do allow soon as circumstances ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, the MO/NP as in which case notify circumstances do not allow, consult MO/NP unless RIPRN must Recommend HMP HMP
6. Referral/consultation 5. Follow up 300 bites and stings 1. Maypresentwith | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement • • • • • • • • • • • • • • • • • • • • • • the PoisonsInformationCentre(PIC) Patients whofailtorespondsimple analgesiashouldbediscussedwithaclinicaltoxicologistvia analgesia Recent trialssuggestanyeffectfrom red-backspiderantivenomislessthaneffectofstandard systemic envenomationorthediagnosis isindoubt Consult MO/NPifpatientnotresponding tosimpleanalgesia,and/ordisplayingclinicalfeaturesof MO/NP willgiveorderforchildrenifopioidanalgesiaisrequired Consult MO/NPifpatientisnotrespondingtosimpleanalgesia Administer analgesiaasclinicallyindicated.See Clean thewoundwithantisepticorwashsoapandwatertohelpprevent secondaryinfection Apply anicepack,orheattobitesite Reassure thepatient – – Perform physicalexamination: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – Include inhistorytaking: Very rarely,severecasescanleadtoprogressivemuscularparalysis several days,howevertheymaypersistforweeksormonths If untreatedthesymptomsmayincreaseinseverityoverseveralhoursandoftenresolve Mild toseverehypertensionandtachycardia Headache, nausea,vomiting,abdominalpain Less commonlyared,hotorswollenbitesite bite siteandspreadsgradually Localised, patchysweatingandpiloerection(erectionofhair)canoccurwithinanhouraroundthe becomes verypainful,withpainradiatingfromthebitesitetobecomeregionalandthengeneral Intense localpain.Thebiteisnotpainfulatfirst,butbetween10-40minuteslaterthesite Puncture marksarenotalwaysseen A historyofbeingbittenbyaspider 773 Check tetanusvaccination statusandgiveboosterifindicated. See Do notapplyapressureimmobilisationbandageforredbackspiderbites.Envenomingis – – – – – features ofbite location ofsite first aidmeasures time andlocationofbite description ofspider(ifseen) 1 1,3 2 life threateningandresuscitationisrarelyrequired
SeeManagement 13 1126(24hours)
Acute painmanagement,page Tetanus immunisation, page Tetanus immunisation, page 35 bites and stings 301 Bites and stings 35 Tetanus immunisation, page . Put both limbs in hot water to 3 Section 3: Emergency | - adult/child Acute pain management, page
centipede bites centipede Not applicable 2 3,4 1 site and feature of sting/bite time and location of sting/bite first aid measures description of sting/bite (if seen)
localised to sting site Scorpion stings and Scorpion Australian scorpion and centipede species do not cause systemic envenomation. Symptoms are centipede species do not cause systemic envenomation. Australian scorpion and – – – – Consult MO/NP if patient not responding to simple analgesia Check tetanus vaccination status and give booster if indicated. See 773 elderly and diabetic. Continue until resolution of pain, or for at least 90 minutes elderly and diabetic. Continue until resolution of Administer analgesia as clinically indicated. See Clean the wound with soap and water to help prevent secondary infection For centipede stings, alternate pain relief to ice pack includes immersion of affected area in hot For centipede stings, alternate pain relief to ice tolerate (45°C) water or under a shower as hot as the patient can and those with poor peripheral circulation e.g. gauge heat. Use with caution in young children Reassure patient Apply an ice pack to sting/bite site Response Tools) Perform physical examination: – – – score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Include in history taking: – malaise Severe local pain is common lasting 15-45 minutes, occasionally longer Severe local pain is common itchiness around sting site Centipede stings may cause and self-limiting include nausea, headache and Occasional systemic symptoms mild, non-specific History of sting/bite scorpion/centipede May or may not have seen and tingling sting/bite - red, tender, mild swelling, numbness Local symptoms at site of Consult MO/NP if severe or persistent local or systemic symptoms if severe or persistent Consult MO/NP Review symptoms and wound daily and wound symptoms Review
• • • • • • • • • • • • • • • • • • •
Recommend
HMP HMP 4. Management 3. Clinical assessment 2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up up Follow 5. 302 bites and stings Tick 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • Related topics
Anaphylaxis, page • • • • • Symptoms canworsenforupto48hours afterkillingthetick – – – – Tick paralysisusuallytakesseveraldaystooccurandcanresultin: at aperipheralsite Evidence oftick:attachmentsitesareoftenclosetothetrunkafterinitially droppingontothebody If tickislocatedonthepatient'shead-swellingofface,eyes Initially, localitchingandirritation6-12hoursafterbite Allergic reaction-rangingfromlocalisedswellingtoseverelife-threatening anaphylaxis Consult MO/NPasaboveorifsystemicsymptoms Advise dailywoundcareandreviewasrequired Check for medicalalertjewellery See See paralysis/tick typhus – – – – MO/NP Note in thehost pose anallergyrisk.Inaddition,aportionofthetick’sheadormouthpiecemayremainembedded Removal ofticksinthismannermayresultthereleasehigheramountstoxinthatcould Previous guidelineshaverecommendedvarioustickremovaldevicesortheuseoffineforceps. inject furthersaliva/toxinintothebody as applyingheatorusingkerosenemethylatedspirits,thesemethodsmaycausethetickto Ticks should notberemovedbutkilledandallowedtodropoff Ixodes saliva producespotentiallysevereandlethalconsequencesinsusceptiblehumans There arenumerousspeciesoftickinAustralia,butonlyonegenus( Tick bites cranial nervepalsy(changestofacial movements,sensorychanges) visual symptomssuchasdifficultyreadinganddoublevision muscle weaknessleadingtodifficultywalking,poorbalanceand coordination regional nervepalsy(numbness,tingling, paralysisinlimbs,handsorfeet) Anaphylaxis, page DRS ABCDresuscitation/the collapsedpatient,page : ticksandscrubmitesmaycarryrickettsiathatcauseticktyphus arefoundthroughouteasternAustraliaandTasmania 1 3,4
102 -adult/child 102 4
54 Ixodes . ) includestickswhose Avoid methodssuch 2 . Consult bites and stings 303 Bites and stings 35 102 or applying permethrin ® Tetanus immunisation, page Section 3: Emergency | Anaphylaxis, page 415 Acute pain management, page
, Elastoplast Cold Spray ® Scabies, page 5 tick cream to small ticks. See ®
4
inspect in hair, between buttocks, groin, labia, ear canals and skin folds if tick envenomation is buttocks, groin, labia, ear canals and skin folds inspect in hair, between as there may be more very difficult to find. Don't stop if one is found, suspected. They can be inspect for ticks. The size of the tick will depend on the type and developmental stage will depend on the type The size of the tick inspect for ticks. due to reaction to A small lump due to bite can persist for weeks inspect for tissue reaction. foreign material first aid measures estimate of how long patient has had the tick had the patient has of how long estimate have occurred area where exposure may geographical ether-containing spray e.g. Wart-Off Freeze e.g. Lyclear brush tick away Wait for the tick to drop off, and then carefully Do not use a tick removal device the Australian Society of Clinical To kill the tick and minimise the risk of allergic reaction, the tick by the application of an Immunology and Allergy (ASCIA) recommends freezing For small ticks (larvae or nymphs) the recommendation is to apply permethrin cream to kill For small ticks (larvae or nymphs) the recommendation them and allow them to drop off attempt made to ensure tick falls off When located, the tick is carefully killed with every use any methods which may agitate the tick Take care not to squeeze the body of the tick or It is recommended that tick removal is achieved by killing the adult tick on the skin with a It is recommended that tick removal is achieved This may take up to 24 hours freezing product and then allowing it to fall off. – – – – – –
• Advise daily wound care after removal and review as required It is normal for a tick bite site to remain swollen and inflamed for several days Consult MO/NP if any signs of tick bite paralysis. The MO/NP will arrange evacuation/ hospitalisation Administer analgesia as clinically indicated. See if indicated. See Check tetanus vaccination status and give booster 773 After tick has fallen off, clean the wound with antiseptic or wash with soap and water to help After tick has fallen off, clean the wound with prevent secondary infection swelling Apply a cold compress to help reduce pain and facilities available and under the guidance of MO/NP. See facilities available and under plan which should be to exist, patient may have an allergy action Where severe allergy is known followed paralysis similar to Bell's palsy may occur paralysis similar to Bell's area with resuscitation tick allergy, tick removal should be done in an If the patient has a known – to a limb. Facial muscle weakness and paralysis which can be localised Observe for progressive Perform physical examination: Perform physical – – – Warning and or other local Early (full Q-ADDS/CEWT score clinical observations Perform standard Response Tools) Include in history taking: in history Include – –
Procedure for removal of • • • • • • • • • • • • • • • • • • •
5. Follow up
4. Management 3. Clinical assessment Clinical 3. 304 bites and stings 6. Referral/consultation | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • • • • • • Related topics Irukandji syndrome,page • • • • • • will increasetheabsorptionoftoxin making firstaidandothermanagement difficult.Furthermore,muscularexertionisdangerousasit Restrain thepatientifnecessary.Severe painmaycauseirrationalbehaviourandvigorousactivity, seconds. Useseawaterifnovinegar isavailable Douse thestingareaandalladherent tentacleswithcopiousamountsofvinegar,foratleast30 Gently removevisibletentacleswith forcepsorglovedfingers,takingcaretoavoidskincontact advises tostop Even ifrespiratoryorcardiacarrest,andnoantivenomavailable,continue CPRuntilMO/NP Consult MO/NPforrequiredresuscitationmedicines See Cardiorespiratory arrest Loss ofconsciousness Attached jellyfishtentacles Wide (upto1cm)whip-likestingmarks,withacharacteristicfrostedladder pattern Severe immediatepaintypicallylastingupto8hours Consult MO/NPifsevereorpersistentlocalsystemicsymptomsevidenceofallergicreaction If symptomshavenotfullyresolvedwithin72hours,advisepatienttoreturn they shouldreturnifsymptomsworsen Advise patientthatsymptomsmaybecomeworseforupto48hoursaftertickremovaland Nil bymouth – Insert 2xIVcannula -usethelargestpossiblegauge given ageandvascularstatus – Box jellyfishinhabitestuariesandcoastalwatersclosetoshore that containingmillionsofstingingcellsdischargeintotheskinuponcontact Box jellyfishhavealargeboxlikebodyaround20-30cminsizeandmultiplelongtentacles Give antivenomassoonpossibleifthereisevidenceoflifethreateningenvenoming CPR, mayrequireprolongedCPR Several metresoftentaclecontactcanresultinrapidcardiovascularcollapseanddeath.Initiate any undischargedstingcells Remove tentaclesifpossiblewithcareanddouseallvisiblestingsitesvinegartoinactivate Antivenom isavailable Box jellyfish( if notpossibletoachieve IVaccessintraosseousroute shouldbeconsidered DRS ABCDresuscitation/thecollapsedpatient,page 1,3 1,2 3
306 Chironex fleckeri 1,4 ) envenomation 54 -adult/child bites and stings 305 3,4,7
Bites and stings stat . An IV opioid Duration 35 Infuse over 5-10 minutes
102 given on MO/NP order ATSIHP/IHW/RIPRN Extended authority Additional doses may be at least 6 vials are given) CPR should continue until (if patient in cardiac arrest Section 3: Emergency | Anaphylaxis, page page Anaphylaxis, 5 See Acute pain management, page Acute pain management, dosage
or Hartmann's Child < 5 years Recommended 0.9% or Hartmann's Serious adverse effects e.g. anaphylaxis and serum Serious adverse effects e.g. anaphylaxis and Adult and child ≥ 5 years 1:10 with sodium chloride 1 vial (20,000 units) diluted 1 vial (20,000 units) diluted 1:5 with sodium chloride 0.9% Consult MO/NP. Box jellyfish antivenom
IV Route of 4 administration 4 units 20,000 Strength note: ensure you have gloves on to avoid envenomation note: ensure you have gloves time of sting first aid measures taken attach to monitor and observe for arrhythmias attach to monitor ECG note in particular cardiovascular system - BP and HR cardiovascular system note in particular
– – – – – – : In cardiac arrest, undiluted antivenom, administered as a rapid IV push can be lifesaving. In the : In cardiac arrest, undiluted antivenom, administered n cardiac arrest, undiluted antivenom, administered as a rapid IV push can be lifesaving n cardiac arrest, undiluted antivenom, administered Schedule Give box jellyfish antivenom for systemic envenomation I Administer analgesia as clinically indicated. See Administer analgesia as MO/NP will be necessary. Consult pain Application of ice packs to affected areas can reduce Manage patient in area equipped for cardiorespiratory monitoring and resuscitation if possible equipped for cardiorespiratory monitoring and resuscitation Manage patient in area Consult MO/NP arrest. This should continue for at least 1 hour Continue CPR if in cardiac – Include in history: – – removed tentacles for toxicology in sealed container If possible, retain some – – size and features of sting examination - site, Perform physical Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Early Warning other local score or Q-ADDS/CEWT (full clinical observations standard Perform Tools) + Response –
Form • • • • • • • • • • • Injection ATSIHP, IHW and RIPRN may proceed RN must consult MO/NP Management of associated emergency: sickness have not been reported with box jellyfish antivenom. Transient rash may occur sickness have not been reported with box jellyfish Note event of IV access not being obtained, the antivenom can be given IM, however studies have shown that IM antivenom is poorly absorbed Provide Consumer Medicine Information:
4. Management 3. Clinical assessment Clinical 3. 306 bites and stings 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • Related topics Box jellyfish(Chironexfleckeri)envenomation,page • • • • • Douse thestingarea andalladherenttentacleswithcopious amountsofvinegar,foratleast 30 Insert 2xIVcannula-usethelargest possiblegaugegivenageandvascularstatus In theeventofrespiratoryorcardiac arrest,continueCPR(EAR±ECC)untilMO/NPadvisestostop Consult MO/NPforrequiredresuscitation medicines See – – – – – – – – – Onset ofsystemicsymptoms15-40minutesaftersting: Minor short-livedpainwithinitialstingormaygounfeltinitially circumstance allow Consult MO/NPonalloccasionsofsuspectedboxjellyfishenvenomationorassoon All patientswithenvenomationfromboxjellyfishwillneedevacuation/hospitalisation Gently removevisible tentacleswithforcepsorgloved fingers,takingcaretoavoidskin contact seconds. Useseawater ifnovinegarisavailable
– – – – – – – – – have amajorenvenomation Only asmallareaofskincontact,aslittlefewsquarecentimetres,isrequiredtobestung Unlike boxjellyfish,Irukandjistingscanoccurneartheshoreorfaroffshoreintropicalwaters symptoms, withasmallnumberofpatientsdevelopingcardiacfailure Irukandji ( This syndromeisassociatedwithstingsbystingingcellsonthetentaclesandbodyof Apply generousvolumesofvinegartoallvisiblestingsites.Noantivenomisavailable Stings maygounnoticedbutwithin20minutesdevelopseveregeneralisedpaininabdomen, Irukandji syndrome back andchest severe hypertension,tachycardia can mimicsymptomsofdecompressionillness severe painintheback,limbsandabdomen vomiting generalised sweating feeling unwell sense ofimpendingdoom severe agitation,restlessness generalised back,abdominal,chestandmusclepain DRS ABCDresuscitation/thecollapsed patient,page 1 2 Carukia barnesi 3,4 ) andsomeotherspeciesofjellyfishcanresultinlifethreatening 4 -adult/child 304 54 bites and stings 307
6 Bites and stings 35 Section 3: Emergency | Acute pain management, page
13 11 26 if assistance is required or referral to a 13 11 26 if assistance is required or referral to a 151 4 , respirations 2
2 4,5 Acute hypertensive crisis, page
trinitrate (GTN) whilst awaiting evacuation. May repeat as required on MO/NP orders trinitrate (GTN) whilst awaiting evacuation. May MO/NP may commence IV glyceryl trinitrate infusion See if systolic BP > 200 mmHg and/or diastolic BP > 120 mmHg - give 2 sprays sublingual glyceryl if systolic BP > 200 mmHg and/or diastolic BP > 120 first aid measures used document site, size and features of sting document site, size and time of sting auscultate the chest for added sounds (crackles or wheezes), as an indication of pulmonary added sounds (crackles or wheezes), as an indication auscultate the chest for oedema monitor BP (severe hypertension may occur) hypertension may monitor BP (severe until evacuation and observe for arrhythmias attach to monitor ECG monitor RR and any signs of respiratory distress any signs of respiratory monitor RR and – – – – – – – – – – –
Consult MO/NP in all cases of suspected irukandji syndrome Consult MO/NP in all cases of suspected irukandji All patients to be evacuated and hospitalised Contact Poisons Information Centre (PIC) Clinical Toxicologist is required – – Administer analgesia as clinically indicated. See number of deaths have occurred due to Control of hypertension may be life saving as a intracerebral haemorrhage: – Consult MO/NP who will arrange evacuation Consult MO/NP who will Apply high flow O Monitor BP, HR, SpO – – Include in history taking: – Perform physical examination: Perform physical – – Cardiac monitoring: – – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Early Warning other local score or Q-ADDS/CEWT (full clinical observations standard Perform Tools) + Response –
• • • • • • • • • • • •
6. Referral/consultation 5. Follow up
4. Management 3. Clinical assessment Clinical 3. 308 bites and stings 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup 4. Management HMP Recommend • • • • • • • • • • • • • • Transport tohospitalormedicalinterventionisrarelyrequired – – Consult MO/NPif: Review ifanyindicationofsystemicsymptomse.g.nausea,headacheor malaise Monitor forallergicreactions Administer analgesiaasclinicallyindicated.See circulation e.g.elderlyanddiabetic.Continueuntilresolutionofpain,orforatleast20minutes hot watertogaugeheat.Usewithcautioninyoungchildrenandthosepoorperipheral Immerse affectedareainwaterorshowerashotpatientcantolerate(45°C).Putbothlimbs Gently pickoffanyremainingtentacleswithforcepsorglovedfingers – Perform physicalexamination: – – Include inhistory: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Systemic effectsareuncommon Linear orspindle(elliptical)redwelts Immediate burningpain(lastsupto2hours) – – – – – Bluebottle ( Do notusevinegar.Itisonlyusedforboxjellyfish( systemic effects,ordoubtovercauseofsting(suspectboxjellyfish Irukandji Syndrome) pain notcontrolledbyoralanalgesia site, sizeandfeaturesofsting first aidmeasuresused time ofsting 1 1,3,4,5 Physalia 1,2
Notapplicable ) and other jellyfishstings
Acute painmanagement,page Chironex Fleckeri ) andIrukandjiSyndrome -adult/child 35 bites and stings 309 Snakebite Bites and stings - adult/child Section 3: Emergency | 54 cone shell envenomation shell cone 2,3,4 292 1,2,3 1,2 2 DRS ABCD resuscitation/the collapsed patient, page DRS ABCD resuscitation/the collapsed patient, page pay particular attention to cardio/respiratory system and neurological assessment time of sting (if possible) first aid measures indication of time of commencement of paralysis double vision difficulty swallowing ptosis, drooping upper eyelid blurred vision harpoon with toxins from their mouths which pierces the skin which pierces the skin toxins from their mouths harpoon with to respiratory failure by paralysis leading both molluscs causes death Venom from Toxins are found in blue-ringed octopus saliva and envenomation occurs from bites by distressed occurs from bites by saliva and envenomation in blue-ringed octopus Toxins are found octopus small a firing by sting They waters. tropical Australian in found are shell cone of species Many Blue-ringed octopus are found in coastal areas throughout Australia including Tasmania areas throughout Australia octopus are found in coastal Blue-ringed – – – – – – – –
Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – – – – Include in history: Apply a pressure immobilisation bandage over the wound site and involved limb. See Apply a pressure immobilisation bandage over the including sea snake, page Apply a splint to immobilise the limb See Continue CPR until MO/NP advises to stop Can progress to muscle unco-ordination and weakness, disturbance of speech, vision and even Can progress to muscle unco-ordination and weakness, hearing loss paralysis if severe envenomation Swallowing/breathing difficulties and respiratory Local pain, swelling and numbness – – Flaccid paralysis - occurs within minutes of sting Respiratory/cardiac arrest Early signs of systemic envenomation: – – Tingling sensation around the mouth and tongue Tingling sensation around or absent Local symptoms are minimal beach shortly after a minor sting Collapse on or near the Often painless sting •
• • •
• • • • • • • • • • • • • • • • Background
Cone shell Blue-ringed octopus
3. Clinical assessment 2. Immediate management
1. May present with Blue-ringed octopus and and octopus Blue-ringed 310 bites and stings 6. Referral/consultation 5. Followup 4. Management | Primary Clinical CareManual 10th edition | 1. Maypresentwith Stonefish, bullrout, HMP Stonefish sting Bullrout sting Background Recommend • • • • • • • • • • • • • • • Related topics Sea urchininjuries,page Acute wound(s),page • • • • Cardiovascular signs Nausea, vomiting,dizziness,shortness ofbreath Systemic effectsarerare Tissue necrosisandinfectionpotentially gangrene Barb orspineinsitu Mechanical traumafrombarb Local swelling,bruising,puncturemarks Immediate andintensepainwhichmaybeoutofproportiontotheextent ofthewound Consult MO/NPinallcasesofsuspectedblue-ringedoctopusorconeshellenvenomation suspected, thebandageshouldbeleftinsituuntilevacuated/hospitalisedinanappropriatefacility Do notremovepressurebandageifenvenomationbyblue-ringedoctopusorconeshellis Cardiorespiratory resuscitation,continueuntilhelparrives/evacuation/transfer If indicatedprovideairwaysupport Consult MO/NP,whowillorganiseevacuation – Perform physicalexamination: In severecasesheadache andvomiting
– Moments), scats,andother Many speciesoffishcancausepainfulstings,includingscorpion(lion)fish,rabbitfish(Happy Severe systemicenvenomationisuncommon Most fishstingsareminoranddonotrequiremedicalintervention Do notapplypressureimmobilisationbandage Fish stings site, sizeandfeaturesofsting 1 3,4 198 - 1,3 adult/child 314 1 cat fishand other spinyfish 2 Water relatedwounds,page 209 bites and stings 311 4 Bites and stings Water related and 35 . Stonefish 8 198 Tetanus immunisation, page Section 3: Emergency | Acute wound(s), page 198 Acute pain management, page . See 4 4 4 Acute wound(s), page 4 : 209 : caution if/when combining with immersion of wound in hot water : caution if/when combining with immersion of
note – antibiotics may be necessary check tetanus vaccination status and give booster if indicated. See check tetanus vaccination status and give booster 773 elevate wound foreign bodies irrigate the wound with sodium chloride 0.9% do not close, this allows for drainage and healing body is suspected x-ray (if available and MO/NP orders) if a foreign incising and opening the entry of the wound may be necessary incising and opening the entry of the wound may dead tissue excised all wounds must be thoroughly cleaned and irrigated, imaging may assist in identifying any pieces of spine should be removed and radiographic consult MO/NP regarding opioid analgesia - depending on severity of injury may order IV consult MO/NP regarding opioid analgesia - depending morphine lidocaine (lignocaine) 1% subcutaneously infiltrated around the wound is effective lidocaine (lignocaine) 1% subcutaneously infiltrated – any requirement for antibiotic prophylaxis stonefish sting with systemic symptoms stonefish sting with systemic day or more after injury) of any stings/wounds delayed presentation (a cannot be adequately excised and cleaned any stings/wounds that large or deep wounds all stonefish stings that warrant opioid analgesia all stonefish stings that inspect site of injury. See inspect site of injury. See time of injury circumstances of injury circumstances – – – – – – – – – – – – – – – – – – – –
antivenom must always be administered in a critical care area with readily available resuscitation antivenom must always be administered in a critical care area with readily available resuscitation drugs and equipment – Evacuation/hospitalisation and MO/NP may consider administration of stonefish antivenom for systemic symptoms or severe pain Stonefish antivenom can be given IM however IV is likely to be more effective – – – – – – – – – Apply general principles of wound management wounds, page Options for pain control may include: – – Reassure the patient Administer analgesia as clinically indicated. See – – – – Consult MO/NP for: – Perform physical examination: – – local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) Include in history: – Pain relief - immerse affected area in water or shower as hot as patient can tolerate (45°C). Put both (45°C). can tolerate as hot as patient or shower area in water affected - immerse Pain relief peripheral with poor and those children caution in young Use with to gauge heat. in hot water limbs least 90 minutes or for at of pain, until resolution Continue and diabetic. e.g. elderly circulation
• • • • • • • • • • •
4. Management
3. Clinical assessment 3. Clinical 2. Immediate management Immediate 2. 312 bites and stings | Primary Clinical CareManual 10th edition | 1. Maypresentwith 6. Referral/consultation 5. Followup HMP Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP MO/NP. See Management ofassociatedemergency: Note or tremors Recommend Injection Schedule • • • • • • • • Related topics Acute wound(s),page Form • • History ofinjuryfromstingray Consult MO/NPasabove Review wounddailyinitially asymptomatic foraperiodof4hours Those treatedwithopioidanalgesiaorantivenommaybedischargedwhentheyhavebeen further observation Stonefish sting-peoplewithoutclinicalfeaturesofsystemicenvenomingat2hoursdonotrequire Barb orspine insitu Local traumaand severe pain Lacerations : Usethelowestdosethatresultsineffectiveanaesthesia Do notusethepressureimmobilisationtechnique treated asamedicalemergency Any stingraywoundonthetrunk,eveninabsenceofapparentlysignificant injury,shouldbe Stingray injuries 50 mg/5mL Anaphylaxis, page Strength 1% 4 198 1 administration 102 Route of Subcut - adult/child 1,2
Lidocaine (lignocaine) Ensureresuscitationequipmentreadilyavailable.Consult 1 Reportanydrowsiness,dizziness,blurredvision,vomiting up to3mg/kgatotalmax.of child ≥12yearsor>50kg up tomax.of3mg/kg Child <12years Recommended 2 Adult and 200 mg dosage Water relatedwounds,page
ATSIHP/IHW/IPAP/RIPRN Extended authority 209 Duration stat 5,6,7 bites and stings 313 1,2,3 Bites and stings . Oral 35 183 4
2 209 Section 3: Emergency | Check tetanus vaccination status and give 4 Abdominal injury, page Abdominal injury,
768 , Acute pain management, page 171
2 Water related wounds, page 2
Chest injuries, page Chest injuries, Immunisation program, page 1
site, size and features of injury site, size and features of time of injury used first aid measures – – –
Stingray wounds to trunk require immediate evacuation for surgical assessment Stingray wounds to trunk require immediate evacuation for possible wound debridement or surgery Transport to hospital or medical intervention Advise daily wound care and review as required Tetanus prophylaxis may apply for penetrating injuries. booster if indicated. See MO/NP may consider antibiotics. See Apply local pressure for bleeding Administer analgesia as clinically indicated. See IV opioid may be necessary paracetamol may be sufficient analgesia or an Pain relief - immerse affected area in water or shower as hot as patient can tolerate (45°C). Put both Pain relief - immerse affected area in water or shower in young children and those with poor peripheral limbs in hot water to gauge heat. Use with caution resolution of pain or for at least 90 minutes circulation e.g. elderly and diabetic. Continue until Wash the wound site. Do not remove penetrating barbs, especially those affecting the chest and not remove penetrating barbs, especially those Wash the wound site. Do abdomen bluish white appearance of the wound bluish white appearance diarrhoea, sweating, they include nausea, vomiting, muscle cramps, Systemic effects are rare, syncope and cardiac arrhythmias Perform physical examination: – and a characteristic pain which spreads to the entire limb, swelling Observe for increasing local – – local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) Include in history: Do not remove any embedded barbs in chest or abdomen, place padding around or above and or above around place padding or abdomen, barbs in chest embedded remove any Do not bleeding. to control over the pads pressure barb and apply below urgently. See If on trunk treat
• • • • • • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management
3. Clinical assessment 3. Clinical 2. Immediate management Immediate 2. 314 bites and stings | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Recommend Background • • • • • • • • • • • • • • Related topics Acute wound(s),page • • • elderly anddiabetic. gauge heat.Usewithcautioninyoung childrenandthosewithpoorperipheralcirculatione.g. patient cantolerate(45°C)forupto 90 minutes.Putbothlimbsinhotwatersoindividualcan Additional paincontrolmeasuresinclude immersingaffectedareainwaterorshowerashot Administer analgesiaasclinicallyindicated. See X-ray mayberequiredtoidentifyany embeddedspines 773 Check tetanusvaccinationstatusandgiveboosterifindicated.See it isunlikelythatembeddedspinesarepresent Skin discolourationmayindicatethepresenceofspines.If resolveswithin46hours, Removal ofspinesclosetosurface.Soapandwarmwatermaydissolve spines Remove visiblespines Wash thewoundsite – Perform physicalexamination: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – Include inhistory: Embedded orbrokenoffspines Redness, swelling,bleedingfrommultiplepuncturewounds Local pain – – – Injuries arecommonwhereanindividualhassteppedonorfallenontoaseaurchin Spines easilybreakoffdeepinthewound. Sea urchinshavelong,sharpspinesthatcanpenetrateflesh,rubbersoledshoesandwetsuits. General principlesofwoundmanagementforpenetratingwoundsshouldbefollowed Sea urchininjuries site, sizeandfeaturesofinjury first aidmeasuresused time ofinjury 2 1 1,3 198 1 -adult/child Notapplicable Acute painmanagement,page Water relatedwounds,page Tetanus immunisation, page Tetanus immunisation,page 35 209 bites and stings 315 Bites and stings 35 Section 3: Emergency | Acute pain management, page Not applicable
1,2 1 - adult/child 3 1,2
site, size and features of sting first aid measures used time of sting Sponges Species of venomous sponges can be found in all coastal waters of Australia Species of venomous sponges are rare Sponge related injuries – – –
Usually not required Review if any ongoing symptoms Wash the site See Oral paracetamol is usually sufficient analgesia. Perform physical examination: – – score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) Include in history: – weeks Occasionally prolonged symptoms of erythema, but also vesicles, local swelling and joint stiffness symptoms of erythema, but also vesicles, local Occasionally prolonged can develop and peeling of the skin can occur after 2-3 Fire sponges are reported to cause delayed reactions Mild local itching and stinging Transport to hospital for medical intervention if required hospital for medical intervention Transport to Review if any ongoing pain or indication of retained spines. Sharp, localised pain exacerbated by exacerbated localised pain Sharp, retained spines. indication of pain or if any ongoing Review may be or ultrasound x-rays in tissue. Further spines retained may indicate of pressure application required
• • • • • • • • • • • • • • Background
HMP HMP 6. Referral/consultation
5. Follow up 4. Management 3. Clinical assessment 2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up Follow 5. 316 bites and stings 1. Maypresentwith | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement HMP Background • • • • • • Related topics Acute gastroenteritis/dehydration-adult,page • • • • – – – Obtain afullhistoryincluding: Take bloodsforUE Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – – – – Symptoms aregroupedintoneurological,gastrointestinalornon-specific: ciguatoxins Symptoms ofciguaterapoisoningdevelopwithin6-12hoursingestionfishcontaminatedwith in hoursbeforepresentation Ask aboutanysymptoms, particularlygastrointestinal symptoms,thatmayhavebeenexperienced – – – – – – – – including hallucinationsanddizziness,ataxia Pacific andIndianOceanciguateracanbeassociatedwithongoingmentalstatuschanges, Diagnosis isclinicalasnolaboratorytestsexistforciguatera Ciguatera iscausedbytheingestionoffishwhichcontainciguatoxins Ciguatera poisoning Ciguatera poisoningisrarelyfatal – – non-specific: – – – – – – – – – neurological: – – gastrointestinal: pruritis dehydration how manyotherindividuals whoatethefishalsofeel unwell when ingested type andamountoffishingested – – – – – – – – – – – – – onset ofsymptomscanvary,usuallywithin1to48hoursingestion slow HR,heartblockhypotension neurological symptomsappearover24hours breathlessness sweating, chills pain onpassingurine joint andmusclepain headache, weakness,faintness,fatigue hot andcoldsensationreversedsuchthatitemsgiveaviceversa sensation thatteethareloose numbness andtinglingofthehandsaroundmouth gastrointestinal symptomsoccurearlyandresolvewithin12hours moderate toseverenausea,vomiting,diarrhoea,abdominalpain 1 1,2,3 2,3 Notapplicable -adult/child 243 2 Toxicology (poisoningandoverdose),page 259 bites and stings 317 Acute 259 Bites and stings 48 Section 3: Emergency | 2 Nausea and vomiting, page Nausea and http://disease-control.health.qld.gov.au/ Toxicology (poisoning and overdose), page Toxicology (poisoning and and
243
2,3
2,3
ongoing mental status changes depression, anxiety difficulty walking fatigue, malaise (which may be debilitating) pork, chicken nuts alcohol caffeine non-toxic seafood, gastrointestinal symptoms usually settle in 1-4 days gastrointestinal symptoms the joint and muscle pains, weakness and temperature reversal may take weeks to months to weakness and temperature reversal may take the joint and muscle pains, resolve completely – – – – – – – – – – –
Contact your Public Health Unit by telephone Reporting resources for Queensland available at Condition/731/ciguatera-poisoning Ciguatera is a notifiable condition in Queensland and may be in other jurisdictions Ciguatera is a notifiable condition in Queensland – – – – If not evacuated/hospitalised advise to be reviewed the next day If not evacuated/hospitalised advise to be reviewed Consult MO/NP if there is: – Opioids can exacerbate symptoms – – – months be avoided for 3-6 by ingestion of some foods and these should Symptoms can be exacerbated months, including: – – in those who have of toxin may lead to a recurrence of symptoms Ingestion of very small amounts type of fish for at least 3-6 by ciguatera. The patient should avoid eating any been recently affected regard to the safety of breastfeeding may be necessary regard to the safety of breastfeeding Advise the patient that: – Consider non-ciguatera causes such as gastric infection or organophosphate poisoning. See poisoning. as gastric infection or organophosphate causes such Consider non-ciguatera - adult, page gastroenteritis/dehydration infants and advice with through breast milk. Assessment of breastfed Ciguatoxin may be passed If bradycardia (slow HR), hypotension or moderate to severe symptoms - insert 2 x IV cannula - use symptoms - insert 2 x IV or moderate to severe (slow HR), hypotension If bradycardia and vascular status gauge given age the largest possible See as clinically indicated. Administer antiemetic symptoms of ciguatera poisoning of ciguatera symptoms ciguatera poisoning in all cases of suspected Consult MO/NP If patient has breastfed an infant since consuming fish, infant should be fully assessed for assessed be fully should infant fish, consuming since infant an has breastfed If patient
• • • • • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management 318 bites and stings | Primary Clinical CareManual 10th edition | Page leftintentionallyblank 4
General
319 320 Mild and moderate allergic reactions Mild andmoderate | Primary Clinical Care Manual 10th edition | Maypresentwith 1. HMP Allergic rhinitis(hayfever) Urticaria Background Recommend • • • • • • • Related topics Acute asthma, page 119 Anaphylaxis, page 102
• • • •
Watery, itchyeyes(allergicconjunctivitis)mayoccurconcurrently Itchy throat,frequentneedtoclearthroat Clear rhinorrhoea,nasalobstruction/congestion Sneezing, itchynose,sniffing,upwardrubbingofnose Angio-oedema sometimesco-exists-swellingofface,tongueorlips Associated itching,orsometimesburningsensation Central swelling(wheal)ofvariablesize,surroundedbyerythema( Urticaria,allergicrhinitis rhinitis-hay-fever-and-sinusitis/allergic-rhinitis-treatment-plan ASCIA Actionplanforallergicrhinitisavailableat considered chronicurticaria Acute urticariacanlastfromafewminutesto24hours.Ifitlastslongerthan6weeksis cardiovascular and/orgastrointestinalsymptoms or angio-oedema.Severeallergicreactions(anaphylaxis)alsoinvolvesrespiratoryand/or Mild allergicreactionstypicallyinvolveskinfeatures-urticarialrashorerythema,flushingand/ Be alerttosignsofanaphylaxis(severeallergicreaction) 3 • • • • • 1,2
Swelling/tightness inthroat Swelling of tongue Difficult/noisy breathing And/or anyacuteonset: Difficulty talking/hoarse voice – – persistent severe gastrointestinal symptoms hypotension, bronchospasmorupper airwayobstruction,OR illness withskinfeatures PLUSrespiratory/cardiovascular or Be alerttosignsofanaphylaxis(severeallergicreaction) allergic reactions 4 Allergic conjunctivitis, page 382
- adult/child • • • •
pain -for insect stings/bites Vomiting and/orabdominal Pale and floppy (young children) Persistent dizziness orcollapse Wheeze orpersistent cough
https://www.allergy.org.au/patients/allergic- hives) Mild and moderate allergic reactions 321 Anaphylaxis, page page Anaphylaxis,
Allergic conjunctivitis, page 382 page conjunctivitis, Allergic Mild and moderate allergic reactions allergic moderate and | Mild Section 4: General Acute asthma, page 119 page asthma, Acute 5 4,6 5 describe lesions - red, swollen, flat, linear pattern describe lesions - red, swollen, flat, linear pattern are lesions diffuse, itchy, painful
– – suspected irritant is a medicine before recommending to cease suspected irritant is a medicine before recommending angio-oedema e.g. swelling of face, tongue or lips auscultate chest for wheezes. See inspect eyes for watering/redness. See inspect skin: – – coexisting conditions e.g. asthma, eczema coexisting conditions e.g. recent intake of foods - seafood, peanuts recent intake of foods - seafood, with irritant time of potential contact current medications contact with plants - stinging tree contact with plants - stinging bird lice, honey bees contact with animals - caterpillars, recent viral infection or insect bite - common causes of urticaria in children common causes of urticaria or insect bite - recent viral infection used, was it effective previous episodes, treatment topical medicines, e.g. nickel, detergents, cosmetics, rubber, contact with irritant/allergens dust mite, animal dander, moulds, pollens shampoo, hair dye, clothing, any known allergies/triggers
– – – – – – – – – – – – – – – 102 Oral antihistamine may be effective to treat angioedema; if not, MO/NP may order oral prednisolone Children > 12 years and adults may need another dose late afternoon Children > 12 years and adults may need another If sleep of older children or adults is disturbed, add a sedating antihistamine at night (promethazine) Usually self-limiting or loratadine Treat with oral non-sedating antihistamine - cetirizine Reduce doses as symptoms improve rhinitis, if not, refer to next MO/NP clinic Check patient has ASCIA treatment plan for allergic – and/or oral non-sedating antihistamine - Treat with intranasal corticosteroid (budesonide) cetirizine or loratadine Consult MO/NP if: – – – – – local Early Warning observations (full Q-ADDS/CEWT score or other Perform standard clinical and Response Tools) Perform physical examination: – – – – – – – – Obtain complete patient history: Obtain complete – If any signs of anaphylaxis give adrenaline (epinephrine) without delay. See without (epinephrine) adrenaline give signs of anaphylaxis If any
• • • • • • • • • • • • •
Urticaria Allergic rhinitis 3. Clinical assessment
2.management Immediate 4. Management 322 Mild and moderate allergic reactions | Primary Clinical Care Manual 10th edition | Schedule Schedule Management ofassociatedemergency : ConsultMO/NP.See Note: IfrenalimpairmentseekMO/NPadvice. Increasedriskofsedationinelderly:monitorcarefully mouth ordiarrhoea.Avoiddrinking alcohol whiletaking Provide ConsumerMedicineInformation:Maycausedrowsiness,fatigue,headache,nausea,dry Management ofassociatedemergency:ConsultMO/NP.See Contraindication: Severenasalinfection,bleedingdisorders,recentsurgery RN mayadminister;forsupplysee RIPRN mayproceed ATSIHP, IHWandIPAPmayproceedforadultschild>12only RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Pregnancy: Donotusein1 nationalasthma.org.au/living-with-asthma/how-to-videos sniffing toohardorliquidlikelytogostraightdownthroat.Videosonadministration: right handforleftnostrilandviseversa.Putnozzlejustinsidenose,aimingtowardsouterwall.Avoid sore throat,drymouthorcough.Avoidsprayingatseptum.Bendneckforwardandlookdown.Use Provide ConsumerMedicineInformation:Maycausenasalstinging,itching,nosebleed,sneezing, Oral liquid Tablet Nasal spray Form Form 32 microgram 2 2 Strength Strength 1 mg/mL 10 mg st trimester administration administration Authority to administer and supply medicines, page 9 Authority to administer and supply medicines, page 9 Intranasal Route of Route of Oral Budesonide (Rhinocort®) Cetirizine Adult andchild>12years Adult andchild>6years 6-12 years10mgmane 2-6 years5mgmane 1-2 years2.5mgbd Recommended Recommended 4 spraysdaily 10 mgmane 2 spraysbd Anaphylaxis, page 102 Anaphylaxis, page 102 dosage dosage Child OR Extended authority Extended authority ATSIHP/IHW/IPAP ATSIHP/IHW/IPAP Supply max.one While symptoms While symptoms https://www. Duration Duration persist persist bottle 5,6,8 6,7 Mild and moderate allergic reactions 323
5,10
5,6,9 9 9 IHW/IPAP / persist IHW/IPAP Duration /
Duration While symptoms 102 102 ATSIHP Extended authority For adult and child be repeated in late afternoon if needed ATSIHP > 12 years, dose may Extended authority authority Extended while symptoms persist while symptoms Once a day in the morning Once a day in Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, Adult dosage 0.5 mg/kg 50 mg nocte
Recommended
Child 2-12 years 5 mg 10 mg dosage to a max. of 50 mg nocte Recommended Recommended Child 1-2 years 2.5 mg (tablet can be Promethazine Adult and child > 30 kg Adult and child quartered and crushed) Loratadine Mild and moderate allergic reactions allergic moderate and | Mild Section 4: General
Child 2-12 years or < 30 kg Child 2-12 years or < 30 May cause sedation, psychomotor impairment, dizziness, May cause sedation, psychomotor impairment, May cause drowsiness, fatigue, headache, nausea and dry May cause drowsiness, Consult MO/NP. See Consult MO/NP. See Oral
Authority to administer and supply medicines, page page medicines, supply and administer to Authority Authority to administer and supply medicines, page page medicines, supply and administer to Authority Route of administration Oral Route of administration 2 3 Safe. Avoid close to delivery: risk of neurological disturbance in infant Safe. Avoid close to delivery: risk of neurological Avoid use in: Phenylketonuria, epilepsy, respiratory depression, Parkinsons disease, Avoid use in: Phenylketonuria, epilepsy, respiratory Severe or immediate allergic reaction to loratadine or desloratadine Severe or immediate allergic 10 mg 25 mg Strength 5 mg/5 mL 10 mg Strength If hepatic impairment seek MO/NP advice If hepatic impairment seek Oral Form liquid Tablet Form Schedule Schedule Tablet Management of associated emergency: Contraindication: the elderly, children < 2 years Use in pregnancy: Provide Consumer Medicine Information: Avoid alcohol urinary retention. dry mouth, confusion, headache, blurred vision, dry eyes, constipation, and other sedating medicines ATSIHP, IHW and IPAP must consult MO/NP RIPRN may proceed RN may administer; for supply see RN may administer; for supply see RN may administer; ASTIHP, IHW, IPAP and RIPRN may proceed may proceed and RIPRN IHW, IPAP ASTIHP, Management of associated emergency: Management of associated mouth Note: Contraindication: Provide Consumer Medicine Information: Provide Consumer Medicine y 5. Follow up r • Advise to be reviewed the next day if symptoms continue and at next MO/NP clinic a r 6. Referral/consultation • Referral to an Allergist may need to be considered to identify the allergen(s) Respi to
Respiratory problems
HMP Upper respiratory tract infection (URTI) - adult Common cold, influenza, sore throat, tonsillitis, bronchitis, pharyngitis
Recommend1 • Be alert to the relationship between group A streptococcal infections and acute rheumatic fever (ARF)/acute post streptococcal glomerulonephritis (APSGN) which are especially common in Aboriginal and Torres Strait Islander communities • Most URTI are caused by viruses and do not require antibiotics1 Background1,2,3 • A viral upper respiratory tract infection can be complicated by secondary bacterial infection requiring antibiotics e.g. acute otitis media, sinusitis, bronchitis, pneumonia • Other complications include exacerbation of asthma/chronic obstructive pulmonary disease (COPD) • Influenza is probably over-diagnosed. Systemic symptoms such as fever, extreme lethargy, sore muscles and joints and headache differentiate it somewhat from a 'common cold' • Recommend influenza vaccination for all persons ≥ 6 months of age. For high risk groups, see the current Australian Immunisation Handbook4
Related topics Acute asthma, page 119 Pneumonia - adult, page 329 Acute bacterial sinusitis, page 327
1. May present with5,6 • Watery or purulent nasal discharge, sneezing • Sore throat, red throat and/or tonsils with or without pus, halitosis • Cough, wheeze, earache, hearing loss • Enlarged tender cervical (neck) lymph nodes • Fever, headache • General malaise, lethargy • Muscular aches and pains • Rash • Facial pain • Diminished sense of smell
2. Immediate management Not applicable 324 | Primary Clinical Care Manual 10th edition | to Respi 3. Clinical assessment7 • Take patient history including: r
– past episodes or complications a – any history of asthma/COPD/rheumatic fever/heart disease – history of pleuritic chest pain, fevers, shortness of breath, productive cough r y • Ask about joint pain - consider acute rheumatic fever • Perform standard clinical observations (full Q-ADDS score or other local Early Warning and Response Tools):
– note in particular RR, T and SpO2 • Perform physical examination: – examine upper respiratory tract - nose, sinuses, throat, tonsils and cervical lymph nodes and ears – urinalysis - if positive for blood, see APSGN, page 700 – listen to the chest for air entry and added sounds (crackles or wheezes) – palpate joints for any swelling • Observe for meningism, with neck stiffness 4. Management1,2,3 • If the patient has: – an increased RR or any chest findings, consider other diagnoses, seePneumonia - adult, page 329 and Acute asthma, page 119 – a cough productive of mucopurulent sputum (bronchitis), consult MO/NP and treat. See Pneumonia - adult, page 329 – facial pain or tenderness, see Acute bacterial sinusitis, page 327 For the adult patient with uncomplicated URTI • Treatment is symptomatic: – encourage rest and increase fluid intake – administer analgesia as clinically indicated. See Acute pain management, page 35 – consider symptomatic treatment such as steam inhalation, lemon or honey drinks and lozenges, which help some patients – if severe nasal congestion consult MO/NP For the adult patient with complicated URTI • Indications for antibiotic treatment are: – patients aged 2-25 years with sore throat in communities with high incidence of acute rheumatic fever e.g. Aboriginal and Torres Strait Islander communities in central and northern Australia – Maori and Pacific Islander people – pustular tonsillitis with fever and local lymphadenitis – existing rheumatic heart disease – quinsy (severe infection of the tonsils causing massive enlargement, evidence of pus on tonsil): – if quinsy is present, consult MO/NP. May need evacuation/hospitalisation for IV penicillin and/ or surgical drainage of pus • If not allergic treat with phenoxymethylpenicillin. If sore throat, take swab for MCS first
Section 4: General | Respiratory problems 325 y • If a lack of adherence with oral medicine is anticipated, treat with IM benzathine benzylpenicillin r (Bicillin LA®) • If allergic to penicillin, treat with azithromycin4 a
r • Advise exclusion from work and school for 5-7 days • Advise to wash hands frequently to minimise transmission to others Respi to Extended authority Schedule 4 Phenoxymethylpenicillin ATSIHP/IHW/IPAP/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed Route of Recommended Form Strength Duration administration dosage 250 mg Capsule Oral 500 mg bd 10 days 500 mg Provide Consumer Medicine Information: May cause diarrhoea, nausea and candidiasis. Food has little effect on absorption Contraindication: Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,8,9
Benzathine benzylpenicillin Extended authority Schedule 4 (Bicillin LA®) ATSIHP/IHW/IPAP/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed Route of Recommended Form Strength Duration administration dosage Injection 1.2 million Adult (pre-filled units/2.3 mL IM 1.2 million units stat syringe) (900 mg) (900 mg) Provide Consumer Medicine Information: May cause diarrhoea, nausea and pain at injection site
Note: Stop injection immediately if patient shows signs of severe pain. See Administration tips for benzathine benzylpenicillin, page 787
Contraindication: Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,10
326 | Primary Clinical Care Manual 10th edition | to Respi
Extended authority Schedule 4 Azithromycin ATSIHP/IHW/IPAP/RIPRN r
ATSIHP, IHW, IPAP and RN must consult MO/NP a RIPRN may proceed r
Route of Recommended y Form Strength Duration administration dosage Tablet 500 mg Oral 500 mg daily 5 days Provide Consumer Medicine Information: Take with or without food. May cause rash, diarrhoea, nausea, abdominal cramps and candidiasis Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1, 11,12
5. Follow up6 • Advise to be reviewed the next day if not improving • If antibiotics have been given for sore throat, advise to be reviewed in 2 weeks. Ask about sore joints, breathlessness, rash and check urinalysis • Consult MO/NP if symptoms persist or abnormal urinalysis on follow up
6. Referral/consultation • Consult MO/NP as above
HMP Acute bacterial sinusitis - adult/child
Recommend1 • Consider foreign body in the nose in children, especially if symptoms are on one side of the nose only • Most cases resolve without treatment, so routine use of antibiotics is not recommended Background1 • Rapid onset of inflammation of the nose and sinuses • Upper respiratory viral infections can be complicated by an acute bacterial infection • Acute bacterial sinusitis can also occur in immunocompromised patients or with some dental cysts, and in nasal obstruction
Related topics Acute and chronic headache, page 336
1. May present with2 • As per URTI, see Upper respiratory tract infection (URTI) - adult, page 324, and additionally: –– significant facial pain and/or tenderness (less common in children) –– frontal headache –– systemically unwell, fever –– mucopurulent nasal discharge (anterior and/or posterior)/nasal blockage/nasal obstruction
Section 4: General | Respiratory problems 327 y –– reduction/loss of smell r –– dental pain
a –– bad breath r 2. Immediate management Not applicable
Respi 3. Clinicalto assessment • Obtain a complete patient history including: –– past episodes –– treatment received –– medicines used • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) • Perform physical examination: –– inspect the patient's face for any swelling around the nose and eyes –– palpate the frontal sinuses above the eyes by gently pressing the thumbs under the bony ridge of the upper orbit, near where eyebrows start - does the patient feel pain –– then palpate the maxillary sinuses on each side of the nose to cheekbones - does the patient feel pain –– percuss these areas using the middle or index finger of one hand onto the finger of the other hand, note the sound. Dullness indicates presence of fluid –– inspect nostrils in children to exclude foreign body 4. Management1 • If any associated symptoms of double or reduced vision, mental status deterioration, severe headache or periorbital oedema consult MO/NP urgently • Consult MO/NP who may advise: –– antibiotics –– analgesia –– nasal saline sprays or nasal douches may relieve nasal congestion from thick mucous9 –– oral decongestant –– oral antihistamine –– nasal decongestants should be used for < 3 days, to prevent rebound congestion and not in children < 6 years old • Symptomatic treatment. See Upper respiratory tract infection (URTI) - adult, page 324 and Upper respiratory tract infection (URTI) - child, page 682 • Administer analgesia as clinically indicated. See Acute pain management, page 35 5. Follow up • Advise to be reviewed the next day. Consult MO/NP if not improving 6. Referral/consultation • Consult MO/NP as above
328 | Primary Clinical Care Manual 10th edition | to Respi HMP Pneumonia - adult
Recommend1 r a • Assessment of pneumonia severity is required to guide management including antibiotic therapy3
• Offer patients at risk of pneumonia (those with co-existent illnesses such as chronic diseases, r alcohol misuse, previous splenectomy, impaired immunity), pneumococcal and influenza y vaccination • Consider Burkholderia pseudomallei (melioidosis) and Acinetobacter baumannii as possible causes of severe pneumonia in northern Australia, particularly in patients who have diabetes ± alcohol misuse and especially in the wet season. It has less classical symptoms and signs, has specific antibiotic requirements and may be resistant to initial treatment • Less common cause to consider is Legionella Background3 • Pneumonia is an infection of the lung tissue. The lungs become filled with microorganisms, fluid and inflammatory cells and lung function is impaired • A common condition, especially in Aboriginal and Torres Strait Islander people and is a significant cause of morbidity and mortality • Pneumonia is classified as community-acquired, or hospital-acquired. Hospital-acquired pneumonia needs different treatment, and develops 48 hours or more after hospital admission
Related topics Upper respiratory tract infection (URTI) - adult, page 324 Sepsis/septic shock, page 80
1. May present with4 • Some patients, particularly older patients, may have few or none of the features of pneumonia • Shortness of breath • Cough with sputum. A dry cough is typical of atypical pneumonia • Fever, rigors • Rash, myalgia (muscle pain) • Rapid breathing • Pleuritic chest pain (sharp pain made worse by deep breath) • Cyanosis • Confusion, drowsiness, loss of consciousness • Diarrhoea, headache • Hypotension/shock 2. Immediate management • Perform standard clinical observations (full Q-ADDS score or other local Early Warning and Response Tools)
• Give O2 to maintain SpO2 > 94%. If > 94% not maintained consult MO/NP. See Oxygen delivery, page 64 • Insert IV cannula • MO/NP may advise IV fluids • Consult MO/NP who may advise:
Section 4: General | Respiratory problems 329 y –– antibiotics3 r –– if possible take blood cultures prior to commencing antibiotics
a –– sputum sample for MCS and/or PCR if possible r –– evacuation/hospitalisation 3. Clinical assessment1 Respi to • Take a complete patient history as soon as possible allowing for severity of condition including: –– past episodes –– immunocompromised - history of cancer, autoimmune disease, patients on steroids, diabetes, kidney disease and chronic lung disease –– recent hospital admission, as hospital-acquired pneumonia requires different treatment to community-acquired pneumonia –– travel history to overseas or northern Australian areas –– misuse of alcohol –– age > 65 years • Where available, perform chest x-ray • Perform physical examination: –– inspect the patient breathing - are they lifting their shoulders, bending forward or sitting straight, using muscles in their neck or chest; any nasal flaring –– is there pain on inhalation; is there any noise made when the patient breathes –– any cough –– any sputum. Note type, colour –– listen to the air entry into the lungs - any decreased air entry, crackles or wheezes –– percuss the lungs - any dullness and in what area –– inspect lips, fingernails - pale or cyanosed –– urinalysis - if positive for blood, see APSGN, page 700 • Check pneumococcal and influenza immunisation status 4. Management1,2,3 • Consult MO/NP • Monitor standard clinical observations (full Q-ADDS score or other local Early Warning and Response Tools) + conscious state • If ≥ 2 of the following apply, pneumonia is considered moderate or severe:5 –– HR ≥ 100 beats/minute1 –– confusion, either new onset, or worsening of previous state
–– SpO2 ≤ 90% –– RR ≥ 30 breaths/minute –– systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg • Closely monitor patient • In addition to severity, other factors are also considered2 to determine if evacuation/ hospitalisation is required, including: –– history of chronic lung disease –– Aboriginal and Torres Strait Islander person –– hospitalisation or antibiotic treatment in last 30 days
330 | Primary Clinical Care Manual 10th edition | to Respi –– aged care facility resident –– corticosteroid use
–– altered conscious state r a –– diabetes
–– chronic kidney disease r –– alcohol dependence y –– failure to improve after 3 days of oral antibiotics –– pregnant women –– wet season in areas north of Port Hedland, Tennant Creek or Mackay –– suspicion of tuberculosis. See Tuberculosis, page 333 –– suspicion of influenza. See Upper respiratory tract infection (URTI) - adult, page 324 • See Suspected pneumonia flowchart on following page Mild pneumonia1 • Consult MO/NP who may advise: –– chest x-ray if available –– oral antibiotics. Antibiotics may not be indicated if typical of viral infection –– encourage rest and increase fluid intake • Administer analgesia as clinically indicated. See Acute pain management, page 35 Moderate to severe pneumonia2 • Consult MO/NP who may advise: –– IV antibiotics within 4 hours –– IV fluids –– urgent evacuation
Section 4: General | Respiratory problems 331 y
r Suspected pneumonia a
r Contact MO/NP Respi to Assess • Pneumonia severity - mild, moderate, severe • Presence of risk factors
Mild pneumonia Moderate or severe pneumonia or presence of risk factors
Consult MO/NP who may order: Consult MO/NP who may order: • Oral antibiotics • IV antibiotics according to • Discharge, ongoing care at home risk factors, local patterns of • Follow up resistance, tropical location • Evacuation/admission to hospital
5. Follow up • Patients with mild pneumonia who are not evacuated/hospitalised should be advised to return for review daily. Consult MO/NP if the patient’s condition has not improved after 3 days • Advise to see at next MO/NP clinic • If a smoker, encourage the patient to stop • If eligible offer pneumococcal and influenza vaccination as per theAustralian Immunisation Handbook. See Immunisation program, page 768 6. Referral/consultation
• Consult MO/NP on all occasions pneumonia is suspected
332 | Primary Clinical Care Manual 10th edition | to Respi Tuberculosis - adult/child
Recommend r a • Always seek advice for assessment and management from local tuberculosis (TB) control unit:
–– in Queensland contact numbers available at: https://www.health.qld.gov.au/clinical- r practice/guidelines-procedures/diseases-infection/diseases/tuberculosis/contact-a-service y –– in other states and territories contact local public health unit –– TB is a notifiable disease • Be guided by local policies for assessment and management of TB and transmission based/ standard precautions Background1 • Air borne lung disease is the most common form of TB, and accounts for approx. 60% of notifications in Australia2 • Cure rates of TB with standardised treatments in drug sensitive disease is 98%1 • Drug resistant TB has emerged globally, and is an ongoing concern in Australia1 • Countries with the most severe burden of TB include: PNG, China, DR Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, South Africa, Thailand, Zimbabwe.3 See World Health Organisation (WHO) TB country profiles for further information: http://www.who.int/tb/ country/data/profiles/en/ • Groups more susceptible to infection and progression to active TB:1 –– children < 5, adolescents, elderly; malnourished; immunocompromised e.g. diabetes, renal failure; taking medicines that can cause immunosuppression e.g. corticosteroids, anti-cancer treatments
Related topics • HIV, page 656
1. May present with1,2 • Common symptoms of pulmonary TB include:1 –– cough > 3 weeks, sometimes with haemoptysis –– fever and night sweats –– weight loss –– feeling generally tired and unwell • Have a high clinical suspicion of TB in any person with:1 –– risk of exposure, and: –– respiratory infection unresponsive to standard treatments, or –– unexplained non-respiratory illness –– in particular if: –– travel/arrival from high incidence countries –– contact of an active case within past 5 years –– history of previous TB treatment –– Aboriginal and Torres Strait Islander person in localised area e.g. NT, North Qld –– HIV positive –– overcrowded living conditions • Non-pulmonary TB (disease involving organs other than lungs) may present with:1 –– a wide range of symptoms, depending on site of disease
Section 4: General | Respiratory problems 333 y –– often accompanied by intermittent fever or weight loss r 2. Immediate management Not applicable a r 3. Clinical assessment • If TB is suspected:1,4 Respi to –– clinician to use PPE including high filtration mask i.e. P2/N95 mask –– if the facility has a negative pressure room, immediately place patient into room –– if no negative pressure room separate patient from others: –– outside; or in well ventilated area, windows open, ceiling fans on –– do not place in a room with re-circulating air conditioning system • Obtain history of symptoms, including onset date of any:5 –– cough - productive/haemoptysis –– night sweats –– fever –– weight loss –– swollen and/or painful lymph nodes –– any other signs/symptoms • Obtain past history:1 –– past episodes or exposure to TB; when, treatment –– close contact with someone with TB; when/who –– travel to TB known area e.g. PNG –– history of chronic disease; diabetes, liver or renal disease –– cancer, seizures, leukaemia, lymphoma, HIV –– major abdominal surgery –– major organ transplant –– currently pregnant - gestation –– medications - any immunosuppressive therapy • Obtain social history:5 –– occupation/number in household –– bong smoking, illicit drug use, betel nut use –– incarceration (prison time) –– alcohol/smoking history • Perform a complete physical examination, including:5 – standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and
Response Tools) including SpO2 –– weight and height –– respiratory assessment –– palpation of lymph nodes - note if any > 1 cm, and have been there > 1 month 4. Management1,4 • For any patient with suspected TB: –– consult with MO/NP –– contact local TB control unit or public health unit for advice and management
334 | Primary Clinical Care Manual 10th edition | to Respi • Give patient a fluid repellent surgical mask to wear and educate on coughing etiquette • Obtain sputum samples x 3 on separate days:1,4
–– 1 'spot sputum' at presentation r a –– 2 early morning samples - can give sterile container to patient to take home
–– request AFB/GXP on pathology form r –– ideally sample should be obtained in negative pressure room if available y –– otherwise, ask patient to go to a well-ventilated area, away from other patients e.g. outside –– if patient has difficulty expectorating, seek advice from TB control unit • Take blood for HIV • Do chest x-ray - regardless of symptoms • Further management as per local TB control unit/MO/NP instructions • MO/NP may advise:4 –– evacuation if critical or suspected multidrug resistant TB, or –– isolate in community to wait for sputum results, or –– evacuation for non-critical cases, but where isolation in the community is not possible • If evacuated, patient should:4 –– wear a surgical mask. Does not need P2/N95 –– not travel on commercial airlines, and/or travel with other patients UNLESS the MO/NP determines they are clinically non-infectious • Diagnosis must be conveyed to:4 –– transferring crew –– receiving hospital - so single room can be prepared 5. Follow up • As determined by TB control unit or MO/NP 6. Referral/consultation • Always contact TB control unit for advice • TB is a notifiable disease
Section 4: General | Respiratory problems 335 336 Nervous system Nervous systemproblems | Primary Clinical Care Manual 10th edition | 2. Immediatemanagement 1. Maypresentwith HMP Secondary headache Primary headache Background Recommend • • • • • • • • • • – – – – – Consult MO/NPurgentlyifthefollowing – – – – – – Causes include: May becausedbyaseriousconditionthatrequiresurgentreferralandmanagement Have ademonstrableunderlyingcause Are potentiallyserious May havenounderlyingcause Include migraine,clusterheadache,medicationoveruseheadaches,andtension-typeheadaches If patientdistressed, lieat30degreesandreassure – – – Headache canbeclassifiedintotwobroadcategories-primaryandsecondary: as a'thunderclap' sudden onsetdescribedasthemostsevereheadachetheyhaveeverhad,sometimes Suspect subarachnoidhaemorrhage(SAH)inanypatientwhopresentswithaheadacheof – – – – – – – – – – – – Acute andchronic activity associatedheadachefollowingexertionorsexual referred painfromneck,eyes,jaw,teethorsinuses a concerningheadache forthepatientthatcannotbe explained > 50yearsoldwith anewordifferentheadache meningism orfever.See neurological changes reached withinminutes sudden onsetheadache-'thunderclap headache',likeablowtothehead,peakpainlevel first orworstheadacheofpatient’s life head trauma-upto7daysaftertrauma.See intracranial pressurechanges lesions -tumours,arteriovenousmalformations,braincysts page Subarachnoid haemorrhage, page vascular -subarachnoidhaemorrhage,temporalarteritis,stroke,hypertension.See – – illness tumour, subarachnoidhaemorrhage-andcanbeconsideredasasideeffectofthemain secondary headachesaretriggeredbyanunderlyingdisorder-suchasinfection,injuryor primary headachesincludemigraine,clusterortensionheadache 158 1,2,3 1,2,3 Meningitis, page headache 157 'red flags' and
- adult/child 91 Transient ischaemic attack (TIA)and stroke, Head injuries, page arepresent: 1,2 175 Nervous system 337 2 and lifestyle modifications, 2 Nervous system problems system | Nervous Section 4: General Acute pain management, page 35 page management, pain Acute Snakebite including sea snake, page 292 page snake, sea including Snakebite therapy 2 2 Heat exhaustion/heat stroke/hyperthermia, page 231 page stroke/hyperthermia, exhaustion/heat Heat
MO/NP may prescribe other medicines management relaxation techniques, such as massage, stress alterations to the diet thoroughly inspect the skin for rashes including hidden regions such as toe webbing and in thoroughly inspect the skin for rashes including other skin folds is the headache progressively worsening is the headache progressively such as certain foods factors that worsen the headache, headache, such as massage factors that improve the other symptoms, such as visual disturbances, vomiting, a sore neck, fever (meningitis), visual disturbances, vomiting, a sore neck, fever other symptoms, such as weakness on one side of fits (convulsions), changes in personality and coordination problems, the body recurs how often the headache location of the pain, such as around one eye or over the scalp pain, such as around location of the pain experienced the degree of headache - does patient wake with pain onset and duration of the snakebite with resultant coagulopathy. See See coagulopathy. with resultant snakebite See to heat. exposure – – – – – – – – – – – – – –
According to underlying cause – – – Cluster headache - medicine or O Administer analgesia as clinically indicated. See Other management techniques include: Migraine headache – treatment medicines and preventative medicines Migraine headache – treatment medicines and Primary headaches - may respond to massage, heat packs, cold packs, relaxation exercises, and Primary headaches - may respond to massage, heat behavioural interventions diet, stress management and attention to Tension headache - lifestyle adjustments, e.g. exercise, posture Encourage rest and treat in a quiet darkened room, encourage sleep in children Encourage rest and treat in a quiet darkened room, Treating a headache depends on its cause is secondary Treatment for the underlying disorder if the headache Consult MO/NP immediately where a red flag is present Consult MO/NP immediately where a red flag is be medically investigated. Tests can include Consult MO/NP if persistent headache - needs to scans, eye tests and sinus x-rays – ADDS/CEWT score or other local Early Warning observations (full Q-ADDS/CEWT score or other Perform standard clinical and Response Tools) Perform physical examination: – – – – – – – – Perform a complete patient history noting current medications, alcohol and other drug use alcohol and other drug current medications, patient history noting Perform a complete headache include: patient with a to consider when assessing Specific factors – – Consider: such as identifying and avoiding factors that trigger an attack such as identifying and avoiding factors that trigger
• • • • • • • • • • • • • • • • •
5. Follow up
4. Management 3. Clinical assessment 338 Mouth and dental Displaced teeth,avulsedbrokenteeth Mouth anddentalproblems Referral/consultation 6. | Primary Clinical Care Manual 10th edition | Clinicalassessment 3. Immediatemanagement 2. Maypresentwith 1. HMP Recommend • • • • • • • • • •
• •
and ResponseTools) Perform standardclinicalobservations (fullQ-ADDS/CEWTscoreorotherlocalEarly Warning Perform physicalexaminationincluding: – – – Obtain patienthistoryincluding: – – – – – – If anavulsed(knockedout)adulttooth: Injury and/orswellingtolips,tongueface Bleeding inmouth Avulsed (knockedout),displacedand/orbrokentooth/teeth Consider referralforcounsellingand/orstressmanagementpeoplewithprimaryheadaches further investigationasappropriate Immediate consultwithMO/NPforallsecondaryheadaches.Patientswillneedurgentreferral Offer ongoingsupportandreassurance – – Traumatoteeth Do notusewatertorinseorstoretheavulsed(knockedout)tooth NSAIDS e.g.Ibuprofenarethedrugclassofchoiceforacutedentalpain – – – – – – – – – – – past episodesorcomplications seek dentalcareimmediately wrap withsomeofpatient'ssaliva if unabletoreplacethetooth,keepitmoistbyplacinginmilk(notwater) orsealinplastic significantly betterprognosisifreplacedwithin15minutes immediately replacethetoothinsocketandholdplace.The toothwillhave damage toothrootsurface if toothisdirty,gentlyrinseonlyinmilkorsodiumchloride0.9%.Avoid waterasthismay do notscrape,ruborremoveanytissuefragmentsfromthetooth handle thetopoftooth,nottoothroot assess bite-suspect jaworfacialfractureifbiteisabnormal. See inspect oralcavity, teeth,softtissues current medications circumstances ofinjury page 191
- adult/child 2 2 Fractured mandible/jaw, 1 Mouth and dental 339 35 2 Tetanus immunisation, page page immunisation, Tetanus 351 2 Acute pain management, page page management, pain Acute Mouth and dental problems dental | Mouth and Section 4: General
2 1 until next Dentist visit or use of a temporary sealing compound until next Dentist visit or ® Post extraction haemorrhage, page page haemorrhage, extraction Post ) may be used to cover the broken tooth/teeth and decrease pain ) may be used to cover the ® 3 ® replace or reposition primary (baby) teeth. There is a risk of damaging the permanent (adult) replace or reposition primary (baby) teeth. There not
this is intended to be a temporary measure only by Dentist patient will require evacuation for further treatment assess bleeding, duration and amount and duration bleeding, assess – – – 773 If bleeding continues, see Splint as above. This is intended to be a temporary measure only. Patient will require evacuation Splint as above. This is intended to be a temporary for further treatment by Dentist Check tetanus vaccination status and give booster if indicated. See If tooth is dirty, wash briefly (10 seconds) with sodium chloride 0.9% or milk. Avoid touching the If tooth is dirty, wash briefly (10 seconds) with sodium root It may be useful to encourage the patient to Replace tooth in the socket with firm finger pressure. the tooth bite on a piece of gauze to assist in positioning patient has inhaled the tooth using chest x-ray better chance of survival therefore it should be a A tooth replaced within 15 minutes has a much priority to replace teeth as soon as possible tooth underneath found at the site of the accident, assess if If a tooth appears to be missing and has not been Assess avulsed teeth in children < 5 years of age to determine if they are primary or permanent Assess avulsed teeth in children < 5 years of age than permanent teeth, although permanent teeth teeth. In general, primary teeth are much smaller root in young children may have short, undeveloped Do Advise soft diet for 2 weeks, and chlorhexidine 0.2% mouthwash 10 mL rinsed in the mouth for one Advise soft diet for 2 weeks, and chlorhexidine a maximum of 10 days minute 8-12 hourly while the tooth is splinted for aluminium foil over them or using beeswax: – – Reposition tooth/teeth still in socket to original position with firm finger pressure in socket to original position with firm finger Reposition tooth/teeth still the tooth to the adjacent teeth either by folding Splint - temporary splinting is achieved by fixing If the patient continues to experience pain consult MO/NP or Dentist who may advise continuing to to experience pain consult MO/NP or Dentist who If the patient continues use orthodontic wax or Blu-tack e.g. Cavit In most cases, pain is due to exposure of dentine or dental pulp, and is usually reversible if dental to exposure of dentine or dental pulp, and is In most cases, pain is due or other inert material If a Dentist is not available orthodontic wax treatment is provided early. (such as Blu-tack Most common presentation Most common to Dentist or Dental clinic is rarely an urgent problem. After analgesia refer A broken tooth or filling hours if dental pulp is exposed (red soft tissue) visit, preferably within 24 Administer analgesia as clinically indicated. See as clinically indicated. Administer analgesia than when dosing intervals rather of treatment' with regular be used as a 'course NSAIDS should pain or discomfort the patient feels Control bleeding with gentle pressure bleeding with Control –
• • • • • • • • • • • • • • • • • • • Avulsed permanent (adult) tooth/teeth (completely out of socket) Avulsed permanent (adult) tooth/teeth (completely Avulsed and displaced primary (baby) tooth/teeth Displaced permanent (adult) tooth/teeth Displaced permanent Broken/fractured tooth/teeth Broken/fractured 4. Management 340 Mouth and dental | Primary Clinical Care Manual 10th edition | In allcases Management ofassociatedemergency: Use inpregnancy: Children ≤8yearsofage.After18weekspregnancy Contraindication: calcium, zinc,orantacidswithin2hoursoftaking.Avoidsunexposure and photosensitivity.Takewithfoodormilk.Donotliedownforanhouraftertaking.takeiron, Provide Consumer Medicine Information: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Schedule • • • • Tablet Form If temporarysplint/bridgerequired,arrangeevacuationforfurthertreatmentbydentist publications.qld.gov.au/dataset/chronic-conditions-manual Manual Reinforce positiveoralhygienemeasures.Seethecurrenteditionof minute 8-12hourlywhilethetoothissplintedforamax.of10days Advise softdietfor2weeksandchlorhexidine0.2%mouthwash10mLrinsedinthemouthone – – – Give antibiotics: – – – if allergictopenicillinanddoxycyclineiscontraindicated(child≤8years)giveclindamycin if doxycyclineiscontraindicatedorchild≤8years,giveamoxicillinOR doxycycline ifnotallergicand>8yearsofageOR : Prevention andManagementofChronicconditionsinAustralia Strength 100 mg Severeorimmediateallergicreactiontotetracyclinestreatmentwithoral retinoids. 50 mg Safeinthefirst18weeksofpregnancy 4 administration Route of Oral Doxycycline ConsultMO/NP.See May causediarrhoea, nausea, vomiting, epigastric burning
5 mg/kg(tomax.200mg)first dose then2.5mg/kgdaily 200mgfirstdosethen Recommended dosage to amax.100mgdaily Child >8-18years 100 mgdaily Anaphylaxis, page Adult ATSIHP/IHW/IPAP/RIPRN Extended authority available from: Chronic Conditions
102 Duration 7 days
https:// 2 Mouth and dental 341 6,7 2,4
7 days Duration 5 days Duration
102 102 IHW/IPAP/RIPRN Extended authority authority Extended / ATSIHP/IHW/IPAP/RIPRN Extended authority ATSIHP mg tds dosage Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, Recommended Recommended dosage Child < 12 years 300 mg tds Recommended 25 mg/kg/dose up to a Child < 12 years Adult and child ≥ 12 years Adult and child Mouth and dental problems dental | Mouth and Section 4: General maximum of 1 g for the first 1 g for the first dose then 500 1 g for the first to a max. of 500 mg/dose tds to a max. of 500 mg/dose dose then 12.5 mg/kg/dose tds dose then 12.5 mg/kg/dose 7.5 mg/kg/dose tds to a max. of 300 mg/dose tds Adult and child ≥ 12 years
Amoxicillin
May cause rash, diarrhoea, nausea and candidiasis May cause rash, diarrhoea, : May cause rash, diarrhoea, nausea, vomiting and abdominal : May cause rash, diarrhoea, nausea, vomiting and Clindamycin Consult MO/NP. See Consult MO/NP. See Oral Cl. difficile Route of Oral administration Route of administration 4 250 mg 500 mg 4 Strength Allergy to clindamycin or lincomycin 250 mg/5 mL 500 mg/5 mL : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity reaction to a penicillin. Be aware of cross-reactivity : Severe or immediate allergic 150 mg Strength Can cause severe colitis due to
Form Form Schedule Capsule dissolve contents of 1 capsule in 2 mL water up to 3 mL (if necessary) draw this solution into a syringe and make the volume remains in the syringe discard any excess solution so that the correct dose taste before giving it mix the dose in juice or soft food to disguise the Capsule Powder for Schedule to oral liquid reconstitution between penicillins, cephalosporins and carbapenems between penicillins, cephalosporins emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine Contraindication RIPRN may proceed ATSIHP, IHW, IPAP and RN must consult MO/NP IPAP and RN must consult ATSIHP, IHW, ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed Contraindication: Management of associated emergency: • • • • pain. Take with a full glass of water Note: solution can be made: There is no oral liquid for children. A 50 mg/mL Provide Consumer Medicine Information 342 Mouth and dental .Referral/consultation 6. Followup 5. | Primary Clinical Care Manual 10th edition | Clinicalassessment 3. Immediatemanagement 2. Maypresentwith 1. HMP Causes ofacutedentalpain • • • • • Background • • • • • • • • •
• Pain worsenswhenheadistiltedforwards swelling intheregionofpain Tender topressureandbiting± sensitive tohot/cold/sweet Dull ache,throb,maybesoretobite,not that persists,sensitivetohot/cold/sweet Sharp, severepain,becomesdullthrob sweet stimulus removed,sensitivetohot/cold/ Short, sharppain,disappearswhen
and ResponseTools) Perform standard clinical observations(fullQ-ADDS/CEWTscore orotherlocalEarlyWarning Obtain patienthistoryincludingdental history Facial swellingand/ordentalabscess(gumboil) Tooth decay-holeintooth,brokendowndarkenedtooth Bad breath(halitosis)and/orbadtasteinmouth Tooth/teeth sensitivetohot/cold Dental pain Consult DentistorMO/NPonalloccasions Refer fornextDentistclinicvisit Toothache-adult/child established inpregnantandlactatingwomen There is insufficient evidence to support the use of Oil of Cloves for oral/dental Ingestion cancauselifethreateningadversereactionsinchildren,andsafetyhasnotbeen 1 Signs/symptoms 2 2
Notapplicable Maxillary sinusitis around thetooth collection ofpus infection/ Localised the toothnerve Inflammation of Probable cause sinusitis, page 327 indicated. See nasal spraysorsolutionsmaybe Antibiotics, inhalationsand See Avoid foodsthatprovokepain Antibiotics notindicated NSAID ifnotcontraindicated Analgesia ifindicated,especially Dental abscess, page 348 Management Acute bacterial indications. Mouth and dental 343 348 https:// 35 348 Yes Chronic Conditions available from: 348 Yes Dental abscess, page page abscess, Dental See Dental abscess, page page abscess, Dental Is the tooth tender to tap tap to tender the tooth Is Do any of the following apply apply the following of Do any See Is the tooth loose and/or sore to bite on bite to and/or sore loose the tooth Is Mouth and dental problems dental | Mouth and Section 4: General Acute pain management, page page management, pain Acute No Dental abscess, page page abscess, Dental Is the gum around the tooth red and swollen and red the tooth around the gum Is Is there obvious facial swelling Is there obvious No No Is the tooth sensitive to hot/cold Is the tooth sensitive to Prevention and Management of Chronic conditions in Australia Prevention and Management of Chronic conditions Yes : toothache
inspect oral cavity, teeth, soft tissues, lymph nodes, ears nodes, tissues, lymph teeth, soft oral cavity, inspect –
Manual publications.qld.gov.au/dataset/chronic-conditions-manual If associated tenderness, swelling, redness see If associated tenderness, swelling, redness see may be applied to tooth Topical lidocaine (lignocaine) e.g. Seda Lotion® current edition of the Reinforce positive oral hygiene measures. See the Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See If severe consult MO/NP – diagnosis with differential to assist flowchart below pain presentation See Dental Perform physical examination: physical Perform • • • • • • • See management below for See management below Dental pain presentation flowchart Dental pain 4. Management 344 Mouth and dental | Primary Clinical Care Manual 10th edition | 2. Immediate management 1. Maypresentwith 6. Referral/consultation 5. Followup HMP Note: Provide ConsumerMedicineInformation: RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Management ofassociatedemergency Background Recommend Schedule • • • • • • Lotion Form • • • publications.qld.gov.au/dataset/chronic-conditions-manual Manual Risk factorsforincreasedriskofdental caries Dental caries Tooth decay-holeintooth,broken down tooth,darkenedtooth Tooth/teeth sensitivetohot/cold;biting orpressure If severeconsultMO/NP/Dentist Refer fornextDentistclinic teeth isassociatedwithasubstantialreductionintheextentofcariesexperienced Application offluoridevarnish2-4timesayeartoprimary(baby)and permanent (adult)tooth/ risk ofdentalcaries Aboriginal andTorresStraitIslanderpeoplefromrural remoteareasareathigh publications.qld.gov.au/dataset/chronic-conditions-manual Prevention andManagementofChronicconditionsinAustralia care plan.Forfurtherinformationseethecurrenteditionof Provide allpatients with personalised oral health promotion advice and develop an oral health
Dental caries Not foruseininfants : Prevention andManagementofChronic conditionsinAustralia Strength
15 mL 2.5% 2
1 administration - adult/child Route of Topical Lidocaine (lignocaine)(Sedalotion Authority to administer and supply medicines, page
Not applicable
: ConsultMO/NP.See Cautionwithhotdrinksasnumbnesscanresultinburns Dip cottonbudinlotionandapplyto biting surfaceoftoothuntilnumbed 1 Max. ofevery2hours - seethecurrenteditionof Recommended dosage Anaphylaxis, page ® ) Chronic ConditionsManual available from: available from: Extended authority ATSIHP 102 use for2-3daysonly Chronic Conditions Supply inoriginal Advise patientto pack (15mL) / IHW/IPAP Duration 3 9 https:// https://
3 : Mouth and dental 345
https:// Chronic Conditions available from: 2 Mouth and dental problems dental | Mouth and Section 4: General 342 Toothache, page page Toothache, fluoride varnish (sodium fluoride) Prevention and Management of Chronic conditions in Australia Prevention and Management of Chronic conditions : apply as a thin film to all tooth surfaces including exposed root surfaces if present (ensure apply as a thin film to all tooth surfaces including the tip/brush is not overloaded with varnish) where to apply it the colour of the varnish will assist you to know use a small brush, applicator or dental probe – – – reapply as indicated assess for any changes in risk status anywhere else during the recall period check if patient has had fluoride varnish applied e.g. by a dentist there are no contraindications there is evidence of dental caries or person is at high risk of dental caries, and caries or person is at high risk of dental caries, there is evidence of dental toothpaste is likely to be ineffective, and regular brushing with fluoride and person is > 18 months old, bad breath or a bad taste in the mouth bad breath or holes/cavities or structural damage which can be brown or black in appearance which can be brown or or structural damage holes/cavities decay indicate early stages of frosty appearance may surfaces with a white or tooth/teeth pain or sensitivity applied and dosage prematurely - advise not to eat or drink for 30 minutes or brush teeth until the following morning prematurely - advise not to eat or drink for 30 minutes Ensure clinical documentation includes all teeth/tooth surfaces to which fluoride varnish was – – and should not be disturbed or removed The fluoride varnish will set in the presence of saliva Dry teeth gently e.g. with gauze or cloth Apply fluoride varnish: – Obtain valid consent from parent/guardian: following varnish application Warn parent/guardian that teeth may appear discoloured first If thick plaque deposits are present, clean the teeth – – – – – – – – – – – – current edition of the Reinforce positive oral hygiene measures. See the Manual publications.qld.gov.au/dataset/chronic-conditions-manual – – – Refer for dentist review fluoride varnish: If patient has been recalled for re-application of – – – If toothache see application associated with previous fluoride varnish Ask about any adverse experience to teeth if: Offer to apply fluoride varnish – – – – Ask when last dental visit was last dental Ask when caries for dental for risk factors Assess for dental caries: Examine teeth
• • • • • • • Application of • • • • • • • • •
4. Management 3. Clinical assessment Clinical 3. 346 Mouth and dental | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup dentist. IfingestionoflargeamountscontactPoisonsInformationCentre (131126)or13HEALTH Management ofassociatedemergency: allergy orbronchialasthmathathasrequiredhospitalisation Contraindication: by cliniciansotherthandentalpractitioners alcohol). Donotleavefluoridevarnishunattendedwheninuse.FluorideisanS4used Note: foods fortherestofdaytominimisedisruptionvarnish application. Donotbrushteethondayofapplication-resumebrushingthenextmorning.Eatsoft Provide ConsumerMedicineInformation: RIPRN mayproceed RN mustconsultMO/NP ATSIHP mayproceedifincludedinthescopeofpracticepractitioner’splan • • Liquid Form Refer highriskandpatientswithobvious dentalcariestodentist – – Arrange re-callforreviewoforalhealthstatusandreapplicationfluoride varnish: Schedule – – Do notapplyifulcerativegingivitisorstomatitistoavoiddiscomfortforpatient(contains if highrisk-every3months if lowrisk-every6months 0.4 g/0.4mL (Single dose preparation) (10 mLtube) 50 mg/1mL Strength Allergytocolophony(naturalrosin)orstickingplaster;anyepisodeofsevere 5% 5% 4 administration Route of Topical Adversereactionsextremelyrare.IfoccurscontactMO/NPor Teethmayappeardiscolouredtemporarilyfollowing
Child 18monthsto6years Fluoride varnish Duraphat® dosingcard if notusingsingledose (Duraphat Recommend useof Child 6to12years Child >12years Recommended up to0.25mL up to0.75mL up to0.4mL preparation and adult dosage ® ) Extended authority Then administer administration) (or 3monthlyif for self/parent (do notsupply ATSIHP/RIPRN indicated) 6 monthly Duration stat 2,4
Mouth and dental 347 4 Acute pain management, page 35 page management, pain Acute Mouth and dental problems dental | Mouth and Section 4: General 3 Not applicable Toothache, page 342 page Toothache, May occur spontaneously as painful solitary or multiple ulcerations on cheek, May occur spontaneously as painful solitary or 3 1,2 1,2 lip or floor of mouth. May occur acutely with smoking cessation lip or floor of mouth. May occur acutely with smoking check serum iron and folate mm in diameter with a red margin and aphthous ulcers are round/oval ulcers usually 3-5 sloughing base. – – – non-healing ulcers - consider squamous cell carcinoma ulcers or neutropenia: recurrent ulcers - consider Behçet syndrome, aphthous – minor ulcer < 5 mm in diameter - lasts 5-10 days without scarring. Usually occur on cheeks, lips minor ulcer < 5 mm in diameter - lasts 5-10 days and floor of the mouth Usually occur on lips, soft palate and fauces major ulcer > 8 mm - can persist for up to 6 weeks. (back of the mouth to the pharynx) and tongue inspect mucous membranes of the oral cavity, lips and tongue inspect mucous membranes of the oral cavity, lips chlorhexidine 0.2% mouth wash or topical anaesthetics such as lidocaine (lignocaine) lotion chlorhexidine 0.2% mouth wash or topical anaesthetics (Seda lotion®). See not salt water mouth rinses
– – – – – – – dentures Ulcers may occur for a range of reasons, but most commonly are due to: trauma within the mouth, are due to: trauma within but most commonly for a range of reasons, Ulcers may occur appliances, teeth, orthodontic hot foods, rough or sharp tongue biting, sharp or cheek and Ulcers persisting for longer than three weeks are potentially serious weeks are potentially for longer than three Ulcers persisting - adult/child ulcers Mouth Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) Refer to MO/NP/Dentist if ulcer persists for longer than 3 weeks – – Management of mouth ulcers must address possible causes of the ulcers, such as trauma within Management of mouth ulcers must address possible the mouth Administer analgesia as clinically indicated. See For symptomatic relief try: Ensure patient can maintain oral intake and hydration (especially in children) Ensure patient can maintain oral intake and hydration – – – – Perform physical examination: – Consider in history taking potential other causes of ulcers: STIs, medicine(s) reaction, viral and potential other causes of ulcers: STIs, medicine(s) Consider in history taking disease, skin/ systemic disease e.g. blood disorders, gastrointestinal fungal infections, carcinoma, mucocutaneous disease Obtain patient history including dental history Obtain patient history including Ulcers on mucosa of mouth - vary greatly in size, pain and duration Ulcers on mucosa of mouth
• • • • • • • • • • • •
Recommend Background
HMP 4. Management 3. Clinical assessment 2. Immediate management 1. May present with 348 Mouth and dental .Maypresentwith 1. Referral/consultation 6. Followup 5. | Primary Clinical Care Manual 10th edition | Management 4. Clinicalassessment 3. Immediatemanagement 2. HMP Dentalabscess-adult/child Recommend • • • • • • • • • • • • • • • •
– and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning – – – Perform physicalexamination: Obtain patienthistoryincludingdental-recenttoothache/previous presentations Patient willrequireevacuation/hospitalisationandIVantibiotics – – – – Consult MO/NPurgentlyif: Maintain airwayifcompromised.See Fever Bad breath(halitosis) Enlarged lymphglands Facial swellingand/orlocalisedaroundtooth Earache Dental pain(howevercanbepainless) Consult DentistorMO/NPifnotimprovingwithinexpectedtimeframe Advise tobereviewedin3weeksifulcerhasnotresolved Administer analgesia asclinicallyindicated(especially NSAIDifnotcontraindicated).See pain management, page 35 increased antibioticresistance increasingly severeepisodesofacutetoothrelatedinfectionwithriskairwaycompromiseand Always referforactiveDentaltreatment.Treatmentwithantibioticsalonecanleadto – – – – – – – BGL systemically unwell marked swellingonfaceorneck breathing and/orswallowingdifficulty severe trismus check abilityofpatienttoopenmouth, swallow,breathe inspect andpalpateface,lymphnodes ofneckandbehindears inspect oralcavitylookingforsofttissue swellingorcollectionofpus
1 DRS ABCD resuscitation/the collapsed patient, page 54 2 Acute Mouth and dental 349 4,5
https:// 5 days 2 Duration 2,3
102 Extended authority Chronic Conditions available from: ATSIHP/IHW/IPAP/RIPRN 2 dosage Anaphylaxis, page page Anaphylaxis, 500 mg tds Recommended Child < 12 years 12.5 mg/kg/dose tds Adult and child ≥ 12 years Mouth and dental problems dental | Mouth and Section 4: General to a max. of 500 mg/dose tds
Amoxicillin May cause rash, diarrhoea, nausea and candidiasis Consult MO/NP. See Oral Route of administration (swelling in the region of pain, discrete swelling of gum): the region of pain, discrete (swelling in 4 (swelling causing dysphagia or dyspnea): dysphagia causing (swelling 250 mg 500 mg Strength 250 mg/5 mL 500 mg/5 mL : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity : Severe or immediate allergic reaction to a penicillin. Prevention and Management of Chronic conditions in Australia Prevention and Management : if not allergic give amoxicillin OR if not allergic acid OR give amoxicillin + clavulanic if facial swelling penicillin give clindamycin if allergic to change to amoxicillin + clavulanic acid if unresponsive to amoxicillin – – – – superficial infections superficial severe infection severe – consult MO/NP/Dentist if no improvement or deteriorating – refer for urgent dental treatment 48 hours: advise to be reviewed within give oral antibiotics: – – consult MO/NP urgently consult management surgical and appropriate IV antibiotics for evacuation/hospitalisation will require can be life threatening present or develops, it airway - if cellulitis is closely monitor – – – – – – – Form Schedule Manual publications.qld.gov.au/dataset/chronic-conditions-manual – measures. See the current edition of the Reinforce positive oral hygiene – – For – – – – For For Capsule Powder for to oral liquid • • • reconstitution Contraindication between penicillins, cephalosporins and carbapenems Management of associated emergency: Provide Consumer Medicine Information: RIPRN may proceed ATSIHP, IHW, IPAP and RN must consult MO/NP 350 Mouth and dental | Primary Clinical Care Manual 10th edition | Management ofassociated emergency: Contraindication: • • • • There isnooralliquidforchildren.A 50mg/mLsolutioncanbemade: Note: pain. Takewithafullglassofwater Provide ConsumerMedicineInformation RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency membranes astheremaybeanincreasedriskofneonatalnecrotisingenterocolitis between penicillins,cephalosporinsandcarbapenems.Avoidinwomenwithprematureruptureofthe Contraindication candidiasis. Cancauseseverecolitisdueto Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution to oralliquid Capsule mix thedoseinjuiceorsoftfoodto disguisethetastebeforegivingit discard anyexcesssolutionsothat the correctdoseremainsinsyringe draw thissolutionintoasyringeand makethevolumeupto3mL(ifnecessary) dissolve contentsof1capsulein2mL water Powder for Form Schedule Tablet
Form Can causeseverecolitisdueto Schedule Strength 150 mg : Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity Allergy toclindamycin orlincomycin 400 mg/5mL+ 57 mg/5mL 875 mg+ Strength 125 mg 4 4 administration
Route of Oral Amoxicillin +clavulanicacid administration Cl. difficile : ConsultMO/NP.See ConsultMO/NP.See : Maycauserash,diarrhoea,nausea,vomitingandabdominal Route of
Clindamycin Takewithfood.Maycauserash,diarrhoea,nauseaand Oral Cl. difficile
Adult andchild≥12years max. of300mg/dosetds 7.5 mg/kg/dosetdstoa Child <12years Recommended (Calculate dosebasedonthe 22.5 mg+3.2mg/kg/dose 300mgtds 875 mg+125mg/dosebd Adult andchild≥12years amoxicillin component) dosage 875 mg+125bd bd uptoamax.of Anaphylaxis, page Child >2months Anaphylaxis, page Recommended to <12years dosage ATSIHP ATSIHP Extended authority Extended authority / IHW/IPAP/RIPRN / IHW/IPAP/RIPRN 102 102 Duration 5 days Duration 5 days
3,6,7 3,8 Mouth and dental 351
Mouth and dental problems dental | Mouth and Section 4: General - adult/child
Not applicable
1 1
dental history - date of tooth extraction, when bleeding started and the nature and amount of dental history - date of tooth extraction, when bleeding blood loss e.g. leukaemia, chronic liver disease medical history for bleeding disorders, chronic diseases therapy medication history - in particular anticoagulant/antiplatelet – – –
Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) Refer to next Dentist clinic Advise patient to be reviewed the next day Apply pressure (bite) at the site of the bleed with gauze roll for 15 minutes Apply pressure (bite) at the site of the bleed with Consult MO/NP/Dentist if bleeding is profuse causes should be investigated If bleeding continues beyond these measures, systemic In healthy patients, a low level ooze for 12-24 hours following a dental extraction is normal and In healthy patients, a low level ooze for 12-24 hours time requires investigation and treatment requires no treatment. Active bleeding beyond this and advise them to sit calmly and upright If bleeding is profuse (flowing) reassure the patient Look for signs of infection e.g. pus, cellulitis, trismus, liver clots (large mobile clots resembling Look for signs of infection e.g. pus, cellulitis, trismus, fresh liver) Is bleeding causing swelling or airway compromise Is bleeding causing swelling or airway compromise Any high flow arterial bleed, tear in gum or mucosa Assess blood loss - examine the oral cavity and identify site of bleeding. Use gauze, suction or Assess blood loss - examine the oral cavity and visibility if needed syringe with normal saline to remove blood for better – – – Obtain patient history including: Bleeding soon after tooth extraction Bleeding soon after tooth Consult Dentist/MO/NP with dentist Consider telehealth consultation Advise patient to return to clinic if their condition deteriorates to return to clinic if their Advise patient Advise to see Dentist as soon as possible as soon to see Dentist Advise resolves until it review swelling daily to patient to return Advise consult MO/NP/Dentist 48 hours or deteriorating to oral antibiotic after If unresponsive
• • • • • • • • • • • • • • • • • • • •
5. Follow up 4. Management
3. Clinical assessment 2. Immediate management
1. May present with Post extraction haemorrhage Post extraction
6. Referral/consultation 5. up Follow 352 Mouth and dental .Maypresentwith 1. / Referral/consultation 6. | Primary Clinical Care Manual 10th edition | Referral/consultation 6. Followup 5. Management 4. Clinicalassessment 3. Immediatemanagement 2. HMP Alveolarosteitis( dry socket) Background • • • • • • • • • • • • • • • • • • • •
and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning Refer fornextDentistclinicvisit Advise patienttoberevieweddaily initially. ConsultDentistorMO/NPifnotimproving If severeorcontinuesformorethan 3weeksconsultMO/NPorDentistforreviewofdiagnosis Should healspontaneouslywithin2-3weeks If Alvogyl®notavailablecontactDentist/MO/NPforfurtheradvice not requireremovallater.Note:Alvogyl®shouldbeusedifpatientisallergictoiodine Place Alvogyl®(antisepticandanalgesic)dressinglooselyintosocketif available.Dressingdoes Irrigate socketgentlywithwarmsodiumchloride0.9%toremovedebris Administer analgesiaasclinicallyindicated(NSAIDpreferred).See Any halitosis Inspect oralcavity(withcare-anemptysocketwithoutaclotisverytender) – Obtain patienthistoryincluding: Halitosis, foultaste Partially ortotallydisintegratedbloodclotinsocket days aftertheextraction,respondingpoorlytoovercounteranalgesia Postoperative paininandaroundatoothextractionsocket,thatincreasesseveritybetween1-4 Consult MO/NPifbleedingheavyorcontinuing Consult Dentist /MO/NPas above 35 effect Alvogyl® isaself-eliminatingdressingwhichprovidesfastsoothing,longlastinganalgesic Treatment withantibioticsisofnobenefit spontaneously in2-3weeks socket followingprematurelysis(disintegration)ofthebloodclot.Itusuallyresolves Alveolar osteitis(drysocket)isalocalpainful(inflammationofbone)anextraction – smoke for24-48hoursafteranextractionasthismaydelayhealing when dentalextractionoccurred,painassessment,smokinghabits.Patientsareadvisednotto 1,2 1,2 1,2 Notapplicable
- adult/child Acute pain management, page Mouth and dental 353 https:// Chronic Conditions Mouth and dental problems dental | Mouth and Section 4: General - adult/child
Not applicable 1,2,3 1,2,3
1,2,3
BGL acute, painful conditions are not improving inspect lips, gums, teeth, tongue, lymph glands in neck inspect lips, gums, teeth, tongue, lymph glands smoking diabetes cleaning regimen rarely (if at all) seen in children ulcers on the gums (may be covered with a grey membrane) ulcers on the gums (may be covered with a grey foul smelling mouth odour fever/other systemic features may be present rarely painful extremely painful rarely seen in children easily red, swollen gums that bleed halitosis, bad taste normally painful teeth, bleeding and/or swollen gums, not gum recession, loose/missing – – – – – – – – – – – – – – – undisturbed plaque causing a nonspecific inflammatory response plaque causing a nonspecific undisturbed Periodontitis can result in loss of the bone that supports the teeth and loss of teeth. Major risk teeth and loss of teeth. bone that supports the can result in loss of the Periodontitis and smoking poorly controlled diabetes factors include presence of It develops due to the of periodontal disease. most common form Gingivitis the Manual: Prevention and Management of Chronic conditions in Australia available from: Consult Dentist/MO/NP if: – Reinforce positive oral hygiene measures. See the current edition of the Reinforce positive oral hygiene measures. See the Perform physical examination: – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – – – – Obtain patient history including dental history. Ask about: Obtain patient history including dental history. – – – – – Acute ulcerative gingivitis: – – Gingivitis: – Periodontitis: – – publications.qld.gov.au/dataset/chronic-conditions-manual publications.qld.gov.au/dataset/chronic-conditions-manual
• • • • • • • • • • Background
Periodontal disease Periodontal HMP 4. Management
3. assessment Clinical 2. management Immediate
1. May present with gingivitis, gum disease gum gingivitis, Periodontitis, 354 Mouth and dental | Primary Clinical Care Manual 10th edition | Additionally Management ofassociatedemergency: cause nausea,anorexia,abdominal pain,vomiting,diarrhoea,metallictaste,dizzinessorheadache tablet withfoodtoreducestomachupset.Takeoralliquid1hourbefore food forbetterabsorption.May Provide ConsumerMedicineInformation: RIPRN mayproceedfor ATSIHP, IHW,IPAPandRNmustconsultMO/NP • • • Tablet liquid Form Oral Schedule – – – – – Acute ulcerativegingivitis: – – Gingivitis: – – Periodontitis: – – – – – – – – – – – – – administer analgesiaasclinicallyindicated.See complete resolutioncanbeexpectedwithin1week (do notuseformorethan10daysassuperficialdiscolourationofteethcanoccur) gums restrictsnormalbrushing.Rinsemouthwith10mLfor1minute8-12hourly5-10days short termuseofchlorhexidinemouthwash0.2%maybeusefulwheninflammationthe antibiotics arerarelyrequired management refer tonextDentalclinicfordebridementofplaque(scalingandrootplanning)ongoing immunocompromised patient hasanunderlyingmedicalconditione.g.uncontrolleddiabetesoris systemic signsandsymptoms to reoccurrence note: refer toDentistforscalingandrootplanningongoingmanagement – – give antibiotics: can brushteetheffectively recommend tousechlorhexidinemouthwash0.2%(asperGingivitis)untilpainhasabatedand – – if patientadherenceisaconcern,tinidazole metronidazole OR 200 mg/5mL antibioticsalone,withoutdebridementandimprovementoforalhygienewillusuallylead Strength 200 mg 400 mg
adults only 4 administration Route of Oral
ConsultMO/NP.See Avoidalcoholwhiletakingandfor24hoursthereafter.Take Metronidazole 10mg/kg/dosebdtoamax.of 400 mg/dosebd Child >1month Recommended Acute pain management, page 400 mgbd dosage Adult Anaphylaxis, page ATSIHP Extended authority / 102 IHW/IPAP/RIPRN Duration 35 5 days
2,5 Mouth and dental 355 2,6,7
stat Duration 102 IHW/IPAP/RIPRN / Extended authority Extended ATSIHP 2 g dosage Anaphylaxis, page page Anaphylaxis, Adult only Recommended Recommended Mouth and dental problems dental | Mouth and Section 4: General
Tinidazole - adult/child
Oral Avoid alcohol while taking and for 72 hours thereafter. Take Avoid alcohol while taking Route of Consult MO/NP. See administration Not applicable thrush)
1,3 4 1 oral 3 Use metronidazole instead of tinidazole Use metronidazole instead 500 mg Strength
1,2 irritability poor feeding and/or feeding refusal may be asymptomatic Schedule
Candidiasis ( – – – Oral thrush occurs commonly in the first 9 months of life. It is rare during the 1st week and peaks Oral thrush occurs commonly in the first 9 months in healthy individuals at the 4th week of life. It is otherwise uncommon Obtain patient history Ask about risk factors associated with thrush: – – – Whitish plaques on the tongue or oral mucosa Severe cases may show ulceration Additionally in infants: Oral discomfort Consider telehealth consult with Dentist If diabetic, consider referral to Diabetic Educator If acute ulcerative gingivitis advise patient to be reviewed the next day If acute ulcerative gingivitis Refer to next Dentist clinic
Form
• Tablet • • • • • • • • • • Background
metallic taste, dizziness or headache metallic taste, dizziness Use in pregnancy: emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine pain, vomiting, diarrhoea, upset. May cause nausea, anorexia, abdominal with food to reduce stomach ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed
HMP HMP 3. Clinical assessment
2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up 356 Mouth and dental | Primary Clinical Care Manual 10th edition | Management 4. • • • • • • and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning – – In dentureusers: – – – – – In infants: – – – Consult withMO/NPif: – – – Inspect: – – – In infantsaskabout: – – – – – – – – – – – – – – – – – – – – – – – – – – – – infection They arebestsoakedincommercialdenturecleanere.g.Steradent®to destroycandida at night,denturesshouldberemoved,cleanedthoroughlyandplacedin adryenvironment. surface ofthedenturesbeforeinsertingthem if candidiasisisconfirmed,advisetoapplytheantifungalgel/drops thecleanedfitting provide supportwithbreastfeedingasrequired refer toChildHealthNurse/Midwife educate regardingcorrectcleaningoffeedingequipment/dummies concurrently treatnipplesofmotherifbreastfeeding(useoralmiconazole) treat withoralmiconazolegel(maybemoreeffectiveininfants lozenges if adultsdonotrespondtomiconazoleornystatin-MO/NP/Dentistmayorderamphotericin and identificationofunderlyingpre-disposingfactorsneedstobeconsidered severe, persistent,orfrequentepisodesofthrush,ifimmunocompromised.Correctdiagnosis an adult mother's nipplearea(ifindicatedfromhistory)-anyredness/crackednipples infant's nappyareaforcandidiasis remove, withtheunderlyingareabeingraworbleeding oral cavity-lookforwhiteorwhitish-yellowplaquesanderythemathatmaybedifficultto pacifiers, asthesecanbeasourceofreinfection method ofcleaninginfantfeedingequipment/otheritemsthatgoininfantsmouthe.g. if breastfeeding,anynipplepain,burningand/oritching,orcracked/redareolae nappy rash frequent orunusualinfections past episodesofthrush denture use(whenandhowaretheycleaned) nutritional deficiencies conditions associatedwithimmunodeficiencye.g.HIV antibiotic use;incorrectuseofcorticosteroidinhalers;poororalhygiene 2,3,4 1 1 ) ornystatinsuspension Mouth and dental 357 7 5,6
Duration 7-14 days 9 9 Duration 7-14 days
102 102 IHW/IPAP/SRH IHW/IPAP/SRH / / Extended authority authority Extended Extended authority ATSIHP ATSIHP
2.5 mL qid 1.25 mL qid dosage 1 mL qid Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, Recommended Adult and child (½ of spoon supplied) (¼ of spoon supplied) Recommended dosage Recommended Adult and child ≥ 2 years Adult and child Child birth (at term) - 2 years Child birth (at term) - 2 Mouth and dental problems dental | Mouth and Section 4: General . Use a clean finger to smear small amounts of gel to . Use a clean finger to smear
Miconazole Nystatin
Use spoon supplied to measure dose. Place directly in the Use spoon supplied to Swish around the mouth for as long as possible before Swish around the mouth for as long as possible Oral consult MO/NP. See : Consult MO/NP. See Route of Oral Route of Authority to administer and supply medicines, page page medicines, supply and administer to Authority Authority to administer and supply medicines, page page medicines, supply and administer to Authority administration administration 3
3 100,000 Strength units/mL 2% : Warfarin and simvastatin Strength Schedule Do not use a spoon to administer to babies Do not use a spoon to administer Schedule
: Form Consult Child Health Nurse or midwife if child or infant Consult MO/NP if severe or not improving or if an immunocompromised patient If mild, advise to be reviewed in one week If moderate, advise to be reviewed daily initially Form
Oral gel Oral liquid • • • • swallowing. Use after eating/feed. If breastfeeding treat nipples with miconazole 2 % oral gel after swallowing. Use after eating/feed. If breastfeeding feeding. May cause nausea, vomiting or diarrhoea Management of associated emergency: Provide Consumer Medicine Information: RN may administer; for supply see ATSIHP, IHW, IPAP, MID, RIPRN and SRH may proceed the front of the mouth so that they don’t choke the front of the mouth so Contraindicated Management of associated emergency mouth and on the tongue after food or drink. Keep in mouth as long as possible before swallowing. as drink. Keep in mouth as long or after food tongue the on and mouth treat nipples concurrently with days after symptoms cease. If breastfeeding, Continue using for several GI upset this gel. May cause mild Note Provide Consumer Medicine Information: Provide Consumer Medicine RN may administer; for supply see RN may administer; ATSIHP, IHW, IPAP, MID, RIPRN and SRH may proceed and SRH may MID, RIPRN IHW, IPAP, ATSIHP,
6. Referral/consultation 5. Follow up 358 Eye Assessment ofthe Eye problems | Primary Clinical Care Manual 10th edition | 2. Examination It 1. History isimportanttoestablish: Visual acuity( Background Recommend • • • • • • • • • • • If anyabnormalityisfound(visionless than6/9),checkVAofthateyewiththepatientlooking without anyerrors.Itwillusuallybe foundunderthelineofletterse.g.6/5,6/6,6/12,etc. e.g. 6.Thebottomnumberrecordsthe smallestlineoflettersthepatientisabletoseeonchart VA isrecordedas2numbers.Thetop numberisthedistancepatientfromchartinmetres by asolidoccluder tested withthepatient'susualspectacles orcontactlenses,withtheothereyecompletelycovered Test VAofeacheyeseparatelyusingaSnellenchartat6metresingood light.Visionshouldbe Any familyhistoryofeyeproblemse.g.chronicglaucoma – – – – Any historyofmedicalormentalhealthproblems,andeyeproblems: – – – – The natureofvisualsymptoms: – – – If theproblemisaresultoftrauma: chart e.g. 3metres.Thetop numberthenbecomes 3e.g.3/60. Ifstillunabletosee thelargest If thepatientcannot readthelargestletteronchart at6metres,movethepatientcloser tothe through apinhole andtheothereyecompletelycovered drops, fluoresceineyedropsorstrips occluder, solidmagnification,cottonbud,ophthalmoscope,topicalanaestheticeye Equipment -small powerful torch,VAchartsuch as Snellenor Snellen-E chart,multiple-pinhole Visual acuity(VA)of6/6doesnotexcludeaseriouseyecondition eye. Failuretodosomayleadlossofsight Identify causeofeyedisorderthroughsystematicandthoroughhistoryexaminationthe – – – – – – – – – – – any surgeryontheeyes does thepatientwearcontactlensesorspectacles medicines thatcanaffecttheeyes,includinguseofeyedrops/ointment current medicalproblemse.g.diabetesorautoimmunedisease associated symptomse.g.flashinglights,floaters,haloesaroundlights rate ofonset one orbotheyesaffected loss ofvision,painorgrittiness,redness,discharge,doublevision of theorbit if therehasbeenaforcefulbluntinjury,suspectruptureoftheeyeand/or'blowout'fracture in anyhighvelocityprojectileinjury,apenetratinginjurymustbesuspected a historyofwhenandhowtheinjurywassustainedisessential 1,2 1 1 VA) 1,2
eye
- adult/child Eye 359 Eye problems Eye Section 4: General | Section 4: General to the eyeball if there is any suggestion of an if there is any suggestion to the eyeball 1,2 1,2,3,4 1,2 not to apply any pressure not to apply pupils and eye movements is there double vision to check if double vision disappears if there is double vision, cover one eye at a time on the corneas i.e. no obvious squint/deviation if a blowout orbital fracture is suspected are they equal in all directions especially upward repeat the procedure on the other eye. Both pupils should constrict when a light is shone on repeat the procedure on the other eye. Both pupils either eye from a torch are positioned symmetrically check both pupils align equally and light reflections coming from the side of the face, bring a torch to shine on one eye coming from the side of the face, bring a torch to or penetrating eye injury part of examination of a red or injured eye in all other cases, eyelid eversion is an essential foreign bodies are often retained on the inner surface of the eyelid foreign bodies are often if there is any suggestion of an eyeball rupture eversion of the upper eyelid should NOT be done do NOT attempt to remove any foreign body e.g. nail, knife, fish hook protruding from a any foreign body e.g. nail, knife, fish hook protruding do NOT attempt to remove penetrating injury abandon examination, place a rigid shield over the eye and evacuate the patient to an a rigid shield over the eye and evacuate the abandon examination, place appropriate facility care should be taken care should or penetrating eye injury eyeball rupture thus avoiding any by using traction over the orbital margins, the eyelids can be separated eye try to pry the eyelids of a child apart to see the pressure on the eye. Never the lower eyelid should be pulled down to examine the conjunctival lining to examine the conjunctival should be pulled down the lower eyelid – – – – – – – – – – – – – – Too much fluorescein dye swamps the tear film and makes it difficult to discern abnormalities. Too much fluorescein dye swamps the tear film and makes it difficult to discern abnormalities. Instil a small amount of fluorescein Contraindicated if a ruptured eyeball or penetrating eye injury is obvious Contraindicated if a ruptured eyeball or penetrating Fluorescein dye pools in areas denuded of corneal epithelium. When exposed to blue light it fluoresces, allowing assessment of the nature and extent of corneal epithelium damage e.g. scratch, herpes simplex ulcer – – Check movements of the eyes: – – – Check and record the shape of both pupils. Pupils are normally round, regular and equal size Check and record the shape of both pupils. Pupils Check both pupils' reaction to light: – (hyphaema) or pus (hypopyon), either of which may present as a fluid level in the lower chamber or (hyphaema) or pus (hypopyon), either of which be diffused and obscure the iris and pupil – iris) should be examined for the presence of blood The anterior chamber (between the cornea and inner aspect of the upper eyelid should be examined by everting the lid. See Procedure for eyelid should be examined by everting the lid. inner aspect of the upper eversion of the eyelid: – – – of grittiness in the eye, the or a history of a foreign body, or a sensation If the patient has a red eye, If there is an obvious or a very strong suspicion of an eyeball rupture or penetrating eye injury: a very strong suspicion of an eyeball rupture or If there is an obvious or – – – Ensure good lighting and use magnification Ensure good and conjunctiva: eyelids, cornea, sclera areas, external Check the periorbital – torch light (perception of light) (perception torch light issues are literacy if there or animal charts Snellen E may involve assessment Further letter, can the patient count fingers or see hand movements at 1 metre. If not, can the patient see patient the not, can If 1 metre. at movements see hand or fingers count the patient can letter, • • • • • • • • • • • • Fluorescein examination of the cornea Examine the Examine the eye systematically Examine the 360 Eye | Primary Clinical Care Manual 10th edition | Eye Padding oftheeye • • • • • • • • • • • • • • • • MO/NP patient feltsomethinghittheeye.Consult hammer strikingsteel,particularlyifthe from ahighvelocitymetalfragmente.g. may havesufferedapenetratingeyeinjury Arrange x-rayoftheorbitforapatientwho eyeball orpenetratingeyeinjuryisobvious when examiningtheeyeunlessaruptured The corneamaybestainedwithfluorescein Evert theuppereyelidwhenexaminingeye Test pupillightreactions Always checkVAandrecordit Ophthalmologist There arenoindicationstopadtheunaffectedeyeunlessinstructeddosobyan should notbeusedunlessadvisedtodosobyanOphthalmologist Double paddingofaneyei.e.2padsappliedtoasingleeye,actsaspressurebandageand monocular visionmayinvalidateinsurance Instruct thepatientnottodrivewithaneyepaddedbecausedepthperceptionmaybealtered,and eye dropstothepatientuseasacontinuingtreatmentforpain There arenoindicationsforcontinueduseoftopicalanaesthesia.DONOTgiveanaesthetic back, withheadelevatedifpreferred pressing ontheeye.Itwillprotecteyefromcompression.Thepatientshouldremaintheir eyeball orpenetratingeyeinjuryisobviouscannotberuledout.Makesuretheshieldnot Use aneyeshieldorcutdownstyrofoamcup use oftopicalanaestheticeyedropstofacilitateexaminationorremovalaforeignbody Routine paddingofaneyeisnotnecessaryforminorcornealorconjunctivaltrauma,afterthe Darken theroomandexposeeyetobluefilterede.g.ophthalmoscope,cobaltor'black'light Gently dabtheclosedeyewithatissuetoremoveanyexcessfluorescein Ask thepatienttoblink.Thiswilldistributefluoresceinovercornea If usingliquidfluorescein,instilasmalldropontotheinsideoflowereyelid – – – If usingfluoresceinstrips,thereisnoneedtopre-moisten: Tips – – – repeat ifmoredyeisneeded the tearswillmoistenandreleaseasmallamountofdye gently touchthedrystriptoinsideoflowereyelid 1 1 Do tapedsecurelytothebrowandcheekifaruptured • • • • • take home Give patientlocalanaestheticeye-dropsto an Ophthalmologist Double padaneyeunlessadvisedtodosoby orders Use steroideyedrops,unlessonMO/NP injury suffered anobviousruptureorpenetrating Put dropsorointmentinaneyethathas penetrating eyeinjury Try toremoveanobjectprotrudingfroma Do NOT E Eye 361 . 2nd ed Eye problems Eye Section 4: General | Section 4: General Eye emergency manual: an illustrated guide Evert the eyelid by using the eyelashes to gently pull the lid upwards over the bud. Remove the bud (Fig.3) Place cotton bud at the lid crease (or 5 mm Place cotton bud at the very light pressure from lid edge) and apply (Fig 1.&.2) downward with the bud Instruct the patient to keep looking downwards patient to keep looking Instruct the then hold of the eyelashes and as you take (Fig.1) lid slightly towards you gently pull the • • • 1 eversion of the eyelid of the eversion Procedure for for Procedure Fig 3. Fig 2. Fig 1. Reproduced with permission from NSW Department of Health. 2009. Reproduced with permission from NSW Department of 362 Eye Red or | Primary Clinical Care Manual 10th edition | • • • • • See page abrasion, corneal body and Foreign page eye injury, Penetrating 369 injury, page Blunt eye page burn to eye, Chemical page to eye, Flash burn History of trauma Significant featuresofassessmentunclearoryouareunsurecause 371 367 366 363 painful eye (particularly reducedvisionthathasnoapparentexplanation) • • • • • Conjunctivitis, fluorescein cornea with No staining of VA isnormal discharge mucopurulent Clear or inflamed diffusely Conjunctiva eyes affected Usually both page See 379
- adult/child
ulceration, page Significant featuresofassessment • • • • • Clinical assessmentperformed fluorescein stains with Cornea or central ulcer large affected if VA only discharge mucopurulent Clear or inflamed diffusely Conjunctiva Unilateral See 385 Corneal
No
• • • • • MO/NP -maybe fluorescein cornea with No stainingof VA normal discharge watery May bea of sclera inflammation Localised Unilateral Discuss with urgent
• • • • • uveitis), page fluorescein cornea with No stainingof impaired later early but VA normal the cornea adjacent to on thesclera pronounced more Inflammation irregular pupil small ± Photophobia, Unilateral Acute iritis (anterior 386 See Yes • • • • • • • • Consult MO/NP lights Halos around Headache Severe pain VA impaired cornea Cloudy pupil Mild-dilated vomiting Nausea and Unilateral adult/child, glaucoma - page
Acute See 387 Eye 363 Eye problems Eye 371 Section 4: General | Section 4: General Penetrating eye injury, page page injury, eye Penetrating - adult/child
1,2 1,2 385 corneal abrasion corneal 1,2 e.g. hammer striking metal, angle grinding 1,2,3,4,5 e.g. dust blowing into eye 1
attached to a 2 mL syringe to provide support decreased VA large or central (over pupil) corneal abrasion high velocity projectile. MO/NP may order x-ray if available high velocity projectile. MO/NP may order x-ray high velocity low velocity Foreign body/ Foreign – – – – – – removal Eye pad is not routinely used as treatment for corneal abrasion or after superficial foreign body or after superficial for corneal abrasion routinely used as treatment Eye pad is not Consult MO/NP if there is a foreign body in a child's eye, or if over or near the pupil of any patient of any pupil the over or near if child's eye, or a body in foreign if there is a MO/NP Consult
An experienced clinician may remove the foreign body using an 18 G needle: – Many corneal foreign bodies can be removed by irrigating with sodium chloride 0.9%. Gently Many corneal foreign bodies can be removed by fully open syringe or use an IV bag with a giving set and regulator If unsuccessful, use moistened cotton bud. Gently wipe the cornea with the bud. Many foreign bodies will stick to the bud – – any corneal foreign body Instil oxybuprocaine eye-drops before removing Consult MO/NP if: – With fluorescein staining, foreign bodies and abrasions are usually obvious under the blue light of With fluorescein staining, foreign bodies and abrasions defect present an ophthalmoscope. Fluorescein will pool in any If pain restricts examination, instill topical anaesthetic oxybuprocaine eye drops unless there is an If pain restricts examination, instill topical anaesthetic obvious ruptured eyeball or penetrating eye injury obvious ruptured eyeball or penetrating eye injury Fluorescein dye may be used unless there is an Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) eye first Examine both eyes starting with VA. Test unaffected Obtain patient history, including time and mechanism of injury: Obtain patient history, including time and mechanism – – Do not remove any protruding foreign bodies Do not remove any protruding Photophobia Contact lens related abrasion A history of, or visible, foreign body, eye pain or grittiness A history of, or visible, foreign Inability to open eye
• • Corneal ulceration, page page ulceration, Corneal Related topics • • • • • • • • • • • • • • • •
Recommend HMP HMP
4. Management 3. Clinical assessment
2. Immediate management 1. May present with 364 Eye | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency: Contraindication Note anaesthetised Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP • • • • • • Eye drops Administer analgesiaasclinicallyindicated.See chloramphenicol eyedrops/ointment If aforeignbodyissuccessfullyremoved,orthereonlysimplecornealabrasion,givetopical chloride 0.9% tangentially tothecorneaifclinicianisexperiencedperform,andirrigatedawaywithsodium Metal foreignbodiesmayleavearustring.Thiscanbegentlyscrapedoffwithan18Gneedleheld – – Consult MO/NP: Note thatthecorneaisonly0.5-1.0mmthick If theforeignbodydoesnotliftoutwithneedle,irrigatesodiumchloride0.9% – – Form : Donotgivetopatienttakehome – – – – Schedule if unsuccessfulornotskilledinremovalofaforeignbody if thereisaforeignbodyoverornearthepupil dislodge theforeignbody using thetipofneedletangentiali.e.notperpendiculartocornealsurface,gently steadying thehandonpatient'scheek Strength : Rupturedeyeballorpenetratingeyeinjury 0.4% 4 administration Route of Eye consultMO/NP.See
Maystingforafewseconds.Donotrubortoucheyeswhile Oxybuprocaine Adult andchild Recommended dosage 1 drop Acute pain management, page Anaphylaxis, page Repeat in1-2minutesifneeded. Up to6dropsmaybeusedfor ATSIHP/IHW/IPAP/ foreign bodyremoval Extended authority Duration 102 stat
35 RIPRN
3 Eye 365 4,5,6
Eye problems Eye 9 Duration Up to 5 days
IHW/IPAP 102 / ATSIHP Extended authority authority Extended Section 4: General | Section 4: General OR OR and Anaphylaxis, page page Anaphylaxis, dosage Recommended Recommended Flash burn to eye 1-2 drops qid and Bacterial conjunctivitis 1-1.5 cm of ointment qid 1-1.5 cm of ointment qid Adult and child > 2 years Adult and child 1-1.5 cm of ointment nocte 1-1.5 cm of ointment nocte Foreign body / Corneal abrasion / Foreign body / Corneal abrasion 1-2 drops 2 hourly for 1 day, then qid 1-2 drops 2 hourly for 1 day, May cause stinging or burning. Discard one month after month one Discard burning. or stinging cause May Chloramphenicol
Consult MO/NP. See Authority to administer and supply medicines, page page medicines, supply and administer to Authority Eye Route of 3 administration 1% (4 g) 0.5% : Ruptured eyeball or penetrating eye injury (10 mL) Strength
Schedule not improving on first review, or not healed by second review not improving on first review, or not healed by VA deteriorates at any time
– – : Consult MO/NP if child ≤ 2 years Form Advise to see MO/NP at next clinic Consult MO/NP as above Consult MO/NP if: – – Advise to be reviewed daily until healed. Re-examine the eye, including VA and fluorescein staining Advise to be reviewed daily until healed. Re-examine
Eye drops • • • • Contraindication Management of associated emergency: Provide Consumer Medicine Information: opened. Do not wear contact lenses during treatment opening. Can be stored at room temperature once Note Eye ointment RN may administer; for supply see RN may administer; ATSIHP, IHW and IPAP must consult MO/NP must consult IHW and IPAP ATSIHP, RIPRN may proceed
6. Referral/consultation 5. Follow up 366 Eye 1. Maypresentwith | Primary Clinical Care Manual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement HMP Background Recommend • • • • • • • • • • • • • • • • • • • • Advise patientnot towearcontactlensesforatleast1 weekaftercorneahashealed page Administer analgesiaand/orantiemetic asclinicallyindicated.See Explain tothepatientimportance ofnotrubbingtheeye(s) page Give topicalchloramphenicoleyedrops andointment.See – – Consult MO/NPif: flash burn,especiallyfromwelding Evert theuppereyelidandcheckforaretainedforeignbodywhichmay occurconcurrentlywith conjunctival rednessinbotheyes particularly wherenotprotectedbyeyelidsinnormalposition)onthecornea. Theremaybe staining willshowsuperficialepithelialdefects(multipledotsofstain across thecornea, Stain eye(s)withfluoresceinandexamineunderbluelightofophthalmoscope. Fluorescein Examine botheyes,startingwithVAafterinstillingoxybuprocaineeyedrops Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Obtain patienthistory,includingtimeandmechanismofinjury page Administer topicalanaestheticoxybuprocaineeyedrops.See Foreign bodysensation(oftensevere) Tearing oftheeye(s) Blepharospasm (involuntaryeyelidclosure) Red eye(s) welding exposureatwork) Pain (oftensevere),whichstartsseveralhoursafterexposurepresentslateinevening History ofweldingorsunlampusewithouteyeprotection Advise patientthat flashburncanbepreventedbyuse ofappropriateprotectiveeyewear epitheliu Intense UVlight,mostcommonlyfromweldingarcintheworkplace,maydamagecorneal Reassure patientthattheoutcomeisusuallyafullrecovery – – Flash burntoeye decreased VA large orcentral(overpupil)cornealabrasion 35 363 363 and m
Nausea and vomiting, page 1,3 1 1,3
- adult/child 1,2,3 48
Foreign body and corneal abrasion, Foreign body and corneal abrasion, Acute pain management, Eye 367 Eye problems Eye Foreign body and and body Foreign Section 4: General | Section 4: General 13 11 26 (24 hours) as required - adult/child
1,2,3
363 1 irrigation with at least 1 litre of fluid is required for 30 minutes irrigation with at least 1 litre of fluid is required
1,2,3 1,2,3
be between 6.5 and < 7.5 wait 5 minutes after ceasing irrigation and then check pH with pad on urine dip stick. It should wait 5 minutes after ceasing irrigation and then Chemical burn to eye Chemical – Ophthalmologist Immediate and prolonged eye irrigation for chemical burns Immediate and prolonged Centre Contact Poisons Information by an burns to the eyes may require urgent assessment Patients with alkaline chemical Alkaline substances include: lime, mortar and plaster, drain cleaner, oven cleaner, ammonia lime, mortar and plaster, drain cleaner, oven Alkaline substances include: eyeball within 24 hours if not to the eye. May result in rupture of the Alkali burns are more harmful treated Acidic substances include: toilet cleaner, car battery fluid, pool cleaner toilet cleaner, car battery fluid, pool cleaner Acidic substances include: completion of irrigation to confirm that a neutral pH has been maintained If pH is ≥ 7.5, instil another oxybuprocaine eye drop and continue to irrigate while reassessing pH If pH is ≥ 7.5, instil another oxybuprocaine eye drop and continue to irrigate while reassessing pH every 15-30 minutes until pH is between 6.5-7.5. Re-measure pH at 5 and 30 minutes after required Check pH after 30 minutes of irrigation: – Evert the upper eyelid and clear it and the eye of any debris/foreign body e.g. lime particles that Evert the upper eyelid and clear it and the eye of a moistened cotton bud may be present, by sweeping the conjunctiva with Initial continuous and instil another 1-2 drops of oxybuprocaine as Review the patient's pain level every 10 minutes corneal abrasion, page page abrasion, corneal an IV bag with giving set and set regulator fully Irrigate copiously with sodium chloride 0.9%. Use open Consult MO/NP urgently to affected eye(s). See Instil topical anaesthetic oxybuprocaine eye drops Pain Reduced vision History of contact with acid or alkali chemical Consult MO/NP as above Consult MO/NP Advise to be reviewed the next day the next to be reviewed Advise not improving MO/NP if Consult
• • • • • • • • • • • • • • • • • • • •
Recommend Background HMP HMP
2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up Follow 5. 368 Eye 4. Management 3. Clinicalassessment | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • • Consult MO/NPasabove followed upaccordingtoMO/NPinstructions If severityofthechemicalburndoesnotrequireevacuationpatient, advisepatienttobe until healed Most caseswillbetreatedascornealabrasions,usingchloramphenicolointmentwithdailyreview Evacuation forreviewbyanOphthalmologistifindicated – – Consult MO/NP,whowilladvisefurthermanagementdependingon: page Administer analgesiaand/orantiemeticasclinicallyindicated.See involved Contact PoisonsInformationCentre Perform irrigation-seeImmediatemanagement – – – Examine botheyes: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – Obtain rapidhistory: – – – – – – – – very red extent ofcornealinjury/fluoresceinstaining/appearancetheconjunctivawhichshouldbe the chemical-acidoralkali assess VAifpossible chemical burn any opacityofthecorneaorareablanchedconjunctivalbloodvesselsindicatesasevere if painrestrictsexamination,instiloxybuprocaineeye-drops what firstaidhasbeengiven,andhowsoonaftertheincident identify thechemical,acidoralkali when itoccurred These maycontinuetocausedamageandneedbephysicallyremoved. Ruptureofthe 35
and Note: These patientsneedurgentassessmentbyanOphthalmologist
Nausea and vomiting, page 1,2,3 Somealkalismayadheretoconjunctivalsurfacesandnotrinseoff. eyeball mayresultifnottreatedwithin24hours. 1,3 13 1126(24hours)forfurtherinformationaboutthechemical 48 Acute pain management, Eye 369 Eye problems Eye Section 4: General | Section 4: General do not: - adult/child
1,2,3 e.g. hit by ball, racquet, fist, champagne cork
1,2,3 175 eyeball is suspected from the history, but not immediately obvious: perform a routine eye examination fluorescein dye or any other instil topical anaesthetic oxybuprocaine eye-drops, 1,2,3 protect the eye by applying an eye shield protect the eye by applying apply an eye pad apply an eye perform a routine eye examination perform a routine instil any eye-drops/ointment pressure on the eyeball apply any direct – – – – apply an eye shield do not do not eye-drops/ointment with the patient lying flat, assess VA - count fingers, hand movements, light perception mechanism of injury changes in vision immediately and subsequently if the patient was wearing eye protection Blunt eye injury eye Blunt
– – – – – – – or a blow-out fracture of a wall or floor of the orbit or a blow-out fracture of A forceful injury with a blunt object e.g. ball, racquet, fist, champagne cork directly on the eye and object e.g. ball, racquet, fist, champagne cork A forceful injury with a blunt of the bony orbit, and/ inside the eye, eyeball rupture, fracture of the rim orbit may cause damage – Do ruptured eyeball requires Ophthalmologist management Any obvious or suspected – – – If an eyeball is obviously ruptured If an eyeball
– If a ruptured – – – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) If a ruptured eyeball is obvious: – – – Obtain patient history in particular: Consult MO/NP urgently Obvious or occult eyeball rupture Double vision Blood in the anterior chamber of the eye (hyphaema) History of injury Pain Reduced or normal vision
• • • • Head injuries, page page injuries, Head Related topics • • • • • • • • • • •
Recommend Background
HMP 3. Clinical assessment
2. Immediate management 1. May present with 370 Eye | Primary Clinical Care Manual 10th edition | 4. Management • • • • • • • • Keep nilbymouth – – Nausea iscommonineyeinjuriesand vomitingcanaggravatetheinjury: Administer analgesiaasclinicallyindicated. See – – – If thereisa – – – – – – – should belookedfor: Orbital fracturesmayoccuraloneorwithaneyeinjuryresultingfromblunttrauma.Thefollowing – – – Examine botheyes: – – – – practitioner isnotcompetenttoperformaroutinesystematicexaminationinthesecircumstances: If arupturedeyeballissuspectedfromthehistory,butnotimmediatelyobvious,and – – – – degrees Where possiblekeep patientindimlightingandonbed restwiththeheadofbedelevated to30 – – – – – – – – – – – – – – – – – – – – – – – on theorbitalmargin fixed overtheinjuredeyetopreventaccidentalpressureoneyeball. Thebaseshouldrest a solideyeshieldeitherpre-madeorconstructedfromcardboardstyrofoam cupshouldbe do notpadtheeye do notremoveanyeyetissueprotrudingfromtherupture examine theeyelid(s)forlacerations is noobviouseyerupture if thereisconsiderableeyelidoedema,carefullylifttheawayfrom theeyetocheckthere contains abloodfluidlevel(hyphaema) clarity oftheanteriorchambereye:clear,cloudyobscuringirisand/orpupilor upper lip,onthesideofinjury anaesthesia ofthecheekbeloweyeand/oranterioruppergum,immediatelybehind restricted eyemovements,especiallyupgaze an eyethatissunkenintotheorbitorlowerthanother step inthebonyrimoforbit,especiallybeloweye appear red,withnoareasofblack after routineeyeexamination,checktheredreflexwithanophthalmoscope.Thepupilshould check thepupils:size,shape,reactivity VA mayhelpdeterminetheextentofinjuryandwillberequiredformedicolegalcases manage asforaconfirmedrupturedeyeball apply aneyeshield assess theVAifMO/NPagreestothis do not examination andapplyaneyeshield if itbecomesevidentduringtheexaminationthatthereisarupturedeyeball,abandon topical anaestheticoxybuprocaineeye-dropsmaybeused.See do notapplyanydirectpressureontheeyeball and theMO/NPagrees routine systematicexaminationoftheeyemaybeperformedifpractitioneriscompetent administer antiemeticasclinicallyindicated. See raised intraocularpressurewhenvomiting cancauseexpulsionofeyecontents abrasion, page performaroutineeyeexamination ruptured eyeball: 1,2,3 363 Acute pain management, page duringexamination Nausea and vomiting, page Foreign body and corneal 35 48 Eye 371
Eye problems Eye Section 4: General | Section 4: General
- adult/child
1,2,3 1,2,3 1,2,3 1,2,3 mechanism of injury check and manage any other life-threatening injuries keep patient nil by mouth daily review if significant hyphaema. This review should include measurement of intraocular hyphaema. This review should include measurement daily review if significant pressure if able review the next day and re-examine eye review the next day and damage to the internal structures of the eye e.g. retina internal structures of damage to the hyphaema (blood in the anterior chamber of the eye). If significant, patients are at risk of patients are at of the eye). If significant, in the anterior chamber hyphaema (blood following injury. Associated the first 2 days, during the 7-10 days, especially re-bleeding common pressure are and high intraocular intraocular inflammation Blunt trauma may cause but has reduced vision. who has no apparent injury, any patient eye lid lacerations. Treatment may vary, depending on eyelid margin and/or lacrimal drainage drainage and/or lacrimal eyelid margin on may vary, depending Treatment lacerations. eye lid damage system Penetrating eye injury
– – – – – – – – Any obvious or suspected ruptured eyeball requires Ophthalmologist management Any obvious or suspected ruptured eyeball requires Includes any foreign body penetration of the cornea e.g. dirt, glass, metal and inorganic material Includes any foreign body penetration of the cornea
Obtain patient history, including: – Consult MO/NP urgently If there is an obvious penetrating eye injury: – – Normal or reduced vision Obvious penetrating eye injury penetrating eye injury e.g. very small entry wound Suspicious history, but no immediately obvious speed made by small metal fragment travelling at high Pain History of feeling a high velocity projectile hit the eye History of feeling a high velocity projectile hit the Consult MO/NP as above – If not evacuated advise to be followed up according to MO/NP instructions, which may include: to be followed up according to MO/NP instructions, If not evacuated advise – Advise patient to rest, not use aspirin or NSAIDS and do no strenuous activity Advise patient to rest, not – – If there is no ruptured eyeball, discuss with MO/NP: discuss with eyeball, is no ruptured If there – Prepare for evacuation for Prepare
• • • • • • • • • • • • • • •
Recommend Background
HMP 3. Clinical assessment
2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up 372 Eye | Primary Clinical Care Manual 10th edition | 4. Management • • • • • • • • • • • • • – A solid Ophthalmologist If inanydoubt,thecharacteristicsof theinjuryshouldbediscussedwithreceiving – – If thelikelihoodofsignificantintraocularairisminimale.g: – – – – If theinjuryissuggestiveofpresence – – – Consult MO/NPwhowilladvise: Keep nilbymouth Administer antiemeticasclinicallyindicated.See Administer analgesiaasclinicallyindicated.See Do notpadtheeye Do notremoveanyforeignbodyoreyetissueprotrudingfromapenetratingwound – – – – If apenetratingeyeinjuryissuspectedfromthehistory,butnotimmediatelyobvious: – – – – If apenetratingeyeinjuryisobvious: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – – – – – – – – – – – – – – – – – – – – – – – – – small, highvelocityforeignbody then intraocular airdetectedonexamination prolapse ofeyeballcontentsOR large penetratingforeignbodyOR preparation forevacuation antibiotics -IVgentamicinPLUScefazolin(givefirst) eye hasbeenpenetrated x-ray (ifavailable)ifthereisahistoryofhighvelocityprojectilehittingthe eyeandifunsurethe examination andapplyaneyeshield if itbecomesevidentduringtheexaminationthatthereisapenetratingeyeinjury,abandon do NOTapplyanydirectpressureontheeyeball if VAis and theMO/NPagreestothis routine systematicexaminationoftheeyemaybeperformedifpractitioneriscompetent apply aneyeshield with thepatientlyingflat,assessVA-countfingers,handmovements,lightperception drops/ointment do NOT do NOT if patientwaswearingeyeprotection velocity -highorlow type ofprojectile the injuredeyeshould notbepaddedbecauseanyextruded ocularcontentsmaystickto the the baseshouldrest ontheorbitalmargin. should befixedover theinjuredeyetopreventaccidental pressureontheeyeball then thepatientshouldbe airtravelwithacabinaltitudeof<4,000 feetisacceptable eye shieldeitherpre-madeorconstructed fromcardboardorstyrofoamcup: instiltopicalanaestheticoxybuprocaineeyedrops,fluoresceindyeoranyother performaroutineeyeexamination not normal,abandonexaminationandapplyaneyeshield 1,2,3,4 transferred atsealevelcabinpressure intraocularaire.g: Acute pain management, page Nausea and vomiting, page duringexamination 48 35 Eye 373 5,7 5,6,8,9
stat Eye problems Eye stat Duration 5 minutes Infuse over minutes Duration 102 IHW/IPAP Infuse over 15-30 / IHW/IPAP / 102 ATSIHP Extended authority Extended authority ATSIHP Extended authority Tetanus immunisation, page page immunisation, Tetanus 2 g Section 4: General | Section 4: General Adult Anaphylaxis, page page Anaphylaxis, Child ≥ 1 month Anaphylaxis, page page Anaphylaxis, dosage 5 mg/kg 50 mg/kg to a max. 2 g Recommended dosage Recommended Recommended Adult and child weight consult MO/NP Base dose on ideal body Base dose on ideal body weight. If > 20% over ideal body weight. If > 20% over ideal
Gentamicin Cefazolin May cause nausea, diarrhoea, rash, headache, dizziness and May cause nausea, diarrhoea, rash, headache, Sometimes hearing and balance is affected and there may be Sometimes hearing and
Consult MO/NP. See : Contact the MO/NP. See Route of administration IV IV/Intraosseous Route of dissolve 1 g in 9.5 mL of administration water for injections to give a concentration of 100 mg/mL 4 4 1 g Severe or immediate allergic reaction to an aminoglycoside or a history of reaction to an aminoglycoside or a history Severe or immediate allergic
Do not use Strength : Severe or immediate allergic reaction to a cephalosporin or a penicillin. Be aware of : Severe or immediate allergic reaction to a cephalosporin Strength 80 mg/2 mL pad, causing further injury further causing pad, Form : Rapid IV injection of large doses may cause seizures. Doses up to 2 g can be given over 5 minutes. : Rapid IV injection of large doses may cause seizures. : Inactivated by cephalosporins and penicillins. Give gentamicin before other antibiotics. and penicillins. Give gentamicin before : Inactivated by cephalosporins Schedule Check tetanus vaccination status and give booster if indicated. See See booster if indicated. and give status tetanus vaccination Check 773 Injection Schedule Form (powder for • Injection ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP Management of associated emergency Note If renal impairment seek MO/NP advice Contraindication and carbapenems cross-reactivity between penicillins, cephalosporins Provide Consumer Medicine Information: pain at injection site reconstitution) Use in pregnancy: Management of associated emergency: result in ototoxicity/vestibular toxicity result in ototoxicity/vestibular Contraindications: vestibular or auditory toxicity caused by an aminoglycoside some permanent hearing loss. Tell your doctor if your hearing becomes worse or you are unsteady or loss. Tell your doctor if your hearing becomes some permanent hearing sit up, stand up or walk) dizzy (especially when you Note IV administration may antibiotics for those > 80 years of age. Rapid Strongly consider alternative Provide Consumer Medicine Information: Provide Consumer Medicine ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP IPAP, RIPRN and RN must ATSIHP, IHW, 374 Eye Sudden, painless 6. Referral/consultation 5. Followup | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Background • • • • • • • • • • • • • – – – – – – – Obtain acompletepatienthistory: Obtain rapidhistoryandconsultMO/NPurgently flashing lights Symptoms thatoccurbeforeorsimultaneouslywithlossofvisione.g.blurredvision,floaters Abrupt lossofvisionthatispartialorcomplete,involvingonebotheyes Consult MO/NPonalloccasionsofsuspectedpenetratingeyeinjury under thecareofanOphthalmologist All patientswithanobviousorsuspectedpenetratingeyeinjuryrequireevacuation/hospitalisation – Response Tools)+ Perform standard clinical observations(fullQ-ADDS/CEWT scoreorotherlocalEarlyWarning and Vision losswithpainisgenerallytheresultofotherconditionse.g.Acuteglaucoma Examination byanOphthalmologistisrequiredtodeterminethecause be reducedpupillightreaction blood vesselocclusion,thatwillnotbeapparentwhenexaminingthefrontofeye.Theremay Painless visionlossisgenerallycausedbyaneventinthebackofeyee.gretinaldetachment, Transient visionlossmaybeduetoTIA Sudden painlessvisionlossmaybetransientorpersistent – – – Vision lossmayinvolve: – – – – – – – – vision losssudden,oroverhoursto days one orbotheyesinvolved medications past visualacuitiesifknown past eyeandmedicale.g.hypertension,diabetes BGL any precedingflashes,floatersorother eyesymptoms – – – pattern ofvisionloss: – – – – – – both centralandperipheralvision-reducedVA the peripheralvisualfield-normalVA central vision-reducedVA fading ofvisionturnedintoblack-out greying startedcentrallyandmoved outward blackout startedatthetopofvisual fieldandmoveddownward 1,2,3
loss ofvision 1,2,3 1,2,3
- adult/child Eye 375 Eye problems Eye Section 4: General | Section 4: General - adult/child
cellulitis 327 periorbital
1,2 1,3 cellulitis/ 1,2
abnormal pupil light reaction painful and/or restricted eye movement conjunctival swelling reduced VA generally unwell, often with fever tenderness over sinuses eye pushed forward against eyelids previous sinusitis carefully check and document pupil reaction to light and document pupil carefully check indicate retinal detachment - loss of reflex may with an ophthalmoscope check red reflex start with VA start with hand on your to count fingers the patient by getting eye separately of each the visual field check face cm from their quadrant, 50 in each presented Orbital – – – – – – – – – – – –
Orbital cellulitis affects the eye socket and surrounding skin usually the result of a paranasal Orbital cellulitis affects the eye socket and surrounding sinus infection threatening emergency Orbital cellulitis is a potentially blinding and life Periorbital cellulitis is a soft tissue infection of the eyelids usually caused by trauma or infection Periorbital cellulitis is a soft tissue infection of of the surrounding skin Periorbital cellulitis is generally not a threat to vision – – – – – – – Pain A history and signs suggestive of orbital cellulitis: – Oedema and redness of the eyelids in one eye Consult MO/NP as above If not evacuated/hospitalised, advise to see MO/NP at next clinic If not evacuated/hospitalised, Consult MO/NP, who will advise urgent evacuation for Ophthalmologist/Neurologist review if an evacuation for Ophthalmologist/Neurologist who will advise urgent Consult MO/NP, retinal artery occlusion, likely e.g. detached retina, vitreous haemorrhage, acute physical cause is TIA or other medical conditions retinal vein thrombosis/suspected – – – – Examine both eyes: Examine
• • • • Acute bacterial sinusitis, page page sinusitis, bacterial Acute Related topics • • • • • • • Background
HMP HMP
1. May present with 6. Referral/consultation
5. Follow up 4. Management 376 Eye 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical Care Manual 10th edition | 4. Management • • • • • • • • Administer analgesiaasclinicallyindicated.See – – MO/NP willorderantibiotics: – – Consult MO/NPinallcases,whowilladviseif: – Suspect particularlyif: Orbital cellulitisisapotentiallyblindingandlifethreateningemergency – – – – – – Examine botheyes,noting: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Obtain acomprehensivepatienthistory,includingrecentstye,insectbitetoeyelid – – – – – – – – – – – – – – – for periorbitalcellulitisMO/NPmayorderoral: – – for orbitalcellulitis: Ophthalmologist and/orENTreviewisrequired evacuation/hospitalisation needed any alterationinVA,pupillightreaction,orrestrictedpainfuleyemovements pupil lightreactions VA range ofeyemovements position oftheeyeinsocket tenderness oversinuses any obvioussourceofinfection – – – – – – if immediatesensitivitytopenicillin,clindamycin amoxicillin +clavulanicacidOR cefalexin OR flucloxacillin OR IV flucloxacillin IV ceftriaxoneAND 1,2 2 Notapplicable Acute pain management, page 35 Eye 377 1,5,12 1,6,13
stat stat 7 days Duration Duration Eye problems Eye 102 IHW/IPAP IHW/IPAP IHW/IPAP / / 102 ATSIHP ATSIHP 12 years Extended authority Extended Extended authority ≥ 2g Adult 2 g Child Adult Section 4: General | Section 4: General dosage Child ≥ 1 month 500 mg qid Anaphylaxis, page page Anaphylaxis, Recommended Child < 12 years 50 mg/kg to a max. 2 g Recommended dosage Recommended Anaphylaxis, page page Anaphylaxis, max. of 500 mg/dose qid 12.5 mg/kg/dose qid to a 50 mg/kg to a max. of 2 g Adult and child
IV Oral Flucloxacillin IV If renal impairment seek MO/NP advice If renal impairment seek Ceftriaxone Route of May cause nausea, diarrhoea, rash, headache, dizziness, dizziness, headache, rash, diarrhoea, nausea, cause May May cause diarrhoea, nausea and candidiasis. Take on an May cause diarrhoea, nausea and candidiasis. Route of Consult MO/NP. See administration : Contact the MO/NP. See : Contact the MO/NP. See administration Cl. difficile. 1 g 4 250 mg 500 mg 500 mg Strength 4 125 mg/5 mL 250 mg/5 mL 1 g History of cholestatic hepatitis with dicloxacillin or flucloxacillin. Severe or immediate History of cholestatic hepatitis with dicloxacillin Strength : Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware of reaction to a cephalosporins or a penicillin. : Severe or immediate allergic Form Can cause cholestatic hepatitis. Rapid IV injection of large doses may cause seizures. Can cause cholestatic hepatitis. Rapid IV injection Schedule Form Capsule : Rapid IV injection of large doses may cause seizures. Give doses > 1 g by infusion over 30 minutes. doses may cause seizures. Give doses > 1 g by : Rapid IV injection of large Injection oral liquid Powder for Injection Schedule (powder for reconstitution to carbapenems Management of associated emergency: Note: minutes Doses ≥ 2 g must be given as an infusion over 30-60 Contraindication: between penicillins, cephalosporins and allergic reaction to a penicillin. Be aware of cross-reactivity Provide Consumer Medicine Information: Medicine Provide Consumer food empty stomach ½ hour before or 2 hours after ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP cross-reactivity between penicillins, cephalosporins and carbapenems cross-reactivity between emergency Management of associated candidiasis and pain at injection site candidiasis and pain at Note due to Can cause severe colitis Contraindication Provide Consumer Medicine Information: Provide Consumer Medicine ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, reconstitution) 378 Eye | Primary Clinical Care Manual 10th edition | ATSIHP, IHW,IPAP,RNandRIPRNmustconsultMO/NP Management ofassociatedemergency membranes astheremaybeanincreased riskofneonatalnecrotisingenterocolitis between penicillins,cephalosporins andcarbapenems.Avoidinwomenwithprematureruptureofthe Contraindication candidiasis. Cancauseseverecolitisdueto Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: cross-reactivity betweenpenicillins,cephalosporinsandcarbapenems Contraindication Note: headache andcandidiasis Provide ConsumerMedicineInformation: reconstitution reconstitution to oralliquid to oralliquid Powder for Powder for Capsule Tablet Form IfrenalimpairmentseekMO/NPadvice Form Schedule Schedule : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity : Severeorimmediateallergicreactiontocephalosporinsapenicillin.Beawareof 125 mg/5mL 400 mg/5mL+ 57 mg/5mL Strength 500 mg 250 mg 875 mg+ Strength 125 mg 4 4
Amoxicillin +clavulanicacid administration Route of administration : ConsultMO/NP.See Oral ConsultMO/NP.See Route of Cefalexin Maycauserash,diarrhoea,nausea,vomiting,dizziness, Oral Takewithfood. May cause rash, diarrhoea, nauseaand Cl. difficile
to amax.500mg/doseqid (Calculate dosebasedonthe Recommended dosage 12.5 mg/kg/doseqid 22.5 mg+3.2mg/kg/dose 875 mg+125mg/dosebd Adult andchild≥12years amoxicillin component) child ≥12years Child >1month 875 mg+125bd 500mgqid bd uptoamax.of Anaphylaxis, page Anaphylaxis, page Child >2months Adult and Recommended to <12years dosage Extended authority ATSIHP Extended authority ATSIHP / IHW/IPAP / 102 102 IHW/IPAP
Duration
7 days Duration 7 days
1,10,11 1,3,4 Eye 379 1,8,9
Eye problems Eye 7 days Duration 102 IHW/IPAP / ATSIHP Extended authority Extended Section 4: General | Section 4: General Anaphylaxis, page page Anaphylaxis, dosage 450 mg tds Recommended Recommended Child > 1 month of 450 mg/dose tds Adult and child ≥ 12 years Adult and child 10 mg/kg/dose tds to a max. 10 mg/kg/dose tds to a
: May cause rash, diarrhoea, nausea, vomiting and abdominal : May cause rash, diarrhoea, Consult MO/NP. See Clindamycin Cl. difficile Oral Route of administration 4 - adult/child Allergy to clindamycin or lincomycin Allergy to clindamycin or 150 mg Strength 1,2
Can cause severe colitis due to Can cause severe colitis
Keratitis is an infection of the cornea caused by herpes simplex virus. It is a major cause of Keratitis is an infection of the cornea caused by If conjunctivitis is not improving in blindness from corneal scarring and opacity worldwide. 3 days consult MO/NP clean their eye(s) as conjunctivitis may be very infectious Observe standard infection control precautions care until discharge from eyes has ceased Children should be excluded from school and child To prevent cross infection, the patient should use a separate towel, pillow and box of tissues to To prevent cross infection, the patient should use Schedule Form Consult MO/NP as above If not evacuated will require close monitoring especially of VA, in consultation with MO/NP If not evacuated will require close monitoring especially Advise to see MO/NP at next clinic
mix the dose in juice or soft food to disguise the taste before giving it mix the dose in juice or dissolve contents of 1 capsule in 2 mL water dissolve contents of 1 capsule syringe and make the volume up to 3 mL (if necessary) draw this solution into a so that the correct dose remains in the syringe discard any excess solution • • • • Capsule • • •
Recommend • Contraindication: Management of associated emergency: • • • Provide Consumer Medicine Information Provide Consumer Medicine of water pain. Take with a full glass Note: children. A 50 mg/mL solution can be made: There is no oral liquid for ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, Conjunctivitis
6. Referral/consultation 5. Follow up 380 Eye 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management HMP • • • • • • • • • • • • • • Consult MO/NPasabove Consult MO/NPifworsening,notimprovingafter2daysorpersists 5daysoftreatment Advise tobereviewedthenextday Treat withtopicalchloramphenicol.See contamination oftheothereye as neededtoremovecrustinganddischarge.Cleanfromtheinneroutermarginavoid Sodium chloride0.9%orcooledboiledwaterareusedtocleantheeyeandeyelidsasfrequently symptoms. See gonorrhoea andchlamydiainacutepurulentconjunctivitissexuallyactiveadultswithSTI Bacterial swabsarenotroutinelyrequired,butmaybeindicatedinspecialcasese.g.for Consult MO/NPifvisionaffected – – – Examine botheyes: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Obtain acompletepatienthistory,includinganycontactwithothersconjunctivitis Unilateral redeyethatfeelsgritty.Maybegininoneandspreadtotheother Difficulty openingtheeyeinmorningduetocrusting/gluingofeyelashes History ofcontactwithapersonconjunctivitis Purulent dischargefromeye(s) – – – Bacterial conjunctivitis note typeofdischargefromtheeye there shouldbenocornealstainingwithfluorescein VA shouldbenormalinbacterialconjunctivitis 1,2 Sexually transmitted infections, page 2 1
Notapplicable
- adult/child Foreign body and corneal abrasion, page 615 363 Eye 381 Eye problems Eye Section 4: General | Section 4: General Not applicable 2,3,4 - adult/child
2,3,4 2,3,4 1,2
cool compresses using separate towels and pillows using separate box of tissues to clean their eyes avoid touching the other eye or other people frequent hand washing after touching the face involvement e.g. multiple punctate areas, small branching ulcers involvement e.g. multiple punctate areas, small note type of discharge from the eye VA is usually normal in viral conjunctivitis, but may be reduced if there is corneal involvement VA is usually normal in viral conjunctivitis, but may e.g. adenovirus but it may be present if there is corneal there is usually no corneal staining with fluorescein, – – – – – – – – Viral conjunctivitis may be extremely contagious, so hygiene is important e.g. frequent hand e.g. frequent important hygiene is so contagious, may be extremely Viral conjunctivitis not sharing towels washing and
Symptomatic relief can be provided by: – Sodium chloride 0.9% or cooled boiled water are used to clean the eye and eyelids as frequently Sodium chloride 0.9% or cooled boiled water are as needed to remove crusting and discharge. Clean from the inner to the outer margin to avoid contamination of the other eye – – – Viral swabs are not routinely required, but may be taken if the cornea is involved or there are any Viral swabs are not routinely required, but may unusual features, and are ordered by MO/NP Advise regular hygiene practices: – Consult MO/NP about any case with unilateral red eye, photophobia, decreased VA or abnormal Consult MO/NP about any case with unilateral red corneal findings – Examine both eyes: – – Obtain a complete patient history, including any URTI or contact with others with conjunctivitis Obtain a complete patient history, including any score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) Burning sensation papule, cold sore on the eyelid A viral lesion e.g. molluscum Watery discharge tract infection History of viral upper respiratory involvement (keratitis) in addition to conjunctivitis Photophobia if there is corneal During an epidemic of 'pink eye' or 'red eye' of 'pink eye' or 'red During an epidemic other - classically begins in one eye and spreads to the Both eyes diffusely red Eyes feel gritty History of contact with a person with conjunctivitis with a person with History of contact
• • • • • • • • • • • • • • • • • •
Recommend 4. Management
3. Clinical assessment 2. Immediate management 2. Immediate management
1. May present with 1. May present Viral conjunctivitis Viral 382 Eye 1.Maypresentwith Allergic conjunctivitis 6. Referral/consultation 5. Followup | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management 3. Clinicalassessment 2. Immediatemanagement • • • • • • • • • • • • • • • • • • • • If thefirstepisode,advisetobereviewed thenextdayandrepeatexaminationofbotheyes If recurrentandnotsevere,seenext MO/NPclinic MO/NP mayadvisetrialoftopicalantihistamine andvasoconstrictoreyedropsforshorttermuse Consult MO/NPifitisthefirstepisodeorsevere Simple lubricantse.g.refrigeratedartificialtearstoeaseirritation Cool compressesasrequired – – – Examine botheyes: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand Obtain acompletepatienthistory standing Changes e.g.papillae,cobblestonesintheconjunctivalliningofeyelidsifallergyislong Mild photophobia Clear, stringydischarge Diffusely inflamedconjunctivae Itchy +++,burning,redeyes.Usuallybotheyesareaffected A historyofallergiessuchasasthma/eczemaorsimilarepisodesinthepast Refer toMO/NPasabove eye ointment5timesadayifherpessimplexkeratitisissuspectedordiagnosed If therehasbeennoimprovementin3daysconsultMO/NPwhomayprescribeacyclovir(Zovirax Advise tobereviewedthenextdayandconsultMO/NPifworsening Reassure thepatientthatviralconjunctivitisisself-limiting,butmaytakeweekstoresolve – Consult MO/NP orseenext MO/NPclinic – – – – note typeofdischargefromtheeye there shouldbenocornealstainingwithfluorescein VA isnormalinallergicconjunctivitis simple eyelubricants-dropsorgel 5
3,4,5 1,2 2
3 - adult/child
Notapplicable
® ) Eye 383 Eye problems Eye in parent and 615 - newborn Section 4: General | Section 4: General Sexually transmitted infections, page page infections, transmitted Sexually 3 chlamydial conjunctivitis chlamydial 1,2,3 1,2,3 1 1,2,3
gonococcal and and gonococcal They present in the first month of life, are potentially blinding and require urgent treatment are potentially blinding in the first month of life, They present newborn with conjunctivitis and chlamydia in any and PCR for gonorrhoea Swab for MCS Neonatal gonococcal and chlamydial conjunctivitis is caused by infection during vaginal delivery. by infection during vaginal conjunctivitis is caused and chlamydial Neonatal gonococcal
Consult MO/NP/Paediatrician Review result of MCS and treat any contacts Consult MO/NP and treat as advised in an appropriate clinic if baby < 1 month old Arrange for the mother and infant to be assessed Examine both eyes chlamydial PCR Take swab MCS, and dry swab for gonococcal and Review antenatal/birth history notes (if available) otherwise contact facility where baby born notes (if available) otherwise contact facility Review antenatal/birth history Urgent referral to Ophthalmologist if photophobic Urgent referral to Ophthalmologist Purulent discharge in the eyes Purulent discharge in the month of life May occur within the first
• • • • • • • • • • • •
Recommend 6. Referral/consultation
5. Follow up 4. Management
3. Clinical assessment 2. Immediate management
1. May present with 1. May present Acute Acute 384 Eye Chlamydia trachomatisconjunctivitis | Primary Clinical Care Manual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background • • • • • • • • • • • • • • • • • If conjunctivitispresent,takeconjunctival swabforchlamydiaPCR Assess facialcleanlinessandgeneral hygieneincludingskinsores – – – Examine botheyes: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand family, andtimespentinregionsknowntohave,orhavehad,endemic trachoma Obtain acompletepatienthistory,includingpreviousepisodesofconjunctivitis forthepatientand Upper eyelidconjunctivalscarring – – In adulthood: – – In childhood,usually: trichomonas/mycoplasma genitalium, page Treat thepatientwith azithromycinasadvisedbyMO/NP. See Consult MO/NP scarring/trichiasis phase Diagnosis isclinicalwithswabconfirmationintheconjunctivitisphase,andalone entropion (in-turnedeyelidmargin),cornealulcerationandopacificationblindness Repeated episodescancauseconjunctivalscarring,trichiasisi.e.misdirectedeyelashes, household itemsandviaeye-seekingflies Transmission isfromocularandnasalsecretionsonfingers,useofcontaminatedshared Preventative measuresincludefacialcleanlinessandreducingflycontact secretions Risk factorsincludepooraccesstowaterandovercrowdingwhichfacilitatestransferofinfected of chlamydia Trachoma istheleadinginfectiouscauseofblindnessworldwide,causedbyspecificserotypes Requires STItreatmentandcontacttracing – – – – – – – Trachoma corneal opacityand/orbloodvessel growthontothecornea scarring evert theuppereyelidstocheckforfollicles,velvetyrednessofintense inflammationand/or the positionofuppereyelidmarginanditslashes corneal opacity upper eyelidtrichiasisand/orentropion upper eyelidconjunctivalfolliclesorvelvetyredness repeated orchronicbilateralconjunctivitiswithamucopurulentdischarge 1,2,3
- adult/child 1,2 1,2,3 Notapplicable
623
Chlamydia/gonorrhoea/ Eye 385 Eye problems Eye Foreign body and corneal corneal and body Foreign Section 4: General | Section 4: General 363 Not applicable - adult/child
1,2,3 363 1,2
opaque spot with a penlight or direct inspection VA may be impaired, depending on the location and size of the ulcer evert the upper eyelid and make sure there is no retained foreign body if pain restricts examination, instil oxybuprocaine eye-drops. See if pain restricts examination, instil oxybuprocaine page abrasion, corneal ulcers tend to be round on fluorescein staining but are typically evident as a white or eyelid inflammations and infections eye trauma including foreign bodies wearing of contact lenses similar previous episodes facial cold sores Corneal ulceration – – – – – – – – – Use fluorescein to ascertain shape and size of any corneal epithelium defect Use fluorescein to ascertain
– – – – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) Examine both eyes: – – – Obtain a complete patient history, including: – – Watery discharge due to reflex lacrimation Purulent discharge with bacterial ulcers a collection of pus Inflammation in the anterior chamber, settling as A painful red eye, although some ulcers are painless Chlamydia trachomatis is a notifiable disease by pathological diagnosis is a notifiable disease by pathological diagnosis Chlamydia trachomatis Consult MO/NP as above Consult MO/NP Refer to an Ophthalmologist if chlamydia trachomatis identified Consult Public Health Unit Advise to see MO/NP at next clinic Advise to see Encourage face and hand washing to reduce spread by contact and flies contact and spread by to reduce hand washing face and Encourage and/or entropion of trichiasis treatment for an Ophthalmologist Refer to Treat all household contacts/community as advised by MO/NP by MO/NP as advised contacts/community all household Treat
• Foreign body and corneal abrasion, page page abrasion, corneal and body Foreign
Related topics • • • • • • • • • • • • • • •
Recommend HMP HMP 3. Clinical assessment 2. Immediate management 1. May present with
6. Referral/consultation 5. Follow up 5. Follow 386 Eye 5. Followup 4. Management | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith 6. Referral/consultation HMP Background Recommend • • • • • • • • • • • • • • • • • detail, ormaysettleatthebottomof thechamberasafluidlevel(hypopyon) Inflammatory i.e.puscellsintheanterior chamberthatmaybesufficientlydensetoobscureiris A small,possiblyirregularpupilwhen comparedwiththeothereye Unilateral redeye,withrednessmorepronouncedoverthescleraadjacent tothecornea Unilateral eyepainandphotophobia May haveprevioushistoryofiritis Consult Advise tosee – – – Consult cornea, presenceofhypopyonuntilhealed If notevacuated/hospitalised,advisetoberevieweddaily.CheckVA,clarityandintegrityof Administer analgesiaasclinicallyindicated.See Ophthalmologist review Unusual ulceratione.g.herpesdendriticulcer,largeandnon-healingulcerswillneed – – Consult MO/NPtodiscussmanagement,including: – Obtain acomplete patienthistory,including: possible geneticdispositionasariskfactor In mostcasesiritisoccursspontaneouslyforwhichthecauseisunknown. Evidencesuggestsa Iritis isinflammationoftheirisandanteriorchamberalone iris andciliarybody Uveitis ischaracterisedbyinflammationoftheuvea;middleportion oftheeyeincluding Urgent Ophthalmologistreferral,ideallywithreviewwithin24hours – – – – – – Acute VA deterioratesatanytime not healedonsecondreview worsened onfirstreview evacuation ifneededforOphthalmologistreview if canbetreatedlocally.See previous eye conditions MO/NP MO/NP 2,3 1 iritis (anterioruveitis) MO/NP asabove if: 1,2,3 2,3 atnextclinic 2,3 Notapplicable Foreign body and corneal abrasion, page
- adult/child Acute pain management, page 363
35
Eye 387 Eye problems Eye 35 Section 4: General | Section 4: General Acute pain management, page page management, pain Acute
- adult/child is characterised by narrowing or closure of the anterior chamber angle. is characterised by narrowing or closure of the is an optic neuropathy characterised by progressive peripheral visual field progressive by characterised neuropathy an optic is 1,2 glaucoma
1,2 e eyeball. When this drainage pathway is narrowed or closed, inadequate drainage leads to is narrowed this drainage pathway When eyeball. e
constricted have irregular shape be sluggish to react – – – rarely any symptoms, usually detected incidentally during ophthalmic examination treatment with topical steroids and pupil dilatation evacuation for Ophthalmologist review – pupil may be: – – check intraocular pressure if have the skill and equipment. Pressure may be high and require if have the skill and equipment. Pressure may check intraocular pressure treatment red and watering eyes there is no corneal fluorescein staining there is no corneal to light size, shape and reaction check pupil has settled chamber, and whether a white collection (hypopyon) check clarity of the anterior VA may be normal at first, but impaired later at first, but impaired VA may be normal family history family medications current previous and present infections, STI, joint and back problems, bowel problems bowel problems, back and STI, joint infections, and present previous Acute – – – – – – – – – – – – –
fills th fills elevated IOP and damage to the optic nerve (IOP) Angle-closure glaucoma for the aqueous humour i.e the fluid that The normal anterior chamber angle provides drainage Open-angle glaucoma Open-angle in the presence of elevated intraocular pressure loss followed by central field loss. It is usually Open-angle glaucoma: – Consult MO/NP as above As advised by the NP/MO/Ophthalmologist Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See MO/NP may order: – – Consult MO/NP – – Ocular findings: – – – – Response Tools) eyes: Examine both – – – Warning and or other local Early (full Q-ADDS/CEWT score clinical observations Perform standard –
• • • • • • • • • • • Background
HMP HMP
1. May present with 6. Referral/consultation
5. Follow up 4. Management 388 Eye 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management • • • • • • • • • As advisedbytheOphthalmologist Specific treatmentswillinvolveOphthalmological consultation – – – – Consult MO/NPurgentlywhomayorder: page Administer analgesiaand/orantiemeticasclinicallyindicated.See – – – – – – Examine botheyes: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – – Obtain acomprehensivepatienthistory,including: – – – – – Angle-closure glaucoma: Consult MO/NPas above – – – – – – – – – – – – – – – – – – – – IOP assessmentevery30-60minutes acetazolamide 500mgIVororal – – prompt administrationofpressure-loweringeyedrops;1dropeach,minute apartof: urgent evacuationtoanappropriatefacilitywithOphthalmologicalservices Ophthalmologist orsomeonewiththeappropriateskillandequipment there isanincreaseinintraocularpressure(IOP),whichmustbemeasuredbyOptometrist, cornea becomesswollenandopaque,soirisdetailsmaybecomeobscured there shouldbenocornealstainingwithfluorescein pupil lightreactionbecomessluggishandthenabsentasepisodeprogresses pupil isfrequentlymid-dilated VA generallybecomesimpairedasanacuteglaucomaepisodeprogresses allergies particularlytosulphurdrugs current medications family historyofglaucoma previous eyetrauma previous episodes nausea andvomiting severe eyepain headache halos aroundlights decreased vision – – 2% pilocarpine 0.5% timololmaleate 35 and
Nausea and vomiting, page 1,2,3,4 1,2,3,4
Notapplicable 48 Acute pain management, Urinary tract 389 Ectopic Ectopic Urinary tract problems tract | Urinary Section 4: General Urinary tract infection in pregnancy, page 516 page in pregnancy, infection tract Urinary - adult
1 any obstruction to the flow of urine (tumour, stone, stricture, prostatic hypertrophy); of urine (tumour, stone, stricture, prostatic hypertrophy); any obstruction to the flow catheterisation; diabetes abnormal renal anatomy; – STI history medications any genitourinary tract problems such as kidney stones, prostate problems (in men), renal any genitourinary tract problems such as kidney abnormalities past medical history, particularly diabetes past episodes of UTI - treatment provided and effectiveness – – – – –
Any woman presenting with low abdominal or suprapubic pain without dysuria or frequency without dysuria or frequency or suprapubic pain presenting with low abdominal Any woman and/or ectopic pregnancy disease (PID) for pelvic inflammatory should be considered causes approximately 80% of acute UTI E. coli causes approximately 80% if there is: The incidence of UTI is increased – UTI is rare in males < 50 years of age. Dysuria in younger males is usually caused by an STI years of age. Dysuria in younger males is usually UTI is rare in males < 50 and urethral men may have predisposing factors such as prostatitis After the age of 50 years hypertrophy obstruction due to prostatic UTI is more common in females UTI is more common in females pregnancy, page 511 page pregnancy, – – Perform standard clinical observations (full Q-ADDS score or other local Early Warning and Response – – Obtain a complete patient history including: – Consider ectopic pregnancy in sexually active women with lower abdominal pain. See Consider ectopic pregnancy in sexually active women Fever > 38⁰C, chills/rigors, flank/loin pain, costovertebral angle tenderness, nausea, vomiting Fever > 38⁰C, chills/rigors, flank/loin pain, costovertebral Frequency, urgency, dysuria (discomfort or burning on passing urine), mild low back pain, lower Frequency, urgency, dysuria (discomfort or burning abdominal/suprapubic pain, haematuria Abnormal findings on urinalysis - nitrites (breakdown of bacteria)/protein/blood/white blood cells Abnormal findings on urinalysis - nitrites (breakdown (leukocytes) or falls Elderly patients with UTI may present with confusion
• • • • • •
Low abdominal pain in female, page 635 page in female, pain abdominal Low Related topics • • • • • • •
Recommend Background Pyelonephritis Cystitis
Urinary tract infection (UTI) infection tract Urinary HMP 3. assessment Clinical
2. management Immediate 1. with May present
pyelonephritis Cystitis/ Urinary tract problems tract Urinary 390 Urinary tract 4. Management | Primary Clinical Care Manual 10th edition | • • • • • • • • – – If pyelonephritislikely,consultMO/NPwhomayadvise: water mayrelievesomeofthesymptomsUTI A urinaryalkalinisere.g.Ural®,Citravescent®or1teaspoonofsodiumbicarbonateinaglass – – – In femaleswithcystitiswhoaresymptomaticandnotpregnantgive: – If asymptomaticbacteriuria,cloudyormalodorousurine: 635 be assessedforpelvicinflammatorydisease(PID).See Any womanpresentingwithlowabdominalorsuprapubicpainwithoutdysuriafrequencyshould If pregnantsee In maleswithUTIconsultMO/NP – – Perform physicalexamination: – – – – Tools) + – – – – – – – – – – – – evacuation/hospitalisation IV ampicillin(oramoxicillin)PLUSgentamicin Note: if allergictotrimethoprimgivenitrofurantoinORcefalexin trimethoprim OR noinvestigationsortreatmentrequiredunlessthepatienthasothersymptomssignsofaUTI perform completephysicalexaminationif>65years palpate abdomenespeciallyforsuprapubicorlointenderness – – – collect if sexuallyactive,doSTIcheck.See point ofcarepregnancytestforwomenreproductiveage urinalysis – – – obtain midstreamspecimen septic). Womenaretowashfromfrontback hold labiaapartorretractforeskin,washurethrawithsodiumchloride0.9%(donotuseanti wash hands checkpatternsoflocalantibioticresistancefirst MSU forMCSasfollows: Urinary tract infection inpregnancy, page 2,3 Sexually transmitted infections, page Low abdominal pain infemale, page 516
615 - Urinary tract 391 2,5 2,3,4
: 3 days : 7 days
5 days 7 days Duration Male
Female Duration Male: Female: 102 102 Extended authority Extended authority Extended ATSIHP/IHW/IPAP/RIPRN ATSIHP/IHW/IPAP/RIPRN/SRH ATSIHP/IHW/IPAP/RIPRN/SRH Adult dosage Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, dosage 300 mg daily 100 mg bd Urinary tract problems tract | Urinary Section 4: General Recommended Recommended Recommended
Oral Take at night to maximise urinary concentration. May cause Take at night to maximise Take with food or milk to reduce nausea and improve Nitrofurantoin Oral consult MO/NP. See Consult MO/NP. See Route of Trimethoprim Route of administration administration 4 4 50 mg 100 mg Strength 300 mg Strength Avoid in first trimester Megaloblastic anaemia : Renal impairment Schedule Schedule Form : If renal impairment seek MO/NP advice. May increase risk of hyperkalaemia especially in the MO/NP advice. May increase risk of hyperkalaemia : If renal impairment seek Form Capsule Tablet Contraindication Management of associated emergency: Provide Consumer Medicine Information: anorexia, diarrhoea, abdominal pain, allergic skin absorption. May cause nausea, vomiting, headache, difficulty breathing, development of a cough or reactions, headache, drowsiness or dizziness. Report colour numbness or tingling. May turn urine a brownish ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed Use in pregnancy: emergency: Management of associated Note conjunction with an ACEI elderly or when taken in Contraindication: Provide Consumer Medicine Information: Provide Consumer Medicine fever, itch, rash and nausea ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, for males Must consult MO/NP may proceed for females. RIPRN and SRH
392 Skin | Primary Clinical Care Manual 10th edition | Skin problems 6. Referral/consultation 5. Followup HMP Management ofassociatedemergency: cross-reactivity betweenpenicillins,cephalosporinsandcarbapenems Contraindication Note: headache andcandidiasis Provide ConsumerMedicineInformation: RIPRN andSRHmayproceedforfemales.MustconsultMO/NPmales ATSIHP, IHW,IPAPandRNmustconsultMO/NP Background Recommend Capsule • • • • • • • • Form Schedule Consult MO/NPasabove woman mayneedurologicalinvestigations.AdvisetoseeMO/NPatnextclinic All patientsotherthantheinitialuncomplicatedlowerurinarytractinfectioninanon-pregnant Consult MO/NPifsymptomspersist,recurorworsenaftertreatmentinmenwomen Check cultureandsensitivityresultsconsultMO/NPiforganismresistanttoantibioticsgiven APSGN. See Impetigo canleadtoserioussystemic complicationsfromstreptococcalskininfection,including existing skinconditionssuchasscabies, eczema,tinea,insectbitesandminorabrasions Impetigo is highly infectious, it occurs primarily in school age children. It may complicate pre- need tobetreated lesions arehealedandafternasaland/orperinealswabstaken).Household contactswillalso mupirocin 2%intranasalointmentandchlorhexidinebodywashes For eradicationofstaphylococcalcarriageinpeoplewithrecurrent infections, Medicines thatareactiveagainst Islander (ordisadvantaged)communities,or Until cultureresultsareavailable,suspect IfrenalimpairmentseekMO/NPadvice Impetigo 2 1,2 : Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware of Strength APSGN, page 500 mg 250 mg
- adult/child 4 700 administration
Route of and Staphylococcus aureus Oral ConsultMO/NP.See Acute rheumatic fever, page Maycauserash,diarrhoea,nausea,vomiting,dizziness, Cefalexin
Streptococcus pyogenes Recommended Staphylococcus 500 mgbd dosage willalsocover Anaphylaxis, page ATSIHP , includingMRSAinotherareas. 705 inAboriginalandTorresStrait Extended authority
/ may beindicated(onceall IHW/IPAP/RIPRN/SRH Streptococcus pyogenes Female Male 102 Duration
: 7days : 5days
2,5 3,5 Skin 393 Skin Skin problems 401 415 Cellulitis, page page Cellulitis, page Scabies, Section 4: General | Section 4: General History and physical examination - examination physical and History for how to take a swab
427 401 Not applicable (2 or more lesions): 705 Chronic wounds, page page wounds, Chronic Cellulitis, page page Cellulitis, (single lesion): 3 Staphylococcus aureus 4 20 700
trimethoprim + sulfamethoxazole OR benzathine benzylpenicillin (Bicillin LA®) - if lack of adherence with oral medicine is anticipated use measures outlined above for skin sores, clothing and personal hygiene use measures outlined above for skin sores, clothing of resistance first commence oral antibiotics - check local patterns clothing/bedding/towels/toys of patient and close contacts should be washed in hot water and clothing/bedding/towels/toys of patient and close dried in direct sunlight should be emphasised personal hygiene, especially hands and fingernails, remove crusts and debris and clean by soaking in soap and water remove crusts and debris and clean by soaking BP or urinalysis is abnormal it may indicate the presence of APSGN BP or urinalysis is abnormal it may indicate the patient is systematically unwell recurrent infections in individual or family wear gloves as impetigo is highly contagious weight - bare weight if < 2 years weight - bare weight if < urinalysis as a baseline irritating, but not painful irritating, but Bullous impetigo as irritating blisters that erode rapidly into ulcers. bullous impetigo presents is caused by crusted or non-bullous impetigo presents as yellow crusts and erosions that are itchy or erosions that are itchy as yellow crusts and impetigo presents crusted or non-bullous
– – In severe/widespread cases – – in central and northern Australia give: In Aboriginal and Torres Strait Islander communities – – Take swab for MCS. See In mild/isolated cases – – – – If patient has fever, see Consult MO/NP if: adult, page adult, page – – – in Perform physical examination as per skin assessment Obtain a complete patient history Obtain a complete patient local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) + – There are two distinct presentations (both are contagious): distinct presentations There are two –
APSGN, page page APSGN, page fever, rheumatic Acute Related topics Related • • • • • • • • • •
4. Management 3. Clinical assessment 2. Immediate management 1. May present with 1. May present 394 Skin | Primary Clinical Care Manual 10th edition | Antibiotic selectionforimpetigo • • • Cover soresonexposedareaswithawatertightdressing centre untiltheyhavetakenantibioticsforatleast24hours exclude themselvesfromcontactwithothers-bynotattendingschool,pre-schoolorchildcare Advise parent/carer/patientthatimpetigoishighlyinfectiousandthechild/patientshould – – – In non-remotesettings,orcommunitieswithlowprevalenceofMRSAgive: Penicillin immediate – – – dosing frequencywillimproveadherenceuse trimethoprim +sulfamethoxazole – cefalexin -ifpenicillinhypersensitivity,excludingimmediatehypersensitivityto flucloxacillin hypersensitivity – tion forchildren note: Patient abletoadhere Community withlow Remote AboriginalandTorresStraitIslandercommunityinnorthernAustralia prevalence ofMRSA No to oralmedicine cefalexinmayalsobeamorepalatablealternativetoflucloxacillinasliquidformula regimen Benzathine benzylpenicillin 7 OR No 4 (Bicillin LA OR No 4,8 Yes ® Yes )
- ifimmediatehypersensitivitytopenicillinorreduced Yes Yes sulfamethoxazole Trimethoprim + 2 6 6 No Penicillin immediate Yes hypersensitivity (see Management) Flucloxacillin Cefalexin OR No
- Skin 395
give 3,4,9
daily doses Duration for 3 days bd doses give for 5 days For
For 102 Extended authority Extended ATSIHP/IHW/IPAP/RIPRN ATSIHP/IHW/IPAP/RIPRN Skin | Skin problems Section 4: General or or Adult dosage Anaphylaxis, page page Anaphylaxis, Recommended Recommended Child ≥ 1 month 320 mg + 1600 mg daily of 320 mg + 1600 mg daily 160 mg + 800 mg/dose bd 160 mg + 800 4 mg + 20 mg/kg/dose bd up to a 4 mg + 20 mg/kg/dose bd max. of 160 mg + 800 mg/dose bd max. of 160 mg + 800 mg/dose 8 mg + 40 mg/kg daily up to a max. 8 mg + 40 mg/kg daily up
May cause fever, nausea, vomiting, diarrhoea, itch, rash and, May cause fever, nausea, Consult MO/NP. See Oral Route of Trimethoprim + sulfamethoxazole Trimethoprim administration 4 + Do not use Severe or immediate allergic reaction to sulfonamides, megaloblastic anaemia, Severe or immediate allergic reaction to sulfonamides, Strength 40 mg/5 mL 200 mg/5 mL 80 mg + 400 mg 80 mg + 400 160 mg + 800 mg 160 mg + 800 : If renal impairment seek MO/NP advice. May increase risk of hyperkalaemia especially when MO/NP advice. May increase risk of hyperkalaemia : If renal impairment seek Schedule Oral Form liquid Tablet Management of associated emergency: Contraindication: severe hepatic impairment, elderly and pregnancy Use in pregnancy: rash, cough, breathing difficulties, joint pain, dark urine or pale stools rash, cough, breathing difficulties, Note taken in conjunction with an ACEi Provide Consumer Medicine Information: Provide Consumer Medicine Report sore throat, fever, to reduce stomach upset. Avoid sun exposure. sore mouth. Take with food ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed 396 Skin | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency: between penicillins,cephalosporinsandcarbapenems Contraindication: benzathine benzylpenicillin, page Note Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: cephalosporins andcarbapenems immediate allergicreactiontoapenicillin. Beawareofcross-reactivitybetweenpenicillins, Contraindication: Note: empty stomach½hourbeforeor2hoursafterfood Provide ConsumerMedicineInformation: reconstitution to (pre-filled Injection syringe) Powder for Form oral liquid Schedule Capsule : Stopinjectionimmediatelyifpatientshowssignsofseverepain.See Schedule Cancausecholestatichepatitis.Ifrenal impairmentseekMO/NPadvice Form units/2.3 mL 1.2 million (900 mg) Strength Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity Historyofcholestatichepatitiswith dicloxacillinorflucloxacillin.Severe 250 mg/5mL 125 mg/5mL Strength 500 mg 250 mg 4 4 administration Route of Benzathine benzylpenicillin 787 IM administration ConsultMO/NP.See ConsultMO/NP.See Maycausediarrhoea,nauseaandpainatinjectionsite Maycausediarrhoea,nauseaandcandidiasis.Takeonan Flucloxacillin Route of (Bicillin LA
Oral 15 to<20kg 10 to<15kg 6 to<10kg 3 to<6kg
Weight ≥ 20kg ® ) Recommended dosage Adult andchild>12years 12.5 mg/kg/doseqidtoa max. of500mg/doseqid Child >1monthto≤12 Anaphylaxis, page Anaphylaxis, page Recommended 500 mgqid 337.5 mg 900 mg 450 mg 225 mg 675 mg dosage Dose years ATSIHP ATSIHP Extended authority Administration tips for Extended authority / IHW/IPAP/RIPRN Volume 0.8 mL 0.5 mL 2.3 mL 1.6 mL / 1 mL 102 IHW/IPAP/RIPRN 102 2,3,10,11,12,13 Stop earlierif infection has Duration resolved 10 days Duration
stat
1,14 Skin 397 15,16
700 10 days Duration Cease earlier if infection esolved 102 IHW/IPAP/RIPRN / APSGN, page page APSGN, Extended authority Extended ATSIHP Skin | Skin problems Section 4: General Adult and Anaphylaxis, page page Anaphylaxis, 500 mg qid child ≥ 12 years Child < 12 years 12.5 mg/kg/dose qid Recommended dosage Recommended to a max. 500 mg/dose qid to a max. 500 mg/dose Cefalexin
May cause rash, diarrhoea, nausea, vomiting, dizziness, May cause rash, diarrhoea, Consult MO/NP. See Oral Route of administration 4 250 mg 500 mg Strength 125 mg/5 mL : Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware of aware a penicillin. Be a cephalosporins or or immediate allergic reaction to Severe : Schedule
If renal impairment seek MO/NP advice If renal impairment seek Form Consult MO/NP as above Consult MO/NP if abnormal blood pressure and/or urinalysis. Consider Consult MO/NP if abnormal blood pressure and/or Advise to be reviewed daily initially. Consult MO/NP if not improving Advise to be reviewed daily initially. Consult MO/NP and check BP and urinalysis If antibiotics have been given review in 2 weeks Capsule
Powder for • • • • to oral liquid reconstitution cross-reactivity between penicillins, cephalosporins and carbapenems cross-reactivity between emergency: Management of associated headache and candidiasis Note: Contraindication Provide Consumer Medicine Information: Provide Consumer Medicine ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed
6. Referral/consultation 5. Follow up 398 Skin | Primary Clinical Care Manual 10th edition | Management 4. Clinicalassessment 3. Immediatemanagement 2. Maypresentwith 1. HMP Folliculitis/furunculosis( boils)/carbuncles -adult/child Background Recommend • • • • • • • Related topics Cellulitis, page 401 • • • • • • • • •
– – – and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning Take aswabforMCStocheckMRSA Perform physicalexaminationasperskinassessmentin – Obtain acompletepatienthistory+ Fever and/ormalaise Folliculitis, furuncle(boil),carbuncle(multipleheadabscess) – – Consult MO/NPif: adult, page 20 sulfate) paste(Magnoplasm There isinsufficientevidencetosupporttheuseofmagnesiumsulfateheptahydrate(magnesium with Streptococcuspyogenes Staphylococcus aureusisusuallythecauseoftheseskininfections,occasionallyincombination A carbuncleisaclusterofboils(furuncles)withmultiplepustularheads axillae, inguinalareaorbuttocks subcutaneous tissue.Theyaretenderandverypainfuloftenoccurinclustersorcropsthe A boiloracutefurunculosis,isahairfollicle-associatedcutaneousabscessthatextendsintothe Folliculitis isaninfectionofthehairfollicle.Itpresentsasapustuleonsmallredbase washes dailyfor5dayspatientswhoexperiencerecurrentboils MO/NP mayorderintranasalmupirocin2-3timesdailytonostrilsfor5-7daysand/ortriclosan which canproduceosteomyelitis,acutebacterialendocarditis(heart)andbrainabscesses Do not squeeze lesions. Squeezing may result in the spread of infection via the Incision anddrainageisthefirstlineoftreatment Most caseswillresolvespontaneously – – – urinalysis weight -bareif<2years BGL any historyofinflammatoryboweldisease infection involving theface orhands infection inachild requiringincision 1,3 1,2 2,4 2 ® ) andmedicinalhoney,inthetreatmentofboils Notapplicable Impetigo, page 392 History and physical examination - 4 bloodstream, Skin 399 401 35 Cellulitis, page page Cellulitis, Do not squeeze Skin | Skin problems Section 4: General 80 588 2,5,6,7,8 Acute pain management, page page management, pain Acute 5,6 below Sepsis/septic shock, page page shock, Sepsis/septic 9 Mastitis/breast abscess, page page abscess, Mastitis/breast Incision and drainage boils > 5 cm infection or those in which incision and moderate to severe infection (patients with systemic drainage has not worked) enlargement of regional lymph nodes, surrounding cellulitis. See enlargement of regional where the patient is immunosuppressed on face, infection on breast when there is finger (pulp space) infection, infection a fever lesions multiple lesions, recurrent when a head appears and the boil feels fluid-like underneath it is ready for incision and the boil feels fluid-like underneath it is ready when a head appears and drainage. See localisation of infection and promotes drainage of infection and promotes localisation by the application of moist heat small boils can be treated sepsis is suspected. See sepsis is suspected. discomfort, aids in the moist heat which relieves by the application of may be treated results of swab show MRSA of swab show results disease bowel with inflammatory in a patient abscess/boil perianal mupirocin order) (for intranasal recurrent boils/carbuncles breast abscess. See abscess. breast – – – – – – – – – – – – – – – Change dressings at least daily pus; avoid tightly packing the cavity After adequate drainage has occurred, cover lesions with a dry dressing Do not suture or perform other closure techniques Express the pus by gently separating the edges of the incision. Express the pus by gently separating the edges chloride 0.9% via a 20 mL syringe with a blunt Irrigate the wound cavity copiously using sodium 18 G needle premature closure and aid drainage of In large abscess insert a ribbon gauze wick to prevent infiltrated with 1% lidocaine (lignocaine) local anaesthetic before incision. Do not inject into the infiltrated with 1% lidocaine (lignocaine) local abscess because this causes increased pain cut incision may be appropriate to prevent the Incise the abscess using a scalpel blade. A cross wound from closing prematurely If the abscess is superficial and 'pointing', local anaesthetic is not necessary as the affected If the abscess is superficial and 'pointing', local further pain and trauma skin does not anaesthetise easily and it will cause 'pointing', then the overlying skin should be If the abscess is fluctuant, but not superficial or Do not incise any boils in children face or breast, or the perianal region of a Do not incise any boils in adults if affecting hands, Consult MO/NP patient with a history of inflammatory bowel disease. If indicated, give trimethoprim + sulfamethoxazole Administer analgesia as clinically indicated. See – – – – – Antibiotics are indicated when there is/are: Antibiotics are indicated – – – to look for are used a swab should be taken for microbiology Regardless of whether antibiotics MRSA Boil/carbuncle (cluster of boils): Boil/carbuncle – – Folliculitis: – – – – – • • • • • • • • • Incision and drainage • • • • • • • • 400 Skin | Primary Clinical Care Manual 10th edition | Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP MO/NP. See Management ofassociatedemergency Note: or tremors Management ofassociatedemergency: Use inpregnancy: severe hepaticimpairment,elderlyand pregnancy Contraindication: taken inconjunctionwithanACEi Note fever, rash,cough,breathingdifficulties,jointpain,darkurineorpale stools and, soremouth.Takewithfoodtoreducestomachupset.Avoidsun exposure.Reportsorethroat, Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Injection Tablet liquid Form Oral Form Schedule : IfrenalimpairmentseekMO/NPadvice.Mayincreaseriskofhyperkalaemia especiallywhen Usethelowestdosethatresultsineffectiveanaesthesia Schedule 160 mg+800 80 mg+400 50 mg/5mL 200 mg/5mL Anaphylaxis, page 40 mg/5mL Strength Strength 1% Donotuse + Severe orimmediateallergicreaction tosulfonamides,megaloblasticanaemia, 4 administration 4 Route of Subcut administration Trimethoprim +sulfamethoxazole 102 Route of Oral
: Ensureresuscitationequipmentreadilyavailable.Consult Lidocaine (lignocaine) ConsultMO/NP.See Reportanydrowsiness,dizziness,blurredvision,vomiting
Maycausefever,nausea,vomiting,diarrhoea,itch,rash up to3mg/kgatotalmax.of max. of160mg+800mg/dosebd child ≥12yearsor>50kg 4 mg+20mg/kg/dosebduptoa up tomax.of3mg/kg 160 mg+800mg/dosebd Child <12years Recommended Adult and 200 mg dosage Child ≥1month Recommended Anaphylaxis, page dosage Adult ATSIHP ATSIHP/IHW/IPAP/RIPRN
Extended authority Extended authority / 102 IHW/IPAP/RIPRN
Duration Duration stat 5 days
10,11 1,12 Skin 401 systemic History and and History Skin | Skin problems Section 4: General Orbital cellulitis/periorbital cellulitis, cellulitis, cellulitis/periorbital Orbital 375page Not applicable 1,2 1,2 - adult/child
1,2
BGL urinalysis pain score toxicity, as opposed to a simple wound infection or impetigo which is a superficial skin infection simple wound infection or impetigo which is a toxicity, as opposed to a
Cellulitis presents with spreading, tender erythema. It is associated with fever and is associated spreading, tender erythema. It Cellulitis presents with Perform physical examination (gently as condition painful) as per skin assessment in Perform physical examination (gently as condition Check for deterioration in any underlying medical condition such as diabetes Obtain a complete patient history Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – – – Tender regional lymph node involvement is common develop rapidly Systemic symptoms - malaise, fever and rigors may a limb 'Wispy' lymphangitis along the medial aspect of Erythema which intensifies and spreads precedes the onset of redness Local pain is sometimes quite marked and often Usually there is a preceding history of skin trauma or skin disease followed within a day or two by Usually there is a preceding history of skin trauma erythema (redness), tenderness and heat Consult MO/NP as above If MRSA is cultured consult MO/NP If MRSA is cultured antibiotic, consult MO/NP does not respond to If skin infection disease inflammatory bowel for patients with up by an MO/NP is recommended Close follow Advise to be reviewed daily initially to assess progress and change dressings and change progress to assess daily initially to be reviewed Advise of pus is pus. If a lot any residual express and gently wick, if present, remove the first review At the gauze wick another ribbon insert expressed, physical examination - adult, page 20 page - adult, examination physical
• Folliculitis/furunculosis (boils)/carbuncles, page 398 page (boils)/carbuncles, Folliculitis/furunculosis Related topics • • • • • • • • • • • • • • • • Background
HMP Cellulitis HMP 3. assessment Clinical 2. management Immediate 1. with May present
6. Referral/consultation 5. up Follow 402 Skin 4. Management | Primary Clinical Care Manual 10th edition | • • • • • • • • • • • • – – Dress anywound/siteofinjury: – If immediatehypersensitivity(anaphylaxis) topenicillingive: – – Streptococcus pyogene In nonAboriginalandTorresStraitIslandercommunities,tocover – – patterns), ifnotallergicgive: Streptococcus pyogenes In AboriginalandTorresStraitIslandercommunitiesincentralnorthern Australia(orif – For mildearlycellulitis: Administer analgesiaasclinicallyindicated.See For severecasesinadults-theMO/NPmayadvise: – – – – Consult MO/NPif: related wounds, page If cellulitiscausedbyforeignbodyfromwater,fishspinesandothermarinecreatures,see occurs overajointandinpatientwithdiabetesorimmunosuppression Consider osteomyelitisandsepticarthritisifaskininfectionistakinglongtimetoresolveor – – – – – – – in patientswithpossiblecellulitisbutnofever: Many othermedicalconditionsmimiccellulitis,considerthesealternativediagnosesinparticular Rest andelevatethe affectedlimb(veryimportant) – – – – – – – – – – – – – – – – – – – cefalexin -forchildrenandifpenicillinhypersensitivity,excludingimmediate hypersensitivity flucloxacillin OR anticipated OR IM procainebenzylpenicillin(procainepenicillin)-ifalackofadherence withoralmedicineis phenoxymethylpenicillin OR giveantibiotics(checklocalpatternsofresistance)asbelow: – – – severe cellulitisorsystemicallyunwell if MRSAisknownorsuspected infection involvingthefaceorhands infection inachild hemosiderin staining(rustydiscolourationoflowerlegskincausedbychronicvenousdisease) contact dermatitis DVT. See gout liver cirrhosis heart failure venous stasis cellulitis maycontinue tospreadfor24hours) measure byoutlining inflamedareabytracingontoOpsite permissions) if possiblephotographtomonitorresponse totreatment(withappropriatelydocumented clindamycin(checklocalpatternsof resistancefirst) – – – evacuation/hospitalisation ifnecessary IV antibiotics-cefazolin+probenecid blood cultures Deep vein thrombosis (DVT), page 4 s, ifnotallergicgive: 209 isconfirmedorsuspectedduetoclinicalpresentationlocaldisease 3 155 Acute pain management, page ® oruserulertomeasure (resolving Staphylococcus aureus 35 and Water Skin 403 4,10,11 2,6,7,8
3 days Duration 5-10 days Duration for at least
IHW/IPAP/RIPRN 102 IHW/IPAP/RIPRN 102 / / Administration tips for for tips Administration Extended authority Extended Extended authority ATSIHP ATSIHP
Adult Child
dosage 500 mg qid Skin | Skin problems Section 4: General to a max. of Child Adult Recommended Recommended dosage 500 mg/dose qid 50 mg/kg 1.5 g daily 12.5 mg/kg/dose qid Anaphylaxis, page page Anaphylaxis, Recommended Anaphylaxis, page page Anaphylaxis, to a max. of 1.5 g daily
Oral
Route of administration IM May cause diarrhoea, nausea and candidiasis. Food has little May cause diarrhoea, nausea May cause diarrhoea, nausea and pain at injection site May cause diarrhoea, nausea and pain at injection Consult MO/NP. See Consult MO/NP. See Phenoxymethylpenicillin Phenoxymethylpenicillin Route of 787 administration 250 mg 500 mg Strength 4 125 mg/5 mL 250 mg/5 mL Procaine benzylpenicillin (procaine penicillin) Strength 1.5 g/3.4 mL Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity reaction to a penicillin. Be aware of cross-reactivity Severe or immediate allergic : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity : Severe or immediate allergic reaction to a penicillin. 4 Form Form Schedule : Stop injection immediately if patient shows signs of severe pain. See : Stop injection immediately if patient shows signs Capsule syringe) Injection oral liquid Powder for (pre-filled Schedule reconstitution to Management of associated emergency: Note page benzylpenicillin, benzathine Contraindication between penicillins, cephalosporins and carbapenems Provide Consumer Medicine Information: RIPRN may proceed ATSIHP, IHW, IPAP and RN must consult MO/NP Contraindication: and carbapenems between penicillins, cephalosporins emergency: Management of associated effect on absorption ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed Provide Consumer Medicine Information: Provide Consumer Medicine 404 Skin | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency: carbapenems andcephalosporins immediate allergicreactiontoapenicillin.Beawareofcross-reactivitybetween Contraindication: Note: empty stomach½hourbeforeor2hoursafterfood Provide Consumer Medicine Information: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: of cross-reactivitybetween Contraindication Note: headache andcandidiasis Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution to reconstitution to oralliquid Schedule Powder for Powder for oral liquid Capsule Schedule Capsule Cancausecholestatichepatitis.IfrenalimpairmentseekMO/NPadvice Form IfrenalimpairmentseekMO/NPadvice Form : Severeorimmediateallergicreaction toacephalosporinsorpenicillin.Beaware Historyofcholestatichepatitiswithdicloxacillinorflucloxacillin.Severe 125 mg/5mL Strength 4 500 mg 250 mg 250 mg/5mL 125 mg/5mL 4 Strength 500 mg 250 mg penicillins, carbapenemsandcephalosporins administration Route of administration Oral ConsultMO/NP.See ConsultMO/NP.See Maycausediarrhoea,nauseaandcandidiasis.Takeonan Route of Maycauserash,diarrhoea,nausea,vomiting,dizziness, Flucloxacillin Oral Cefalexin
to amax.500mg/doseqid Recommended dosage 12.5 mg/kg/doseqid Child >1monthto≤12years Adult andchild>12years 12.5 mg/kg/doseqidtoa max. of500mg/doseqid Child <12years child ≥12years 500mgqid Anaphylaxis, page Anaphylaxis, page Adult and Recommended 500 mgqid dosage ATSIHP ATSIHP Extended authority Extended authority / penicillins, IHW/IPAP/RIPRN 102 / 102 IHW/IPAP/RIPRN
5-10 days Duration 5-10 days Duration
15,16
4,5 Skin 405 2,4,14 stat
4,15,16,17,18 Duration 5 minutes infuse over Duration 5-10 days 102 IHW/IPAP / 102 IHW/IPAP/RIPRN / ATSIHP Extended authority Extended authority Extended 2 g ATSIHP Adult Skin | Skin problems Section 4: General Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, Recommended dosage dosage 450 mg tds Recommended Recommended Child < 12 years of 450 mg/dose tds Adult and child ≥ 12 years Adult and child 10 mg/kg/dose tds to a max. 10 mg/kg/dose tds to a
Cefazolin
May cause nausea, diarrhoea, rash, headache, dizziness and May cause nausea, diarrhoea, rash, headache, dizziness : May cause rash, diarrhoea, nausea, vomiting and abdominal : May cause rash, diarrhoea, Clindamycin Consult MO/NP. See : Contact the MO/NP. See Route of Cl. difficile administration Oral IV/Intraosseous Route of Dissolve 1 g in 9.5 mL of administration water for injections to give a concentration of 100 mg/mL penicillins, carbapenems and cephalosporins 4 4 1 g Allergy to clindamycin or lincomycin Strength : Severe or immediate allergic reaction to a cephalosporin or a penicillin. Be aware of : Severe or immediate allergic reaction to a cephalosporin 150 mg Strength Can cause severe colitis due to Can cause severe colitis
Form : Rapid IV injection of large doses may cause seizures. Doses up to 2 g can be given over 5 minutes. : Rapid IV injection of large doses may cause seizures. Form Schedule Injection discard any excess solution so that the correct dose remains in the syringe discard any excess solution soft food to disguise the taste before giving it mix the dose in juice or dissolve contents of 1 capsule in 2 mL water dissolve contents of 1 capsule syringe and make the volume up to 3 mL (if necessary) draw this solution into a Schedule Capsule (powder for If renal impairment seek MO/NP advice Contraindication cross-reactivity between Management of associated emergency Provide Consumer Medicine Information: pain at injection site Note ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP reconstitution) Management of associated emergency: • • Contraindication: Note: children. A 50 mg/mL solution can be made: There is no oral liquid for • • Provide Consumer Medicine Information Provide Consumer Medicine of water pain. Take with a full glass ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed 406 Skin | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup HMP Use inpregnancy: Contraindication: Note: reduce stomachupset Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: Background Recommend • • • • Schedule Related topics Tinea versicolor(pityriasis versicolor),page • • • • Tablet Form Consult MO/NPasabove Consult MO/NPifnotimproving Perform dressingsasrequired Advise toberevieweddailyinitially,monitorinflammation Checkforinteractionswithothermedicinespriortogiving.Cautionifpepticulcer combs, caps,clothing,footwear,linen andwetfloors,includingoccupationalexposure Can betransmittedbydirectcontactwithothersorinfectedanimals or objectssuchas conditions, poorlycontrolleddiabetesandbeinginamalnourishedstate Transmission isfosteredbyovercrowding,sharedbathroomfacilities,poor hygiene,humid edge asitexpands (forming aring)orarcuate(bowshaped).Itisusuallyscalyanditchywith adefiniteredorpink dermatophytes, afungusparasite,andhastypicalappearancewhich isdescribedasannular Tinea orringwormcaninfectanypartofaperson'sskin,hairandnails. It iscausedby Prevent transmissionofringworm.Alwaystreatsecondaryinfection Tinea/ 1,2 1 1
Strength ringworm
500 mg Impairedrenalfunction,blooddyscrasias,uricacidstonespresent Contactpregnancydruginformationcentreforadvice 4 administration
- adult/child Route of Oral Consult MO/NP.See
Maycauserash,nauseaandvomiting.Takewithfoodto Probenecid 411 Recommended Adult only 1 gdaily dosage Anaphylaxis, page
Extended authority ATSIHP 102 minutes priorto Give atleast30
cefazolin Duration / IHW/IPAP stat 4,17,19,20
Skin 407 4
Skin | Skin problems Section 4: General , miconazole 2% or clotrimazole 1% 5 Impetigo, page 392 page Impetigo, History and physical examination - adult, page 20 - adult, page examination physical and History Not applicable 1,2 1 BGL
(wear gloves) For isolated lesions treat topical terbinafine 1% (preferred) For isolated lesions treat topical terbinafine 1% Treat any secondary bacterial infection first. See helpful. This can be done by avoiding synthetics and Efforts to decrease occlusion and moisture are footwear, and by the judicious use of an wearing lighter and better ventilated clothing and absorbent powder Consult MO/NP if there is widespread skin involvement or tinea capitis present Consult MO/NP if there is widespread skin involvement area for microscopy/mycology, if there is any Perform a skin scraping from the edge of an affected doubt about the diagnosis Review nutritional status Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – Obtain a complete patient history Examine skin as per skin assessment in Usually occurs between the toes and is characterised by itching, odour, scaling and fissuring. the toes and is characterised by itching, odour, Usually occurs between infection and this may be a site of entry of streptococcal Secondary infection is common Predominantly occurs in males in the groin. Unlike candidiasis, satellite lesions are unusual. Often males in the groin. Unlike candidiasis, satellite Predominantly occurs in the inner thigh is affected Has a variable appearance ranging from small lumps about the hair shafts to a kerion, which is an the hair shafts to a kerion, small lumps about appearance ranging from Has a variable It is usually purulent material. with broken hairs and oozing boggy mass, studded inflammatory cats and commonly acquired from in children and is Occurs almost exclusively itchy or painful. need to be considered devoid of hair are seen, non-tinea conditions may dogs. If smooth patches effluvium e.g. alopecia areata or telogen May be diverse in its presentation but most commonly presents as an itchy lesion or rash with an or rash an itchy lesion presents as commonly but most its presentation diverse in May be from central clearing. Excoriation red scaly border with shaped, raised advancing, irregularly is common secondary infection scratching and
• • • • • • • • • • • • •
Tinea capitis Tinea corporis Tinea Tinea pedis Tinea cruris
1. with present May 4. Management
3. assessment Clinical 2. Immediate management 408 Skin | Primary Clinical Care Manual 10th edition | RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Management ofassociatedemergency not coverwithadressing.Continuetreatmentforfewdaysafteryourskinlooksbetter the affected and surrounding skin. For this treatment tobesuccessful you have to use it regularly. Do Provide ConsumerMedicineInformation: Management ofassociatedemergency attention toskinfolds.Forthistreatmentbesuccessfulyouhaveuseitregularly Provide Consumer Medicine Information: RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Management ofassociatedemergency: Provide ConsumerMedicineInformation: RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Cream Cream Cream Lotion Schedule Schedule Form Form Form Schedule Strength Strength 2% Strength 1% 1% 3 2 administration administration Route of Route of 2 Topical Topical Authority to administer and supply medicines, page Authority to administer and supply medicines, page Authority to administer and supply medicines, page administration : ConsultMO/NP.See : ConsultMO/NP.See ConsultMO/NP.See Route of
Topical Applythinlayertoaffectedskin.Generally welltolerated Cleananddryaffectedareasthoroughlybeforeapplyingto Apply to the affected and surrounding skin. Pay particular Miconazole Terbinafine Clotrimazole Recommended dosage Recommended dosage
Apply athinlayerbd Apply athinlayerbd Apply athinlayer2-3 Recommended Anaphylaxis, page Anaphylaxis, page Anaphylaxis, page times aday dosage Extended authority Extended authority ATSIHP ATSIHP Continue usingfor2weeks after symptomshavegone Extended authority ATSIHP 102 102 102 / / Until 2weeksafter IHW/IPAP IHW/IPAP symptoms cease / 1-2 weeks Duration Duration IHW/IPAP Duration 9 9 9
2,3 1,5 4 Skin 409 Skin | Skin problems Section 4: General Candidiasis/vaginal (thrush), page 630 page (thrush), Candidiasis/vaginal History and physical examination - adult, page 20 - adult, page examination physical and History Not applicable 1,2 1
3 1,2
BGL if diabetic or candidiasis is persistent and recurrent connecting moist red patches, sometimes with vesicles and satellite pustules connecting moist red patches, sometimes with armpits, between the buttocks, under common locations include the groin and genitals, the abdomen and between the digits pendulous breasts, between the folds of skin on most commonly found in moist skin folds tinea capitis or toenails involved fingernails widespread skin involvement widespread – – – – – –
immunocompromised status and corticosteroid use immunocompromised status Candidiasis is a yeast infection usually confined to the skin, nails, mucous membranes, vagina usually confined to the skin, nails, mucous Candidiasis is a yeast infection and gastrointestinal tract and antibiotics (for diabetes, pregnancy, oral contraceptives Predisposing factors include humid conditions, obesity, occlusive and tight fitting garments, vulvovaginal infections), Investigate for diabetes, treat other skin conditions if present Provide education on predisposing factors, personal hygiene and not sharing towels Treat with topical miconazole 2% or clotrimazole 1% Remove/modify predisposing factors where possible Review nutritional status Obtain a complete patient history Examine skin as per skin assessment in Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – – – Cutaneous candidiasis: – Consult MO/NP as above – – terbinafine treatment e.g. usually require oral antifungal These patients Advise to be reviewed in 2 weeks to be reviewed Advise if: at next clinic to see MO/NP Advise –
• • Candidiasis (oral thrush), page 355 page thrush), (oral Candidiasis Related topics • • • • • • • • • • • • • Background
- adult/child Candidiasis (skin) HMP
4. Management 3. assessment Clinical
2. management Immediate 1. with May present
6. Referral/consultation 5. up Follow 410 Skin | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Management ofassociatedemergency attention toskinfolds.Forthistreatmentbesuccessfulyouhaveuseitregularly Provide ConsumerMedicineInformation: Management ofassociatedemergency: Provide ConsumerMedicineInformation: RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed • • • • Cream Schedule Cream Lotion Form Form Consult MO/NPasabove These patientsmayrequireoralantifungaltreatment – – Advise toseeMO/NPatnextclinicif: Advise tobereviewedin2weeks – – fingernails ortoenailsinvolved persistent orrecurrentcandidiasis Schedule 1 Strength 2% Strength 1% 3 administration
Route of 2 Topical Authority to administer and supply medicines, page Authority to administer and supply medicines, page administration : ConsultMO/NP.See ConsultMO/NP.See Route of
Topical Applythinlayertoaffectedskin.Generallywelltolerated Applytotheaffectedandsurroundingskin;payparticular Miconazole Clotrimazole Recommended dosage Apply athinlayerbd
Anaphylaxis, page 2-3 timesaday Recommended Anaphylaxis, page dosage Extended authority ATSIHP Continue usingfor2weeks after symptomshavegone Extended authority ATSIHP 102 / 102 Until 2weeksafter IHW/IPAP symptoms cease / Duration IHW/IPAP Duration 9 9
5 4 Skin 411 Skin | Skin problems Section 4: General History and physical examination - adult, page 20 - adult, page examination physical and History Not applicable 1,2 1,2,3 1,2
miconazole 2% shampoo once daily for 10 minutes for 10 days miconazole 2% shampoo once daily for 10 minutes MO/NP may consider oral treatment with fluconazole. For children consult with specialist ketoconazole 2% shampoo once daily for 3-5 minutes then wash off for 5 days OR ketoconazole 2% shampoo once daily for 3-5 minutes to wet skin and leave overnight for 3 nights apply econazole 1% foaming solution e.g. Pevaryl® and repeat in 1 and 3 months OR recurrence is common there are a variety of application schedules e.g. after showering, apply the shampoo liberally to there are a variety of application schedules e.g. is left on for at least 10 minutes or overnight wet skin over and beyond the affected area. This 7-10 days and then washed off. This is repeated daily for take several weeks for new normally note that even after successful treatment, it may pigmented skin to replace the discoloured skin – – – – – – –
yeasts which are normal yeasts which is caused by Malassezia (tinea versicolor) Pityriasis versicolor sweating is exacerbated by heavy in tropical climates and of the skin. It is common commensals – Notify MO/NP if not responding: – – – – Alternative treatments: – – Perform a skin scraping for microscopy/mycology if there is a doubt about the diagnosis Perform a skin scraping for microscopy/mycology is selenium sulfide shampoo: The cheapest, safest and most convenient treatment Review nutritional status Obtain a complete patient history Examine skin as per skin assessment in Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) Commonly found on the upper trunk, neck and shoulders Commonly found on the after swimming in salt water, or heavy sweating Mild itchiness, more marked Well defined, irregularly shaped macules (a discoloured flat spot on the skin) shaped macules (a discoloured flat spot on the Well defined, irregularly hypopigmented lesions in from reddish brown in fair skinned people to Macules may vary in colour dark skinned people with a fine scale The macules may be covered
• Tinea/ringworm, page 406 page Tinea/ringworm, Related topics • • • • • • • • • • • • • Background
- adult/child versicolor) (pityriasis versicolor Tinea HMP
4. Management 3. assessment Clinical
2. Immediate management 1. May present with 412 Skin | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup Management ofassociatedemergency: applied 1or2timesamonthafterinitialtreatment Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmayproceed Management ofassociatedemergency: Provide ConsumerMedicineInformation: RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Shampoo Shampoo • • Schedule Schedule Form Form Consult MO/NPasabove Advise toseeMO/NPatnextclinicifpersistentorrecurrenttineaversicolor 4 25 mg/mL Strength Strength (2.5 %) 2% Unscheduled 2 Authority to administer and supply medicines, page administration administration Route of Route of Topical Topical Consult MO/NP Consult MO/NP Completecourse.Tohelppreventrecurrance,canbe Asingleapplicationmaybeeffective Ketoconazole
Selenium sulfide Apply andleaveonfor5 Leave onforatleast10 minutes thenwashoff minutes orovernight Apply towetskin.
Recommended Recommended dosage dosage
Daily Daily
Extended authority ATSIHP / Up to5days IHW/IPAP 7-10 days Duration Duration 9
1,3 1,5 Skin 413 Skin | Skin problems Section 4: General Not applicable 2 . It is a slow developing disease (from 1-20 years) and years) 1-20 (from disease developing slow a is It Mycobacterium leprae. 2 1 pale patches, never totally white, may be red in light skins, single or few in number, with well demarcated edge, may be a little thickened, anaesthesia to light touch e.g. with a piece of cotton wool, destruction of hair follicles and loss of sweat and sebaceous glands skin lesions are multiple, often a coppery or violet colour, no anaesthesia to touch and showing leprosy bacilli on skin smears – – good immunity (tuberculoid leprosy) is characterised by: good immunity (tuberculoid leprosy) is characterised – little or no immunity (lepromatous leprosy) is characterised by: – – – – – inspect and palpate the entire skin surface for lesions which can include macules, papules, inspect and palpate the entire skin surface for lesions may appear coppery on dark skin and pink plaques, nodules and urticaria-like lesions. Patches on the buttocks on fair skin. Sometimes the only lesions may be skin lesions:
– – Leprosy can affect the skin, the peripheral nerves, the upper respiratory tract and the eyes the peripheral nerves, the upper respiratory Leprosy can affect the skin, Leprosy is curable Consider leprosy in any patients with any unexplained peripheral lesion or any chronic skin lesion or any chronic any unexplained peripheral in any patients with Consider leprosy localised with if associated treatment, particularly 'conventional' to respond to fails which lesion nerves or palpable, thickened decreased sensation is especially important stigma attached, confidentiality has a strong social Because leprosy Leprosy (Hansen's disease) is a notifiable disease a notifiable disease) is (Hansen's Leprosy Leprosy is caused by caused is Leprosy from the nose and mouth but is not highly infectious is transmitted via droplets
– – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) Perform physical examination: Obtain a complete patient history. Enquire specifically about the presence and duration of lesions, Obtain a complete patient history. Enquire specifically and injuries, eye pain and worsening vision. nerve pain, numbness and tingling, weakness, ulcers Ascertain previous possible exposure to leprosy Eye pain and worsening vision Lagophthalmos (unable to completely close eyes) Loss of eyebrows and lashes Weakness, particularly the small joints in the hands and feet Weakness, particularly the small joints in the hands face are rare Sharp shooting pains in the legs, arms, body and Areas of skin discolouration may appear coppery on dark skin and pink on fair skin with loss of may appear coppery on dark skin and pink Areas of skin discolouration area sensation in the discoloured on hands and feet as a result of trauma to Limb deformities and chronic ulceration and scarring areas with loss of sensation Skin lesions, nerve pain, numbness and tingling, weakness, ulcers and injuries numbness and tingling, weakness, ulcers and Skin lesions, nerve pain, nerves Palpable or thickened peripheral
•
• • • • • • • • • • • • • • • • •
Recommend Background
3. assessment Clinical 2. management Immediate
1. May present with - adult/child disease) (Hansen's Leprosy 414 Skin | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management • • • • • • • • • • • • Leprosy requiresimmediatenotification tothelocalPublicHealthUnit Consult MO/NPonalloccasionsifleprosy issuspected All patientswithleprosyrequirelifelongfollowup Advise topresentiftheyhaveanysuddenorincreasingweakness/numbness orskinproblems Regular longtermfollowupneeded feet duetolossofsensation.Encouragethewearingsuitablefootwear It isvitaltoteachthepatientavoidinjury,mainlyburnsofhands and frictiondamagetothe Ensure patientadhereswithmedicines.Involvefamilymembersasmuch aspossible Public HealthUnitwillprovidecontacttracingofhousehold/familyand provideadvice clofazimine breaking thecycleoftransmission.MDTconsiststhreemedicines-dapsone,rifampicinand Multi-drug therapy(MDT)ofdiagnosedcasesisthekeytoachievingcureinindividualand within hoursordays Untreated acutereactionscancausefunctionallossthatbecomeirreversibleveryrapidly, Diagnosis alwaysrequiresabiopsyormicrobiologicalconfirmation Consult MO/NP – – – – – – – – – – lesions: other – the eyes:lepromatousleprosy: – – – the nose:lepromatousleprosy: – – nerve damage: – – – – – – – – testicular atrophy swelling ofinfectedlymphglandswhichmaybreakdownanddischarge iritis, cornealscarring there maybedestructionoftheseptumandadjacentbone ulceration ofthemucosamayoccur mucoid discharge,containinghighlevelsofbacteria – – – – – other nervesinvolvedare: then tolossofmotorfunction,deformityinthearea4 tender inthegroovebehindelbow.Damagetoulnarnerveleadsanaesthesiafirst, peripheral neuropathyaffectsmostcommonlytheulnarnerve,whichisthickened,andmaybe – – – – – Sensation ismoreoftenthefirstsymptom trigeminal: cornealanaesthesia.Nervedamageaffectsbothsensoryandmotorfunctions. facial: agophthalmusi.e.inabilitytofullyclosetheeye radial: wristdrop common peroneal:foot-drop posterior tibial:anaesthesiaofthesolefoot 2
2
th and5 th fingers Skin 415 392 Impetigo, page page Impetigo, Skin | Skin problems Section 4: General http://conditions.health.qld.gov.au/HealthConditions/2/ http://conditions.health.qld.gov.au/HealthConditions/2/ Not applicable : 705 3,4,10 - adult/child
700 Norwegian) scabies occurs when thousands of mites are present rather than the usual when thousands of mites are present rather Norwegian) scabies occurs 1,2 1,2,3
often, but not always, on buttocks, hands, feet, elbows, armpits often, but not always, on buttocks, hands, feet, scale may have distinctive creamy colour tinea, psoriasis, eczema or dermatitis may look similar thickened, scaly patches, often not itchy compared to scabies thickened, scaly patches, often not itchy compared Scabies – – – – Severe crusted scabies (Norwegian scabies) requires intensive treatment scabies) requires intensive scabies (Norwegian Severe crusted Provide a second treatment 1 week after first treatment to kill all eggs first treatment to treatment 1 week after Provide a second time to avoid be treated at the same close contacts need to members and All household/family need to be treated not have any symptoms Even contacts who do re-infestation. Inspect all skin surfaces in patients with marked itchiness looking for scabetic lesions with marked itchiness looking surfaces in patients Inspect all skin Immunocompromised, mentally or physically incapacitated people are at greater risk of crusted Immunocompromised, mentally or physically incapacitated scabies See Queensland Health Fact Sheet at: Infections-Parasites/101/Parasites/545/Scabies Secondary bacterial infection occurs frequently Secondary bacterial infection Crusted ( with poverty or overcrowding 3-50. It is not a different species. It is usually associated Multiple family members/householders tend to be affected Multiple family members/householders helps in control that treating clothes, linen, mattresses and furniture There is limited evidence and prevention responsible for the signs and symptoms responsible for the signs be a source of skin contact, although clothing and bedding can Usually spread by skin to a host e.g. in bed linen, live away from the skin for 1-2 days or, if near infestation. The mite can for up to 4 days Caused by a mite that burrows into the skin. An allergic reaction to the presence of the mite is into the skin. An allergic reaction to the presence Caused by a mite that burrows
– – – Burrows, e.g. on hands, are diagnostic of scabies but often difficult to find. They are short and Burrows, e.g. on hands, are diagnostic of scabies the site of the female mite superficial and have a small distal vesicle overlying Crusted (Norwegian) scabies – Scabetic lesions are usually small raised, itchy nodules that are typically found in the softer Scabetic lesions are usually small raised, itchy elbows, wrists, genitalia, buttocks, axillae and hairless skin areas e.g. between fingers and toes, head in infants Marked itchiness, scratching while asleep bacterial infection are the most common skin Excoriations, eczematous eruptions and secondary lesions
• • • • • • • • • • • • APSGN, page page APSGN, page fever, rheumatic Acute Related topics • • • • •
Recommend Background HMP
2. Immediate management 1. May present with 416 Skin .Management 4. Clinicalassessment 3. | Primary Clinical Care Manual 10th edition | • • • • • • • • • • • • • – and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning re-infestation isinevitable Simultaneous treatmentofallfamily membersandclosepersonalcontactsiscrucialotherwise – – – – – – If Norwegianorcrustedscabies: – – – – – To treatscabiesuse: Impetigo, page 392 Treat anysecondarybacterialinfectionsatthesametime.See – – – – Consult MO/NPif: Consider skinscrapingforfungalelements/scabies – Look foranysignsofsecondaryinfection.See Do urinalysis Weight -bareweightif<2years Examine skinasperassessmentin Obtain acompletepatienthistory and contactsincreases thelikelihoodofcure Inadequate coverage isafrequentcauseoftreatment failure.Fullysupervisedtreatment of patients – – – – – – – – – – – – – – – – cured. Applyheadtotoeandwashoffafter24hours note inparticularBP clothes, bedsheetsandtowelsshould bewashedinhotwaterdailyanddriedthesun – and helppenetrationofpermethrin5%: days topermethrin5%,andonlyareasofcrustedorthickenedskin, softentheskincrusts apply Calmurid®(10%urea,5%lacticacidinmoisturisingcream)after bathingonalternate apply permethrin5%every2 specialist orclinicalmicrobiologist consult MO/NPwhowillorderivermectinfollowingapprovalbyaninfectious diseases if treatmentfails,consultMO/NPwhomayorderivermectin be balancedagainstthehighmorbidityofuntreatedscabies Note: althoughpermethrin5%isnotapprovedforuseinchildren<6monthsofage,thismust can beappliedtoscratched/brokenskinonlyavoidingopenlesionsifobviousirritationoccurs apply toentirebody,headtoe permethrin 5%andrepeatin1week secondary bacterialinfectioncanleadtoAPSGNandARF/RHD or skinflakes vacuum thefloorsandfurniturein house,andthefloorsseatsincars,toremovemites to killanymites if awashingmachineisnotavailable, leaveclothes,linenandbeddinginasealedplasticbag secondary dermatitisfromretainedmiteproducts-mayrequiretopicalsteroid infant <6monthsofage severe crustedscabies BP orurinalysisabnormal – soak orscrubthecrustswithaspongenextday,priortoapplyingpermethrin 5% 2,3,6,10 2,3,5 nd dayafterbathingfor1week,then2-3timeseveryweekuntil History and physical examination -adult,page 20 Cellulitis, page 401 Cellulitis, page 401 , and Impetigo, page 392 , and Skin 417 8,9,10 1,6,7,10
Repeat Duration after 7 days Apply on day 1 stat IHW/IPAP Duration / 102 to permethrin repeat in 1 week
For crusted scabies ATSIHP once on days 1, 2 and 8 Extended authority
For scabies not responsive ) Skin | Skin problems Section 4: General ® years up to 1 dosage to 1 year up to 1/4 up to 1/2 up to 1/8 30 g tube Recommended Recommended Anaphylaxis, page page Anaphylaxis, Adult and Child ≥ 12 Infant aged 6 months Child aged 1 to 5 years for a single application Approximate amount of Approximate Child aged 5 to 12 years 0r ≥ 15 kg
200 microgram/kg Ivermectin Recommended dosage 3 mg) to a max. of 18 mg Adult and child ≥ 5 years Permethrin 5% (Lyclear Permethrin Apply from the chin down and wash off with warm soapy Apply from the chin down and wash off with (rounded up to the nearest May infrequently cause headache, fatigue, dizziness, May infrequently cause headache, fatigue, dizziness, Consult MO/NP Consult MO/NP. See Topical Route of
administration Oral Route of 4 administration Unscheduled 5% Do not use Strength 30 g tube 3 mg Strength
Schedule hours after commencement of treatment of after commencement hours If a school-aged child, the school should be notified. Children with scabies can return to school 24 24 to school return can scabies with Children be notified. should the school child, school-aged If a Form Schedule Cream Form Tablet • ATSIHP, IHW and IPAP must consult a specialist infectious disease physician ATSIHP, IHW and IPAP must consult a specialist RIPRN and RN must consult MO/NP Use in pregnancy: Management of associated emergency: Provide Consumer Medicine Information: abdominal pain, vomiting and diarrhoea water 8-14 hours later. Rinse thoroughly. Also apply to the scalp, face and ears in children < 2, elderly or water 8-14 hours later. Rinse thoroughly. Also apply failiure, or those with atypical or crusted scabies immunocompromised people, people with treatment Management of associated emergency: Provide Consumer Medicine Information: ATSIHP, IHW, IPAP, MID, RIPRN and RN may proceed IPAP, MID, RIPRN and RN ATSIHP, IHW, 418 Skin 6. Referral/consultation 5. Followup | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Head lice/nits Background • • • • • • • • • • • • • • • • bacterial infection. See Inspect thenapeandocciputof neckforexcoriationsandpapules-signsofsecondary – – – – Perform physicalexaminationofthescalpandhair: Obtain patienthistory Outbreak inschoolorotherfacility Evidence ofwhiteeggsinhair Itchy, 'crawling'scalp Severe crusted(Norwegian)scabiesrequiresnotificationtothelocalPublicHealthUnit Consult MO/NPifrecurrentorchroniccasecrusted(Norwegian)scabies scabies ispresent.Thisdoesnotindicatetreatmentfailure Itchiness aftertreatmentiscommonandcanlastuptoamonthormore,especiallyifnodular referral co-morbid condition(immunocompromised).Mayrequiresupervisedtreatmentorspecialist If topicaltreatmentfailsconsiderotherdiagnosis,unidentifiedsourceofre-infestationor Repeat treatmentwithpermethrin5%in7daystoeradicatenewlyhatchedmites condition/14/165/351/headlice See QueenslandHealthFactSheetat: combing is moreeffectiveinkillingeggsthanlivelice-thisachievingacurewet Applying heatwithahairdryertosmallsectionsoffor1-3minutesoverperiod30 Hair conditionerondryhairstunsliceandstopsthemcrawlingforabout20minutes hats ifusedwithinashortperiodoftime Lice aremainlytransmittedbydirectheadtocontactandpossiblycombs,hairbrushesor but layeggs(nits)onthehair Head licearecrawling( – – – – the scalpbutmaypersistformanymonths aftersuccessfultreatment eggs (nits)cementedsecurelytothehairsmaybeseenbynakedeye oncloseinspectionof use afinetoothedcombtofindlive licewiththickwhitehairconditionerappliedto mobile licemayalsobeseen finding manynitsclosetothescalp ismoresignificant 1
2 6
- adult/child Impetigo, page Pediculus capitis
Notapplicable www.conditions.health.qld.gov.au/HealthCondition/ 392 ) insectsthesizeofasesameseed,thatliveonscalp Skin 419 1,4 days Duration Repeat after 7 Apply on day 1
) ® Skin | Skin problems Section 4: General dosage Adult and as required Recommended child > 2 months and can be applied to scabbed/broken skin, skin, to scabbed/broken be applied and can 3
Permethrin 1% (Quellada Apply to damp hair after washing with usual shampoo. Leave Apply to damp hair after washing with usual shampoo. Consult MO/NP Topical Route of administration
Unscheduled 1,3 1% Strength repeat every day until no lice are found over 10-14 consecutive days repeat every day until no note: divide the hair into sections and comb from roots to tips using a fine tooth head lice comb and comb from roots to tips using a fine tooth divide the hair into sections tissue for head lice. comb onto a white tissue, checking the comb and after each stroke, wipe for lice Comb the whole head, checking bin plastic bag, tie the top and put the bag in a rubbish put all the tissues into a from roots to tips. Hair conditioner on dry hair stuns the lice and stops them crawling for about and stops them crawling dry hair stuns the lice tips. Hair conditioner on from roots to 20 minutes de-tangle hair and evenly distribute the conditioner use an ordinary comb to repeat treatment 7 days after initial treatment 7 days after initial repeat treatment and hair completely cover the scalp to dry hair to thick white hair conditioner apply sufficient
– – – – – – – Consult MO/NP if persistent or recurrent head lice Advise to repeat Permethrin 1% after 7 days All family members and close personal contacts should be treated simultaneously All family members and close personal contacts be washed in hot water or dried in direct Contaminated combs, hairbrushes and hats should sunlight for a day after each use after the initial treatment of head lice It is not necessary to exclude children from school Removal of nits after effective chemical treatment is not necessary but may be psychologically chemical treatment is not necessary but Removal of nits after effective white hair conditioner by with a fine tooth head lice comb and thick, important and can be done to the tips combing from the roots – have not worked use more than once per week. If three treatments Do not apply chemical treatment of treatment described above the non-chemical method – – – – – non-chemical treatment: An effective – Treat any secondary bacterial infection at the same time infection at bacterial secondary Treat any choice treatment of chemical 1% is the Permethrin irritation occurs: open lesions if obvious only avoiding
Form Schedule
Lotion • • • • • • • • • •
on hair for 10 minutes before rinsing. Use a fine tooth comb to remove eggs and dead lice. on hair for 10 minutes before rinsing. Use a fine from lice. Avoid contact with eyes May temporily increase itch, redness and swelling Management of associated emergency: Provide Consumer Medicine Information: ATSIHP, IHW, IPAP, MID, RIPRN and RN may proceed 6. Referral/consultation 5. Follow up 4. Management 4. 420 Skin 1. Maypresentwith | Primary Clinical Care Manual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement HMP Background • • • • • • • • • • Related topics Candidiasis (skin), page • • • Consult ChildHealthNurseorMO/NPifseverenotimprovingaftersimple measures Candidiasis (skin), page Treat secondarybacterialinfectionorcandidiasisifpresent.See Administer analgesiaasclinicallyindicated.See unexpected inchildrenorothervulnerablepeople.See Always considernon-accidentalinjurywhereorpresentationisinconsistent withhistoryoris Advise carerofstrategiestomanagenappyrashathomeandprevent recurrence(seetable) – – – Perform physicalexaminationoftheskin.Lookfor: – – Obtain acompletepatienthistory: Recent antibioticuse Irritability, especiallywithnappychanging Red, weepingskinrash Virtually allcasesbecomecolonisedwith and exposuretourinefaecalenzymes Irritant nappyrashisduetothelossofepidermalbarrierskinmoisturefriction Most nappyrashisasimpleirritantdermatitis,buttherearemanycauses – – – – – Nappy rash satellite lesions-consider evidence ofskindiseaseelsewheree.g.atopiceczema,psoriasis bathing assess nappychangingroutine-frequency,typeofused,usepowders,creams, assess bowelmovementhistory;anydiarrhoea any evidenceofsecondarybacterialinfection.See 1 1,2 -child 1 409 409 Candidiasis (skin), page Notapplicable Candida albicans
Acute pain management, page Impetigo, page 409 Child protection, page (thrush) Impetigo, page 392 760 392 35
or
Foot infection in diabetes 421 and Streptococci 1,4 , Avoid × Avoid Staphylococci Foot infection in diabetes infection | Foot Section 4: General Removing barrier cream at every nappy change cream at every nappy Removing barrier Using soap alcohol containing fragrances or Using wipes baking soda, powder, cornstarch, Applying talcum boric acid powders Nappy liners Waterproof nappy covers/pilchers 1,2 Suggest √ Suggest 1,2 3 Foot infection in patient with diabetes Foot infection in patient with diabetes
a foot lesion/infection Be aware of bone or joint destruction due to underlying loss of sensation, fractures/dislocations sensation, or joint destruction due to underlying loss of Be aware of bone (also known as Charcot’s Foot) with or without trauma and changes in bone metabolism for any patient who has diabetes and A specialist diabetic foot service is strongly recommended Early treatment (antibiotics and wound care) may prevent the need for the patient to be evacuated, Early treatment (antibiotics and wound care) may hospitalised and undergo amputation friction or pressure when immobile, foot deformities, poor foot self-care, lack of awareness of friction or pressure when immobile, foot deformities, poor foot self-care, lack of awareness risks, diabetic peripheral neuropathy with sensory loss Reducing pressure and/or improving vascularisation is required to heal a diabetic foot ulcer Reducing pressure and/or improving vascularisation Precipitating causes of foot ulceration and infection include: previous history of foot ulcer, friction in ill-fitting shoes, untreated or self-treated callus, foot injuries, burns, corn plaster, nail infection, amputation ulcer are The most likely organisms to infect a superficial sometimes anaerobes to develop a foot ulcer Up to one third of people with diabetes are likely Foot infections in patients with diabetes are a serious complication that frequently lead to Foot infections in patients with diabetes are a serious
improving Consult Child Health Nurse or MO/NP as above If mild, advise to be reviewed in one week If mild, advise to be reviewed or MO/NP if not reviewed daily initially. Consult Child Health Nurse If moderate, advise to be
• • • • • • • • • • •
Recommend Background Apply petroleum jelly over the barrier cream to Apply petroleum jelly over into nappy avoid absorption of cream Use cotton wool and water to clean perineum, and water to clean Use cotton wool groin and buttocks skin to prevent Apply a barrier cream to oxide progression of rash e.g zinc during the day) to air wherever feasible Expose skin and a soap substitute Use damp cloths Strategies to manage nappy rash at home nappy rash to manage Strategies 2 hourly nappy changes (at least More frequent
HMP Foot infection in diabetes
6. Referral/consultation 5. Follow up 422 Foot infection in diabetes .Immediatemanagement 2. Maypresentwith 1. | Primary Clinical Care Manual 10th edition | Management 4. Clinicalassessment 3. • • • • • • • • • • Related topics Osteomyelitis inthefoot of patient with diabetes, page 425 – and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning Obtain woundswabforMCS.See – Collect bloods: – – – – – – – Perform physicalexamination.Inspect/assessallsurfacesofthefoot: – – – – – – – – – Obtain acompletepatienthistoryincluding: Signs ofsepsis.See 'Painless' footinjurysecondarytodiabeticperipheralneuropathy – – Patient withdiabeteswith: For severe casesorifsystemically unwellMO/NP mayadvise: gangrene orischemic ulcer Consult MO/NPurgently iflimbthreateningischaemia i.e.absentpedalpulseswithpain at rest, – – – – – – – – – – – – – – – – – – – BGL assess groinlymphnodesforenlargement andtendernessiflymphnodeinvolvement assess protectivesensationusingamonofilament assess pulses-dorsalispedisandposteriortibial signs ofinfection-redness,swelling,warmth,exudate(colourandodour) describe size,location,depthofanylesion(s)ortakephotowhereavailable andwithconsent ulcers, cracksbetweentoes,callusesordeformities check forskinpallor,discolouration,oedema home support observance withwoundcare recent traumatofoot current medications assess usualfootcareandfootwearpractices levels, takingmedicines/insulin,footcare measures takentopreventormanagefootinfection(s)e.g.footwear,managingbloodglucose surgical treatmentreceivedforfootinfection(s),suchasamputation past episodesoffootinfection(s) known ornewlydiagnoseddiabeticperipheralneuropathyvasculardisease ulcer orwoundonfoot foot injury/trauma,signsofinfection-swollen,inflamed HbA1c, FBC,CRP,urea,creatinineand GFR,randomvenousBGL 1,3 Sepsis/septic shock, page 80 2,3 3 Notapplicable Chronic wounds, page 427 fortechnique Foot infection in diabetes 423 5,7 5,6
7 days Duration
IHW/IPAP Duration / IHW/IPAP 102 102 / At least 5 days ATSIHP Extended authority ATSIHP Extended authority 427 Adult dosage Recommended Anaphylaxis, page page Anaphylaxis, Anaphylaxis, page page Anaphylaxis, 875 mg + 125 mg bd dosage Foot infection in diabetes infection | Foot Section 4: General . Avoid in women with premature rupture of the 500 mg qid Recommended
Chronic wounds, page page wounds, Chronic Cl. difficile Cefalexin Oral Take with food. May cause rash, diarrhoea, nausea and Take with food. May cause rash, diarrhoea, May cause rash, diarrhoea, nausea, vomiting, dizziness, May cause rash, diarrhoea, nausea, vomiting, Route of Consult MO/NP. See : Consult MO/NP. See Oral administration Route of Amoxicillin + clavulanic acid Amoxicillin + clavulanic administration
penicillins, carbapenems and cephalosporins 4 125 mg Strength 875 mg + 4 250 mg 500 mg : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity : Severe or immediate allergic reaction to a penicillin. Strength : Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware of aware Be penicillin. a or cephalosporins a to reaction allergic immediate or Severe : penicillins, carbapenems and cephalosporins amoxicillin + clavulanic acid OR amoxicillin + metronidazole OR cefalexin PLUS clindamycin ciprofloxacin PLUS hypersensitivity to penicillin: if immediate evacuation/hospitalisation blood cultures, IV cannula, IV antibiotics IV cannula, cultures, blood Schedule Form – – – – – If renal impairment seek MO/NP advice Tablet Check footwear and ensure correct fit. Leave footwear off if compromises infected foot correct fit. Leave footwear off if compromises Check footwear and ensure of foot Encourage rest and elevation An x-ray is useful is present or lesion not healing consider osteomyelitis. If deep penetrating ulcer Manage hyperglycaemia in consultation with MO/NP and diabetes team. Insulin may be required in team. Insulin may with MO/NP and diabetes in consultation Manage hyperglycaemia to control BGL the short term dressing and with specialist diabetic foot service type of primary Determine in consultation required. See secondary dressing where – – – – may MO/NP or septic arthritis of osteomyelitis with no evidence infection to moderate For mild order: – Schedule Form • • • • • • Capsule Management of associated emergency candidiasis. Can cause severe colitis due to Contraindication between neonatal necrotising enterocolitis membranes as there may be an increased risk of Provide Consumer Medicine Information: ATSIHP, IHW, IPAP, RN and RIPRN must consult MO/NP ATSIHP, IHW, IPAP, RN and Note: Contraindication cross-reactivity between Management of associated emergency: Provide Consumer Medicine Information: headache and candidiasis ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP ATSIHP, IHW, IPAP, RIPRN and RN must consult 424 Foot infection in diabetes | Primary Clinical Care Manual 10th edition | reduce absorption.Maycauserash,itch,nausea,vomiting,diarrhoea,abdominalpain,dyspepsia fluids. Avoiddairyproducts,zinc,ironorcalciumsupplementswithin2hoursoftakingdoseasthey Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: Pregnancy Contraindication Note soreness orinflammation,numbnesstinglinginyourfingerstoesoccurs.Avoidsunexposure operationg heavymachineryifaffected.Stoptakingandnotifyhealthprofessionalanytendon and increaseeffectsofcaffeinealcohol.Maycausedizzinessorfaintness.Avoiddriving ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: metallic taste,dizzinessorheadache with foodtoreducestomachupset.Maycausenausea,anorexia,abdominalpain,vomiting,diarrhoea, Provide ConsumerMedicineInformation: Tablet Schedule Form Tablet Form Schedule : Cancauseseverecolitisdueto : Notrecommended.Reserveforsevereorlife-threateninginfections Strength 200 mg 400 mg Strength 500 mg 250 mg 750 mg : Severeorimmediateallergicreactiontociprofloxacinotherquinolones 4
4 administration Route of administration Oral Route of Oral Cl. difficile.
ConsultMO/NP.See ConsultMO/NP.See Take1hourbefore,or2hoursaftermeals.Drinkplentyof Avoidalcoholwhiletakingandfor24hoursthereafter.Take
Ciprofloxacin Metronidazole If renalimpairmentseekMO/NPadvice
Adultandchild≥12years Recommended 400 mgbd dosage Recommended Adult 500 mgbd Anaphylaxis, page Anaphylaxis, page dosage Extended authority Extended authority ATSIHP ATSIHP 102 102 / At least5days / IHW/IPAP IHW/IPAP At least5days Duration Duration
5,9,10 5,8 Foot infection in diabetes 425 5,11,12 Duration At least 5 days /IHW/IPAP ATSIHP Extended authority authority Extended 102 page Anaphylaxis, Adults dosage 450 mg tds Foot infection in diabetes infection | Foot Section 4: General Recommended Recommended : May cause rash, diarrhoea, nausea, vomiting and abdominal vomiting and abdominal rash, diarrhoea, nausea, : May cause Clindamycin Not applicable Oral Route of administration 2 4 150 mg Strength
1,2,3
If the ulcer is > 2 x 2 cm or bone is probable, then osteomyelitis is likely. Further non-invasive If the ulcer is > 2 x 2 cm or bone is probable, then testing is not necessary to initiate treatment ulcers over bony prominences Osteomyelitis should be suspected in long term Patient often has a history of diabetic peripheral neuropathy with sensory loss Patient often has a history of diabetic peripheral are at risk of having underlying Patients with diabetes who have a foot lesion/infection osteomyelitis Clinical diagnosis is difficult
Form Schedule Inflammation may not be present, osteomyelitis may be an incidental finding on x-ray A foot ulcer, red hot swollen foot, which may be painless All presentations must be referred to the high risk foot service or other specialist team for All presentations must be referred to the high risk assessment, for pressure relief and long term management Consult MO/NP/specialist diabetic foot service on all occasions Consult MO/NP/specialist diabetic foot service support as good glycaemic control helps to Refer to Diabetes Educator for self-management prevent infections Ensure feet are inspected at each visit Ensure feet are inspected Advise to be reviewed daily initially to assess progress and change dressings Advise to be reviewed daily on good foot care practices Provide ongoing education
• • • • • Capsule Foot infection in patient with diabetes, page 421 page diabetes, with in patient infection Foot Related topics
• • • • • • • • Background
Provide Consumer Medicine Information Provide Consumer a full glass of water pain. Take with due to Cl. difficile Note: Can cause severe colitis lincomycin Contraindication: Allergy to clindamycin or emergency: Consult MO/NP. See Management of associated ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP RN must consult RIPRN and IHW, IPAP, ATSIHP, 1. May present with
2. Immediate management Osteomyelitis in the foot of patient with diabetes Osteomyelitis in the foot of patient
6. Referral/consultation 5. Follow up 426 Foot infection in diabetes .Management 4. Clinicalassessment 3. | Primary Clinical Care Manual 10th edition | Referral/consultation 6. Followup 5. • • • • • • • • • • diabetes, page4 Obtain acompletepatienthistoryincludingdetailedin local EarlyWarningandResponseTools)+ prevent infections Refer toDiabetesEducatorforself-managementsupportasgoodglycaemic controlhelpsto Consult MO/NPonalloccasions Continue oralantibiotictherapyfor3months Confirm followupappointmentwithhighriskfootserviceorotherspecialist team Provide ongoingeducationongoodfootcarepractices supplements andCRP Follow uppatientafterdischargefromhospital,monitorwound,glycaemiccontrol,nutritional – – – – – – MO/NP/specialist diabeticfootservicemayadvise: suspected osteomyelitisinthefoot Consult MO/NP/specialistdiabeticfootserviceimmediatelyifapatientwithdiabeteshas detailed in Perform physicalexamination.Inspectallsurfacesofthefootandconductassessmentas – – – – – – – – evacuation/hospitalisation IV antibiotics x-ray plainfilms(maybenormalforupto6weeks) involved intheboneinfection,whichrequiresaspecimen ± woundswabforMCS.Notethatthismayidentifysuperficialpathogensandnottheorganism – – – – take bloods: IV cannula BGL – – – – ESR, CRP-usually>5mg/L white cellcount(maynotbeelevated) HbA1c, FBC,CRP,urea,creatinineandGFR,randomvenousBGL blood cultures 1 Foot infection inpatient with diabetes, page 421 3 4 2 1
Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother 2,3 Foot infection in patient with infection inpatient Chronic wounds 427 Chronic wounds Chronic Section 4: General | Section 4: General 421 3 Not applicable - adult/child 3 1 2,3 neuropathic - due to loss of protective sensation e.g. diabetic neuropathic - due to loss of protective sensation lymphoedema pressure injury arterial - involving arteries and arterioles venous - involving veins and venules mixed etiology e.g. neuroischaemic, arteriovenous cancer (skin cancer, fungating wound); inflammatory conditions e.g. vasculitis; less common wound); inflammatory conditions e.g. vasculitis; cancer (skin cancer, fungating diabeticorum, pyoderma gangrenosum, necrobiosis lipoidica causes of ulceration e.g. meliodiosis mycobacterium ulcerans, – – – – – – – retained foreign body underlying co-morbidities size and nature of wound secondary infection Chronic wounds Chronic
– – – – – Extreme care must be taken if arterial disease (ischaemia) is suspected due to the risk of lower suspected due to the risk disease (ischaemia) is must be taken if arterial Extreme care limb amputation etiology: Consider wounds of uncommon Underlying diseases or factors contributing to poor wound healing should be assessed and their should be assessed to poor wound healing or factors contributing Underlying diseases optimised management – – – – – – dressings and adjuvant therapies e.g. compression therapy dressings and adjuvant therapies e.g. compression of underlying disease, trauma or allergic An ulcer is a loss of skin integrity. They are a sign and their origin may be: response. The causes of leg ulcers are multifactorial The primary aim of chronic wound management is to identify and correct the intrinsic and wound management is to identify and correct The primary aim of chronic healing extrinsic factors that inhibit wounds with the selection of appropriate Wound care should promote moisture balance in Chronic wounds do not go through the phases of wound healing i.e. haemostasis, inflammation, go through the phases of wound healing i.e. haemostasis, Chronic wounds do not in an orderly and timely manner reconstruction and maturation, drug therapies complicated by underlying co-morbidities and Chronic wounds are often – – Acute wound that is not healing due to: – – Ulcer
• • • • • • • • Foot infection in patient with diabetes, page page diabetes, with in patient infection Foot Related topics • •
Recommend Background
HMP HMP 2. Immediate management
1. May present with Chronic wounds Chronic 428 Chronic wounds 3. Clinicalassessment | Primary Clinical Care Manual 10th edition | • • • • • • Take woundswabforMCSifclinicallyindicated differential diagnosisofulcers Seetable – – – – Perform physicalexamination: – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – – – Ask aboutwound: – – – – Obtain completepatienthistory: – – – – – – – – – – – – – – – inspect forlowerlimboedema check forskinquality,presenceofhair feel fornormalskintemperatureinfootandlowerleg(withbackofhand) palpate lowerlimbpulses(popliteal,posteriortibialanddorsalispedis) BGL ifdiabetessuspectedorknown recent investigationse.g.woundswab,biopsy,x-ray,duplexultrasoundscan history ofwoundinfection type andfrequencyofdressingchanges pain duration/progression likely cause nutritional status previous ulcers;interventionstomanage current medicationsandallergies – relevant medicalandsurgicalhistoryincludingriskfactors: – • • • • • • • • How to ease, cerebrovasculardisease,obesity,DVT diabetes, smokinghistory,alcoholuse,hypertension,hyperlipidaemia,ischaemicheartdis Place swabinappropriatecontainer -ageltypeswabandtube.Adryisnot Ensure swabissaturatedwithwoundexudate Avoid swabbinganynecrotictissue,woundedgesorperiwoundskin within woundtissue Rotate swabover1cmareaof the woundwithsufficientpressure toexpressfluidfrom Avoid touchingthewound,swabsurfaceorcontaineropening Rinse thewoundthoroughlywithsterilewater/sodiumchloride0.9% Debride anysuperficialnecrotictissue Clean woundthoroughlywithsterilewater/sodiumchloride0.9% appropriate andaglassslideisnot essential Assessment ofvenous,arterialandneuropathiclowerlimbulcers collect a wound swab/culture 3,5 5 toassistwith - Chronic wounds 429
Chronic wounds Chronic 35 Neuropathic ulcer Neuropathic Possible bounding pulses Sites of pressure e.g. metatarsal heads, heels and toes Variable depth partial thickness to severe ulcer involving tendon, fascia, joint capsule or bone itself Surrounding callus. May be sinus a have or undermined track formation Prolonged bacterial infection may be associated with underlying osteomyelitis Normal if no associated arterial disease Frequently callused History of numbness, History of numbness, burning, loss parasthesia, in foot. of sensation patients with Common in diabetes mellitis
5,6 Section 4: General | Section 4: General
Acute pain management, page page management, pain Acute Arterial ulcer Arterial lower limb ulcers lower osteomyelitis A prolonged capillary refilling time (> 4-5 seconds) Pale, loss of hair, shiny and atrophic skin, cool feet Weak/absent dorsalis pedis or posterior tibialis pulse and over bony prominences The base tissue within the wound is often non viable, pale or discoloured or black or necrotic Round or punched out with a sharply demarcated border Prolonged bacterial infection may be associated with underlying History of smoking, History of smoking, diabetes , hypertension, arteriosclerosis, claudication intermittent exertion especially after and leg elevation ulcers may not feel pain Patients with neuro ischaemic Frequently occurs distally Venous ulcer Venous 4 and palpable Pigmented (haemosiderin deposition), oedema, atrophy blanche (white scar formation), indurated (lipodermatosclerosis) Pulses generally present Prolonged bacterial infection may be associated with underlying osteomyelitis Normal < 3 seconds ulcer bed with moderate to ulcer bed with moderate heavy exudate Shallow, irregular margins. Can vary from small to nearly encircling the leg. Margins are either flat or have slight steep elevation especially after exertion especially after exertion and leg elevation Between the malleolus and the lower calf. Majority of venous ulcers are located over the medial malleolus Fibrinous material at the pregnancies. Aching and pregnancies. at end of swelling worse with day relieved leg elevation. History of smoking, diabetes, hypertension, arteriosclerosis, intermittent claudication Past history of varicose Past history trauma, veins ± DVT, or multiple surgery to leg,
optimising management of underlying co-morbidities thorough clinical assessment – – – – Administer analgesia as clinically indicated. See Consult MO/NP as clinically indicated for:
• • Vascular status Surrounding skin Capillary refill time Infection Appearance Ulcer bed Location History Assessment of venous, arterial and neuropathic and neuropathic arterial of venous, Assessment 4. Management 430 Chronic wounds | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup Wound dressings • • • Dressings foroptimalmoisturebalance • • • • • • • • • dressings Interactive wet Hydrocolloids wound honey Hydrogels or Referral toaDermatologistmayberequired service isrequired For diabeticfootulcers,referraltoapodiatristorspecialisthighrisk service/diabeticfoot or toavascularsurgeonforassessmentofarterialand/orvenousdisease For non-healinglegulcers,theMO/NPmayreferpatienttoaspecialist woundserviceforadvice As determinedinconsultationwithMO/NP,woundspecialistorpodiatrist Document dressingtypeandfrequencyaswellanyotherintervention(s) podiatrist onthemostappropriatemethodofoffloading Diabetic footulcersmustbeoffloadedtodecreasepressureonthewound.Consultwitha specialist highriskfootservice/diabeticserviceconsulted Diabetic footwoundsshouldbereviewedregularly(atleasttwiceweekly)andaPodiatristor regular dressingchanges. applying Cavilon®wipeorzinccream.Hydrocolloidsheetwindowwillprotectperiwoundskinfrom All exudatingwoundsshouldhavetheskinareaaroundwoundprotectedfrommacerationby – Determine appropriatedressingregimen.See – – – – – – – – – – – – – – – Dry Wounds as needed,consultwithMO/NP,woundspecialistorpodiatristforassistance admission tohospitalifsignificantinfectionispresentorpatientsystemicallyunwell wound nothealing antibiotics ifclinicallyinfected need forfurtherinvestigationsincludingimagingorwoundbiopsy compression bandages compression therapyforvenousdisease.Musthaveappropriatetraininginapplicationof need forwounddebridementorsurgicalreview underlying structuresorsinus exploration ofwoundforforeignbodyortoassessunderminingedge,probing • • • • Acryllic Calcium alginates films Semi-permeable Hydrocolloids Minimal Exudate Not infeetofapatientwithdiabetes 5 Guidelines formanagementofchronicwounds • • • • • Hydroregulating Mulitlayer Foams Hydrofibre Calcium alginate Moderate Exudate • • • • • NPWT devices Wound/ostomy bags Super absorbentdry Foam sheets/cavity Hydrofibre Heavy Exudate
Chronic wounds 431 Chronic wounds Chronic : Debridement Goal Proceed to next page Environmental assessment Environmental Provide client/carer education Provide client/carer environment to optimise • Hydrogels Hydrocolloids Cadexomer iodine dressings Wound honey Iris scissors/scalpel Adson toothed forceps Use aseptic technique Irrigation Normal saline compresses Hypertonic saline dressings Interactive wet dressings Chronic wound management Chronic wound Evidence of slough/necrosis Leg ulcers, pressure injuries, Leg ulcers, pressure injuries, malignant wounds, complex draining wounds (see next page) Autolytic Conservative sharp wound debridement (CSWD) Parasitic: Larval Surgical Mechanical Low frequency Ultrasound • • • • • • • • • • • Section 4: General | Section 4: General 5
ASSESSMENT COMPREHENSIVE COMPREHENSIVE Wound assessment Restore bacterial balance Hypertonic saline dressings Cadexomer iodine powder/ paste Povidone iodine tulle gras Chlorhexidine tulle gras Silver impregnated dressings PHMB solution and dressings Wound honey dressings Review frequency of dressing change Exudate management Topical antimicrobials: Friable hypergranulation Tissue bridging Pocketing Rolled wound edges Increased exudate Static healing Wound cleansing – – – – – – – – – – – – – – Goal: • • • • • • • • • • Evidence of critical colonisation
management of chronic wounds of chronic management : Infection, critical General assessment General Restore bacterial balance : Wound bed preparation Evidence of infection Delayed wound healing Delayed wound PHMB solution and dressings Povidone iodine tulle gras Silver impregnated dressings Cadexomer iodine powder/ paste Provide client/carer education Provide client/carer health status to optimise Management of co-morbities Management Systemic antibiotics Topical antimicrobials: Wound cleansing Review frequency of dressing change Exudate management Medical review Wound swab Sepsis Heat Pain Malaise, pyrexia Spreading infection Erythema Increased exudate/pus Swelling – – – – Assess colonisation, necrosis Goal Guidelines for for Guidelines – – – – • • Goal: • • • • • • • • • • • • • • • 432 Chronic wounds | Primary Clinical Care Manual 10th edition | • • • • • • • • Goal Neuropathic footulcers perfusion Goal Arterial legulcers Goal Venous legulcers Lower legassessment dressings Interactive wet Hydrocolloids wound honey Hydrogels or Client educationforcareofthefeet Medical/podiatry/orthotic consult Medical review Do not ankle brachialpressureindex(ABPI) Compression therapyasindicatedby Continued Dressing options : Off-loadplantarpressure : Preventinfection,promotearterial : Promotevenousreturn Dry wound • usecompressiontherapy separation prior todischarge/ Preventative education LEG AND FOOT ULCERS SECONDARY DRESSING IF REQUIRED FOR ABSORPTION OR PROTECTION Yes Promote granulation,contractionandepitheliasation • • • • Acryllic Calcium alginates films Semi-permeable Hydrocolloids Dressing options Optimise pHandwoundtemperature Minimal Exudate Goals WOUND BEDPREPARED : Maintainmoisturebalance Wound healed • • • • • Hydroregulating Mulitlayer Foams Hydrofibre Calcium alginate Dressing options • • • • • • Moderate Assess andmanagecomplicatingfactors Wound management Assess andstageinjury Determine risk Implement preventionstrategies Assess andmanagecomplexproblems Exudate 5
• • • Complex drainingwounds Establish goalsof care Medical consult wound, environment Reassess client, PRESSURE INJURIES Malignant wounds No • • • • • NPWT devices Wound/ostomy bags Super absorbentdry Foam sheets/cavity Hydrofibre Dressing options Exudate Heavy
Communicable diseases 433 Communicable diseases | Communicable Section 4: General Acute hepatitis C, page 437 C, page hepatitis Acute Not applicable 1 1,2 1 1 detection of HAV by nucleic acid testing detection of anti-hepatitis A IgM, in the absence of recent vaccination detection of anti-hepatitis A IgM, in the absence
– – Perform contact tracing Perform contact Acute hepatitis A is a notifiable condition A is a notifiable condition Acute hepatitis of risk and advise avoidance Program schedule to National Immunisation Vaccinate according factors Most cases resolve with complete recovery. Relapsing HAV for up to one year can occur, severity Most cases resolve with complete recovery. Relapsing increases with age Two cases constitute an outbreak Two cases constitute an severely disabling from a mild illness lasting 1-2 weeks to a HAV varies in clinical severity disease lasting several months HAV is excreted in the stools for 2 weeks before illness is apparent and continues for up to 1 for 2 weeks before illness is apparent and HAV is excreted in the stools week after onset of jaundice Transmission of hepatitis A virus (HAV) is by the faecal-oral route, from contaminated food, less A virus (HAV) is by the faecal-oral route, from Transmission of hepatitis that involve contact in people who participate in sexual practises commonly through sexual oral-anal contact with a 2-7 weeks (average 28-30 days). HAV is self-limiting Incubation period is between and never becomes chronic duration around 6 months Immunisation history Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Obtain comprehensive patient history - specifically ask about contact with others with the disease, Obtain comprehensive patient history - specifically ask about contact with others with the disease, environmental circumstances, history of travel, medicines, and occupation – Itchy skin (pruritis) Laboratory findings: – Skin and whites of the eyes look yellow (jaundice) Dark urine (bilirubinuria) Faeces (stools) can be pale-coloured No symptoms (particularly in infants and children) Fever, malaise, nausea and abdominal discomfort Loss of appetite
• • • • • • • • • Acute hepatitis B, page 435 B, page hepatitis Acute Related topics • • • • • • • • • • •
Recommend Background 3. Clinical assessment 2. management Immediate 1. with May present
hepatitis A - adult/child hepatitis Acute Communicable diseases Communicable 434 Communicable diseases 4. Management | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • • • Liaise withPublicHealthforcontacttracingandothercontrolmeasures HAVisanotifiableconditioninmostjurisdictions Consult MO/NPasabove Advise patienttoreturnwithin24hours HealthCondition/condition/14/217/72/Hepatitis-A preventive measures.SeehepatitisAfactsheet: Educate thepatientandhouseholdcontactsontransmissionofvirusappropriate – – – – – – – – symptoms), advisethepatient During theinfectiousperiod(7daysafteronsetofjaundice/darkurine,or2weeksinitial – – Treatment ofhepatitisAissupportiveandsymptomatic: Consult urgentlyifINR≥1.5 Consult MO/NPonalloccasionsjaundicedetectedorhepatitisAissuspected Diagnosis isconfirmedwithserologyforhepatitisA – – – Take bloodsfor: Perform physicalexamination Response Tools) – – – – – – – – – – – – – share food,drinks,cigarettesorothersmokingimplements share druginjectionequipment provide personalcaretoothers attend preschool,childcare,school,work have sex prepare orhandlefoodforotherpeople drink alcoholortakeparacetamol donate blood bed restisadvisedifpatienthasjaundice rarely requireevacuation/hospitalisation INR LFTs hepatitis A,BandCserology 1
1,2 not to: http://conditions.health.qld.gov.au/
Communicable diseases 435
437 Communicable diseases | Communicable Section 4: General Acute hepatitis C, page C, page hepatitis Acute
433 1,3 - adult/child http://conditions.health.qld.gov.au/HealthCondition/condition/8/217/74/ https://publications.qld.gov.au/dataset/chronic-conditions-manual 1 1,2 perinatal transmission from mother to child perinatal transmission from sexual transmission percutaneous (primarily IV drug use) and permucosal exposure percutaneous (primarily hepatitis B hepatitis – – – positive HBcIgM in patient with no documented HBV infection detection of HBV PCR/NAT (nucleic acid testing) with no documented hepatitis B virus infection positive HBsAg in a patient with a negative test in last 2 years
– – – Screen all patients who have tested positive for an STI for hepatitis B virus (HBV) and C B virus (HBV) and positive for an STI for hepatitis who have tested Screen all patients clippers or similar items razors, toothbrushes, nail Do not share Acute hepatitis B is a notifiable condition B is a notifiable condition Acute hepatitis See fact sheet at: hepatitis-b HBsAg should be repeated at 6 months. For management of patients with chronic hepatitis B see HBsAg should be repeated at 6 months. For management Management of Chronic Conditions in Australia The Chronic Conditions Manual: Prevention and available from: – – (HBsAg) should be fully assessed and the Patients with a positive hepatitis B surface antigen Up to 25% of people living with chronic Up to 25% of people living will die from complications HBV such as liver failure, cirrhosis and liver cancer three major routes: Transmission occurs by – The risk of acute HBV infection developing into chronic HBV infection decreases with age. 90% of 90% age. with decreases infection HBV chronic into developing infection HBV acute of risk The will develop chronic will develop chronic infection, and < 10% of adults infants infected at birth HBV infection Chronic hepatitis B is common in Aboriginal and Torres Strait Islander communities and some Islander communities and Torres Strait B is common in Aboriginal Chronic hepatitis but acute HBV infection is rare migrant populations in Australia, infection of children with acute HBV have a subclinical 50-70% of adults and 90% – – Faeces (stools) can be pale-coloured Laboratory findings: – Rash Skin and whites of the eyes look yellow (jaundice) Dark urine (bilirubinuria) Loss of appetite (precedes jaundice by 1-2 weeks) (precedes jaundice by 1-2 weeks) General aches and pains, weakness and tiredness Low-grade fever No symptoms Pain in the abdomen, nausea, vomiting
• • • • • • • • • • Acute hepatitis A, page hepatitis Acute Related topics • • • • • • • • • • Recommend Background
1. May present with Acute Acute 436 Communicable diseases .Clinicalassessment 3. Immediatemanagement 2. | Primary Clinical Care Manual 10th edition | Management 4. • • • • • • • • • • • • • • • • and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning Australian Immunisation Handbook Give immunoglobulinandhepatitis B vaccinetocontactsasperthecurrenteditionof Perform contacttracing(contactsup to180days)inconsultationwithMO/NPorPublicHealthUnit preventive measuresandprovideinformation Educate thepatientandhousehold contacts ontransmissionofthevirusandappropriate – – – – Advise: If anti-HBsnegativethenconsiderneedforhepatitisimmunisation Diagnosis isconfirmedwithserologyforHBV If anti-HBcpositiveandHBsAgpositive,thenensuretestingforHBeAg Treatment ismainlysupportive.Willrarelyrequireevacuation/hospitalisation Consult urgentlyifINR≥1.5 Consult MO/NPonalloccasionsifjaundicedetectedandhepatitisBis suspected – – – – – – – – Take bloodfor: – – – Perform physicalexamination.Palpateabdomenfor: Medication history – – – Obtain comprehensivepatienthistory-specificallyask: Patients withfulminant liverfailurerequirereferralto a specialistlivertransplantservice – – – – – – – – – – – – – – – – – – avoid fatty/oilyfoods drink plentyofwater rest INR LFTs hepatitis C hepatitis A HBcIgM anti-HBs HBsAg anti-HBc ascites (fluidintheabdomen) right upperquadranttenderness enlarged liver HBV vaccinationhistory family historyofHBVinfectionandlivercancer previous 45-180days,andpossiblecontacts about possiblemodeoftransmissione.g.injectiondruguse,alcoholunsafesexin avoid alcoholandparacetamolduring acuteillness 3
2,3 Notapplicable Communicable diseases 437 433 1 Communicable diseases | Communicable Section 4: General Acute hepatitis A, page hepatitis Acute
3 - adult/child 435 3 2 http://conditions.health.qld.gov.au/HealthCondition/media/pdf/14/217/75/ hepatitis C
1 1 2 spontaneously clears in 20-25% of individuals is characterised by the appearance of HCV RNA in the blood within 2-14 days of exposure is characterised by the appearance of HCV RNA ALT results in the elevation of liver enzymes, particularly 30-60 days of exposure results in the development of HCV antibodies within refers to the 6 month period after being infected refers to the 6 month period chronic disease is an uncommon presentation; most patients have – – – – – – detection of anti-HCV antibody Acute
– See fact sheet at: hepatitis-c-v11 There is currently no approved treatment for acute HCV infection There is currently no approved treatment for acute effective anti-viral medication that can be Chronic HCV infection is now curable with a highly prescribed by an MO/NP in primary care settings Any patient with antibodies to hepatitis C virus (HCV) must have a HCV PCR test and LFTs to hepatitis C virus (HCV) must have a HCV Any patient with antibodies if the infection is still present performed to determine Acute hepatitis C is a notifiable condition Acute hepatitis C is a notifiable C have tested positive for an STI for hepatitis B and Screen all patients who – patient is considered to have chronic HCV If no spontaneous clearance of HCV after 6 months, 2 or more cases is considered an outbreak – – – Acute HCV infection: – – Laboratory findings: – Nausea, vomiting Lethargy Upper abdominal pain - uncommon No symptoms (majority of cases) Jaundice Anorexia Consult MO/NP as above Consult MO/NP diagnosis Unit based on pathological the local Public Health notification to Hepatitis B requires clinic where applicable Specialist/Liver Advise to be reviewed in 24 hours. Repeat education Repeat in 24 hours. to be reviewed Advise
• • • • • • • • • Acute hepatitis B, page B, page hepatitis Acute Related topics • • • • • • • • • • •
Recommend Background
HMP HMP 1. May present with
6. Referral/consultation 5. Follow up Follow 5. 438 Communicable diseases .Clinicalassessment 3. Immediatemanagement 2. | Primary Clinical Care Manual 10th edition | Followup 5. Management 4. • • • • • • • • • • • • • • • – and ResponseTools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning MO/NP mayadvise regularLFTsandINR,arepeat HCVRNAafter6months Advise toseeMO/NPatnextclinic Advise tobereviewedin24hours.Repeat education Perform contacttracing(contactsup to180days)inconsultationwithMO/NPorPublicHealthUnit Vaccinate againsthepatitisAandB.See – – – – – preventive measures,includingnotto: Educate thepatientandhouseholdcontactsontransmissionofvirus andtheappropriate Bed restisadvisedifthepatienthasjaundice Diagnosis isconfirmedwithserology Consult MO/NPurgentlyifINR≥1.5orsevereillness(mayrequireevacuation/hospitalisation) Consult MO/NPonalloccasionsjaundicedetectedorhepatitisCissuspected – – Perform physicalexamination: – – – Take bloods: – – – – Obtain comprehensivepatienthistory.Specificallyaskabout: – – Advise patientwith ongoingriskfactorstohaveanannual HCVRNAbloodtest – – – – – – – – – – – – – – – – urinalysis forbilirubinorurobilinogen take paracetamol drink alcohol contaminated withblood share razors,toothbrushesornail/hairclipperssimilaritemswhichcould become share needles,syringes,spoons,filtersoranyotherinjectingequipment donate bloodorotherbiologicalmaterial palpate theabdomenforatender/enlargedliver inspect forjaundice HCV PCR,HIVandhepatitisAserology,HBsAg,HBcAb,HBsAb LFTs, INR urea, creatinine,electrolytes IV druguse alcohol use medication history the possibilityofcontactwithothersdisease detection ofelevatedliver-associatedenzyme,particularlyALT detection ofHCVRNA 3
2,3 4 Notapplicable Immunisation program, page 768
Communicable diseases 439 - adult/child
Communicable diseases | Communicable Section 4: General Acute pain management, page 35 page management, pain Acute Not applicable 3 3 3 1,2
see fact sheet for Barmah Forest Virus at: http://disease-control.health.qld.gov.au/ Condition/717/barmah-forest-virus-arbovirus-infection see fact sheet for Ross River Virus at: http://disease-control.health.qld.gov.au/Condition/746/ ross- river-virus taking blood for arbovirus serology (state the virus being tested for on request form) taking blood for arbovirus serology (state the virus problems non-steroidal anti-inflammatory medicine for joint – – – –
RRV can cause significant arthralgia for several months in some patients, most usually recover in arthralgia for several months in some patients, RRV can cause significant 4-7 months conditions RRV and BFV are notifiable These arboviruses are common and widespread in Australia and are caused by a variety of common and widespread in Australia and are These arboviruses are mosquitoes dawn these illnesses are most active at dusk and at The mosquitoes causing Ross River Virus (RRV) and Barmah Forest Virus (BFV) are similar arboviral illnesses transmitted by Barmah Forest Virus (BFV) are similar arboviral Ross River Virus (RRV) and by fever, rash and joint pains mosquitoes and characterised
– Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See Educate to take precautions against being bitten by mosquitoes and provide information: – Consult MO/NP who may advise: – – Inspect and palpate joints for swelling, heat and redness Inspect and palpate joints for swelling, heat and Obtain complete patient history, including history of recent travel Obtain complete patient history, including history Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) Perform relevant physical examination Rash - may or may not be present, transient, usually maculopapular and not itchy Rash - may or may not be present, transient, usually Rarely - chills, rigors, delirium Joint symptoms of pain and stiffness - any joint may be affected though most commonly the ankles, Joint symptoms of pain and stiffness - any joint of the palms and soles knees, fingers, wrists and elbows, tenderness Joint swelling in more severe cases Common viral symptoms - fever, chills, headache, loss of appetite, nausea and malaise - fever, chills, headache, loss of appetite, nausea Common viral symptoms discharge, sore throat, cough There may also be preceding URTI symptoms - nasal Consult with MO/NP as above with MO/NP Consult Unit Public Health to the local notification C requires Hepatitis applicable clinic where Referral to Specialist/Liver
• • • • • • • • • • • • • • • • • • • • • Background
Barmah Forest Virus Barmah Virus and Ross River HMP
6. Referral/consultation 4. Management 3. assessment Clinical 2. management Immediate 1. May present with 440 Communicable diseases 6. Referral/consultation 5. Followup | Primary Clinical Care Manual 10th edition | 1. Maypresentwith HMP Background Recommend • • • • • • • • • • – – – – – Severe dengue-asabovewithanyofthefollowing: – – – – – – – – – – Classical presentation: Mild febrileillness Consult MO/NPonalloccasionsofsuspectedRossRiverFeverorBarmahForestVirus Advise toseeMO/NPatnextclinic Serology mayneedtoberepeatedin14daysconfirmdiagnosis One ormoreconfirmedcasesoflocallyacquireddengueisconsideredanoutbreak houses The mosquitothattransmitsdengueis in children repeat infectionwithadifferentserotypeincreasestherisk.Theriskofseverediseaseisgreater There arefourserotypes(strainsorvariations)-allmaycauseseveredengue,but require bloodtestresultsi.e.dengueshouldbenotifiedonsuspicion A bloodtestisneededtoconfirmsuspecteddengue.However,notificationofdenguedoesnot – – – – – – – – – – – – – – – D low BP(shock),rapidweakpulse extreme fatigue vomit minor bleedingofnoseandgums,vaginalbleeding,bloodinurine, instool,blood rash onarmsandlegs,severeitching,peelingofskinhairloss flushed skinonfaceandneckrashasfeversubsides vomiting and/ordiarrhoeaandabdominalpain loss ofappetite unpleasant metallictasteinmouth muscle andjointpain intense headache,especiallyinorbehindtheeyes sudden onsetoffeverlasting2-7days altered consciousness consciousness), heartandotherorgans severe organinvolvement-liver(AST/ALT >1000U/Lonbloodtests),brain(alteredlevelof severe bleeding fluid accumulationinlungswithrespiratory distress(pulmonaryoedema) engue fever 1 1
3
1,2
-adult/child
Aedes aegypti , aday-bitingmosquitothatlivesaround Communicable diseases 441 Communicable diseases | Communicable Section 4: General Acute pain management, page 35 page management, pain Acute 3
1 for further management https://www.health.qld.gov.au/cdcg/index/dengue 3
1,3 Shock, page 77 page Shock,
and other Do not use aspirin, methyl salicylate (found in some topical pain relief preparations) NSAID e.g. Ibuprofen as they can lead to bleeding very young children diabetes or kidney disease elderly severe dengue pregnant dengue PCR (direct detection of virus) - during first 5 days of illness dengue PCR (direct detection FBC (low white cells and platelets are common) FBC (low white cells and at least 5 days following onset of symptoms dengue serology - after - all patients up to 9 days following onset of symptoms NS1 antigen (a rapid test) See consult MO/NP urgently consult age and vascular status possible gauge given cannula - use the largest insert 2 x IV – – – – – – – – – – – – –
Consult MO/NP on all suspected cases of dengue Dengue requires notification to the local Public Health Unit based on a provisional i.e. suspected Consult MO/NP if deteriorating Advise to re-present if there is any deterioration particularly if there are any signs of bleeding or Advise to re-present if there is any deterioration other signs of severe dengue clinic Advise to be reviewed the next day and next MO/NP See fact sheet at: Provide preventative mosquito bite education. avoid being bitten, especially while patient is All household members should take measures to febrile Encourage oral fluids Administer analgesia as clinially indicated. See – – – – Evacuation/hospitalisation may be needed for: – – – Consult MO/NP – – – Inspect skin for rashes, palpate joints for pain/swelling, lymph nodes (lymphadenopathy), palpate joints for pain/swelling, lymph nodes (lymphadenopathy), Inspect skin for rashes, liver (hepatomegaly) abdomen for tenderness/enlarged Take blood for: Complete patient history - ask about travel especially overseas and past history of dengue travel especially overseas history - ask about Complete patient local Early Warning observations (full Q-ADDS/CEWT score or other Perform standard clinical and Response Tools) – If signs and symptoms of severe dengue: of severe and symptoms If signs – –
• • • • • • • • • • • • • • • • •
6. Referral/consultation
5. up Follow 4. Management
3. Clinical assessment 2.management Immediate 442 chronic conditions child Chronic conditions | Primary Clinical Care Manual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend • • • • Related topics Acute rheumatic fever, page • • • • – Prior tobenzathinebenzylpenicillin (BicillinLA®)injectiondeliverydiscusswithpatient: plan Check andcompletecareitemsonthepatient'srheumaticfever heartdiseasecare Diagnosis ofrheumaticheartdisease(RHD) History ofacuterheumaticfever(ARF) and/or pathologicaldiagnosis – – – same resource referstobenzathinebenzylpenicillinaspenicillinG(BPG)thesearethe acute rheumaticfeverandheartdisease Recommended resource: [email protected] clinical supportandeducation.ContactsforQLDRHDProgramare: The QLDRHDProgramholdstheBicillinLA for BicillinLA® recurrent episodeofARFmayleadtofurtherdamagetheheartvalves-hencerequirement RHD isachronicconditionresultingfromscarringanddeformityoftheheartvalves.Each – – – recurrences ofARF: Strict longtermbenzathinebenzylpenicillin(BicillinLA – – – – Secondary prophylaxisforacuterheumaticfever(ARF) consider methods ofpaincontrol. See preferred sitetoreceive injection(thigh,ventrogluteal orbuttocks) any problemsfollowing previousbenzathinebenzylpenicillin (BicillinLA®)injections any medicationallergies – – – never missaninjection every dayofnon-treatmentover28daysputsthepersonathighriskarecurrenceARF 13 injectionsayearareneeded-every21-28days 1 Australian guidelineforprevention,diagnosisandmanagementof 705 Notapplicable Administration tips for benzathine benzylpenicillin, ® andechocardiogramregisters,isavailablefor
http://www.RHDaustralia.org.au ® ) prophylaxisiscriticaltoprevent 1300135854oremail: - adult/ . Note : this chronic conditions 443 5,6
35
Duration Chronic conditions Chronic 102 Administration tips for for tips Administration IHW/IPAP/RIPRN recommended regimen Every 21-28 days as per / Extended authority ATSIHP Section 4: General | Section 4: General Anaphylaxis, page page Anaphylaxis, dosage (450 mg) (900 mg) Adult and child ≥ 20 kg Child < 20 kg Recommended Acute pain management, page page management, pain Acute 1.2 million units 0.6 million units ) ®
Bicillin LA May cause diarrhoea, nausea and pain at injection site May cause diarrhoea, nausea and pain at injection IM ( Consult MO/NP. See Route of 787 administration Benzathine benzylpenicillin Benzathine benzylpenicillin 4 Strength (900 mg) Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity to a penicillin. Be aware of cross-reactivity Severe or immediate allergic reaction 1.2 million As an option for analgesia for regular administration, nitrous oxide can be be can oxide nitrous administration, for regular analgesia for an option As units/2.3 mL . 787 administered See indicated. as clinically analgesia administer page page – : Stop injection immediately if patient shows signs of severe pain. See : Stop injection immediately if patient shows signs Schedule If IM route not possible, has resulted in significant bleeding or is refused, give oral or is refused, give oral in significant bleeding possible, has resulted If IM route not phenoxymethylpenicillin penicillin, give erythromycin If allergic to – of a number based on decision specialist clinical is a prophylaxis of secondary The duration MO be ceased by a Specialist Prophylaxis should only environmental factors. individual and Form syringe) Injection • • • (pre-filled Management of associated emergency: Note page benzylpenicillin, benzathine Contraindication: between penicillins, cephalosporins and carbapenems Provide Consumer Medicine Information: ATSIHP, IHW, IPAP and RN must consult MO/NP (or have current order) ATSIHP, IHW, IPAP and RN RIPRN may proceed 444 chronic conditions | Primary Clinical Care Manual 10th edition | 5. Followup Contraindication: effect onabsorption Provide ConsumerMedicineInformation: Management ofassociatedemergency: between penicillins,cephalosporinsandcarbapenems RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Note with foodifcausesstomachupset food. Maycausenausea,vomiting,diarrhoea,abdominalpain,cramps and candidiasis.Canbetaken Provide ConsumerMedicineInformation: Management ofassociatedemergency: Contraindication: myasthenia gravis with manydrugs,includingoverthecounterandherbalproducts.Use cautioninpatientswith RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution to Schedule reconstitution tooral • • • Powder for Schedule oral liquid reminder-card Fill outinjectioncardavailablefrom Discuss strategies toensurepatientreturnsfornextinjection Inform therelevant StateRHDRegisterandControlProgram datesofinjections : IfrenalimpairmentseekMO/NPadvice.Usewithsimvastatiniscontraindicated. Interacts Capsule Form Powder for Capsule liquid Form Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity Severeorimmediateallergicreactiontomacrolides.hepaticimpairment 4 4 250 mg/5mL 125 mg/5mL 200 mg/5mL Strength 500 mg 250 mg Strength 250 mg Phenoxymethylpenicillin Consult MO/NP.See Consult MO/NP.See https://www.rhdaustralia.org.au/resources/injection- May causediarrhoea,nauseaandcandidiasis.Foodhaslittle Take onanemptystomach1hourbeforeor2hoursafter administration Erythromycin administration Route of Route of Oral Oral
Anaphylaxis, page Anaphylaxis, page child >1month Recommended 250 mgbd child >1month Adult and Recommended dosage 250 mgbd
Adult and dosage ATSIHP/IHW/IPAP/RIPRN
Extended authority ATSIHP
Extended authority 102 102 / on MO/NPadvice IHW/IPAP/RIPRN
Duration Ongoing on MO/NP Duration Ongoing advice
1,6,7,8
1,8 chronic conditions 445 Strong Strong Authorised Chronic conditions Chronic and injection reminder cards from cards reminder and injection https://publications.qld.gov.au/ Section 4: General | Section 4: General
available from: available from: Chronic Conditions Manual: Prevention and Manual: Prevention Chronic Conditions Not applicable
https://www.rhdaustralia.org.au/resources/strong-heart-strong-body- https://www.health.qld.gov.au/system-governance/licences/medicines- book
are they taking the medicine as prescribed any side effects any other concerns Access DTPs at: poisons/legislation-standards/acts-regulation DTP - Aboriginal and Torres Strait Islander Health Practitioner - Isolated Practice Area OR DTP - Aboriginal and Torres Strait Islander Health Area OR DTP - Indigenous Health Worker Isolated Practice are legislatively changed) equivalent document(s) (if the Drug Therapy Protocols COPD chronic heart disease chronic kidney disease diabetes asthma hypertension Supply of chronic condition medicines by ATSIHP and IHW condition medicines by ATSIHP Supply of chronic – – – – – – – – – – – – – This HMP is for Aboriginal and Torres Strait Islander Health Practitioners (ATSIHP) and and Torres Strait Islander Health Practitioners This HMP is for Aboriginal ATSIHP and IHW may be required to supply medicines prescribed by MO/NP for chronic required to supply medicines prescribed by MO/NP ATSIHP and IHW may be since last medical consultation conditions if < 6 months This topic is not intended for assessment and treatment of acute conditions This topic is not intended Indigenous Health Workers (IHW) to supply medicines for ongoing management of chronic (IHW) to supply medicines for ongoing management Indigenous Health Workers areas only conditions in isolated practice – – – – Ask how patient is going with medicines: – – – Check order for medicine is current and written within last 6 months Check order for medicine is current and written - it will be listed in the appendix of the Check medicine is approved for supply by the clinician relevant Drug Therapy Protocol (DTP): – – – – – – Diagnosis of chronic condition and medicine(s) prescribed by MO/NP Diagnosis of chronic condition and medicine(s) condition e.g. for ongoing management of: Patient requesting supply of medicines for chronic Queensland RHD Register and Control Program RHD Register and Control Queensland of the care see the current edition For ongoing in Australia of Chronic Conditions Management dataset/chronic-conditions-manual Provide ongoing education and support to patient and family using resources including resources family using patient and support to and ongoing education Provide Strong Body Heart information-about-rheumatic-fever-and-rheumatic-heart-disease
• • • • • • • • • •
Recommend Background HMP HMP
3. Clinical assessment 2. Immediate management
1. May present with 6. Referral/consultation 6. 446 chronic conditions If medicine(s)isformanagementofhypertension: If medicine(s)isformanagementofdiabetes | Primary Clinical Care Manual 10th edition | 4. Management If medicine(s)isformanagementofchronicheartdisease(CHD) If medicine(s)isformanagementofchronickidneydisease(CKD): If medicine(s)isformanagementofchronicobstructivepulmonarydisease(COPD): If medicine(s)isformanagementofasthma: Where practical,checkandcompleteactionsaccordingtothepatient’scareplanattimeofsupply. relevant: Provide healtheducation/supportformanagementand/orpreventionof thechronicconditionas • • • • • – – – – – – – – – – – – – – – – Check medicineallergies Refer tothe Refer tothe Australia Australia Exercise Alcohol intake Healthy eating Smoking cessation – – – – – – – – – – – – – – – – check andcompletecareitemsonCOPDpatientplan discuss smokingandpassive(ifapplicable) as appropriate,checkinhalertechniques check andcompletecareitemsonasthmaplan ensure patienthasanAsthmaActionPlan discuss smokingandpassive(ifapplicable) as appropriate,checkinhalertechnique check andcompletecareitemsonhypertensionplan hypertensive crisis -adult, page if systolicBP≥200mmHgand/ordiastolic130contactMOurgently.See if BPisoutsideofnormalrangescontactMO/NPforadvice check BP check andcompletecareitemsondiabeteshigh-riskfootplan(s) if BGLoutsideofnormalranges,consultMO/NPforadvice check BGL check andcompletecareitemsonchronicheartdiseaseplan check andcompletecareitemsonCKDpatientplanaccordingtostage ofkidneydisease forguidance: forguidance ChronicConditionsManual:PreventionandManagementofin Chronic Conditions Manual:PreventionandManagement ofChronicConditionsin :
https://publications.qld.gov.au/dataset/chronic-conditions-manual https://publications.qld.gov.au/dataset/chronic-conditions-manual 151 : :
Acute chronic conditions 447 Chronic conditions Chronic Section 4: General | Section 4: General
how to store what it is for, and how it works should not be taken warnings/precautions, such as when the medicine common side effects record supply how to take the medicine medicine with a different brand name medicine with a different than 1 months supply, contact MO/NP for approval if patient requests more label appropriately when did the patient last get the medicine when did the patient last the same of the medicine - ensure patient is not already taking check the generic name check date order written - ATSIHP and IHW may only supply if order is within last 6 months IHW may only supply written - ATSIHP and check date order can you read the order properly is the medicine in stock any concerns about reading the medicine order about reading the medicine any concerns anything or you are unsure about any concerns condition is worsening or not managed well with medicines managed well or not is worsening condition health for their other concerns breath; any of elevated; shortness BP remains BGL or medicine any concerns about their if patient has – – – – – – – – – – – – – – – – – –
Refer as appropriate e.g. to diabetes educator, dietician, exercise physiologist, podiatrist, Refer as appropriate e.g. to diabetes educator, dietician, physiotherapist Support patient to access specialist appointments If concern condition is worsening or not managed well with medicines, consult MO/NP If concern condition is worsening or not managed – Discuss need for next MO/NP appointment as appropriate – – – – information as appropriate including: Offer consumer medicine – – – – according to MO/NP order: Select medicine for supply – – – – – – order: medication chart for medication rural and remote Check non-inpatient – – – Consult MO/NP if: MO/NP Consult • • • • • • • •
6. Referral/consultation 5. Follow up 4
Section 4 Page left intentionally blank General
448 | Primary Clinical Care Manual 10th edition | 5
Mental health and substance misuse
449 Mental health assessment m ent Mental health assessment - adult/child
Recommend1,2 • Always ensure the safety of patient, self and others, particularly children under 18 years. If at all concerned never leave the patient alone • It is often not possible to organise immediate assessment with a Mental Health Specialist. For this reason, primary care workers should be able to carry out assessments to determine the severity and nature of an individual's problems and the risk of danger to self or others • Optimise shared decision making with the patient and their carer • Involve culturally appropriate Health Workers/Mental Health Workers in Aboriginal and Torres
Mental health assess health Mental Strait Islander communities Background3,4 • Substance abuse disorder and exposure to trauma commonly co-exist with mental health disorders
Related topics Acute severe behavioural disturbance, page 467 Suicidal behaviour, page 456 Depression, mania and anxiety, page 484 Delirium, page 161 Psychotic disorders, page 481
1. May present with2,5 • Altered cognition, altered consciousness, memory loss, poor concentration, disorientation • Restlessness, tremor, tardive dyskinesia i.e. involuntary movements such as grimacing, blinking, smacking lips • Repetitive behaviour e.g. rocking, hand wringing • Alcohol and other substance intoxication • Suicidal behaviour i.e. suicide attempt, suicide plan, suicidal ideation • Self-harm, including injury from self-harm • Violent, aggressive, angry behaviour • Danger to self and/or others • Previous history of mental illness or dementia • Hallucinations, delusions • Elevated or depressed mood • Inappropriate behaviour • Social withdrawal, neglect • Altered speech pattern • Concurrent/pre-existing/underlying medical conditions 2. Immediate management5,6,7 • If relevant, see DRS ABCD resuscitation/the collapsed patient, page 54 • Assess conscious state. See Glasgow Coma Scale/AVPU, page 785
450 | Primary Clinical Care Manual 10th edition | Mental health assessment 451
Other Acute , . See
Spinal injuries, pageinjuries, Spinal History and physical and Mental health assessment
. See Absconding risk Absconding
1,2 Other drugs/substances, page 494 Other drugs/substances, Acute alcohol intoxication, page 487 , . See Traumatic injuries, page 163 page injuries, Traumatic Assess physical health
Acute severe behavioural disturbance, page 467 behavioural disturbance, Acute severe . See MSE observations and questions : History and physical examination - child, page 664 Suicide risk assessment, page 464 Suicide risk assessment, , or . Consider history of trauma/abuse/domestic violence, age, cognitive . Consider history of trauma/abuse/domestic violence, Toxicology (poisoning and overdose), page 259 and overdose), (poisoning Toxicology and 1,2,4,5,6,7 Acute severe behavioural disturbance, page 467 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Suicide risk assessment, page 464 Acute alcohol intoxication, page 487 Acute alcohol Acute wound(s), page 198 page Acute wound(s), , including:
identifying the immediate interventions that reflect the assessment findings identifying the immediate interventions that reflect at Team Health Mental Practitioner/Psychiatrist/Community Health MO/NP/Mental consulting any time assessment. Use family/carers/support people to provide collateral information. Other assessment. Use family/carers/support people and police officers, other service providers, sources may include medical records, ambulance teachers, social workers a mental health management plan, clearly ensuring mental health assessments conclude with Workers are a critical component of meeting the needs of Aboriginal and Torres Strait Islander Workers are a critical component of meeting the in completing assessments patients and should be partnered with where possible must occur as part of management and the collection of collateral information. This the culture of the patient you are assessing. Aboriginal and Torres Strait Islander Health Islander Strait Torres and Aboriginal assessing. are you patient the of culture the violence risk. See severe behavioural disturbance, page 467 examination - adult, page 20 suicide risk. See – – – – – – health assessment urgently contact MO/NP/Psychiatrist or local mental health service (if available) for acute mental or local mental health service (if available) urgently contact MO/NP/Psychiatrist airway and spinal injury from hanging. See hanging. from injury spinal and airway 180 acute injury. See acute See poisoning/overdose. See intoxication. – – – – – – – – Perform a Mental State Examination (MSE) Additional considerations include – Assess patient vulnerability impairment, disability, lack of supports Assess for alcohol and other substance use drugs/substances, page 494 – Assess risk –
Evacuation may be required. For specific requirements around transporting a disturbed patient, see For specific requirements around transporting Evacuation may be required. page 29 Patient retrieval/evacuation, If presentation is a result of suicide attempt, a suicide plan or suicidal ideation, see or suicidal ideation, see attempt, a suicide plan is a result of suicide If presentation page 456 Suicidal behaviour, or in crisis: assessment for patients who are acutely unwell Perform rapid mental health – – risk, see self or others at If safety of patient, – – – Manage: • • • • • • • • • • Important steps and principles for mental health assessments Important steps and principles 3. Clinical assessment • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) +
m ent –– BGL to exclude glycaemic causes of behaviour changes. See Hyperglycaemia, page 113 and Hypoglycaemia, page 115 7 –– SpO2 to exclude hypoxia as cause of behaviour change • Perform general health assessment and physical examination as tolerated by patient • Document description of current situation: –– use complete risk screening tool available at https://qheps.health.qld.gov.au/__data/assets/ pdf_file/0027/579240/a_risk_scr_tool.pdf • Complete a Rapid Assessment where a patient is not known to be currently under the care of a men- tal health service and the patient is presenting acutely unwell or in crisis: –– a Rapid Assessment Form and a Rapid Assessment user guide is available at https://qheps. health.qld.gov.au/mentalhealth/resources/clinicaldocs
Mental health assess health Mental • Complete a General Assessment if one is not already completed for the patient from the previous 12 months: –– a General Assessment Form and a General Assessment user guide is available at https://qheps. health.qld.gov.au/mentalhealth/resources/clinicaldocs
Note: above tools and user guides only available on Queensland Health Intranet
• Record Mental State Examination (MSE). See Mental State Examination (MSE), page 453 • Review patient’s manual and electronic records for current management plan for known patients particularly in respect to recurrent presentations • It is important to establish the patient’s behaviour and personality prior to the current presentation. Focus on: –– obtaining as much detail as possible. A clear account of what has transpired in the patient’s re- cent history will assist in diagnosis –– obtaining supporting history from family and carers –– obtaining a history of how the patient related to health care professionals in the past including a history of: –– past episodes, admissions –– history of suicide attempts and/or self-harm –– family history (psychiatric and medical) –– history of violence –– forensic history (may not have been charged therefore not in forensic system) –– personal and developmental history –– drug and alcohol history –– trauma/abuse –– mood - their pre-morbid personality, rather than behaviour –– absconding –– medicines adherence • For children, assess for sudden or significant, unexplained changes of behaviour or emotional state such as: –– unusual fearfulness or severe distress e.g. inconsolable crying –– self-harm or social withdrawal –– aggression or running away from home –– indiscriminate attention seeking with adults –– development of new soiling or wetting behaviours, thumb sucking
452 | Primary Clinical Care Manual 10th edition | Mental health assessment 453
Mental health assessment Suicide risk assessment, page
https://qheps.health.qld.gov.au/ Child protection, page 760 page Child protection, (Qld Health only)
on the following page as a guide
454 | Primary Clinical Care Manual 10th edition | Mental health assessment 455 - - - - - Uri , https://www. www.health.qld.gov.au/ Meningitis, page 91 Meningitis, page Mental health assessment , www.health.gov.au/internet/publica Delirium, page 161 Delirium,
Sepsis/septic shock, page 80 Sepsis/septic Behavioural and psychological symptoms of dementia (BPSD), psychological symptoms Behavioural and Child protection, page 760 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental http://www.healthinfonet.ecu.edu.au/other-health-conditions/mental-health 9 http://qheps.health.qld.gov.au/mentalhealth/resources/clinicaldocs.htm 4
clinical-practice/guidelines-procedures/clinical-staff/mental-health/act/forms Available at Centre for Mental Health Learning: MSE training is available online from Queensland health.qld.gov.au/qcmhl Act 2016 are available at: Forms relating to the Queensland Mental Health National standards for mental health services. Available at National standards for mental health services. tions/publishing.nsf/Content/mental-pubs-n-servst10-toc Drugs Directorate - Statewide Mental Health forms. Queensland Mental Health Alcohol and Other Resources to support clinicians in the delivery of social and emotional wellbeing and mental health Resources to support clinicians in the delivery of for health workers, clinicians, consumers and car services in Indigenous communities: guidelines ers. Available at: Determine if patient has responsibilities towards other vulnerable people such as people with disa with people as such people vulnerable other towards responsibilities has patient if Determine and consider the support that may be required. bilities or elderly people Liaise with Psychiatrist/Community Mental Health Team Liaise with Psychiatrist/Community liaise and consider support parent/carer or has contact with children and Determine if patient is a that may be required. See Evacuation and hospitalisation may be required for further assessment Evacuation and hospitalisation Discuss results of assessment, including risk assessments, with MO/NP/Psychiatrist or Community with MO/NP/Psychiatrist risk assessments, of assessment, including Discuss results Team Mental Health to inform a care or manage to develop a clinical and risk formulation Use the information obtained ment plan nary tract infection (UTI) - adult, page 389 nary tract infection see a history of dementia In patients with page 478 Maintain patient and staff safety patient and Maintain See delirium. onset, consider had an acute have If symptoms See evidence of infection. If there is any
• • • • • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management 4. Suicidal behaviour
Suicidal behaviour - adult/child
Recommend1,2,3 • Ensure immediate safety of patient, family, carers, staff and especially the needs of children • Consult MO/NP/Psychiatrist urgently if there is imminent risk of suicide • In the case of actual self-harm that has/will cause serious physical harm, contact emergency
Suicidal behaviour Suicidal services immediately • Assessment of likelihood of suicide focuses on the prevention of suicide rather than predicting suicide • Clinicians should involve the family or support people - Life Promotion Officer/Aboriginal and Torres Strait Islander Health Workers/Mental Health Workers/Transcultural Mental Health Workers in the care of the suicidal patient wherever possible • Removing or restricting access to the lethal means (method) of suicide has reduced suicides by 30-50% in some countries Background2,5,6,7 • Suicidal behaviour includes death by suicide, suicide attempt, suicide plan and suicidal ideation • Asking about self-harm does not provoke acts of self-harm • Intoxication is often associated with suicidal behaviour • Deliberate self-harm is not always associated with suicide and can be used to alleviate distress, as self-punishment, to reduce dissociative feelings, to reduce suicidal thoughts and/or for sensation seeking • In 2016, suicide was the leading cause of death among all people 15-44 years of age • Most people who die by suicide have consulted a health professional in the few weeks before they die
Related topics Acute alcohol intoxication, page 487 Other drugs/substances, page 494 Acute severe behavioural disturbance, page 467 Suicide risk assessment, page 464
1. May present with5,8 • Verbalises suicidal ideas/suicidal intent • Depressive symptoms • Anxiety symptoms • Distress associated with a recent psychosocial stressor or loss e.g. bereavement, marital separation, relationship breakdown, loss of job • Ambivalence • Attempted suicide • Intoxication, overdose, poisoning • Self-destructive behaviour • Violent behaviour • Self-destructive actions • Possession of a weapon
456 | Primary Clinical Care Manual 10th edition | MentalSuicidal health behaviour assessment 457
- - Suicidal behaviour Emergency Examination
Interventions in non-consenting patients, page 474 in non-consenting patients, Interventions 7,9,10 1,5,7,11 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 5,7,8,12,13,14,15 Mental Health Act (Queensland) 2016 DRS ABCD resuscitation/the collapsed patient, page 54 DRS ABCD resuscitation/the collapsed patient, page under the Patient retrieval/evacuation, page 29 Acute severe behavioural disturbance, page 467 outside of Queensland, follow your local laws governing compulsory examination of patients at outside of Queensland, follow your local laws governing serious risk Authority in Queensland an ambulance officer or police officer can initiate an in Queensland an ambulance officer or police health assessment around transporting a disturbed patient, evacuation may be required. For specific requirements see urgently contact MO/NP/Psychiatrist or local mental health service (if available) for acute mental urgently contact MO/NP/Psychiatrist or local mental reassure and observe in a safe environment communicate clearly with relatives and local staff ensure active follow up liaise early with a Psychiatrist or Mental Health Practitioner liaise early with a Psychiatrist or Mental Health or supervised until the situation is clari prevent further drinking and keep the patient engaged fied set a high criterion for accepting that the situation is safe set a high criterion for accepting are usually not safe situations involving intoxication and/or impulsivity are more likely to have a mental illness are more likely to have a trivial such as recent events even if they appear experience social precipitants clusters) episodes or suicides in the community (suicide may have recent self-harm are less likely to seek help, and are less likely to have sought help in the period leading up to this and are less likely to have sought help in the are less likely to seek help, presentation – – – – – – – – – – – – – – –
See in attempted be should not Assessments conduct assessment. should staff two possible, Where – requires immediate examination, treatment or care: – – has a major disturbance of mental capacity, and If a patient is at immediate risk of serious harm, Do not leave patient alone suitable for management in the community: If risk of suicide is imminent or the patient is not – As relevant, see – – – – – When alcohol is a current factor with suicidal behaviour consider the following: When alcohol is a current – – – – – When considering risk factors when working with Aboriginal and Torres Strait Islander people, the when working with Aboriginal and Torres When considering risk factors be considered including that they: following factors need to – Is under an emergency authority. See authority. See Is under an emergency mand auditory hallucinations mand auditory state syndrome or acute confusional Organic brain life threatening with severe pain or it is this is associated illness, especially when Chronic medical Loss of consciousness, extreme lethargy extreme consciousness, Loss of self-harm signs and suspected or physical injury Unexplained com or experiencing patients who are agitated/distressed - especially Psychotic symptoms/illness Bleeding from self-inflicted wound from self-inflicted Bleeding
• • • • • • • • • • • • • • • Considerations for assessing suicidal behaviour in Aboriginal and Torres Strait Islander suicidal behaviour in Aboriginal and Considerations for assessing is involved people when alcohol
3. Clinical assessment 2. Immediate management home situation if possible. Assistance from other staff or police should be readily available7 • Assess if the person has attempted a medically serious act of self-harm e.g. poisoning/overdose, intoxication, bleeding from wounds, loss of consciousness, extreme lethargy • Patients who have attempted suicide by hanging may have an obstructed airway and fractured cervical spine. See Traumatic injuries, page 163 and Spinal injuries, page 180 • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) • Preliminary suicide risk assessment. See Suicide risk assessment, page 464 • History, including current or past history of mental, neurological and substance use disorders,
Suicidal behaviour Suicidal chronic pain history, extreme emotional distress • The following general framework may assist in developing an informed opinion of the overall risk and the capability to manage the risk
Protective factors such as good mental health and well-being, the capacity to cope with difficult situations, community involvement, family support and positive educational experiences reduce the influence of existing risk factors across the continuum
Risk factors Warning signs Tipping points Imminent risk • Mental health • Hopelessness • Relationship • Expressed problems • Feeling trapped separation intent to die • Gender (male) • Escalating • Loss of status • Has plan in mind • Family discord, substance or respect • Has access to violence or abuse misuse • Death or suicide lethal means • Substance • Withdrawing of relative or • Impulsive, misuse from friends, friend aggressive • Social or family or society • Debilitating or anti-social geographical • No reason for physical illness behaviour isolation living, no sense or accident • Financial stress of purpose in life • Argument at • Bereavement • Uncharacteris- home • Prior suicide tic or impaired • Being abused attempt judgement or or bullied behaviour • Bullying • Media report on suicide or suicide methods
• Explain the limits of confidentiality to the patient when obtaining a history e.g. What“ you say is confidential, but if I believe you are at serious risk of harm to yourself or others, I may have to disclose some of the information discussed” • Develop and maintain rapport (a therapeutic alliance) with the patient. A good therapeutic alliance between the health professional and the patient may be a key protective factor for a patient experiencing a suicidal crisis. Use strategies such as: –– reflecting on your own values and beliefs in relation to suicide. Be mindful of your own reaction, ensuring they do not interfere with the assessment or management of the patient –– conveying a sense of warmth, non-judgemental acceptance, and a strong interest in understanding the patient and the nature of the cause of their pain/distress –– being respectful and empathic. Collaborate with the patient, asking his or her opinion and where possible include them in decision making
458 | Primary Clinical Care Manual 10th edition | MentalSuicidal health behaviour assessment 459 - ” ” - (ensure 14 ” Suicidal behaviour Assessment includes Assessment Hopelessness Helplessness Worthlessness Ease of access Knowledge of access Presence of detailed plans to gain access Negative or positive experience Types of services (inpatient, emergency de partment, other services, recent discharges) Level of detail actions for Knowledge of method, preparatory loading of gun method e.g. tying of noose, frame Number of times and time Number of attempts Lethality Potential for rescue Knowledge of method, preparatory actions for method e.g. tying of noose, loading of gun Feelings after surviving the attempt Number of types of injury Number of times NSSI occurred in conjunction with an attempt Frequency of thoughts Severity of thoughts Presence of ambivalence (verbally or writ Communication of thoughts ten) lethality Effectiveness of plan i.e. Potential for rescue • • • • • • • • • • • • • • • • • • • • • • • • • It sounds like you are saying X and that you feel Y you are saying X and that It sounds like Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental I know it can be very difficult to talk about thoughts of wanting to die about thoughts of wanting be very difficult to talk I know it can I can see you are very upset, and this is difficult for you to talk about for this is difficult upset, and you are very I can see Questions to ask Questions to your life?” “Have you received mental health treatment in the past?” “Have you hurt yourself on purpose without the intent to die?” “How are you feeling now?” “Have you a plan to end “Have you tried to end your life?” “Have you thought about “Have you thought about how you would end your life?” “Have you ever made a plan in the past?” “Have you thought about “Have you thought about suicide/ending your life?” Key area using reflective listening e.g. “ using reflective using open body language and direct eye contact (if culturally appropriate) contact (if culturally direct eye and open body language using e.g. “ distress validating e.g. “ validating strength using precise and non-stigmatising language non-stigmatising and precise using – – – – – – with suicidal behaviour when assessing a patient following key questions Consider the their suicidality alone): an opportunity to discuss patient has – – – – • Previous help-seeking Access to means. See “Lethal means” counselling Current mood Previous non-suicidal self-injury (NSSI) Previous attempt(s) Plans/intent Suicidal thoughts • Seek collateral information from patient’s family, friends, or support person and others such as treating health professionals, school counsellor, welfare workers and: –– advise them of safety plan and risks to the patient –– obtain consent from the patient where possible –– reassure patient that the information is being sought for the purpose of providing appropriate treatment and care to them and to ensure their safety 4. Management5,7 • Consult MO/NP/Life Promotion Officer/Mental Health Worker (including Transcultural Mental Health Worker if relevant and available). MO/NP will discuss with Psychiatrist Suicidal behaviour Suicidal • Stabilise any medical condition. Manage airway and cervical spine in patients who have attempted suicide by hanging. See Spinal injuries, page 180 • In consultation with MO/NP, patient and support people, determine the most appropriate and available management setting • The management process must be planned, coordinated and documented • Utilisation of the provisions of the Mental Health Act 2016 (or relevant Act if outside Queensland) may be required. See Interventions in non-consenting patients, page 474 • Carers and/or families of the patient should be contacted and provided with clear and concise information regarding the involuntary provisions of the Mental Health Act 2016 • Refer to local protocols which should specify lines of responsibility and provide access to senior clinicians • Suicide risk is dynamic. Ongoing assessment and monitoring of a patient’s risk is important. Plan to assertively follow-up the patient • Develop a Safety Plan. See Safety Plan on next page
460 | Primary Clinical Care Manual 10th edition | MentalSuicidal health behaviour assessment 461 - - - - Suicidal behaviour https://www. https://www.beyondblue.org.au/get-support/ Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental
should incorporate: 4,7,14,16,17 a “no-suicide contract” a “no-suicide professional support information on 24-hour access and support options a list of helpful and unhelpful interventions relatives, a café, the library, the park, talk to connections with people and places e.g. visit friends internal coping strategies i.e. things that the patient can do themselves, including distraction including do themselves, can patient the that things i.e. strategies coping internal a shower, exercise, holding ice cubes/snap techniques to manage intense feeling e.g. taking ping a rubber band on a wrist, writing out feelings reasons to live minimise alcohol and recreational drug creating a safe environment e.g. stay with friends, consumption, not driving while distressed details of the risk assessment that outlines patterns of repeated self-harming and acute sui assessment that outlines patterns of repeated self-harming and risk of the details cide risk situations, and indications for evacuation/admission thoughts, images, mood, situation, behav warning signs that a crisis may be developing e.g. iour diagnosis or summary of presentation details in case they cannot be reached patient’s contact details and secondary contact and/or carers involved in patient’s care names and contact details of clinicians, teams, input from all members of the treatment team if the support person is both willing and able to provide the level of care and support required both willing and able to provide the level of care if the support person is as part of the safety planning process carer fatigue and burnout not intended to be the only form of support to the patient to be the only form of support not intended to the patient and to their support person copied, with copies given NOT Safety Plan – – – – – – – – – – – – – – – – – – – – – – – – – – – – – ly-and-friends A – and for desktop and laptop from BeyondNow. See and for desktop and laptop beyondnow-suicide-safety-planning/create-beyondnow-safety-plan at for family and support persons is available Information on Safety Plans beyondblue.org.au/get-support/beyondnow-suicide-safety-planning/information-for-fami – – from app stores Safety Planning app is available (Apple or Android) A free to download Suicide – – It is important to consider: Safety plans are: Safety plans • • • • • external resources. Each Safety Plan is unique to that patient, so each plan will be different. A Safety so each plan will be different. is unique to that patient, Each Safety Plan external resources. Plan is A Safety Plan is a discharge summary or written list developed in collaboration with the patient and with the patient collaboration in list developed or written summary Plan is a discharge A Safety internal and to enhance safety using a list of coping strategies support person. It is their identified Safety Plan Safety “Lethal means” counselling3
• Limiting access to means and preferred methods can prevent suicide • Explain to patient that risk can escalate quickly so it is important to consider access to means during these periods of increased risk • Thoroughly explore with the patient and support persons access to means, identify strategies to: –– decide who is responsible for managing means –– remove or restrict access to identified means Suicidal behaviour Suicidal • Other considerations include: –– notifying Weapons Licensing Branch if patient has access to a firearm under theQueens - land Weapons Act 1990 at https://www.police.qld.gov.au/programs/weaponsLicensing/ licenceApplication/applicant/Documents/HealthWeaponsForm.pdf or applicable procedure in other jurisdictions –– considering risk of toxicity of any prescribed medicines e.g. opioids, tricyclic antidepres- sants (TCAs), benzodiazepines –– arranging reduction in prescriptions for medicines to non-lethal quantities –– the support person should be holding and dispensing medicines –– the support person should be disposing of, or placing into locked storage, all non-essential medications in the home –– considering if the patient’s occupation gives access to lethal means e.g. council workers accessing pesticides, police officer accessing guns, health workers accessing medicines
5. Follow up7,8 • Discuss follow up plan with MO/NP/Psychiatrist • Criteria for considering whether a patient with suicidal behaviour/ideation should go home: –– acute problems identified, addressed and resolved –– patient agrees to seek help if suicidal ideas recur –– patient is not demented, intoxicated, sedated, delirious or psychotic –– a written Safety Plan has been provided to both the patient and their support person –– patient does not have access to lethal means such as firearms or medicines. See “Lethal means” counselling, above –– follow up arrangements have been documented with a copy given to the patient and support(s) have been mobilised –– treatment has been arranged for any current mental health problems and/or medical problems –– family/supports understand and agree with Safety Plan • If the patient is the primary carer for children, older persons or other vulnerable people, consider alternate arrangements for care.14 See Child protection, page 760 • If a suicide attempt has been made, a mental health history and assessment, general medical as- sessment, MSE, suicide risk assessment and risk management plan must be made before discharge by a trained Mental Health Practitioner/MO/NP/Psychiatrist • Avoid minimising the seriousness of the risk of suicide • Explain the patient’s behaviour to family or friends to reduce their anxiety and anger towards the patient
462 | Primary Clinical Care Manual 10th edition | MentalSuicidal health behaviour assessment 463 - - - Acute severe be Suicidal behaviour (or relevant Act if outside until help arrives (previous pages) Mental Health Act 2016 Safety Plan should not be left alone Interventions in non-consenting patients, page 474 and Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 7,16,18 (previous pages)
deterioration of family relationships increase in symptoms temporary unavailability of the clinician ensuring the patient and identified support person is provided with a schedule of follow-up ap ensuring the patient and identified support person included in the referral. See Safety Plan pointments including contact details of services troubleshoot potential barriers to accessing the considering the patient’s needs and identify and appointment e.g. transport, employment, availability contacting the referral agency to confirm they can accommodate the referral request and arrange contacting the referral agency to confirm they can the appointment on behalf of the patient times for follow-up appointment emergency care. See when to present again for recover from suicidal behaviour and feeling if treatment is followed recover from suicidal behaviour substance use thoughts increased frequency and intensity of suicidal signs of deterioration e.g. current condition, options for treatment, medicine and medicine adherence current condition, options will help people Tell patient that research indicates that treatment effectiveness of treatment. be impulsive and lack problem-solving skills; each of which increases risk of suicidal behaviour increases risk of suicidal skills; each of which and lack problem-solving be impulsive increases suicide risk or psychosis which risk of developing depression have a higher treatment in their care and and require consistency to perceived rejection be acutely sensitive have an underlying mental illness where they engage in repeated self harm e.g. depressions, e.g. depressions, self harm in repeated they engage where mental illness underlying have an or borderline disorder (PTSD) stress post-traumatic disorders, disorder, eating abuse substance condition co-morbid more than one (BPD), or disorder personality self-harm ideation or deliberate assistance with suicidal repeatedly seek – – – – – – – – – – – – – – – – –
– – – Safety Plan Contingency planning requires the clinician and the patient at risk and/or family/carer to anticipate likely escalations of risk such as: Where appointments are not kept, assertive follow up must be undertaken. Information covering 24 covering undertaken. Information must be not kept, assertive follow up appointments are Where to all patients being managed in the community hour access and support options must be given seek further help if the situation deteriorates. See Advise the patient and their support person to – – Make a “warm” referral to support services, which includes: Make a “warm” referral to support services, which – involvement of the patient and family considered safe to be managed in the community Patients assessed at elevated risk of suicide but a relevant mental health care provider. Follow up should have follow up contact within 24 hours with should be linked to the risk assessment Queensland) may be required if the patient demonstrates risk to self or others. See Queensland) may be required if the patient demonstrates havioural disturbance, page 467 a patient should be made on clinical grounds with The rationale and decision to transfer/hospitalise If there is a crisis situation with imminent risk of suicide, an emergency referral to mental health or If there is a crisis situation with imminent risk of medical services should be made and patient Involuntary admission under the provisions of the – – – – ment options that may facilitate adherence to ongoing care. Include information on: adherence to ongoing care. Include information ment options that may facilitate – – Lethal means counselling - limiting access to means (preferred method of suicide) is one of the most method of suicide) is to means (preferred counselling - limiting access Lethal means (previous pages) to reduce suicide risk. See ”Lethal means” counselling well-evidenced strategies treat and condition their understand to patient the enables which education patient brief Provide – – – – – A patient may have a chronic risk of self-harm or suicide. The patient may: The patient or suicide. of self-harm risk chronic a may have A patient • • • • • • • • • • • 6. Referral/consultation • Management in the community is not appropriate when suicide risk escalates beyond the available level of care, support from the health service and family and social supports • Resources for clinicians: –– Centre for Clinical Interventions http://www.cci.health.wa.gov.au/resources/mhp.cfm –– Headspace, Understanding self-harm http://www.cci.health.wa.gov.au/resources/mhp.cfm –– LIFE, suicide prevention https://www.lifeinmindaustralia.com.au/splash-page/docs/ LIFE-framework-web.pdf –– Mental Health First Aid training https://mhfa.com.au/ –– NSW Health Framework for Suicide Risk Assessment and Management http://www.health.nsw.
Suicidal behaviour Suicidal gov.au/mentalhealth/programs/mh/Publications/framework-suicide-risk-assess.pdf • Self-help for patients: –– coping with suicidal thoughts https://www.getselfhelp.co.uk//docs/CopingSuicidalThoughts. pdf –– dealing with distress https://www.getselfhelp.co.uk//docs/DealingwithDistress.pdf • Other resources for patients: –– for younger patients https://headspace.org.au –– for children, parents/carers, teachers https://kidshelpline.com.au/ –– for men https://mensline.org.au/ –– for Aboriginal and Torres Strait Islanders https://www.lifeline.org.au/static/uploads/files/ suicide-prevention-aboriginal-torres-strait-island-wffchhzmsysl.pdf –– Suicide call back service https://www.suicidecallbackservice.org.au/, 1300 659 467 –– SuicideLine Victoria https://www.suicideline.org.au/ 1300 651 251 (Victoria only)
Suicide risk assessment2,5
Background • Suicidality is a dynamic and fluctuating state that can be influenced by a range of factors • Categorical stratification of suicide risk (low, medium, high) is not helpful in predicting future risk of suicide • Not all people who attempt suicide have a mental health condition • Non-suicidal self-injury (NSSI) or self-harm: –– can be associated with subsequent suicide attempts. Each presentation (whether considered NSSI or a suicide attempt) requires appropriate assessment and safety planning. –– is the intentional harm to one’s own body without the intent to cause death e.g., by cutting, burning, banging, biting –– may be used by an individual to alleviate distress, as self-punishment, to reduce dissociative feelings, to reduce suicidal thoughts and/or for sensation seeking
Related topics Suicidal behaviour, page 456
Determining suicide risk: • Asking directly about suicide and self-harm does not prompt a person to start to think about harming themselves
464 | Primary Clinical Care Manual 10th edition | MentalSuicidal health behaviour assessment 465 -
Suicidal behaviour Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Anxiousness or agitation Engaging in risky behaviour Sleeping too little or too much Negative view of self - ‘I am worthless’, ‘I am not good for anything’ Negative view of self - ‘I am worthless’, ‘I am not would be better off without me’ Talking about being a burden to others – ‘people Increasing the use of alcohol or drugs Acquiring the means to end one’s life to live Talking about feeling hopeless or having no reason Talking about feeling trapped or in unbearable pain Talking about or non-verbal e.g. writing expressions of wanting to die or to kill one self Talking about or non-verbal e.g. writing expressions online about methods or buying a gun Looking for a way to kill oneself, such as searching Social and geographical isolation LGBTIQ+ (important: elevated risk commonly found among LGBTIQ+ is not due to sexual LGBTIQ+ (important: elevated risk commonly found through key social determinants of health orientation, sex or gender identity alone, but rather including discrimination and exclusion) Transition points e.g. primary to high school or transitioning in the workforce Transition points e.g. primary to high school or transitioning suicide) Male (however women are more likely to attempt Identifying as Aboriginal and Torres Strait Islander Psychosocial difficulties (such as financial difficulties, unemployment, impending court case, or Psychosocial difficulties (such as financial difficulties, custody issues) abuse, violence, sexual assault, torture, or Adverse life events (such as trauma including bullying, refugee status) Access to harmful means such as medication or weapons Access to harmful means Recent bereavement Physical illness or disability Losing a friend or family member to suicide Losing a friend or family conflict with parents and/or romantic partners Relationship problems - Legal or disciplinary problems Prior suicide attempt and/or substance abuse conditions - depression, anxiety, bipolar, PTSD History of mental health health conditions or substance abuse Family history of a mental overall suicide risk overall suicide problem probability that a the increase may factors Risk factor. risk a sign is different from warning A has already begun indicate that a problem a warning sign may will occur, while suicide or in determining acceptance of treatment or allocation of resources of or allocation of treatment acceptance or in determining suicide or as used in isolation not be value and should predictive have limited tools risk assessment Suicide management and subsequent risk for determining a checklist contribute to available resources that and protective factors or signs, risk factors Look for warning Categorical stratification of suicide risk (low, medium, high) is not helpful in predicting future risk of risk future predicting in helpful not is high) medium, (low, risk suicide of stratification Categorical • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • vention. Warning signs include: Warning signs: and are more likely to be targeted for immediate inter Warning signs are indicators of more imminent risk Characteristics of people most at risk of suicide: of people most at Characteristics most at risk tend to share certain and ethnicity die by suicide, however people People of all genders, ages, characteristics: • Giving away possessions • Making preparations for death and saying goodbye • Withdrawing or feeling isolated • Showing rage or talking about seeking revenge • Drastic changes in mood and behaviour, or other indications of mental health deterioration Risk factors: Risk factors can imply enduring or long-term risk. In isolation, the presence or absence of risk factors does not predict suicide or repetition of self-harm. Risk factors include a wide range of biological, psychological and social factors:
Suicidal behaviour Suicidal • Mental health conditions - depression, anxiety, bipolar, PTSD and/or substance abuse • Prior suicide attempt • Contact with services (particularly post-hospitalisation) • Male • Aboriginal and Torres Strait Islander identification • Patient’s from cultural and linguistically diverse backgrounds • Post-partum • Pain and physical illness • Sexual orientation and gender identity • Social or geographical isolation • Adverse life events • Family history of mental health conditions • Exposure to suicidal behaviour Protective factors and available resources: Protective factors may serve to protect or buffer an individual against suicide. Protective factors should not be valued over the presence of warning signs. Protective factors include: • Therapeutic alliance between clinician and patient • Family warmth, support and acceptance • Community support and a strong cultural identity • Pregnancy (self/partner) or having young children (pregnancy can be a period of elevated risk for women) and child rearing responsibilities • Strong sense of belonging and connection • Support from ongoing medical and mental health care relationships • Skills in coping and problem solving, conflict resolution, and non-violent ways of handling disputes • Being involved in activities/hobbies that an individual finds meaningful • Help-seeking behaviour, being amenable to intervention, and access and engagement of professional help • Cultural and religious beliefs that discourage suicide and support instincts for self-preservation • Experiences with success and feelings of efficacy • Interpersonal competence • Resiliency to change or loss • Lack of access to a means of suicide, such as restricting the presence or accessibility of guns or medication. See Lethal means counselling in Suicidal behaviour, page 456 • Available resources are internal and external resources immediately available to the patient and treatment team to support safety and treatment planning. See Safety plan, page 461
466 | Primary Clinical Care Manual 10th edition | MentalBehavioural health distur assessbancesment 467 -
Behavioural disturbances - adult/child https://qheps.health.qld.gov. https://www.health.qld.gov.au/clinical-practice/ for guidance on questioning techniques to elicit suicidal intent elicit suicidal techniques to for guidance on questioning behavioural disturbance (ASBD) behavioural disturbance Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 1 severe 1 2 Suicidal behaviour, page 456 page Suicidal behaviour, in all patients with mental health presentations before making a diagnosis of mental illness Acute Psychiatric disorders associated with behavioural emergencies may include schizophrenia, Psychiatric disorders associated with behavioural and post traumatic stress disorder. Dementia mania, agitated depression, personality disorders and acquired brain injury may also be contributing causes Alcohol and substance misuse and physical illness or injury should be suspected and excluded conditions (hypoglycaemia), cerebral conditions (head injury, following a fit, stroke, conditions (hypoglycaemia), cerebral conditions even constipation and urinary retention in meningitis), infections (pneumonia, urinary tract), the elderly mental health condition or the behavioural/mental health consequence of a possible underlying mental health condition or the behavioural/mental physical illness conditions and may mimic mental illness Acute confusion can be caused by many physical side effects), hypoxia, metabolic Causes include alcohol, drugs (intoxication, withdrawal, situation in which the health practitioner becomes aware, either from statements or behaviour of situation in which the health practitioner becomes of is imminent risk information from collateral sources, that there patient or because of the or others resulting from a known or presumed significant harm being sustained by the patient guidelines-procedures/clinical-staff/mental-health/act/forms severe behavioural disturbance (ASBD) is any A mental health behavioural emergency or acute responsibilities available at: Mental health statewide suite of clinical documents au/mentalhealth/resources/clinicaldocs Mental Health Act 2016 forms available at: Consider use of (telephone) interpreter and/or transcultural Mental Health Workers for cultural Consider use of (telephone) interpreter and/or transcultural and linguistically diverse (CALD) populations people for whom the patient has care Consider safety of any children or other vulnerable Management should use the least restrictive approach possible, be collaborative and patient the least restrictive approach possible, be collaborative Management should use centred Strait Islander Health Workers in Aboriginal and Torres Involve Health Workers/Mental communities Speak to MO/NP/Psychiatrist at referring facility as soon as possible in all psychiatric at referring facility as soon as possible in Speak to MO/NP/Psychiatrist emergencies alone if at all concerned Do not leave the patient
See behaviour of a person with suicidal non-acute management and acute and Foreseeable changes are changes that could occur in the patient’s life and rapidly increase a pa a rapidly increase life and patient’s the in occur could that changes are changes Foreseeable risk tient’s should plan is in place contingency ensure a changes and potential significant at least two Identify occur these changes • • • • • • • • • • • • •
Recommend • • • Background Consider foreseeable changes: foreseeable Consider
HMP HMP Behavioural disturbances Behavioural disturbances Related topics Delirium, page 161 Toxicology (poisoning and overdose), page 259
ances Head injuries, page 175 Transient ischaemic attack (TIA) and stroke, page 158
1. May present with3,4 • Violent behaviour, extreme agitation, restlessness • Possession of a weapon • Self-destructive behaviour, aggressive behaviour or threats to others • Bizarre, disorientated behaviour e.g. talking to people who are not there, unable to stand still, awake all night, inappropriate anger or sadness, becoming suspicious of people or things in surroundings • ‘Command’ hallucinations i.e. hallucinations ordering person to harm themselves • Hallucinations, delusions, paranoia, grandiosity
b distur Behavioural • Physical and verbal aggression • Confusion, delirium • Ambivalence, withdrawn behaviour e.g. refusing to talk or eat • Suicidal ideation or attempt (past or current) • Situational crisis • Family member seeking help because of strange, disruptive or frightening behaviour by one of their family • Recurrence/exacerbation of known mental health problem • A first presentation with a mental health problem 2. Immediate management1 • Initial brief assessment aimed at determining the most likely cause of agitation and the risk of inju- ry/violence5 • Consult MO/NP/Psychiatrist as early as possible • If presentation is a result of suicide attempt, a suicide plan or suicidal ideation. See Suicidal behaviour, page 456 • Rapid mental health assessment for patients who are acutely unwell or in crisis. See Mental health assessment, page 450 –– urgently contact MO/Psychiatrist or local mental health service (if available) for acute mental health assessment –– see Interventions in non-consenting patients, page 474 –– evacuation may be ordered. For specific requirements around transporting a disturbed patient, see Patient retrieval/evacuation, page 29
468 | Primary Clinical Care Manual 10th edition | MentalBehavioural health distur assessbancesment 469 History Toxicology Behavioural disturbances and Acute alcohol intoxication, Mental health assessment, page 450 History and physical examination - child, page 664 Delirium, page 161 , and Other drugs/substances, page 494 , - Code black - Code 1,5 1 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Alcohol withdrawal, page 490 ,
delirium (especially in the elderly). See head injury, encephalitis, meningitis, seizures agitated depression anxiety disorders borderline and anti-social disorders psychotic disorders mania pulse oximetry to exclude hypoxia as a cause of behaviour changes pulse oximetry to exclude hypoxia as a cause of BGL to exclude glycaemic causes of behaviour changes – – – – – – – – –
Consider general medical conditions that may cause ASBD, including: – – – – – Consider mental health conditions that may cause ASBD, including: Consider mental health conditions that may cause – – Consider whether features of presentation are substance related. See Consider whether features of presentation are substance page 487 (poisoning and overdose), page 259 – examination as tolerated by patient. See Perform general health assessment and physical and physical examination - adult, page 20 Complete a mental health Rapid Assessment. See form link in Complete a mental health Rapid Assessment. See observations (full Q-ADDS/CEWT score or other Once the patient is calm, perform standard clinical local Early Warning and Response Tools) + – See Safety considerations/Code black above Conduct search of patient and possessions according to relevant legislation or local policies, if Conduct search of patient and possessions according potentially dangerous items or drugs into there is reasonable suspicion that patient has brought the facility alarms patient has care years) or other vulnerable people for whom the Identify any children (0-18 responsibilities Use a calm, confident manner, avoid sudden or threatening gestures Use a calm, confident the patient and do not confront, corner or stand over Avoid prolonged eye contact, or at risk Seek help if you feel threatened personal duress including duress alarms. If available, carry portable, Be familiar with locality (knives, scissors, IV poles) which staff can quickly escape Always consider exits from who has a weapon Never approach a patient Assess in a space where distractions are minimised and you can give full attention to the patient can give full attention are minimised and you where distractions Assess in a space an important vicinity (family may have from the immediate patients and bystanders Remove other role during patient assessment) access to a weapon environment e.g. avenues for absconding, Consider risks in the immediate Always have at least one other staff member present, call security personnel if available member present, call security at least one other staff Always have Safety considerations Safety • • • • • • • • • • • • • • • • • • emergency. Never attempt to manage an ASBD without adequate support and resources. If the support and resources. an ASBD without adequate Never attempt to manage emergency. by resources cannot be managed or their own safety which a risk to public safety patient presents call Police. within the facility, • earlier occur at a much should and escalation referral remote areas, and in health facilities In small a Code Black activating Plan, including Preparedness facility’s Emergency Follow your stage. 3. Clinical assessment –– infections, sepsis –– liver and/or kidney failure –– glucose abnormalities, electrolyte imbalance ances –– hypoxia –– behavioural and psychological symptoms of dementia (especially in the elderly)
4. Management1 • Consult MO/NP and provide findings of assessment • Never leave the patient alone • Reassure the patient but do not make promises that cannot be kept • Provide support for family members and relatives of patient, including children. This may be a very frightening experience for them • If previous mental illness diagnosed, manage in consultation with MO/NP/Psychiatrist for this b distur Behavioural presentation • Evacuation/hospitalisation in appropriately equipped and staffed facility may be required for a comprehensive mental health assessment • There are special considerations for people who require evacuation by air. Keep nil by mouth. See Patient retrieval/evacuation, page 29 • If patient does not consent to evacuation/hospitalisation/medicine or does not have the capacity to give consent use of the Mental Health Act 2016 in consultation with the MO/NP/Psychiatrist may be appropriate. See Interventions in non-consenting patients, page 474 • Sedation may be required to: –– control severe behaviour disturbance for patient’s safety and safety of others –– allow diagnostic assessment and management –– relieve distress
470 | Primary Clinical Care Manual 10th edition | MentalBehavioural health distur assessbancesment 471
.
Repeat Monitor minutes every 15 Sedation Assessment minutes for 60 Behavioural disturbances OR required No sedation IM Droperidol Oral Diazepam who may order Contact MO/NP Oral Olanzapine - if safe for patient, staff and others staff and others - if safe for patient, 0 ≤ +1 NO continue to use de-escalation techniques continue to +2 or +3 7 2 Administration of medicine, patient does not consent toAdministration of medicine, patient does not consent Score +2 +1 0 -1 -2 -3 +3
- Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Speech None Speaks normally Slurring or prominent slowing Few recognisa ble words Continual loud outburst Loud outburst Normal/ talkative - to sedation Have all de-escalation techniques been attempted prior to sedation prior been attempted techniques de-escalation Have all Sedation for ASBD in adults outside a mental health facility* health a mental outside in adults ASBD for Sedation Sedation assessment tool Sedation assessment assess score using this table) assess score using this * For children, adolescents and medically frail patients, consult MO/MP/Psychiatrist * For children, adolescents and medically frail patients, De-escalation techniques, page 789 ( - notify MO/NP you are proceeding - notify MO/NP Aim for rousable drowsiness - sleepy when undisturbed but rousable and cooperative to voice or Aim for rousable drowsiness - sleepy when undisturbed but rousable and cooperative to voice or pain never be given with any other benzodiazepine IM No sedation protocol is 100% safe. Sedation is used when de-escalation fails. Confirm no other medical cause of patient’s altered mental state MO/NP may order droperidol in very anxious, violent or out of control patients MO/NP may order droperidol in very anxious, violent (intramuscular) with olanzapine Never use benzodiazepines e.g. lorazepam or diazepam 1 hour of each other i.e. olanzapine IM should (intramuscular) simultaneously and never within See If patient is not consenting to medication, see treatment, page 477 treatment for this group of patients, although the Benzodiazepines are the recommended first line Consult MO/NP/Psychiatrist at de-escalation have been attempted Sedation can only be considered after all attempts YES Responsiveness • • • • • • • cal stimulation No response to stimulation Asleep but rouses if name is called Responds to physi Anxious/restless Awake and calm/ cooperative out of control Very anxious and agitated Combative, violent, Combative, Medication management of agitation/arousal • If dystonic side effects (muscle twisting, contractions, repetitive movements, more common in children and young adults) occur give benzatropine6 • If respiration rate < 10 breaths/minute following sedation with benzodiazepine, reverse with ances flumazenil • Sedated patients should be monitored continuously until evacuated, including:
–– maintain SpO2 ≥ 94%. See Oxygen delivery, page 64 –– perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) every 15 minutes –– Sedation Assessment Tool and GCS. See Glasgow Coma Scale/AVPU, page 785
Extended authority Schedule 4 Diazepam ATSIHP/IHW/IPAP/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP
b distur Behavioural RIPRN may proceed Note: In non-consenting patients, can only be given by an RN or RIPRN under the instruction of a doctor Route of Form Strength Recommended dosage Duration administration 2 mg Adult Tablet Oral stat 5 mg 10 mg Adult stat Injection 10 mg/2 mL IV 5 mg Repeat once if required Provide Consumer Medicine Information: May cause drowsiness, oversedation, light-headedness, hypersalivation, loss of coordination, slurred speech and effects on vision Note: Inject undiluted at a max. rate of 1 mL/min. Monitor respiratory rate closely. Halve the usual adult dose in the elderly and/or debilitated Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,2,7,8,9,14
Extended authority Schedule 4 Olanzapine ATSIHP/IHW/IPAP/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN must consult MO/NP unless circumstances do not allow, in which case notify the MO/NP as soon as circumstances allow Route of Recommended Form Strength Duration administration dosage Adult only 2.5 mg stat 5-10 mg 5 mg Tablet Oral to max. of 7.5 mg Further doses on 20 mg/24 hours 10 mg MO/NP order Provide Consumer Medicine Information: Caution if moving from lying to sitting or to standing position. May cause sedation Management of associated emergency: consult MO/NP. See Anaphylaxis, page 102 1,6
472 | Primary Clinical Care Manual 10th edition | MentalBehavioural health distur assessbancesment 473 1,10
stat 11,12,13,17 after 60 seconds seconds Duration stat Second dose Inject over 15 may be given Duration MO/NP order Further doses on Further doses
IHW/IPAP/RIPRN / Behavioural disturbances
Extended authority
Extended authority Extended ATSIHP/IHW/RIPRN ATSIHP Adult 1-2 mg dosage dosage Max. dose Adult only Initial dose Second dose 100 microgram Recommended Recommended Recommended 200 microgram 1 mg in 24 hours Anaphylaxis, page 102 Anaphylaxis, page 102
-
IM IV tion Flumazenil Benzatropine Benzatropine Route of Route of May cause nausea and vomiting May cause drowsiness, dizziness or blurred vision. May May cause drowsiness, administra administration Consult MO/NP. See Consult MO/NP. See Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Strength 4 0.5 mg/5 mL 4 Strength 2 mg/2 mL GIT or urinary obstruction, myasthenia gravis GIT or urinary obstruction, Do not use in benzodiazepine-dependent women; risk of precipitating withdrawal in Do not use in benzodiazepine-dependent women; Form : Use with caution in patients with epilepsy receiving long-term benzodiazepine treatment. : Use with caution in patients with epilepsy receiving Used as an antidote for extrapyramidal side effects such as tardive dyskinesia and acute extrapyramidal side effects such as tardive dyskinesia Used as an antidote for Form Injection Schedule Injection Schedule Prengnancy: fetus Note on awakening. Use in those who have mixed Patients may become agitated, anxious or fearful drugs may result in uncontrollable seizures and overdoses of benzodiazepines and proconvulsant death Provide Consumer Medicine Information: Management of associated emergency: ATSIHP, IHW, IPAP and RN must consult MO/NP do not allow, in which case notify the MO/NP as soon RIPRN must consult MO/NP unless circumstances as circumstances do allow Contraindication: emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine increase effects of alcohol Note: caution in heart disease, fever and elderly dystonic reaction. Use with ATSIHP, IHW and RN must consult MO/NP must consult IHW and RN ATSIHP, RIPRN may proceed 5. Follow up • If a patient has required sedation and is not evacuated consider:
ances –– any underlying mental disorders (dementia, delirium, psychosis, depression) and the impact of these on patient capacity/safety at home –– that intoxicated patients are not considered safe until they are sober • If not evacuated/hospitalised, follow local protocols or MO/NP instructions for observation and management • Consider the immediate safety needs of any children or other vulnerable people for whom the patient has care responsibilities • Seek details of any medication plans, behaviour support plans or sensory considerations for patients with an intellectual disability or autism • Provide patient and family/carer with copy of management plan
b distur Behavioural 6. Referral/consultation • Follow MO/NP instructions for this presentation • Arrange comprehensive mental health assessment
Interventions in non-consenting patients8
Background14 • In Queensland, the Mental Health Act 2016 has three main objects: –– to improve and maintain the health and wellbeing of persons who have a mental illness who do not have the capacity to consent to be treated –– to enable persons to be diverted from the criminal justice system –– to protect the community if persons diverted from the criminal justice system may be at risk of harming others • The main objectives are achieved in a way that: –– safeguards the rights of persons –– is the least restrictive of the rights of a person who has a mental illness and –– promotes the recovery of a person who has a mental illness, and the person’s ability to live in the community • A patient’s views in decision making are encouraged as much as possible • Family, carers and other support persons are involved in decisions about treatment and care
1. Examinations, assessment and treatment authorities14 • If a patient: –– is in imminent serious harm to themselves or to others, and –– has a mental illness, and –– does not have the capacity to give consent to be treated for the illness, and –– is suffering serious mental or physical deterioration, then use of the appropriate process under Mental Health Act 2016 will apply
474 | Primary Clinical Care Manual 10th edition | MentalBehavioural health distur assessbancesment 475
form
Public
15 Form is required Recommendation Recommendation AND Public Health Act Public Form Behavioural disturbances under the or process 2005 Emergency Examination Emergency Examination Authority Health Act 2005 Recommendation for Assessment Examination authority Request for Police Assistance Form Detention for one hour to Detention a determine if for Assessment - https://www.health.qld.gov.au/__data/ Mental Health Act 2016 Health Act Mental Who practitioner who has already practitioner who has already to 7 examined the patient (up days prior) Member of the public to contact Mental Health Review Tribunal (MHRT) Any health practitioner or person appointed by a mental health administrator Doctor or authorised mental Doctor or authorised health practitioner Ambu A Police Officer or an lance Officer A doctor or mental health - - - - - Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Situation there appears to be no other way for the person to receive treatment there appears to be no other way for the person the treatment criteria under section 12 of the Act may apply to the person; the treatment criteria under section 12 of the Act – – assets/pdf_file/0019/574012/f_recommend_assess.pdf An assessment under a recommendation for Assessment is conducted by an authorised doctor to An assessment under a recommendation for Assessment determine if further treatment is required for the person The recommendation for Assessment is available at: – may detain a person for a period of not more than A doctor or authorised mental health practitioner for Assessment one hour for the purpose of making a recommendation evacuating MO can complete this form can only make the recommendation for The doctor or authorised mental health practitioner Assessment if satisfied that: – recommendation for Assessment is needed made if the doctor or authorised mental health A recommendation for Assessment can only be seven days. When there is no local MO, an practitioner has examined the person in the last A doctor or authorised mental health practitioner may examine a person to decide if a A doctor or authorised mental health practitioner • • • • • • Review Tribunal Assistance is needed to exam ine or transport an involuntary patient health of a person where a risk is likely to happen in the near future i.e. non-urgent, refer concern to Mental Health A member of the public who A member of the public has concerns about the mental provide consent To determine if further treat ment is required may be at immediate risk of may be at immediate risk harm and they need urgent con examination either with to sent or is without capacity A patient needs to be trans A patient needs ported and examined where they their behaviour indicates A patient needs to be exam A patient needs either with ined immediately without capacity consent or is to provide consent Recommendation for Assessment Form: Summary of processes to examine or transport an involuntary patient involuntary an or transport examine to of processes Summary • For more information, see the Chief Psychiatrist Practice Guideline, Examinations and Assessments at: https://www.health.qld.gov.au/__data/assets/pdf_file/0041/573998/pg_examinations_as- sessments.pdf ances Examination Authority Form: • In non-urgent situations, any adult member of the public may apply to the Mental Health Review Tribunal for an ‘Examination Authority’ • The person must obtain advice from a doctor or an Authorised Mental Health Practitioner about the clinical matters for the person who is the subject of the application • An Examination Authority allows a doctor or Authorised Mental Health Practitioner to go to the person’s location in order to conduct an examination to determine if a recommendation for Assessment is required. Available at: https://www.health.qld.gov.au/clinical-practice/ guidelines-procedures/emergency-examination-authorities-eeas • For more information, see the Chief Psychiatrist Practice Guideline, Examination Authorities, at: https://www.health.qld.gov.au/__data/assets/pdf_file/0036/629757/pg_examination_authori- b distur Behavioural ties.pdf Request for Police Assistance Form: • This form is a formal request to police to provide assistance in transporting a person under the Mental Health Act 2016, or to assist in executing an Examination Authority • A health practitioner must accompany the police officer while assistance is being provided • If the patient is already subject to a Treatment Authority, Forensic Order or Treatment Support Order (information about a patient’s status under the Mental Health Act 2016 can be accessed via Queensland Health’s clinical information portal, The Viewer) and requires inpatient treatment, the treating Psychiatric Registrar or Psychiatrist should be contacted. After hours, contact the on-call Psychiatric Registrar or Psychiatrist at the relevant Authorised Mental Health Service. Immediate return of the patient to the Authorised Mental Health Service with the assistance of police if required can be arranged • Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0020/574013/f_req_police_ assist.pdf Emergency Examination Authority:15 • Police officers and ambulance officers may detain and transport persons under the emergency examination authority provisions of the Public Health Act 2005 to a public sector health service in emergency circumstances. The emergency examination authority provisions apply if the police officer or ambulance officer reasonably believes that: –– a person’s behaviour indicates that the person is at immediate risk of serious harm e.g. by threatening to commit suicide, and –– the risk appears to be the result of major disturbance in the person’s mental capacity caused by illness, disability, injury, intoxication or other reason, and –– the person appears to require urgent examination • When the patient arrives at the public sector health service, the police officer or ambulance officer must immediately make an Emergency Examination Authority and give it to health staff • The patient may be detained at the facility while the Emergency Examination Authority is being made. An Emergency Examination Authority enables the person to be detained and examined without consent • The decision made by the examining clinician will determine the person’s treatment needs. A possible outcome is making a recommendation for Assessment under the Mental Health Act 2016. Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0039/639777/329_170206_ v1-00_PH-Emergency-Examination-Authority_LIVECYCLE-4.pdf
476 | Primary Clinical Care Manual 10th edition | MentalBehavioural health distur assessbancesment 477 - - https://www. permits urgent health Behavioural disturbances https://www.health.qld. a recommendation for assessment has been completed a recommendation for assessment [the Act] can be accessed via the Queensland Health’s be accessed via the [the Act] can must be used and is available at 1,16 De-escalation techniques, page 789 Management of patients with Acute Severe Behavioural Management of patients with Acute Severe Behavioural Guardianship and Administration Act 2000 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Mental Health Act 2016 Mental Health https://www.health.qld.gov.au/__data/assets/pdf_file/0038/639785/Guide physical restraint health that the patient has impaired capacity regarding their illness that the patient has impaired capacity regarding meet imminent risk to the patient’s life or the health care should be carried out urgently to – – – – Section 63 of the Queensland if the health care provider believes: care to be carried out without consent of the patient these instructions in the circumstances. the help, and using the force, that is reasonable may be administered with below See Avoiding physical restraint must be administered by an MO or a Registered Nurse under the specific instructions of the MO. an MO or a Registered Nurse under the specific must be administered by route and frequency of include the medicine name, the dose and These instructions must keep a written record of who administers the medicine must administration. The nurse/MO/NP, may be administered to the patient only if an MO is satisfied it is necessary to ensure the safety the patient only if an MO is satisfied it is necessary may be administered to being taken to the health service of the patient or others while – – – –
1,4,8 Disturbance in Emergency Departments gov.au/__data/assets/pdf_file/0031/629491/qh-gdl-438.pdf Physical restraint can only be used where a patient presents a severe risk to themselves or others Physical restraint can only be used where a patient of patients who are being restrained There are strict requirements around physical monitoring The Queensland Health Guideline Physical restraint is only attempted after all other methods and alternatives for managing the Physical restraint is only attempted after all other patient have been exhausted. See a qualified health professional Physical restraint must only be implemented by choiceandmedication.org/queenslandhealth/ Information for patients about medicines used in mental health available at: Information for patients about medicines used If an MO or an authorised health practitioner is not available to complete paperwork for Involuntary If an MO or an authorised health practitioner is Assessment: – – – The patient is to be transported to an Authorised Mental Health Service The patient is to be transported that medicine: Additionally, the Act states – status under the status under – The Viewer), or clinical information portal under the Act (see below) and for involuntary assessment The patient is being treated under an emergency examination authority (in Queensland a patient’s authority (in Queensland emergency examination is being treated under an The patient Services at: Services line-for-Emergency-Examination-Authorities.pdf For more information, see Emergency Examination Authorities: Guidelines for Hospital and Health and Health for Hospital Guidelines Authorities: Examination see Emergency information, more For
• • • • • • • • • • • Medicine administration can be carried out if the following conditions exist: carried out if the following can be Medicine administration
3. Avoiding 2. Administration of medicine where a patient does not consent to treat does not consent where a patient of medicine 2. Administration ment Dementia
HMP Behavioural and psychological symptoms of dementia (BPSD) - adult Dementia
Recommend1,2 • Utilise non-pharmacological strategies as a first-line measure to manage the symptoms of dementia, including environmental, behavioural and social strategies • For information on Dementia, refer to The Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://publications.qld.gov. au/dataset/chronic-conditions-manual Background2,3,4 • People living with dementia will experience a good quality of life for long periods. As dementia progresses, behavioural and psychological symptoms of dementia (BPSD) occur in 80% of people. BPSD may be expressions of unmet need by a person living with dementia. BPSD may include agitation, aggression, and depression. Intervention strategies can alleviate these symptoms • Incidence rates of dementia for Aboriginal and Torres Strait Islander people are up to 3-4 times higher and occur 10-15 years earlier than for the whole population
Related topics Delirium, page 161 Acute severe behavioural disturbance, page 467 Depression, mania and anxiety, page 484
1. May present with1,5,6 • A patient with known dementia may present with: –– arguing with caregivers, complaining, becoming easily upset –– inappropriate crying out, screaming, verbal and physical aggression –– repetitive questioning –– pacing, wandering –– hoarding, rummaging –– inappropriate robing and disrobing –– rejection of care –– sleep disturbances –– inappropriate sexual behaviour 2. Immediate management1,2,7 • Ensure safety of patient, self and others. See Mental health assessment, page 450 and Acute severe behavioural disturbance, page 467 See De-escalation techniques, page 789 • Communicate in a slow, calm manner. Allow time for patient to express themselves • Allow familiar people to be present if felt appropriate e.g. carer/family member • The MO/NP may order acute sedation only if there are immediate risks to the person, carers, staff
478 | Primary Clinical Care Manual 10th edition | MentalDementia health assessment 479 - Depres , Dementia Delirium, page 161 Delirium, page Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 1,2,5,7
use of pyschotrophic medicines side effects of medicines temperature extremes separation from family unmet needs such as hunger, thirst, warmth presence of wounds sensory impairment (vision, hearing difficulties) patient-caregiver conflict pain, constipation environmental stimuli unmet needs medical conditions behaviour, describe what happened i.e. verbal aggression, use of a weapon behaviour, describe what the consequences of the behaviour consequence, what was antecedent, identify the trigger of the BPSD antecedent, identify the medicines – – – – – – – – – – – – – – – –
– is inconsistent with history or is unexpected in Consider non-accidental causes where presentation older people or other vulnerable people – – – – – – – of BPSD such as: Identify possible causes – – – – – – or triggers for BPSD including: Identify the antecedents sion, mania and anxiety, page 484 sion, mania and model to assess BPSD: Use the ABC – Physical examination + Physical examination – See as delirium and depression. related conditions such Consider other Conduct assessments and management in quietly, in a calm manner, with a familiar person present person with a familiar a calm manner, quietly, in in and management assessments Conduct and Early Warning or other local score Q-ADDS/CEWT (full clinical observations standard Perform Response Tools) • • • • • • • • 3. Clinical assessment Clinical 3. Signs and symptoms of delirium, dementia and depression8 Delirium Dementia Depression Relatively rapid over Acute illness, medical Onset Chronic, progressive weeks to months, Dementia emergency episodic May be self-limiting, Stable during day, recurrent, or chronic. Course Fluctuates hourly progresses Worse in morning, improves during day Hours to weeks, Progressive, Months or years, Duration resolves with treatment irreversible resolves with treatment Impairment progressively Disoriented to time worse, loss of ability to Orientation Selective disorientation and place recognize function of everyday objects Impaired short term, May be impaired, Memory Impaired short term unconcerned about concerned about memory loss memory loss Quiet and minimal, can Incoherent, loud, Repetitive, trouble finding be belligerent, Speech belligerent words, confabulates aggressive. Language skills intact Disturbed, early morning Disturbed, changes Disturbed, day/night Sleep wakening, sleepy hourly reversal during day Infection, drug Cause may be unknown, Contributing side-effect, renal failure, advancing age, Recent or cumulative factors head trauma, cardiovascular deficits, loss, medicine toxicity substance use substance dependence
4. Management1,2 • Consult MO/NP/General Physician/Geriatrician/Psychiatrist • Where safe, use non-pharmacological actions to prevent behaviour escalating • Administer analgesia as clinically indicated. See Acute pain management, page 35 • Consult MO/NP who may consider a pharmacological strategy should other interventions fail, minimising medicines which affect cognitive functioning.2 See Acute severe behavioural disturbance, page 467 • Prepare a behavioural management plan with patient, carer and family, consider factors such as: –– access to dangerous items –– access to exits where patient is wandering –– overstimulation - too many people in house, excessive noise, clutter –– under stimulation-lack of activities or items of interest to patient such as gardening, cooking, music, access to pets –– regular exercise, in particular walking • If Dementia Kit is available, supply to family and carer
480 | Primary Clinical Care Manual 10th edition | MentalPsychotic health disorders assessment 481 - http:// Psychotic disorders puerperal http://www.dementiaresearch.org.au/ (can supply Dementia Kits) https://www.health.qld.gov.au/clinical- 1800 699 799 drug-induced psychosis and
1800 100 500, Dementia Support Australia/Dementia Behaviour Man 1800 100 500, Dementia Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 2 https://www.dementia.org.au/ schizophrenia, 2 1
The patient's ability to make sense of their thinking, perception and mood is seriously affected The patient's ability to make sense of their thinking, Psychosis is a general term used to describe mental health problems in which a patient has lost Psychosis is a general term used to describe mental by distortion of thinking, perception and some contact with reality and may be characterised mood her significant others at: Clinical guidelines and procedures available practice/guidelines-procedures/clinical-staff/mental-health/guidelines Puerperal psychosis is considered a psychiatric emergency. The potential for harm to the fetus Puerperal psychosis is considered a psychiatric with the harm to mother and infant if the or the breastfed infant must be carefully balanced the woman and the input of with prescribed only be should Medicines untreated. remains mother Involve Health Workers/Mental Health Workers in Aboriginal and Torres Strait Islander Involve Health Workers/Mental Health Workers communities Transcultural Mental Health Workers for cultural Consider use of (telephone) interpreter and/or and linguistically diverse (CALD) populations Consult MO/NP and provide details of symptoms and signs of psychosis elicited from the history Consult MO/NP and provide details of symptoms and examination of the patient agement Advisory Service Helpline agement Advisory Service indigenous people in remote areas: National guidelines for images/dcrc/output-files/364-rr3_guidelines.pdf dementiakt.com.au/doms/ Alzheimer’s Australia: See National Dementia Helpline Consider and discuss referral of an older person to the local Aged Care Assessment Team (ACAT) via Aged Care Assessment person to the local discuss referral of an older Consider and of assistance may require higher levels are concerns that they for assessment if there My Aged Care with longer term care needs (DOMS): Suite Measurement Outcomes Dementia KT Dementia through available are Tools Referral to Geriatrician/Psychiatrist/Older Persons Mental Health Team where behavioural and Health Team where Persons Mental Geriatrician/Psychiatrist/Older Referral to symptoms (BPSD) occur psychological According to MO/NP instructions to MO/NP According management on pharmacological review if commenced Regular
• • • • • • • Recommend • • • • • • • •
Background
Psychosis, psychosis Psychotic disorders Psychotic disorders
6. Referral/consultation 5. Follow up Follow 5. Related topics Delirium, page 161 Acute severe behavioural disturbance, page 467 Suicidal behaviour, page 456 Other drugs/substances, page 494
1. May present with2 • Positive signs and symptoms (thoughts, behaviours, or sensory perceptions that are not usually present in the general population): –– delusions –– hallucinations (visual and auditory)
Psychotic disordersPsychotic –– disorganised thought and speech –– disorganised behaviour • Negative signs and symptoms (thoughts or behaviours that the person used to have before they became ill but no longer have or have to a lesser extent): –– social withdrawal –– flattened affect, reduced ability to express emotions –– restricted speech fluency –– lack of drive. This needs to be differentiated from major depression by a mental health professional • Family member may seek help because of strange, disruptive or frightening behaviour by one of their family • First presentation - often late adolescence to mid-thirties but can be at any time • Irritability and a lower threshold for anger • Suicidal thoughts or behaviours. See Suicidal behaviour, page 456 • Elevated or depressed mood 2. Immediate management2 • Ensure safety of patient, self and others • Consult MO/NP/Psychiatrist 3. Clinical assessment3 • See Mental health assessment, page 450 • Always consider non-accidental injury where injury or presentation is inconsistent with history or is unexpected in children or other vulnerable people. See Child protection, page 760 • Full Q-ADDS/CEWT score or other local Early Warning and Response Tools • Conscious scale. See Glasgow Coma Scale/AVPU, page 785 • BGL, lactate • Obtain patient history, seek history from family members if patient unable to give a history • Medication history, including non-prescription and illicit drugs. See Other drugs/substances, page 494 • Consider other conditions that may mimic a primary psychotic disorder, including another psychiatric disorder, a delirium, medical conditions, or a drug induced psychosis. Non-primary conditions include: –– adverse medication event, substance use (including marijuana) or withdrawal –– infections, sepsis, encephalitis, HIV, syphilis –– head injury, trauma, seizures, stroke, TIA, headaches, brain tumour, epilepsy, sleep deprivation
482 | Primary Clinical Care Manual 10th edition | MentalPsychotic health disorders assessment 483 Psychotic disorders Acute severe behavioural disturbance, page 467 Acute severe behavioural Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 2 2
if there is a significant risk of suicide or danger to others, psychotic symptoms or severe agitation if there is a significant risk of suicide or danger if psychosis is suspected managing any adverse effects regular physical health checks metabolic monitoring closely monitor until intoxication has resolved and then reassess closely monitor until intoxication the dose of prescribed antipsychotic or sedative medicine may need to be adjusted or sedative medicine may need to the dose of prescribed antipsychotic discuss with MO/NP evacuation/hospitalisation for mental health assessment and treatment evacuation/hospitalisation be undertaken. See emergency measures should antipsychotic and sedative medicine antipsychotic drug screen blood/urine tests including hypoxia disease Huntington disease, Parkinson dementia mood disorders, delirium, disorders such as other psychiatric hyperglycaemia, hypoglycaemia, electrolyte or metabolic disorder, thyroid disorder, SLE disorder, thyroid disorder, or metabolic electrolyte hypoglycaemia, hyperglycaemia, – – – – – – – – – – – – – – – –
patient has a poor or nonexistent support network – to ATODS with patient consent If alcohol or drug use is also a problem, referral cases where symptoms persist and/or where the Consider referral to community agencies in all other Consult MO/NP as above Refer to Mental health services: – – Monitoring of adverse effects of antipsychotic medication include: Monitoring of adverse effects of antipsychotic – – As per MO/NP instructions Psycho-education Family support and education – If under the influence of alcohol or drugs, illicit or otherwise: If under the influence of – – – is a risk of deterioration or may be a threat to themselves or others or there If the patient is unwilling without treatment: – MO/NP or psychiatrist may order: MO/NP or psychiatrist – – Consult MO/NP or psychiatrist and describe findings of assessment or psychiatrist and describe Consult MO/NP – – – –
• • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management Mood disorders
Depression, mania and anxiety - adult/child
Recommend1,2 • These topics are covered in detail in the current edition of The Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://
Mood disorders Mood publications.qld.gov.au/dataset/chronic-conditions-manual • Consult MO/NP and provide details of symptoms and signs elicited from the history and examination of the patient • Involve culturally appropriate Health Workers/Mental Health Workers in Aboriginal and Torres Strait Islander communities • Consider use of (telephone) interpreter and/or Transcultural Mental Health Workers for cultural and linguistically diverse (CALD) populations • Statewide Mental Health forms available at: https://www.health.qld.gov.au/clinical-practice/ guidelines-procedures/clinical-staff/mental-health Background3,4,5,6 • Mood refers to a prolonged emotional state that influences an individual's whole personality and life functioning. It pertains to a person's prevailing and pervading emotion and is synonymous with the terms affect, feeling state and emotion • Depression is the most common mental health disorder and is often encountered in the primary care setting • Some groups are at higher risk of depression e.g. those who are psychotic, have recently experienced loss or stress, women in the perinatal period, the chronically ill, people with physical disorders • Anxiety is a normal reaction to threat. Anxiety disorders are characterised by irrational anxiety when a threat does not exist or has passed. Behaviour designed to avoid the onset of anxiety is often an important aspect of the clinical presentation • Anxiety disorders includes: –– panic disorder –– generalised anxiety disorder –– post-traumatic stress disorder (PTSD) –– obsessive compulsive disorder –– social phobia –– specific phobias • Further information about the full range of anxiety disorders can be found at: www.beyondblue. org.au
Related topics Suicidal behaviour, page 456 Acute severe behavioural disturbance, page 467
484 | Primary Clinical Care Manual 10th edition | MentalMood disorders health assessment 485 Elevated,
Mood disorders 8
3 4 7 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental Mental health assessment, page 450
If tolerated, perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + See See the current edition of The Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://publications.qld.gov.au/dataset/chronic-condi- tions-manual Consult MO/NP See Acute severe behavioural disturbance, page 467 Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Sleep disturbance (difficulty falling or staying health and physical health related Preoccupation with, or excessive response to, physical unexplained symptoms. Symptoms may be somatic or medically Difficulty concentrating or mind ‘going blank’ Irritability Muscle tension Restlessness or feeling ‘keyed up’ or ‘on edge’ Being easily fatigued Poor judgement, out of character impulsive and risk-taking behaviour e.g. excessive spending, Poor judgement, out of character impulsive and promiscuous behaviour Symptoms of psychosis e.g. grandiose delusion Decreased need for sleep, often being active in the middle of the night Decreased need for sleep, thoughts Pressured speech and racing Increased goals, plans and activities Acute severe behavioural disturbance, page 467 emergency, see Acute severe behavioural Acute mania is a medical Inflated self esteem Headaches Use of alcohol or other substances Difficulty concentrating such as financial or marital difficulties Concerns about social problems or hopelessness Expressed feelings of helplessness Insomnia or other sleep pattern changes Insomnia or Appetite changes mood, tiredness, Irritability, low Existing history of depression, mood disorders, mania and/or anxiety disorders and/or anxiety mania mood disorders, depression, history of Existing page 456 See Suicidal behaviour, Suicidal ideation/attempts. expansive or irritable mood
• • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Anxiety presentations may include: Mania presentations may include: Mania presentations Depression presentations may include: presentations Depression 3. assessment Clinical
2. management Immediate 1. with present May –– BGL to exclude glycaemic causes of behaviour changes. See Hypoglycaemia, page 115, Hypergly- caemia, page 113 7 –– SpO2 to exclude hypoxia as cause of behaviour change • Perform general health assessment and physical examination as tolerated by patient. See History and physical examination - child, page 664 and History and physical examination - adult, page 20 • Consider differential diagnoses such as: –– thyrotoxicosis –– alcohol use or withdrawal. See Alcohol withdrawal, page 490 Mood disorders Mood –– drug use (or withdrawal) such as benzodiazepines, opiates. See Other drugs/substances, page 494 4. Management • Consult MO/NP • Refer to the current edition of The Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://publications.qld.gov.au/dataset/ chronic-conditions-manual • Exclude medical reason for presentation 5. Follow up • According to MO/NP instructions 6. Referral/consultation • Consider referral to mental health services if: –– there is a significant risk of self-harm, suicide or danger to others, psychotic symptoms or severe agitation (must refer to MO/NP/Psychiatrist) –– the patient is difficult to assess and manage • Refer to ATODS with patient’s consent if alcohol or drug misuse is a problem • For women in the perinatal period: –– consult MO/NP or midwife –– consider the impact of maternal mental illness on their capacity to safely care for their child –– consider the quality of the mother-infant relationship5 –– refer to child health services or infant/child and youth mental health services if concerned
486 | Primary Clinical Care Manual 10th edition | MentalAlcohol health and other assess drugsment 487 Alcohol and other drugs https://publications.qld.gov.au/dataset/ available from: available from: - adult/child Acute severe behavioural disturbance, page 467 Fits/convulsions/seizures, page 109 The Chronic Conditions Manual: Prevention and Management of and Management Conditions Manual: Prevention The Chronic for management of ongoing misuse of alcohol for management of ongoing
Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 4,5,6 intoxication 1,2,3 1,4
trauma (falls, motor vehicle crash, assault) intoxication due to another substance head injury insomnia blackouts/stupor, respiratory depression and coma may occur with very high doses mood instability/impulsivity/sexual or aggressive behaviour mood instability/impulsivity/sexual or aggressive impaired judgement or memory sedation poor motor coordination slurred/incoherent speech poor concentration Patients presenting intoxicated from alcohol may subsequently develop a withdrawal state, if Patients presenting intoxicated from alcohol may such history are likely to recover uneventfully there is a history of dependence. Those with no missed on assessment or withdrawing from alcohol should be An individual who presents to a facility whilst intoxicated extended the same level of care as any other patient containing products such as medicines, mouthwashes, perfumes and hand sanitiser as medicines, mouthwashes, perfumes and hand containing products such of can significantly complicate the provision use, particularly intoxication, alcohol While more likely to present not compromise it. Intoxicated individuals are appropriate care, it should below) and to have these contributing factors late, to have underlying contributing factors (see Alcohol intoxication is potentially fatal Alcohol intoxication is potentially or from ethanol from ingesting large amounts of alcoholic beverages Alcohol intoxication results Assessment findings should be reviewed after signs of intoxication have abated be reviewed after signs of intoxication have Assessment findings should patient alone Do not leave an intoxicated IV) for hypoglycaemia administering glucose (including dextrose 5% Always give thiamine before Chronic Conditions in Australia Chronic Conditions chronic-conditions-manual as far as is possible. individuals is difficult but should be pursued Assessment of intoxicated See the current edition of See the current – – – – – – – – – – –
– – – – – As above due to intoxication plus any of the following contributing factors: – – – – – – Acute intoxication with no associated medical condition:
• • • • • • • • • Alcohol withdrawal, page 490 Head injuries, page 175 Related topics Recommend • •
Background 1. May present with Ethanol, methanol, ethylene glycol methanol, ethylene Ethanol, Acute alcohol alcohol Acute Alcohol and other drugs other and Alcohol –– hypoglycaemia –– hypothermia (low body temperature) –– epilepsy –– hypotension/shock due to blood loss or sepsis –– organic brain disease –– respiratory failure –– stroke, brain injury
nd other drugs nd other –– brain tumour a –– acute alcohol withdrawal. See Alcohol withdrawal, page 490 • Children may ingest products that contain various proportions of alcohol (methylated spirits, mouthwash, aftershave, perfume) and this renders them susceptible to hypoglycaemia which may be delayed
Alcohol Alcohol • Intoxication and chronic abuse of alcohol increases the frequency and severity of injury • Never assume that an alteration in a patient’s level of consciousness is due to intoxication alone • Always re-examine a patient when sober 2. Immediate management • See DRS ABCD resuscitation/the collapsed patient, page 54 • If confused or withdrawn, strange, aggressive or acutely disturbed: –– ensure your own safety - you may need to enlist the help of the police or others. Have assistance visibly close by and ready to help, but not to further frighten or intimidate the patient –– do not approach the patient if they have a weapon and don’t put yourself in a position where you could be trapped by the patient –– See De-escalation techniques, page 789 –– explain what is happening at all times. Reassure the patient and avoid confrontation. See Acute severe behavioural disturbance, page 467 and consult MO/NP 3. Clinical assessment4 • Obtain a full patient history including past episodes: –– amount, type and duration of alcohol and any other drug or medicine intake –– the possibility of alcohols other than ethanol may need to be considered e.g. methanol and ethylene glycol initially present similar to ethanol but subsequently develop other more serious effects. See Toxicology (poisoning and overdose), page 259 –– information may come from other sources as the patient may not be able to answer questions • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + – BGL – confusion, eye signs (paralysis of extra-ocular muscles), walking abnormality and poor nutrition (signs of Wernicke’s encephalopathy) • Expose and examine the patient systematically starting at the head and progressing downwards to the toes. Remove the clothing as you move down. Do not let the patient get cold and maintain privacy with a blanket. Look and feel for any abnormalities, signs of injury • Assess suicidal intent. See Suicidal behaviour, page 456. Enquire specifically about: –– suicidal thoughts –– previous deliberate self-harm
488 | Primary Clinical Care Manual 10th edition | MentalAlcohol health and other assess drugsment 489 - - 3 Alcohol and other drugs Alcohol withdrawal, page 3 5 Child protection, page 760 See 3 3 https://publications.qld.gov.au/dataset/ Alcohol withdrawal, page 490 available from: The Chronic Conditions Manual: Prevention and Management The Chronic Conditions Manual: Prevention and
Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental
1 Glasgow Coma Scale/AVPU, page 785 Glasgow Coma Scale/AVPU, 4 4,5 in patients showing no clinical features of Wernicke’s encephalopathy or memory impairment features of Wernicke’s encephalopathy or in patients showing no clinical thiamine is recommended as a prophylactic measure present or patient has suspected or is at if signs and symptoms of Wernicke’s encephalopathy emergency high risk of Wernicke’s encephalopathy, it is a vitamin – –
for thiamine administration in patients with alcohol withdrawal, see for thiamine administration in patients with alcohol 490 weeks. See the current edition of of Chronic Conditions in Australia chronic-conditions-manual healthy patients with good dietary intake should commence on oral thiamine 300mg daily for 3-5 healthy patients with good dietary intake should days status or are chronic alcohol drinkers may be patients with poor dietary intake, poor nutritional oral thiamine 300mg daily for several ordered IM thiamine 300mg daily for 3-5 days, with – diazepam to prevent acute withdrawal diazepam to prevent acute IM or IV thiamine. – other significant findings being at risk to themselves or others if patient is assessed as as per alerts in the Q-ADDS/CEWT score as per alerts in the Q-ADDS/CEWT if GCS < 14. See abnormal BGL chronic alcohol misuse or drug dependency chronic alcohol single, male a baby after having mental illness including depression and schizophrenia depression illness including mental car crash hanging or shooting, attempt such as jumping, violent self-harm evidence of a premeditated act without the intention of being found of being the intention act without of a premeditated evidence – – – – – – – – – – – – – – – –
Be aware of the potential over the following days to develop withdrawal symptoms in a heavy drink er who ceases drinking abruptly. See evidence to show that an MO/NP or Health Care Worker’s advice can be influential in modifying or Health Care Worker’s advice can be influential evidence to show that an MO/NP drinking patterns Consider child protection for parents and carers of children. Consider child protection for parents and carers patients being discharged Consider family violence and safe transport for effects of excessive alcohol intake. There is good Offer advice and information regarding the harmful Regularly assess vital signs and GCS until either the patient sobers up or patient is evacuated/ hos Regularly assess vital signs and GCS until either that is falling pitalised. Always act on a GCS below 14 and one the care of a responsible person If allowed home, patient should be discharged into – An intoxicated patient should not be left alone to avoid aspiration Protect airway and nurse in a semi-prone position – – Thiamine dose, route and duration depend on patient’s nutritional status as follows: Thiamine dose, route and duration depend on patient’s – – – – MO/NP may order: – – – Consult MO/NP – – – Consider other high-risk factors: other high-risk Consider – – – • • • • • • • • • • • •
5. Follow up 4. Management • Advise to be reviewed the next day
6. Referral/consultation • Consult MO/NP • Consider referral to alcohol and other drugs service: –– to obtain advice if no mental illness is present –– for targeted counselling, if available, to help deal with the psychological consequences of drink- ing e.g. psychological counselling, relationship counselling nd other drugs nd other
a –– for hospital inpatient withdrawal if patient motivated but cannot safely withdraw in the community –– mental health services if there is a severe mental illness or if symptoms of mental illness persist after detoxification and abstinence –– if enforced abstinence at outstations and camps organised by the community or utilising other Alcohol Alcohol organisations, e.g. Alcoholics Anonymous, have met with some success –– Queensland Alcohol and Drug Information Service 1800 177 833
HMP Alcohol withdrawal - adult
Recommend1,2 • Treat any alcohol dependent patient presenting in a state of established withdrawal as a potential medical emergency. Delirium tremens (DT) is a medical emergency with a significant mortality rate if not treated appropriately • There is no role for antiepileptic medicines in DT - benzodiazepines are indicated • Children and youth should be managed with a Specialist MO Background3 • Progression from mild to moderate/severe withdrawal can occur quickly without treatment • The course of withdrawal depends on: –– the severity of dependence –– illnesses such as physical and mental health disorders –– psychological factors e.g. the physical environment, fears and expectations
Related topics Acute alcohol intoxication, page 487 Acute severe behavioural disturbance, page 467 Fits/convulsions/seizures, page 109
1. May present with • Variable symptoms depending on degree of dependence and time since last drink Mild withdrawal1,3 • Tremor • High pulse rate • High blood pressure • Raised temperature • Anxiety, agitation/restlessness • Insomnia
490 | Primary Clinical Care Manual 10th edition | MentalAlcohol health and other assess drugsment 491 - - - and Alcohol and other drugs Delirium, page 161 , autonomic instability e.g. autonomic instability e.g.
4 Mental health assessment, page 450 Acute severe behavioural disturbance, page 467 Acute severe behavioural 3 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental 1,3 DRS ABCD resuscitation/the collapsed patient, page 54 DRS ABCD resuscitation/the page 109 Fits/convulsions/seizures, significant medical problems e.g. delirium, visual/auditory hallucinations significant medical problems e.g. delirium, visual/auditory suicidal behaviour significant psychiatric problems e.g. psychosis, seizures for additional information, see De-escalation techniques, page 789 the patient may be in a hyper stimulated state. Attend to the patient in a quiet room with low the patient may be in a hyper stimulated state. or relative light, in the company of a familiar person, friend if restraint is required consult MO/NP do not approach the patient if they have a weapon and don’t put yourself in a position where you do not approach the patient if they have a weapon could be trapped by patient may be frightened. Reassure the patient and explain what is happening at all times, the patient avoid confrontation ensure the safety of the patient, yourself and others hallucinations affecting any of the senses hallucinations affecting severe hyperactivity, severe tremor, severe agitation severe hyperactivity, severe of delusional intensity paranoid ideation, typically response to external stimuli distractibility and accentuated confusion and disorientation, extreme agitation or restlessness - ensure safety of staff, visitors extreme agitation or restlessness - ensure confusion and disorientation, and other patients. See raised temperature disturbance of fluid balance and electrolytes, fluctuation in BP or pulse, – – – – – – – – – – – – – –
Document when last drink consumed Check for withdrawal from other sedatives (similar presentation) e.g. benzodiazepines and intoxi Obtain a full patient history including past episodes, amount, type and duration of alcohol and any Obtain a full patient history including past episodes, amount, type and duration of alcohol and drug and/or medicine intake, nutrition intake – – – – with: Urgent hospital admission is required for people – – – – There is no simple way of predicting whether a withdrawal will be serious or straightforward There is no simple way of predicting whether a withdrawal acutely disturbed behaviour: If confused or withdrawn, strange, aggressive or – drawals, DT, seizures and other medical conditions and increase the safety of the patient over the next The immediate aim is to modify the withdrawal 3-4 days See See with past to relating particularly history, recent past and including assessment rapid a Conduct – – – – sumption. The usual course is 3 days but it can be up to 14 days. Clinical features are: but it can be up to 14 days. usual course is 3 days sumption. The – Seizures may occur, usually within the first 48 hours of cessation of drinking first 48 hours of cessation occur, usually within the Seizures may alcohol con or significantly reducing 2-5 days after stopping usually develops Delirium tremens Sweating Headache Palpitations Nausea and vomiting and Nausea
• • • • • • • • • • • • • • • • Severe withdrawal
3. Clinical assessment 2. Immediate management cation with stimulants e.g. amphetamines. See Toxicology (poisoning and overdose), page 259 • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) + –– BGL –– observe for confusion, eye signs (paralysis of extra-ocular muscles), walking abnormality and poor nutrition (signs of Wernicke’s encephalopathy) • Alcohol withdrawal scale to assess severity of withdrawal and to monitor changes - Clinical Institute Withdrawal Assessment (CIWA-Ar) or Alcohol Withdrawal Scale (AWS) available from Queensland nd other drugs nd other Alcohol and Drug Withdrawal Clinical Practice Guidelines at: https://www.health.qld.gov.au/clini- a cal-practice/guidelines-procedures/medicines/drugs-of-dependence?a=167070 • Observe outstretched hands for tremor • Expose and examine the patient systematically: –– start at the head and progressing downwards to the toes Alcohol Alcohol –– do not let the patient get cold, maintain privacy and cover with a blanket –– look and feel for any abnormalities/signs of injury 4. Management
Mild withdrawal3 • Explain the situation to family and assess their support • Patient should be cared for in a calm, friendly environment and not left alone • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Re-sponse Tools) 4 hourly + – GCS. See Glasgow Coma Scale/AVPU, page 785 – observe for signs of progression or recovery • If the patient is agitated or tremulous give oral diazepam • Consult MO/NP who may order a withdrawal regimen of regular doses of diazepam • Thiamine is required. See Severe withdrawal below • Administer antiemetic as clinically indicated.3 See Nausea and vomiting, page 48 • Underlying disease or infection should be attended to Severe withdrawal1 • As for mild withdrawal + –– constant reassurance and orientation are necessary –– consult MO/NP • If signs and symptoms of Wernicke’s encephalopathy present this is a vitamin emergency –– MO/NP will order IM or IV thiamine 300 mg daily for 3-5 days then oral thiamine 300 mg daily for several weeks2,4 • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Re-sponse Tools) and GCS ½ hourly until the patient recovers or patient is evacuated/hospitalised • Administer antiemetic as clinically indicated.3 See Nausea and vomiting, page 48 • Always act on GCS < 14 or falling GCS • Diazepam is the sedative of choice for alcohol withdrawal3 • If patient is fitting, has delusions or is having hallucinations give IV diazepam. Administer with ready access to emergency equipment. See Acute severe behavioural disturbance, page 467 for antedote (flumazenil)
492 | Primary Clinical Care Manual 10th edition | MentalAlcohol health and other assess drugsment 493
4 2,5 4 Suicide
stat stat Duration Child protection, page IHW/IPAP/RIPRN Alcohol and other drugs / Repeat once if required Extended authority authority Extended See 4 ATSIHP 4 Anaphylaxis, page 102 5 mg Adult Adult 10 mg 7 and for supply of daily benzodiazepine 6 Diazepam Diazepam Recommended dosage Recommended : May cause drowsiness, oversedation, light-headedness, drowsiness, oversedation, light-headedness, cause : May
Consult MO/NP. See IV Oral Route of 4 administration . Consult MO/NP if suicidal risk present . Consult MO/NP if suicidal Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental elderly and/or debilitated
5 mg 2 mg Strength
10 mg/2 mL
Schedule 760 consideration of family violence and safe transport needs withholding benzodiazepines if resumes alcohol use withholding benzodiazepines if resumes alcohol a clear plan in case of deterioration or emergency consideration of child protection for parents and carers of children. a reliable adult to regularly monitor progress assessment of withdrawal (use same scoring daily review for 7 days by a health worker for clinical method that was used at initial presentation), has repeated failure with home withdrawal attempts a safe, alcohol-free environment is withdrawing from multiple substances has concurrent acute medical problems has an unsuitable home environment for withdrawal has moderate to severe alcohol withdrawal hallucinations has a history of complication e.g. seizures, delirium, single, male after having a baby mental illness including depression and schizophrenia or shooting violent self-harm attempt such as jumping, hanging chronic alcohol misuse or drug dependency Inject undiluted at a max. rate of 1 mL/min. Monitor respiratory rate closely. Halve the usual rate of 1 mL/min. Monitor respiratory rate closely. Inject undiluted at a max. – – – – – – – – – – – – – – – – – – – or naltrexone commencing consider clinic, MO/NP next at and day next the reviewed be to Advise – – – – – – care of responsible adult and may require: If allowed home, patient should be discharged into – – – – where patient: – – – – which exist in some regional and remote areas, Consider transfer to residential treatment units – – – Before allowing any patient home it is especially important to assess suicidal intent. See home it is especially important to assess Before allowing any patient risk assessment, page 464 Consider other high-risk factors:
Form Tablet • • • • • Injection Management of associated emergency: Management of associated hypersalivation, ataxia, slurred speech and effects on vision hypersalivation, ataxia, Note: adult dose in the Provide Consumer Medicine Information Provide Consumer Medicine ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed 5. Follow up acamprosate • Offer advice and information regarding the harmful effects of excessive alcohol intake. See the cur- rent edition of The Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia available from: https://publications.qld.gov.au/dataset/chronic-conditions-manual –– advice from a health professional can be influential in modifying drinking patterns
6. Referral/consultation1 • Consult MO/NP as above: nd other drugs nd other
a –– as per alerts in Q-ADDS/CEWT score –– GCS < 14 or falling GCS or other significant findings –– if thiamine or diazepam is required –– if patient is assessed as being at risk to themselves or others
Alcohol Alcohol • Consider referral: –– to obtain advice from alcohol and other drugs service, if no mental illness is present –– for targeted counselling, if available, to help deal with psychological consequences of drinking e.g. psychological or relationship counselling –– for hospital inpatient withdrawal if motivated but cannot safely withdraw in the community –– to mental health services if there is a severe mental illness or if symptoms of mental illness per- sist after detoxification and abstinence –– if enforced abstinence at outstations or camps organised by the community or utilising other or- ganisations e.g. Alcoholics Anonymous, have had some success –– Queensland Alcohol and Drug Information Service 1800 177 833 –– NSW Drug and Alcohol Information Services 1800 422 599 –– Victoria DirectLine, alcohol and other drugs support, advice and referral 1800 888 236
Other drugs/substances - adult/child
Recommend • The Queensland Health Dual Diagnosis Clinical Guidelines available at: http://www. dualdiagnosis.org.au/home/images/documents/Qld_DDx_Guidelines_2011.pdf • Queensland Alcohol and Drug Withdrawal Clinical Practice Guidelines available at: https:// www.health.qld.gov.au/clinical-practice/guidelines-procedures/medicines/drugs-of- dependence?a=167070
Related topics Sniffing petrol/glue/aerosol, page 289 Toxicology (poisoning and overdose), page 259 Psychotic disorders, page 481 Fits/convulsions/seizures, page 109
1. May present with1 • Acute intoxication/overdose • Dependence/tolerance issues such as asking to quit using (elective withdrawal) • Crisis (physical) withdrawal • Under the influence • Altered level of consciousness • Seizures • Drug induced psychosis 494 | Primary Clinical Care Manual 10th edition | MentalAlcohol health and other assess drugsment 495 The availa- Alcohol and other drugs Q-ADDS/CEWT score or other local Early Warning and 1 Section 5: Mental health and substance misuse | misuse substance and health Section 5: Mental
alcohol and other drugs Health Worker/Service if available alcohol and other drugs Health Worker/Service 1800 177 833 Queensland Alcohol and Drug Information Service or local state/territory services route of administration average daily consumption frequency duration and pattern of use time and amount of last use other substances such as mouthwash, methylated spirits other substances such as quantity recreational drugs such as cannabis, amphetamines, heroin, bath salts, party drugs, ecstasy, as cannabis, amphetamines, heroin, bath salts, recreational drugs such mushrooms, ketamine, PCP GHB, cocaine, LSD, magic oxycodone/oxycontin, as benzodiazepines, methadone, morphine, prescription medicines such steroids, pain killers inhalants (petrol, glue, aerosols) – – – – – – – – – – – – –
Outside of Queensland - refer to local protocols For more information on alcohol reduction and smoking cessation refer to the current edition of For more information on alcohol reduction and smoking – – – As per MO/NP instructions Consult MO and consider referral to: Contact Poisons Information Centre 13 11 26 Chronic Conditions Manual: Prevention and Management of Chronic Conditions in Australia ble from: https://publications.qld.gov.au/dataset/chronic-conditions-manual Consult MO/NP if required – – dose For prescribed medicines, record the prescribed – – – – record the: For each substance used, – – – Take comprehensive patient history Take comprehensive patient or substances have been used, which may include: Consider which substance – Perform standard clinical observations (full Insert 2 x IV cannula - use the largest possible gauge given age and vascular status possible gauge given cannula - use the largest Insert 2 x IV page 259 and overdose), See Toxicology (poisoning Response Tools) DRS ABCD resuscitation/the collapsed patient, page 54 patient, collapsed resuscitation/the See DRS ABCD MO/NP ± ECC) until CPR (EAR arrest, continue or cardiac respiratory the event of MO/NP in Consult advises to stop
• • • • • • • • • • • • • • •
6. Referral/consultation
5. up Follow 4. Management
3. Clinical assessment 2.management Immediate 4
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496 | Primary Clinical Care Manual 10th edition | 6
Obstetrics and neonatal
497 a l Antenatal t
Unintended pregnancy a Anten Recommend1 • For legal issues/consent regarding termination of pregnancy, see Queensland Clinical Guideline Therapeutic Termination of Pregnancy: https://www.health.qld.gov.au/qcg/ publications#maternity • If the health professional has a conscientious objection to involvement with decision making around termination of pregnancy care, they have a professional responsibility to ensure appropriate transfer of care within a reasonable time frame for the circumstances • Facilitate women in rural and remote areas to access termination of pregnancy services as would occur for any specialist procedure. Ensure referral and transfer systems are in place with other service level facilities • A request for a termination of a pregnancy is managed in partnership with the woman (and her family where appropriate) and her health care professional. It is led by the woman, with the health professional mindful of her physical, mental and psychosocial needs Background1 • The choice of a medical termination of pregnancy (MTOP) or surgical termination of pregnancy (STOP) is determined by factors such as; gestation, co-morbidities, certain medications, allergy to medicines, woman’s choice
Related topics Antenatal care, page 500
1. May present with • Missed period • Positive pregnancy test
2. Immediate management Not applicable
3. Clinical assessment1,2 • Confirm pregnancy by point of care pregnancy test • Provide support to woman and respect her choices • Obtain history of this pregnancy: –– expectations, experiences –– first day of LMP, usual menstrual cycle –– does the woman wish to continue with pregnancy • Calculate gestational age: –– if available, offer USS for accurate assessment of gestation –– can be performed locally by Midwife/MO - who have specific training • Social and emotional assessment: –– consider sexual assault, family violence, mental health issues, safety and privacy issues • Perform standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Warning and Response Tools)
498 | Primary Clinical Care Manual 10th edition | Anten a 4. Management1 • For routine pregnancy care. See Antenatal care, page 500 • If woman is unsure if she wants to continue the pregnancy, and/or considering termination of t
pregnancy, as early as possible in pregnancy: a l –– obtain gynaecological, obstetric and sexual health history –– confirm gestational age - this may impact on termination method –– if USS not able to be done on site, may require transfer – arrange promptly –– take routine 1st visit antenatal pathology. See Antenatal care, page 500 –– include STI screen and serum quantitative β-hCG –– offer Cervical Screening Test if due • If symptoms of STI, treat at this visit. See Sexually transmitted infections, page 615 • Options for woman to assist with decision making and counselling may include: –– The Tabbot Foundation: https://www.tabbot.com.au 1800 180 880 –– specialise in medical termination support, including for rural and remote areas –– Children by Choice: https://www.childrenbychoice.org.au/ –– Marie Stopes: https://www.mariestopes.org.au/ –– Queensland Clinical Guideline Therapeutic Termination of Pregnancy: https://www.health.qld. gov.au/qcg/publications#maternity • Consider involving social worker in decision making if appropriate/available • Women who request termination require assessment by a medical officer (who is not a conscientious objector) • Ideally, termination of pregnancy should occur within 2 weeks of the decision to proceed being agreed 5. Follow up • Advise woman to have follow up within 1-2 days: –– further support woman in her decision making, or as appropriate to individual circumstances –– check pathology results and treat as appropriate 6. Referral/consultation1
• In all cases of a woman considering termination, ensure support and appropriate referral is provided
Section 6: Obstetrics and neonatal | Antenatal 499 a l Antenatal care t
Recommend1,2 • Antenatal care should be woman centred - focus on woman’s unique needs, expectations,
a Anten aspirations, right to self-determination in terms of choice, control, continuity of care; consider social, emotional, physical, psychological, spiritual and cultural needs and expectations • In uncomplicated pregnancies, aim for around 10 visits for first pregnancy, and 7 in subsequent pregnancies • Accurate establishment of gestation is important • Dipstick testing is the least accurate method to ascertain true proteinuria (high false positives). Where possible use point of care automated analyser for dipstick. Alternatively send urine sample to pathology for PCR which is more accurate • If woman is reluctant to present for antenatal care, refer to a MO/Midwife/Aboriginal and Torres Strait Islander Health Worker or other relevant support person; ensure culturally safe environment • Cervical Screening Test can be done at any time in pregnancy, using a cyto-broom. Do not insert cytobrush or combi-brush into cervix which may cause bleeding and distress the woman • Queensland Health use the Pregnancy Health Record to guide antenatal visits. Available from https://qheps.health.qld.gov.au/caru/clinical-pathways/maternity Background1,3 • There has been a resurgence in syphilis in Aboriginal and Torres Strait Islander people in regional and remote areas of Northern Australia. This has resulted in several deaths associated with congenital syphilis infection in north Queensland. Contact the Queensland Syphilis Surveillance Centre for recommendations for treatment 1800 032 238 North-Qld-Syphilis- [email protected] • There is limited evidence to support testing for all women for vitamin D status in pregnancy. The benefits and harms of vitamin D supplementation in pregnancy remain unclear • See Queensland Clinical Guidelines: https://www.health.qld.gov.au/qcg/ publications#maternity • Multicultural Edinburgh Postnatal Depression Scales (EPDS) available at https://www. dchealthcheck.net/documents/10-2015-EPDS-Translations.pdf
1. May present with • Missed period • Urinary symptoms • Gestational diabetes • Positive pregnancy test
2. Immediate management Not applicable
3. Clinical assessment • Confirm pregnancy by urine/blood test β( -hCG) • Establish a shared plan of care early in pregnancy with Midwife, MO/Obstetrician, Aboriginal and Torres Strait Islander Healthworker as appropriate, and birthing facility • On first presentation non-Midwife should still take initial bloods if Midwife not available • If late first presentation, perform all antenatal care activities recommended for first antenatal visit
500 | Primary Clinical Care Manual 10th edition | Anten a plus those which correspond to current gestation, especially if greater than 32 weeks gestation • Woman may require transfer to a facility with adequate capacity for birthing in consultation with obstetric staff/MO at 36-38 weeks gestation (as per local policy) or earlier based on individual woman’s needs t a l If transfer out of community planned/required • Assess the need for planned transfer and discuss with the woman at each visit throughout pregnancy: consider social, cultural and medical situation • Document care plan for 36 weeks and each week thereafter. Review and update at each visit • If transfer is required, plan transfer at a gestation that: ––optimises maternal and neonatal outcomes ––minimises dislocation from supports ––minimises disruption to the family unit
Routine Antenatal Care1 • Visits require flexibility considering each woman’s clinical and emotional needs and preferences
First visit (Midwife/MO) - preferably before 10 weeks1 • Advise woman this will be a long visit Obtain history of this pregnancy • Planned, unplanned, wishes to continue with pregnancy: ––see Unintended pregnancy, page 498 • Expectations, experiences • First day of LMP; usual menstrual cycle • Calculate due date: ––offer ultrasound for accurate assessment of gestation and for early identification of multiple pregnancies (best performed at 8-13 weeks +6 days). Performed locally by Midwife/MO (who have specific training) or arrange transfer to appropriate facility ––if only LMP is available, calculate from first day of LMP + 282 days Obtain past history1 • Obstetric - previous pregnancies, gestation, place of birth, duration and type of labour (induced/ spontaneous), type of birth, birth weight of baby, infant feeding, any complications e.g. PPH, APH, pre-eclampsia, diabetes, baby with early onset Group B Streptococcal disease, preterm labour • Gynaecological - last pap smear/Cervical Screening Test, fertility problems, STIs • Medical/Surgical - hypertension, rheumatic heart disease, haematological (blood) conditions, thyroid problems, asthma, mental health/emotional e.g. depression, post-natal depression, anxiety, eating disorder, diabetes/previous gestational diabetes mellitus (GDM), operations, oral health • Medications: ––review existing medication(s) for safety in pregnancy ––immunisation e.g. influenza • Social/family - support available, financial issues, social environment • Smoking, alcohol, drugs/substance misuse - use screening tools and initiate brief intervention. See Queensland Health Pregnancy Health Record4 • Physical activity, nutrition • Travel - has women or partner travelled to a Zika affected area in previous 6 months.5 See http:// www.health.gov.au/internet/main/publishing.nsf/content/ohp-zika-health-practitioners.htm (continued)
Section 6: Obstetrics and neonatal | Antenatal 501 a l 1 t Physical examination • Weight, height, calculate BMI: –– if BMI < 20 or > 30 woman is at increased risk of complications.6 See Queensland Clinical Guideline Obesity in Pregnancy: https://www.health.qld.gov.au/qcg/publications#maternity
a Anten • BP - if elevated see Hypertension in pregnancy, page 526 • Auscultate heart (if skilled) for murmurs in areas with high prevalence of rheumatic heart disease7 • If ≥ 12 weeks assess: –– fundal height (cm) –– fetal heart rate (FHR) Pathology tests1 • Bloods - non-Midwife to take at first presentation if Midwife not available: ––FBC, BGL, blood group and antibodies, rubella antibodies ––Hepatitis B (HBsAg), Hepatitis C ––Syphilis serology, HIV (with pre-test information and consent) ––HbA1C, iron studies - in Aboriginal and Torres Strait Islander/other high risk women • Also consider: ––Vitamin D if risk factors: dark skin, limited sunlight exposure or pre-pregnancy BMI > 301 ––if BMI > 30 - LFT, UE6 ––thyroid function test (TFT) - if age > 30, ≥ 2 previous pregnancies or other risk factors for thyroid dysfunction. See Pregnancy Care Guidelines, Part D for risk factors: http://www. health.gov.au/internet/main/publishing.nsf/Content/pregnancycareguidelines ––cytomegalovirus (CMV) - only if in frequent contact with large numbers of very young children e.g. child care worker • Urine: ––dipstick and MSU for MCS (for asymptomatic bacteriuria). See Urinary tract infection in pregnancy, page 516 ––urine PCR to establish baseline proteinuria1 ––chlamydia PCR + for Aboriginal and Torres Strait Islander/other high risk people also obtain gonorrhoea PCR and trichomonas PCR. See Sexually transmitted infections, page 615 • Offer: ––Cervical Screening Test (CST) if due2 ––HVS for asymptomatic bacterial vaginosis if previous preterm birth1 Discuss chromosomal anomalies testing options to all women (regardless of age)1,7 • Every effort should be made to support rural and remote women to access this screening • Screening tests: ––combined first trimester tests: –– fetal nuchal translucency 11-13 weeks + 6 days (ultrasound), combined with –– maternal serum of pregnancy associated placental protein-A (PAPP-A) and chorionic gonadotrophin (β-hCG) between 9-13 weeks + 6 days gestation ––OR NIPT (non-invasive pre-natal screening test) - from 10 weeks gestation (if applicable/available)4 • Diagnostic tests may be offered after counselling if increased probability of chromosomal anomalies detected in screening test or according to woman’s preference: –– chorionic villus sampling < 14 weeks –– amniocentesis > 15 weeks Offer ultrasound scan (morphology) at 18-20 weeks1 Book appointment (continued)
502 | Primary Clinical Care Manual 10th edition | Anten a
Risk assessments to complete on first visitand provide advice/plan care as appropriate1,6,8,10 • Venous Thromboembolism (VTE) prophylaxis e.g. as per the Queensland Pregnancy Health
Record t • Psychosocial screening: a l ––Edinburgh Postnatal Depression Scale (EPDS), and at least once more antenatally. Available at www.blackdoginstitute.org.au/docs/CliniciansdownloadableEdinburgh.pdf ––SAFE Start Psychosocial Form (Qld) - including routine domestic violence questions (or similar tool), repeating as necessary. Available at https://qheps.health.qld.gov.au/__data/ assets/pdf_file/0031/417748/mr63ak.pdf • Assess risk factors for: ––pre-eclampsia. See Preeclampsia/eclampsia, page 530 and advise if at risk, low-dose aspirin in early pregnancy may help prevent it (preferably < 16 weeks), and calcium supplements if dietary intake low ––gestational diabetes mellitus (requires a GTT in first trimester). SeeDiabetes in pregnancy, page 521 ––preterm birth. See https://www.health.qld.gov.au/qcg/publications#maternity and advise on risk and protective factors ––women with obesity in pregnancy. See https://www.health.qld.gov.au/qcg/publications Midwife to assess for indications requiring further discussion, consultation, or referral as per the National Midwifery Guidelines for Consultation and Referral. See https://www.midwives.org.au/ resources/national-midwifery-guidelines-consultation-and-referral-3rd-edition-issue-2 Recommend • Folic acid 500 microgram daily - pre-conception until 12 weeks:1 –– increase dose to 5 mg daily if diagnosed with diabetes, previous pregnancy with neural tube defect, close family history of neural tube defects, or taking antiepileptic • Iodine 150 microgram daily - pre-conception, pregnancy and while breastfeeding (except if pre-existing thyroid condition. Seek further advice)11 • Although routine iron supplementation is not recommended1 a multivitamin which also contains iron such as Elevit® may be the preferred way to provide folic acid and iodine supplementation in your community. Check local policies • Influenza vaccine - recommended to be given to all women at any stage of pregnancy, timing depends on time of year/availability of vaccine.12 See Immunisation program, page 768 Discuss1 Using a woman centred approach start maternal counselling/education, discussing for example: • Models of care and preference identified • Birth options, including transfer out of the community at 36-38 weeks (if required as per local policy) • Support/counselling for issues that may arise as a result of leaving the community for birth, such as child care, being away from family, financial support, interruption to partners work, support person to travel with woman, cultural factors • Booking in referral (send) • Offer support for psychosocial concerns/issues (continued)
Section 6: Obstetrics and neonatal | Antenatal 503 a l
t Continuing antenatal care At every visit1 • Standard clinical observations (use Q-MEWT Rural and Remote - Antenatal/other early warning
a Anten tool) • Weeks/gestation calculation • Weight - offer woman the opportunity to be weighed and encourage self-monitoring of weight gain • BP • urine dipstick (if possible, use point of care analyser for increased accuracy of measure of protein). For an initial result detecting 1+ or greater of protein, confirm by urine PCR1 • MSU if indicated 12 weeks onwards: ––fundal height (cm) ––FHR 20 weeks onwards: ––consider pre-eclampsia i.e. proteinuria and raised BP at every visit ––discuss fetal movements (usually felt from 16-20 weeks) - advise importance of maternal awareness of fetal movements, and to contact health care professional immediately if any concerns about decreased or absent movements.13 Do not wait until the next day Additionally:1 • Check influenza vaccine has been given • Discuss test results as appropriate • General wellbeing/health check • Offer information on health in pregnancy/early parenthood/other antenatal education • Support woman to share her expectations/experiences • Discuss any concerns, including psychosocial support and mental health issues • Re-visit counselling on tobacco/drug/alcohol cessation as needed • Support the woman to prepare/plan emotionally, culturally, financially, and socially if required to travel out of community for birth14 Midwife to continually review risk assessment throughout antenatal care for indications developed or discovered during pregnancy requiring further discussion, consultation or referral as per the National Midwifery Guidelines for Consultation and Referral. See https://www. midwives.org.au/resources/national-midwifery-guidelines-consultation-and-referral-3rd-edition- issue-2 (continued)
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Additionally at 12-18 weeks • Morphology ultrasound scan due at 18-20 weeks - write woman's BMI on request form t
• At 16-24 weeks - in a syphilis outbreak-declared area, an additional syphilis tests is required a l See Queensland Clinical Guideline Syphilis in Pregnancy: https://www.health.qld.gov.au /qcg/publications#maternity Additionally at 20 weeks Discuss: • Anti-D for RhD negative women - why required, when to have i.e. 28, 34 weeks and at birth, additionally within 72 hours of any sensitising events15 • dTpa vaccination for pertussis - recommended anytime from 20-32 weeks gestation. Give every pregnancy regardless of time since last dose12 Additionally at 24-26 weeks • Ongoing support and education
Additionally at 28 weeks1
Pathology due between 24-28 weeks: • OGTT unless already diagnosed diabetes mellitus.10 See Diabetes in pregnancy, page 521 • FBC • Syphilis serology • RhD Antibody blood screen (prior to administering 1st Anti-D)15 • Urine for gonorrhoea and chlamydia PCR for Aboriginal and Torres Strait Islander women and other women with risk factors • Trichomonas PCR - only if symptomatic Give: • dTpa vaccination if not already given - ideally given at 20-32 weeks. Give every pregnancy regardless of time since last dose.12 See Immunisation program, page 768 • First dose of Anti-D for RhD negative women. Take bloods for antibody titre prior to 28 week dose. See Rh(D) immunoglobulin (anti-D) prophylaxis, page 508
Additionally at 31 weeks
• If placenta over cervical os at 18-20 week ultrasound scan, offer repeat scan at 32 weeks1 Discuss: • Planning/support for transfer to regional maternity service for birth at 36-38 weeks (as per local policy); birth preferences/length of hospital stay, supports available, expectations, concerns, time of discharge, return to community, postnatal support • Recommend family/close contacts of baby have dTpa booster (if not had in previous 10 years) at least 2 weeks prior to contact with baby12
Additionally at 34 weeks15 • EPDS reviewed and repeated • Review 28 week pathology and ensure has been actioned • Give 2nd dose of Anti-D for RhD negative women.15 See Rh(D) immunoglobulin (anti-D) prophylaxis, page 508 (continued)
Section 6: Obstetrics and neonatal | Antenatal 505 a l
t Additionally at 34-36 weeks1 Pathology due: • FBC • Additionally, for Aboriginal and Torres Strait Islander women, or women with other risk factors: a Anten ––syphilis serology, HIV ––gonorrhoea and chlamydia PCR ––trichomonas PCR - only do if symptomatic See Sexually transmitted infections, page 615 Assess: • Fetal presentation from 36 weeks via abdominal palpation: ––if suspected mal-presentation, arrange for confirmation by ultrasound if available in collaboration with MO • Recalculation of VTE risk assessment4 • Risk factors for early onset Group B Streptococcal disease:16 ––see Group B Streptococcus prophylaxis, page 540 • BMI - as relevant, discuss how a high BMI may influence ongoing clinical decision making:4 ––see https://www.health.qld.gov.au/qcg/publications Discuss: • Signs of early labour and when to go to hospital/seek advice • If not cephalic presentation, discuss options in collaboration with MO e.g. external cephalic version for breech presentation Plan: • Book elective caesarean if applicable • Transfer to obstetric facility at 36-38 weeks as per local policy (or earlier based on individual woman's needs) • Send original Pregnancy Health Record with woman. Copies in woman's medical record and for woman Additionally > 36 weeks Continue to review weekly in collaboration with MO until transferred
4. Management • Discuss with MO risk assessments undertaken and any concerns identified • Review all test results from each visit, and treat in collaboration with MO as needed: –– syphilis - contact Queensland Syphilis Surveillance Centre for recommendations for treatment 1800 032 238 [email protected] –– trichomonas - asymptomatic trichomonas should not be treated. If woman is symptomatic and tests positive for trichomonas, treat with metronidazole stat 2 g (at any stage of pregnancy).17 See Chlamydia/gonorrhoea/trichomonas/mycoplasma genitalium, page 623 –– other STIs, see Sexually transmitted infections, page 615 –– positive BV, see Bacterial vaginosis, page 628 –– if Hb low, anaemia may need investigation and treatment.18 Discuss with MO –– other test results - discuss with MO as needed
506 | Primary Clinical Care Manual 10th edition | Anten a
General counselling and education1,4 • Nutrition, physical activity, mental health, domestic/family violence
• Financial and housing issues - availability of support services, food security t a l • Lifestyle risks such as alcohol, tobacco and other drug use and benefits of cessation, fetal alcohol syndrome • Normal breast/body changes • How to manage common pregnancy symptoms. See https://www.thewomens.org.au/ health-information/pregnancy-and-birth/a-healthy-pregnancy/common-concerns-in-early- pregnancy/ • Breastfeeding (BF). See https://www.breastfeeding.asn.au/ –– skin to skin contact at birth, rooming in, feeding on demand, partner support, safe infant formula feeding if woman chooses to formula feed –– initiation of BF/baby led feeding –– positioning and attachment of baby –– exclusive BF, how to get BF off to a good start, signs baby is getting enough milk –– why teats/dummies discouraged whilst establishing BF –– benefits fo exclusive BF for around 6 months • SIDS and SUDI. See https://www.betterhealth.vic.gov.au/health/healthyliving/sudden- unexpected-death-in-infants-sudi-and-sids • Plans for pregnancy, birth, family support, cultural considerations • Preparation for birth, signs of labour, managing the pain of normal labour, birth process • Risk factors for Early Onset Group B Streptococcal disease. See Group B Streptococcus prophylaxis, page 540 • Warning signs of complications during pregnancy
General lifestyle considerations during pregnancy1 Tobacco smoking Can have negative effects on pregnancy and baby Food-acquired To prevent listeriosis, drink only pasteurised or UHT milk, avoid ripened soft infections cheese, pate, uncooked or under-cooked prepared meals Physical activity Ok to commence or continue moderate exercise. Avoid scuba diving, contact or high impact sports that may risk abdominal trauma, falls or excessive joint stress Cannabis Avoid during pregnancy Medicines Limit use to where the benefits outweigh the risk Herbal medicines Avoid in first trimester Vitamins Supplements of vitamins A, C and E are not of benefit during pregnancy and may cause harm Travel Correct use of 3 point seat belts during pregnancy ‘above and below the bump, not over it’ Compression stockings during long haul air travel Discuss travel vaccinations with Midwife or MO Oral health Safely provided during pregnancy, advise to have check/treatment if required7 Sexual Not associated with adverse outcomes during pregnancy intercourse
Section 6: Obstetrics and neonatal | Antenatal 507 a l 5. Follow up t • Follow up test results, and treat as needed 6. Referral/consultation
a Anten • As required as part of shared plan of care and/or for risks or concerns identified • Dietitian if diabetes, or BMI indicates obesity or under weight
HMP Rh(D) immunoglobulin (anti-D) prophylaxis
Recommend1,2 • All RhD negative pregnant women who have not actively formed their own anti-D should be offered Rh(D) immunoglobulin at 28 and 34 weeks of pregnancy, and for any sensitising events, including birth Background1,2 • About 1 in 7 women have a rhesus (D) negative blood group. If the baby's blood group is positive there is a risk that the baby’s blood might stimulate an immune response in the mother’s blood (sensitisation). This may result in maternal antibodies crossing the placenta and destroying the baby’s cells causing haemolytic disease of the fetus and the newborn (HDFN). Administration of Rh(D) immunoglobulin prevents HDFN • HDFN has devastating effects to the baby, such as severe anaemia or neurological damage • IgG antibodies against other Rh antigens and blood group antigens can occur but are rare • Frequently Asked Questions About the Use of Rh(D) Immunoglobulin are available at http:// resources.transfusion.com.au/cdm/ref/collection/p16691coll1/id/822 • Patient handout: https://www.ranzcog.edu.au/Womens-Health/Patient-Information-Guides/ Patient-Information-Pamphlets/Red-Blood-Cell-Alloimmunisation
1. May present with • Pregnancy with Rh(D) negative blood group identified through routine antenatal bloods • Sensitising event of a woman with Rh(D) negative blood group
2. Immediate management Not applicable
3. Clinical assessment1 • Establish current gestation • For routine doses of Rh(D) immunoglobulin given as part of antenatal care to Rh(D) negative women: –– establish that the woman has a Rh(D) negative blood group and have not actively formed their own anti-D antibodies (review 1st visit bloods) –– if unsure still give • If a sensitising event: –– determine nature of event, trimester, and assess if Rh(D) immunoglobulin is indicated (see table)
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Sensitising events requiring Rh(D) immunoglobulin1,3 First trimester Second and third trimester Postpartum
weeks 0-12 beyond week 12 t • Revealed or concealed antepartum a l • Chorionic villi sampling haemorrhage (each occasion) • Miscarriage • Amniocentesis • Termination of pregnancy • Cordocentesis (TOP) (medical or surgical) • Fetoscopy • Ectopic pregnancy • External cephalic version (whether • Following birth of a • Hydatidform mole successful or not) Rh(D) positive baby • Abdominal trauma A threatened miscarriage • Miscarriage before 12 weeks gestation • TOP does NOT require anti-D • Any other suspected intrauterine bleeding or sensitising event
4. Management1,2,3
Routine administration • All Rh(D) negative women who do not have preformed antibodies should receive Rh(D) immunoglobulin at: –– 28 weeks and –– 34 weeks and –– within 72 hours of birth • Take bloods for antibody titre at 28 weeks just PRIOR to administering the first dose of Rh(D) immunoglobulin to detect those who have already become immunised: –– no need to repeat bloods at 34 weeks, if the 28 week dose of Rh(D) immunoglobulin was given • If not logistically possible to give at these dates, it is acceptable to give within 2 weeks of the recommended timing • If the 28 week dose is inadvertently missed, give as soon as recognised, and then give the second dose 6 weeks after the first dose
For a sensitising event • If a sensitising event for an Rh(D) negative woman or if maternal blood group unknown: –– consult MO –– take bloods for: group and antibodies and Kleihauer Test –– then administer Rh(D) immunoglobulin as soon as possible, but ideally within 72 hours of the event • Follow up blood results promptly in collaboration with MO: –– Note: bloods are to assess for existing maternal antibodies and the magnitude of the fetomaternal haemorrhage (FMH) to determine if more than one dose is needed to ensure sufficient immunoprophylaxis –– if FMH quantification indicates a bleed larger than 6 mL additional Rh(D) immunoglobulin dose(s) may be required –– if further dose(s) are required, they should preferably be given within 72 hours • Routine 28 and 34 week Rh(D) immunoglobulin should still be given regardless if additional dose(s) are given for a sensitising event
Section 6: Obstetrics and neonatal | Antenatal 509 a l Extended authority t Schedule 4 Rh(D) Immunoglobulin MID RN and RIPRN must consult MO/NP MID may proceed a Anten Route of Recommended Form Strength Duration administration dosage Routine antenatal prophylaxis 28 and 34 weeks 625 units
Sensitising event in the 1st trimester stat Single pregnancy 250 250 units Inject deep and units IM Multiple pregnancy e.g. twins slowly Injection 625 units 625 If more than units Sensitising event 5 mL is required give beyond the 1st trimester in divided doses in 625 units different sites
Postpartum Unless the baby is known to be Rh(D) negative 625 units Provide Consumer Medicine Information: Note: For women with a BMI of ≥30, consider factors which may impact on adequacy of injection, including site given and needle length Contraindication: A baby, an Rh(D) positive woman Management of associated emergency: Consult MO. See Anaphylaxis, page 102 1,3
5. Follow up • If maternal antibodies are present in antenatal bloods consult with MO as ongoing monitoring may be required 6. Referral/consultation
• For sensitising events consult with MO
510 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy Pregnancy complications
HMP Ectopic pregnancy B Recommend1,2 • Ectopic pregnancy must be considered in all women of child bearing age (12-52) who present with abdominal pain and/or vaginal bleeding even if the woman does not think she is pregnant. p lications Always do a pregnancy test • The woman’s psychological needs should be acknowledged and considered at all times Background1,3 • An ectopic pregnancy occurs outside of the uterus, usually in the fallopian tube (96%) • Diagnosis cannot be excluded on physical examination • Rupture of an ectopic pregnancy can result in life-threatening haemorrhage • Diagnosis is based on a combination of transvaginal ultrasound scan (TVS) and serum ß-hCG • Symptoms of ectopic pregnancy typically appear 6-8 weeks after the last normal menstrual period (LNMP), but may occur later e.g. if the site somewhere other than the fallopian tube • See Queensland Clinical Guideline Early Pregnancy Loss: https://www.health.qld.gov.au/qcg/ publications#maternity
Related topics Acute abdominal pain, page 238 Vaginal bleeding in early pregnancy, page 513 Low abdominal pain in female, page 635
1. May present with1 • Woman may not know she is pregnant • Low abdominal pain: –– can also be in middle or upper abdomen –– timing, character and severity of pain may vary –– diffuse or to one side • Irregular vaginal bleeding (spotting) may or may not be present:2 –– volume and pattern of bleeding may vary • Ruptured ectopic pregnancy may result in haemorrhage in abdominal cavity. Symptoms include: –– shoulder tip or diaphragmatic pain –– signs of shock4 –– ↑ HR, ↓ BP, ↑ RR –– restlessness –– sweating –– cool, clammy skin –– decreased urine output • May be asymptomatic or resemble common signs and symptoms of other conditions:5 –– e.g. UTI, PID, miscarriage, appendicitis 2. Immediate management • If signs of shock: –– call for help
Section 6: Obstetrics and neonatal | Pregnancy complications 511 –– urgently contact MO/NP for advice/arrange evacuation –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status –– take blood for urgent FBC, group and hold –– commence fluid/other resuscitative measures. See Shock, page 77 –– if ruptured ectopic pregnancy, woman will require urgent surgery2
p lications –– take rapid history 3. Clinical assessment2 • Take history of this presentation. Ask about: –– bleeding/spotting - amount, when did it start, any clots –– lower abdominal pain or cramping, where, how severe –– shoulder tip pain –– feeling faint when standing Pregnancy com –– any recent abdominal trauma –– date of first day of last normal menstrual period –– any dysuria/frequency of urine –– any other symptoms/concerns • Obtain past history, including: –– antenatal history if pregnancy known - check records –– has pregnancy location been confirmed by transvaginal USS - is fetus in the uterus –– estimate fetal age based on dating scan if available –– check documentation of blood group and antibody status –– obstetric history - prior pregnancies, miscarriages, previous ectopic pregnancy, tubal surgery, infertility, contraceptives, intrauterine device use –– bleeding disorders –– medicines and allergies –– chronic diseases - diabetes, thyroid disease, polycystic ovary syndrome, celiac disease –– any known anomalies of the reproductive tract –– STIs, when, treatment, last tested –– pelvic inflammatory disease (PID) - when, treatment • Perform physical examination: –– standard clinical observations (full Q-ADDS Rural and Remote or other local Early Warning and Response Tools) –– do pregnancy test even if the woman does not think she is pregnant –– estimate amount and rate of blood loss as applicable - check loss on pad: –– colour of blood - bright, dark, presence of clots, size –– urinalysis + MSU if indicated –– gently palpate abdomen - any tenderness, rigidity, guarding, distension 4. Management • If location of fetus is not known treat as ectopic pregnancy until proven otherwise • Consult MO/NP urgently • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Take blood for FBC, group and hold • Evacuation will be required for USS confirmation of location of fetus • Keep nil by mouth • Administer analgesia as clinically indicated. See Acute pain management, page 35
512 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy • If Rh(D) negative with no pre-formed anti-D antibodies and > 12 weeks gestation offer Rh(D) immunoglobulin.6 See Rh(D) immunoglobulin (anti-D) prophylaxis, page 508 5. Follow up • Consider grief counselling if appropriate 6. Referral/consultation
• Consult MO/NP on all occasions of woman with suspected ectopic pregnancy p lications
HMP Vaginal bleeding in early pregnancy Up to 20 weeks gestation
Recommend1 • Location of fetus must be established to exclude ectopic pregnancy in all women who present with bleeding in early pregnancy • The woman’s psychological needs should be acknowledged and considered at all times • If products of conception (POC) are obtained, send for histopathology to confirm pregnancy, exclude ectopic pregnancy or detect unsuspected gestational trophoblastic disease (GTD) • For further information see: Queensland Clinical Guideline Early Pregnancy Loss available at: https://www.health.qld.gov.au/qcg/publications#maternity Background1,2 • Most common causes of bleeding in early pregnancy include viable intrauterine pregnancy, threatened miscarriage and ectopic pregnancy • Other obstetric causes include implantation bleeding (about 9 days after ovulation), sub chorionic haemorrhage, embryonic demise, anembryonic pregnancy, incomplete or threatened abortion, hydatidiform mole • Serum ß-hCG first becomes positive at 9 days post conception. ß-hCG > 5 units/L confirms pregnancy • A single ß-hCG value does not differentiate between a viable and non-viable pregnancy
Related topics Antepartum haemorrhage (APH), page 535 Ectopic pregnancy, page 511
1. May present with1,2 • Pregnancy ≤ 20 weeks gestation with: –– vaginal spotting or bleeding –– abdominal and/or shoulder tip pain –– backache –– passage of products of conception (POC) • If bleeding very heavy, may have signs of shock:3,4 –– ↑ HR, ↓ BP, ↑ RR –– restlessness –– sweating –– cool, clammy skin –– decreased urine output
Section 6: Obstetrics and neonatal | Pregnancy complications 513 2. Immediate management1 • If signs of shock: –– call for help –– consult MO/NP urgently –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status p lications –– commence fluid/other resuscitative measures. See Shock, page 77 –– insert IDC to empty bladder –– take blood for urgent FBC, group and hold –– if skilled, perform urgent speculum examination to remove POC from cervix/vagina - this may stop bleeding and restore BP • For persistent bleeding where ectopic pregnancy has been excluded MO may consider/order: –– ergometrine 250 microgram IV or IM, AND/OR –– misoprostol 800-1000 microgram per rectum AND/OR Pregnancy com –– activation of massive transfusion protocol –– See Primary postpartum haemorrhage, page 572 • Always suspect ectopic pregnancy regardless of amount of bleeding/pain:5 –– if pregnancy location unconfirmed i.e. woman has not had an USS to confirm pregnancy is in the uterus. See Ectopic pregnancy, page 511 3. Clinical assessment1,2 • Obtain history of this presentation: –– bleeding/spotting - amount, when did it start, any clots –– lower abdominal pain or cramping, where, how severe –– shoulder tip pain - may indicate intra-abdominal bleeding –– feeling faint when standing –– any recent abdominal trauma –– date of first day of last normal menstrual period –– any other symptoms/concerns • Obtain past history, including: –– antenatal history - check records –– has pregnancy location been confirmed - is fetus in the uterus confirmed by Transvaginal USS performed by experienced sonographer: –– if not confirmed always consider ectopic pregnancy until proven otherwise. SeeEctopic preg- nancy, page 511 –– estimate fetal age - based on dating scan if available –– check documentation of blood group and antibody status –– obstetric history - prior pregnancies, miscarriages, previous ectopic pregnancy, tubal surgery, infertility, contraceptives, intrauterine device use –– bleeding disorders –– medicines and allergies –– chronic diseases - diabetes, thyroid disease, polycystic ovary syndrome, coeliac disease –– any known anomalies of the reproductive tract –– STIs, when, treatment, last tested –– pelvic inflammatory disease (PID) - when, treatment • Perform physical examination: –– standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or if not available other local Early Warning and Response Tools) –– confirm pregnancy by urgent serum quantitative ß-hCG: 514 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy –– use urine ß-hCG if serum result is likely to be delayed –– estimate amount and rate of blood loss - check loss on pad: –– colour of blood - bright, dark, presence of clots, size –– urinalysis + MSU if indicated –– gently palpate abdomen - any tenderness, rigidity, guarding, distension 4. Management1 • For women with unconfirmed/uncertain pregnancy location (not known if in the uterus) consider p lications ectopic pregnancy until proven otherwise. See Ectopic pregnancy, page 511 • Keep nil by mouth • Consult with MO/NP on all occasions of bleeding in early pregnancy who may advise: –– blood for FBC + blood group, serial ß-hCG levels –– evacuation for USS, further investigations and/or treatment –– IV antibiotics - if fever or offensive cervical discharge –– STI check. See Sexually transmitted infections, page 615 –– speculum examination if clinician skilled, to check for: –– blood coming through os –– os closed or open/products of conception protruding - gently remove with sponge forceps –– offensive cervical discharge • If Rh(D) negative with no pre-formed anti-D antibodies and > 12 weeks gestation offer offered Rh(D) immunoglobulin.6 See Rh(D) immunoglobulin (anti-D) prophylaxis, page 508 5. Follow up • Consider grief counselling for parents who have experienced miscarriage/intrauterine fetal death • If not evacuated/hospitalised advise patient to be reviewed according to MO instructions • If applicable follow up STI test results and treat 6. Referral/consultation • Consult MO on all occasions of vaginal bleeding in pregnancy
Section 6: Obstetrics and neonatal | Pregnancy complications 515 HMP Urinary tract infection in pregnancy
Recommend • Ectopic pregnancy and pelvic inflammatory disease must be considered in any woman of childbearing age (12-52) who present with low abdominal pain1 p lications • Treat all asymptomatic bacteriuria (ASB) and urinary tract infections (UTI) in pregnancy with antibiotics2 • MSU culture is the standard for diagnosing ASB. In rural and remote areas, dipstick tests may be used to exclude asymptomatic bacteriuria, with positive results confirmed by urine culture. Appropriate storage of dipsticks is essential for accuracy3 Background • UTI is associated with threatened preterm labour2
Pregnancy com • ASB has been associated with preterm birth (PTB) and an increased risk of pyelonephritis in pregnant women1 • Antimicrobial therapy significantly reduces a pregnant woman’s risk of developing pyelonephritis4
Related topics Group B Streptococcus prophylaxis, page 540
1. May present with
Asymptomatic bacteriuria1,3 • Detected on routine antenatal screening MSU • Leucocytes/nitrites/protein on urinalysis • No other signs or symptoms
Cystitis - acute infection of the bladder1 • Dysuria - discomfort/burning on passing urine • Urgency • Frequency • Haematuria without evidence of systemic illness • Lower abdominal pain and sometimes mild low back pain • Leucocytes/nitrites/protein on urinalysis
Pyelonephritis - acute infection of the kidney1 • Fever, rigors, nausea, vomiting • Flank pain
2. Immediate management Not applicable
3. Clinical assessment3,4 • Obtain history of this presentation. Ask about: –– current urinary symptoms - dysuria, frequency, urgency, haematuria –– abdominal pain –– suprapubic pain
516 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy –– vaginal discharge –– fever, rigors, flank tenderness –– nausea, vomiting –– anorexia –– altered mental status - suspect sepsis. See Sepsis/septic shock, page 80 –– fetal movements - feeling as normal or decreased –– any other symptoms/concerns • Obtain past history, including: p lications –– antenatal history - check records –– estimate fetal age based on dating scan if available; or LNMP –– previous UTIs - when, treatment –– relevant medical history - e.g. diabetes, anatomical abnormalities with urinary tract –– STIs, when, treatment, last tested • Perform physical examination: –– standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or if not available use other local Early Warning and Response Tools) –– palpate abdomen. Any: –– tenderness in loin, groin, or suprapubic area - may indicate calculi or upper tract infection –– contractions, tightening –– FHR (if skilled) - maternal systematic infection can increase FHR • Obtain: –– MSU for MCS on all pregnant women prior to treatment5 –– STI tests for gonorrhoea, chlamydia and trichomonas PCR and bacterial vaginosis. See Sexually transmitted infections, page 615 –– syphilis serology if not already completed antenatally, or due. See Antenatal care, page 500 4. Management
• If symptomatic, ensure differential diagnosis are considered.1 See: –– Ectopic pregnancy, page 511 –– Low abdominal pain in female, page 635 –– Preterm labour, page 544 –– Sexually transmitted infections, page 615 –– Acute abdominal pain, page 238 e.g. appendicitis • Consult with MO if uncertain • If pyelonephritis or signs of sepsis:6 –– consult MO urgently –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status –– MO will order IV ceftriaxone and arrange evacuation/hospitalisation –– ensure MSU taken prior to giving antibiotics, unless clinically inappropriate • If asymptomatic bacteriuria (ASB):5 –– treat based on results of urine MCS –– if dipstick suggests ASB e.g. nitrite, protein, blood, leukocyte AND there are concerns treatment might be delayed while waiting for results of MCS e.g. difficulty to recall woman:3 –– consider commencing antibiotics without waiting for results –– treat as per acute cystitis • If acute cystitis:5 –– start antibiotics based on symptoms –– check local patterns of resistance before selecting antibiotic
Section 6: Obstetrics and neonatal | Pregnancy complications 517 –– give: –– nitrofurantoin - except if near term or delivery OR –– amoxicillin + clavulanic acid OR –– cefalexin –– ensure MSU for MCS is obtained prior to starting antibiotics –– check results and modify treatment based on culture and susceptibility testing p lications –– encourage increasing fluid intake and complete bladder emptying7
If Group B Streptococcus on culture, antibiotic cover in labour is required even if previously treated. Make a note in antenatal record and advise woman See Group B Streptococcus prophylaxis, page 540
Pregnancy com Extended authority Schedule 4 Nitrofurantoin ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP MID and RIPRN may proceed Route of Recommended Form Strength Duration administration dosage 50 mg Capsule Oral 100 mg bd 5 days 100 mg Provide Consumer Medicine Information: Take with food or milk to reduce nausea and improve absorption. May cause nausea, vomting, headache, anorexia, diarrhoea, abdominal pain, allergic skin reactions, headache, drowsiness or dizziness. Report difficulty breathing, development of a cough or numbness or tingling. May turn urine a brownish colour Contraindication: Renal impairment. Women near term or delivery due to risk of neonatal haemolytic anaemia Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 5,9
518 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy
Extended authority Schedule 4 Amoxicillin + clavulanic acid ATSIHP/IHW/IPAP/RIPRN/MID
ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN and MID may proceed Route of Recommended Form Strength Duration administration dosage p lications 500 mg + Adult Tablet Oral 5 days 125 mg 500 mg + 125 mg bd
Provide Consumer Medicine Information: Take with food. May cause rash, diarrhoea, nausea and candidiasis. Can cause severe colitis due to Cl. difficile Contraindication: Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems. Avoid in women with premature rupture of the membranes as there may be an increased risk of neonatal necrotising enterocolitis Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 5,8
Extended authority Schedule 4 Cefalexin ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP MID and RIPRN may proceed Route of Recommended Form Strength Duration administration dosage 250 mg Capsule Oral 500 mg bd 5 days 500 mg Provide Consumer Medicine Information: May cause rash, diarrhoea, nausea, vomiting, dizziness, headache and candidiasis Note: If renal impairment seek MO/NP advice Contraindication: Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 5,10
Section 6: Obstetrics and neonatal | Pregnancy complications 519 Extended authority Schedule 4 Ceftriaxone ATSIHP/IHW/IPAP ATSIHP, IHW, IPAP, MID, RIPRN and RN must consult MO/NP Route of Recommended Form Strength Duration
p lications administration dosage Injection Adult (powder for 1 g IV stat 1 g reconstitution) Provide Consumer Medicine Information: May cause nausea, diarrhoea, rash, headache, dizziness, and candidiasis Note: Inject over 2-4 minutes. Can cause severe colitis due to Cl. difficile.If renal impairment seek MO/ NP advice Contraindication: Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware Pregnancy com of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Contact the MO/NP. See Anaphylaxis, page 102 11,12,13
5. Follow up5 • Check results of MSU. Modify treatment if required, based on culture and susceptibility testing • If Group B Streptococcus on culture, antibiotic cover in labour required, even if treated. Make a note in antenatal record and advise woman. See Group B Streptococcus prophylaxis, page 540 • Repeat MSU 1-2 weeks after treatment completed. If persistent bacteriuria, treat with a second course of antibiotics • Following resolution, repeat MSU at antenatal visits to monitor • If recurrent infections, or at risk of complications e.g. has diabetes, consider prophylaxis for remainder of pregnancy - discuss with MO • Follow up STI test results and treat as required. See Sexually transmitted infections, page 615 • Consult MO if UTI persists or recurs after treatment 6. Referral/consultation • Consult MO/NP as above
520 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy Diabetes in pregnancy
Recommend1 • Pre-existing diabetes should be treated as a complicated pregnancy • It is strongly recommended that pre-pregnancy and pregnancy care of women with pre-existing diabetes is provided by a multidisciplinary team • Encourage women with pre-existing diabetes to obtain as near as non-diabetic glycaemic control p lications as possible prior to becoming pregnant • High dose folate supplementation is recommended pre-pregnancy for women with diabetes: –– 5 mg per day, commencing 1 month prior to pregnancy Background1,3 • Women with pre-existing diabetes (types 1 and 2) are more prone to complications of pregnancy, such as higher rates of preeclampsia, prematurity and caesarean section • Principles of management of diabetes in pregnancy include: –– aiming for BGL as close to the normal (non-diabetic) range as possible –– ensure risks for maternal hypoglycaemia are minimised • Basic management includes: –– monitoring BGLs –– adopting healthy eating pattern –– physical activity • See Queensland Clinical Guideline Gestational Diabetes Mellitus: https://www.health.qld.gov. au/qcg/publications#maternity
Related topics Antenatal care, page 500
1. May present with1 • Pregnant with: –– pre-existing diabetes - type 1 or 2 diagnosed prior to pregnancy –– risk factor(s) for gestational diabetes mellitus (GDM) –– diagnosis of GDM
2. Immediate management Not applicable
3. Clinical assessment • If pre-existing diabetes and pregnancy test positive: –– obtain medication history –– promptly discuss with MO/Pharmacist regarding the need for/safety of use of current medicines in pregnancy –– oral hypoglycaemics may need to be substituted with insulin –– refer to MO/obstetrician for further assessment and pregnancy care planning • For gestational diabetes mellitus (GDM) - see following flowchart
Section 6: Obstetrics and neonatal | Pregnancy complications 521 Screening and diagnosis of GDM2
Assess all pregnant women for risk factors p lications Risk factors for GDM GDM diagnosis • BMI > 30 kg/m2 - pre-pregnancy or on entry to care OGTT - preferred test for diagnosis • Ethnicity - Asian, Indian subcontinent, Aboriginal, Torres One or more of: Strait Islander, Pacific Islander, Maori, Middle Eastern, • Fasting ≥ 5.1 mmol/L Non-white African • 1 hour ≥ 10 mmol/L • Previous GDM • 2 hour ≥ 8.5 mmol/L • Previous elevated BGL
Pregnancy com • Maternal age ≥ 40 years HbA1c (if OGTT not suitable) • Family history DM - 1st degree relative or sister with GDM • 1st trimester only • Previous large for gestational age - birth weight > 4500 g or > • Result ≥ 41 mmol/mol (or 5.9%) 90th percentile OGTT advice for women: • Previous perinatal loss • Fast (except for water) for 8-14 • Polycystic ovarian syndrome hours prior to OGTT • Medications - corticosteroids, antipsychotics • Take usual medications • Multiple pregnancies
First trimester No Risk factors Yes 2 hour 75 g OGTT (or HbA1c)
24-28 weeks gest OGTT 2 hour 75 g OGTT No (or HbA1c) abnormal
Yes
OGTT No normal
Yes
Routine GDM Care antenatal care
Flowchart adapted from: Queensland Clinical Guideline: Gestational Diabetes Mellitus (2015)
522 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy 4. Management • Multidisciplinary approach recommended: –– include the woman, Midwife, Obstetrician, Endocrinologist (or physician experienced in diabetes care during pregnancy), Diabetes Educator and Dietitian –– consider optometrist and dental input –– ensure early referral(s) • Provide advice on the importance of monitoring and controlling BGL during pregnancy
• Provide emotional support to the woman p lications
Pre-existing diabetes in pregnancy1,3 • First antenatal visit should occur as soon as possible once pregnancy confirmed • Initial evaluation may include: –– usual antenatal testing. See Antenatal care, page 500 –– serum glucose, HbA1c, lipid profile, TSH, thyroid peroxidase antibodies, urine albumin/creatine ratio, creatinine clearance, Hb, serum ferritin –– if > 35 years of age, resting ECG –– recommend and continue high dose folate (5 mg/day) until 12 weeks gestation • A management plan will be developed to achieve near-normal glycaemia. This may include: –– individualised dietary advice –– encouraging daily physical activity –– self-monitoring BGL - fasting and 1-2 hours postprandial (after meals) –– insulin in place of oral hypoglycaemics, titrated as needed • Additionally specialist may consider: –– examination of retina during each trimester, more frequent if retinopathy is present –– USS monitoring of fetal growth and amniotic fluid volume 4 weekly from 28-36 weeks –– close surveillance for new diabetes complications and monitoring of existing complications Gestational diabetes mellitus (GDM)1,2 • See Antenatal schedule of care for GDM (table) • Suggested BGLs for GDM are: –– fasting ≤ 5.0 mmol/L –– 1 hour after commencing meal ≤ 7.4 mmol/L –– 2 hours after commencing meal ≤ 6.7 mmol/L • Insulin may be required for optimal control: –– must be calculated and ordered by clinician with expertise in diabetes in pregnancy –– will need regular review and titration to achieve glycaemic goals
Section 6: Obstetrics and neonatal | Pregnancy complications 523 Antenatal schedule of care for GDM2 At initial GDM diagnosis Discuss/review/refer Considerations Review history Previous GDM, medications p lications Diabetes Educator consult For GDM education within 1 week of diagnosis Dietitian review Within 1 week of diagnosis Psychosocial assessment/support Refer as required BGL self-monitoring Commence self-monitoring BMI (pre-pregnancy) Discuss healthy weight gain targets Physical activity, lifestyle advice Include smoking cessation
Pregnancy com Baseline ultrasound scan (USS) At 28-30 weeks Initial laboratory investigations Serum creatinine If diabetes in pregnancy (pre existing/ Optometrist/ophthalmologist review for undiagnosed diabetes mellitus suspected) diabetic retinopathy Microalbuminuria for diabetic nephropathy Each visit Discuss/review/refer Considerations Clinical surveillance Review for complications (e.g. pre-eclampsia) Weigh Review weight gain trends, diet, exercise Test urine Investigate ketonuria, proteinuria Review BGL self-monitoring record Review patterns, trends and mean BGL Psychosocial assessment/support Refer as required Fetal growth and wellbeing (abdominal circumference; USS 2-4 weekly as indicated) If pharmacological therapy commenced Follow-up contact within 3 days Weekly diabetes educator review Dietitian review Review suitability of model of care Low risk GDM (Low risk not suitable if insulin or metformin Diabetic Clinic required) Obstetric Other Review next contact requirements Fortnightly until 38 weeks (increase frequency if: suboptimal BGL, Fortnightly until 36 weeks early diagnosis, diabetes in pregnancy, pharmacological therapy commenced) Weekly until birth Other
524 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy Hypoglycaemia in pregnancy2 • Fasting BGLs tend to decrease in pregnancy • Levels of 3.5 mmol/L may by physiologically normal and asymptomatic • Hypoglycaemia is uncommon in women with GDM: –– if asymptomatic confirm the accuracy of results prior to treatment –– for symptoms. See Hypoglycaemia, page 115 • Mild hypoglycaemia:
–– BGL < 4.0 mmol/L p lications –– may or may not have symptoms of low BGL • Severe hypoglycaemia: –– BGL very low, generally < 3.0 mmol/L –– confusion, potential loss of consciousness
Treating hypoglycaemia in women on glucose lowering medication2 • Give 15 g serve of fast acting carbohydrates, such as: –– 5-7 glucose jelly beans –– glass of soft drink - not diet –– Lucozade® 100mL –– 3 heaped teaspoons of sugar or honey dissolved in water • If after 15 minutes symptoms persist or BGL < 4.0 mmol/L –– repeat one serve of above –– do not over treat with fast acting carbohydrates, as may lead to rebound hyperglycaemia –– when BGL is ≥ 4.0 mmol/L give sandwich, crackers, a glass of milk (longer lasting carbohydrate) or usual meal if within 30 minutes 5. Follow up • As per individualised plan of care 6. Referral/consultation • Early referral for a multidisciplinary approach to care as per local protocols/individualised plan of care
Section 6: Obstetrics and neonatal | Pregnancy complications 525 HMP Hypertension in pregnancy
Recommend1 • Severe hypertension in pregnancy is life threatening and should be treated as a medical emergency p lications • Hypertension in pregnancy, whether chronic or newly arising is a significant risk to the health of both the mother and her baby and must always be managed in consultation with an MO/ Obstetrician • Correct BP measurement techniques are critical to correct diagnosis Background1,2 • Pre-existing hypertension is a strong risk factor for preeclampsia • Hypertensive disorders of pregnancy: Pregnancy com –– gestational hypertension - arises after 20 weeks with no features of pre-eclampsia and resolves within 3 months postpartum. Up to 25% of women will be in the process of developing preeclampsia but have not yet developed proteinuria or other manifestations –– chronic hypertension - hypertension confirmed preconception or < 20 weeks without a known cause (essential, secondary, white coat) –– preeclampsia - a multi-system disorder characterised by hypertension and involvement of one or more other organ systems and/or the fetus –– preeclampsia superimposed on chronic hypertension - where a woman with pre-existing hypertension develops systemic features of preeclampsia after 20 weeks gestation • Dipstick testing is the least accurate method to ascertain proteinuria (high false positives): –– where possible use point of care automated analyser for dipstick and confirm proteinuria of 2+, 3+ or repeated 1+ with urine protein/creatinine ratio (urine PCR)2,3 • See Queensland Clinical Guideline Hypertensive Disorders of Pregnancy: https://www.health. qld.gov.au/qcg/publications#maternity
Related topics Preeclampsia/eclampsia, page 530
1. May present with2 • Pregnant woman with: –– new onset of hypertension arising > 20 weeks gestation –– normotensive with rise in sBP ≥ 30 mmHg and/or rise in dBP ≥ 15 mmHg –– pre-natal diagnosis of chronic hypertension with increase in BP –– ± signs of preeclampsia. See Preeclampsia/eclampsia, page 530
526 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy
Hypertension definitions in pregnancy1 systolic BP (sBP) ≥ 140 mmHg AND/OR Hypertension diastolic BP (dBP)≥ 90 mmHg sBP ≥ 141 mmHg to 159 mmHg AND/OR Moderate hypertension dBP ≥ 91 mmHg to 109 mmHg sBP ≥ 160 mmHg AND/OR Severe hypertension dBP ≥ 110 mmHg p lications sBP ≥ 170 mmHg with or without dBP ≥ 110 mmHg is a medical emergency Note: a rise in sBP ≥ 30 mmHg and/or rise in dBP ≥ 15 mmHg may be significant in some women (who are not hypertensive), and require further investigation for features of preeclampsia
2. Immediate management1 • Consult MO/Obstetrician urgently if: –– severe hypertension –– and/or any signs of preeclampsia. See Preeclampsia/eclampsia, page 530 –– and/or any concerns about fetal wellbeing e.g. decreased fetal movements • If severe hypertension: –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status –– antihypertensive required urgently if sBP ≥ 160 and/or dBP ≥ 100 mmHg –– consider giving antihypertensive if sBP ≥ 140 or dBP ≥ 90 mmHg –– when giving antihypertensive aim: –– to reduce the sBP to 130-150 mmHg and dBP to 80-100 mmHg –– for gradual and sustained lowering of BP to avoid maternal hypotension and fetal compromise –– monitor BP 15-30 minutely until stable –– continual monitoring of FHR should occur via CTG - if available and if skilled –– urgent evacuation required for specialist Obstetric care
Extended authority Schedule 4 Nifedipine ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO RIPRN must consult MO unless circumstances do not allow, in which case notify the MO as soon as circumstances do allow MID may proceed to a max. of 2 doses Route of Recommended Form Strength Duration administration dosage stat Tablet 10 mg May be repeated after 45 (conventional Oral 10-20 mg 20 mg minutes on MO orders to a release) max. dose of 80 mg Provide Consumer Medicine Information: May cause nausea, headache, flushing, dizzinesss, hypotension, peripheral oedema Note: May increase effects of magnesium sulfate and risk of hypotension; use cautiously Management of associated emergency: Consult MO. See Anaphylaxis, page 102 1,2,3
Section 6: Obstetrics and neonatal | Pregnancy complications 527 Schedule 4 Hydralazine Prescribing guide
MID, RIPRN and RN only. Must be ordered by an MO Route of Recommended Form Strength Duration administration dosage p lications *Intermittent bolus dose 5-10 mg injected over 3-10 minutes Repeat doses of 5 mg, 20 stat minutes apart if required Injection (to max. of 30 mg) (powder for 20 mg IV Cease if maternal reconstitution) pulse greater than Infusion 125 beats/minute (via controlled infusion Pregnancy com device) Commence at 10-20 mg/ hour and titrate to BP Provide Consumer Medicine Information: May cause tachycardia, headache, flushing and palpitations Note: *5 mg if fetal compromise. Monitoring BP and pulse every 5 minutes during administration and until stable. Detailed administration advice available in Appendix C of Queensland Maternity and Neonatal Clinical Guideline: Hypertensive disorders of pregnancy, available at: https://www.health.qld. gov.au/qcg/publications Contraindications: Severe or immediate allergic reaction to hydralazine. SLE, severe tachycardia, myocardial insufficiency and right ventricular heart failure Management of associated emergency: Consult MO. See Anaphylaxis, page 102 1
3. Clinical assessment1,2 • Refer to Midwife/MO for clinical assessment. If Midwife not available, complete what you can within your scope of practice, and always consult with MO • Take patient history including: –– any symptoms of preeclampsia. See Preeclampsia/eclampsia, page 530 –– other associated symptoms –– obstetric history: –– current gestation, BP during this pregnancy, pre-existing proteinuria - if so, has this increased –– ask about fetal movements - normal, decreased, any concerns. See Antenatal care, page 500 –– past history. Ask about: –– diabetes, kidney disease, endocrine disorders - Cushing’s syndrome, SLE –– known pre-natal hypertension –– medicines • Perform standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or if not available other local Early Warning and Response Tools) • Perform physical examination, including: –– weight –– urinalysis dipstick for protein - use point of care automated analyser if possible –– if ≥ 2+, 3+ or repeated 1+ proteinuria, or preeclampsia is suspected, obtain urine PCR –– FHR if skilled –– inspect for signs of preeclampsia. See Preeclampsia/eclampsia, page 530
528 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy 4. Management1,2 • Consult MO for all occasions of hypertension in pregnancy • Take pathology: –– blood tests for FBC, UEC, urate, LFT including LDH –– if proteinuria if positive on dipstick obtain urine PCR • Monitor FHR - use CTG if accessible, > 24 weeks gestation and skilled • MO may advise USS for fetal growth, amniotic fluid volume and umbilical artery Doppler assessment p lications • Admission to hospital likely if: –– fetal wellbeing a concern –– sBP > 140 mmHg or dBP > 90 mmHg –– symptoms of preeclampsia, proteinuria or abnormal bloods • If non-severe hypertension: –– confirm by measuring BP over several hours –– if sBP < 140 mmhg and dBP < 90mmHg on subsequent checks and no symptoms of preeclampsia or proteinuria, MO may suggest continued review/antenatal appointments according to the woman’s clinical needs 5. Follow up1,2 • Ongoing close monitoring is required to detect the development of preeclampsia in collaboration with MO • If diagnosed with gestational or chronic hypertension, advise woman to present immediately if any symptoms of preeclampsia arise. See Preeclampsia/eclampsia, page 530 6. Referral/consultation • Always consult with MO and refer to Obstetrician for this presentation and ongoing antenatal care
Section 6: Obstetrics and neonatal | Pregnancy complications 529 HMP Preeclampsia/eclampsia
Recommend1 • Women who have preeclampsia must be evacuated/hospitalised and monitored closely under the care of an obstetrician p lications • Magnesium sulfate is the anticonvulsant medicine of choice for prevention and treatment of eclampsia Background2,3,4 • Preeclampsia: –– is a major cause of morbidity and mortality for a woman and her baby –– is a multisystem disorder characterised by hypertension arising after 20 weeks gestation and accompanied by one or more signs of organ involvement
Pregnancy com –– can progress at an unpredictable rate • Raised BP is commonly (but not always) the first manifestation • Eclampsia is the development of one or more convulsions superimposed on preeclampsia in the absence of other neurological conditions that could account for the seizure • Proteinuria is the most commonly recognised feature after hypertension, but is not mandatory for a clinical diagnosis • Dipstick testing is the least accurate method to ascertain proteinuria (high false positives). Where possible use point of care automated analyser for dipstick and confirm proteinuria of 2+, 3+ or repeated 1+ with urine protein/creatinine ratio (urine PCR) • Risk factors for preeclampsia: past history of preeclampsia, preexisting medical conditions (diabetes, chronic hypertension, systemic lupus erythematosus, chronic kidney disease), pre pregnancy BMI > 25, multiple pregnancy, family history of preeclampsia, first pregnancy, prior placental insufficiency, advanced maternal age, use of assisted reproductive technology • See Queensland Clinical Guideline: Hypertensive Disorders of Pregnancy: https://www.health. qld.gov.au/qcg/publications#maternity
Related topics Hypertension in pregnancy, page 526
1. May present with2 • Pregnant woman with: –– hypertension arising > 20 weeks gestation –– accompanied by one or more features of preeclampsia • The degree of hypertension and proteinuria, and presence/absence of other clinical manifestations of preeclampsia is highly variable
530 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy
Features of preeclampsia in addition to hypertension1,2,4
• Proteinuria on dipstick - 2+, 3+ or repeated 1+ • Fetal growth restriction • Severe features: ––systolic BP ≥ 160 or diastolic BP ≥ 110 (confirmation within 15-30 minutes is sufficient) ––persistent new and/or severe headache: ‘worst headache of my life’
––visual disturbances - blurred vision, flashing lights or sparks, dark areas or gaps in visual field, p lications double vision, blindness in one eye ––altered mental state/confusion ––severe epigastric pain and/or right upper quadrant pain ––hyper-reflexia and ankle clonus ––dyspnea, pulmonary oedema ––oliguria ––nausea and/or vomiting ––stroke
Imminent eclampsia - at least two of the following:1 • Frontal headache • Visual disturbance • Altered level of consciousness • Hyper-reflexia • Epigastric tenderness Eclampsia - fitting
2. Immediate management1,2 If fitting (eclampsia) • Send for help • Urgently consult MO • Commence resuscitative measures. See DRS ABCD resuscitation/the collapsed patient, page 54
• Ensure patent airway, give O2 by mask. See Oxygen delivery, page 64 • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Magnesium sulfate will be ordered by the MO • Midazolam IV or IM may be given if: –– the seizure is prolonged while initiating magnesium sulfate OR –– if seizures reoccur during administration of magnesium sulfate –– see Fits/convulsions/seizures, page 109 (note: seizures are normally self -limiting) • Arrange urgent evacuation • Be guided by MO for further management whilst awaiting evacuation, including: –– perform standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Warning and Response Tools) –– BP and HR every 5 minutes
–– SpO2 –– conscious state. See Glasgow Coma Scale/AVPU, page 785 –– insert IDC and monitor urine output hourly, strict fluid balance monitoring –– RR and patella reflexes hourly
Section 6: Obstetrics and neonatal | Pregnancy complications 531 –– monitor fetal HR –– continuous CTG if > 24 weeks pregnant if available/skilled to use
If features of severe preeclampsia or imminent eclampsia1 • Urgently consult MO p lications • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Arrange urgent evacuation for further management • Monitor standard clinical observations every 5 minutes • MO may order: –– nifedipine or hydralazine to treat hypertension. See Hypertension in pregnancy, page 526 and/or –– magnesium sulfate to prevent eclampsia Pregnancy com
If magnesium sulfate ordered1 • See Queensland Clinical Guideline Hypertensive Disorders of Pregnancy for detailed administration advice: https://www.health.qld.gov.au/qcg/publications#maternity - or relevant local policy • Prior to commencing ensure: –– calcium gluconate monohydrate 10 % in 10 mL vial available in case of respiratory depression/overdose –– resuscitation/ventilator support immediately available –– dedicated IV line available • Take base line observations: –– BP, HR, RR, level of consciousness
–– SpO2, patella reflex, abdominal palpation, FHR - if skilled • Monitor during loading dose: –– BP, HR, RR 5 minutely until stable - for minimum of 20 minutes
–– SpO2 continuously –– FHR 15-30 minutely. Monitor via continuous CTG - if available and skilled in use –– observe for side effects • After loading dose - check deep tendon (patella) reflexes • Cease the infusion and consult MO/Obstetrician immediately if: –– RR < 12 breaths/minute or > 4 breaths/minute below baseline –– absent deep tendon reflexes, OR –– diastolic BP decreases > 15 mmHg below baseline
532 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy
Schedule Unscheduled Magnesium sulfate Prescribing guide
MID, RIPRN and RN only. Must be ordered by an MO Use local protocols for administration of magnesium sulfate if available Route of Recommended Form Strength Duration administration dosage Loading dose stat 4 g p lications Infuse over Ampoule/vial 20 minutes Draw up dose and dilute to a total of Injection 2.47 g/5 mL using controlled 20 mL with sodium chloride 0.9% infusion device e.g. syringe Prefilled syringe pump No dilution required Maintenance dose 1 g/hour Commence after last seizure or birth whichever comes first IV Infuse at Loading dose 5 mL/hour for 24 Ampoule/vial 4 g/20 mL hours Draw up 10 g and further dilute with water for using controlled sodium chloride 0.9% injections infusion device Pre-filled to a total of 50 mL syringe Maintenance (Baxter®) dose Prefilled syringe 10 g/50 mL No dilution required water for New onset or persistent seizures Infuse over injections while on magnesium sulfate 5 minutes Give a further 2 g Repeat in 2 diluted in a minimum of 10 mL minutes if sodium chloride 0.9% seizures persist Provide Consumer Medicine Information: May cause nausea, vomiting and transient hot flushing Note: If impaired renal function, reduce maintenance dose to 0.5 g/hour. Monitor for signs of magnesium toxicity: nausea, vomiting, flushing, hypotension, muscle weakness, muscle paralysis, blurred or double vision, CNS depression and loss of reflexes Management of associated emergency: Contact MO/Obstetrician. Cease infusion. Calcium gluconate 10% in 10 mL should be readily available in case of respiratory depression/overdose. Hypotension alone will generally respond to IV fluids and parenteral calcium is rarely necessary. Also see Anaphylaxis, page 102 1,5,6,7,9
Section 6: Obstetrics and neonatal | Pregnancy complications 533 Schedule Unscheduled Calcium gluconate monohydrate Prescribing guide
MID, RIPRN and RN only. Must be ordered by an MO Route of Recommended Form Strength Duration administration dosage p lications stat
Injection 0.22 mmol IV 2.2 mmol (10 mL) Inject slowly over in 1 mL 5-10 minutes in a large peripheral vein Provide Consumer Medicine Information: Given for overdose of magnesium sulfate Note: High risk medicine which can be rapidly fatal in overdose. Hypotension alone will generally respond to IV fluids and parenteral calcium is rarely necessary. Avoid extravasation as will cause
Pregnancy com tissue necrosis. Subcut and IM route contraindicated Management of associated emergency: Consult MO/Obstetrician. See Anaphylaxis, page 102 5,8
3. Clinical assessment2,4 • Refer to Midwife/MO for clinical assessment. If no Midwife available, complete what you can within your scope of practice and always consult with MO • Obtain history of presenting concern: –– any associated symptoms –– specifically ask about signs of preeclampsia • History of current and previous pregnancy. See Antenatal care, page 500 • Establish current gestation: –– ask about fetal movements - normal, decreased, any concerns • Past history - any: –– renal disease, preexisting hypertension –– risk factors for preeclampsia • Perform standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Warning and Response Tools) • Fetal HR • Dipstick for proteinuria - use point of care automated analyser if available for increased accuracy • Confirmation of proteinuria 2+, 3+ or repeated 1+ by urine PCR • Check for signs of preeclampsia 4. Management2
• Promptly refer to MO for further investigations and management for all women who present with hypertension in pregnancy with symptoms of preeclampsia. • These women will likely require evacuation/hospitalisation for further investigations 5. Follow up6 • If not evacuated/hospitalised review according to MO instructions • Once a diagnosis of preeclampsia is established, testing for proteinuria is no longer useful • Consult MO promptly if BP raised again
534 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy 6. Referral/consultation • Consult MO on all occasions of BP > 140/90 mmHg in pregnancy
HMP Antepartum haemorrhage (APH) Vaginal bleeding after 20 weeks gestation
1,2 Recommend p lications • APH associated with maternal or fetal compromise should be treated as an obstetric emergency • Do not perform digital vaginal examination • Suspect placenta praevia in any woman > 20 weeks who presents with vaginal bleeding Background1 • Antepartum haemorrhage (APH) is bleeding > 20 weeks gestation which is unrelated to labour or delivery. Causes may include: –– placenta praevia (20%) - placenta partially or completely overlies the cervical os –– placental abruption (30%) - part of the placenta has separated from the uterine wall: –– bleeding may be concealed - retained in the uterine cavity –– uterus tender ± uterine contractions –– always consider in women with history of trauma e.g. motor vehicle crash, fall, domestic violence –– vasa praevia (rare) - fetal blood vessels are present in the membranes covering the cervical os: –– rupture of the vasa previa is an obstetric emergency and may lead to fetal death –– uterine rupture (rare) –– unknown cause • See Queensland Clinical Guideline Early Pregnancy Loss: https://www.health.qld.gov.au/qcg/ publications#maternity
Related topics Vaginal bleeding in early pregnancy, page 513
1. May present with1 • Vaginal bleeding > 20 weeks gestation - symptoms may vary depending on cause: –– minor spotting –– blood-stained amniotic fluid –– like a period –– massive haemorrhage –– onset - sudden or gradual • May have: –– abdominal pain or cramping –– back pain –– contractions –– been provoked by sexual intercourse –– history of recent trauma • If bleeding very heavy, may have signs of shock:3 –– ↑ HR, ↓ BP, ↑RR
Section 6: Obstetrics and neonatal | Pregnancy complications 535 –– restlessness –– sweating –– cool, clammy skin –– decreased urine output
2,4
p lications 2. Immediate management • If blood loss is heavy or continuing, or increased HR, or hypotension/shock: –– call for help –– consult MO/NP urgently –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status –– commence sodium chloride 0.9% or Hartmann’s solution 1000 mL - then as ordered by MO –– continuously monitor - or at least every 15 minutes: –– standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Pregnancy com Warning and Response Tools) + SpO2 –– obtain rapid history/examination - do not perform digital vaginal examination –– take blood for FBC, coagulation studies, group and x-match, LFT, UE –– lie woman in left lateral position - not supine 3. Clinical assessment1,2 • Obtain history of this presentation, including: –– bleeding - amount, when did it start, any clots –– was the bleeding provoked by sexual intercourse –– any pain - where, how severe, continuous/intermittent: –– consider placental abruption if continuous, or labour if intermittent –– any recent trauma to abdomen - accidental or domestic violence –– fetal movements - feeling as normal/decreased –– smoking and drug use during this pregnancy –– any other symptoms/concerns • Obtain past history, including: –– antenatal history - check records –– estimate fetal age based on dating scan if available or LNMP –– USS results if available - check location of placenta in the uterus –– blood group and antibody status –– obstetric history - prior pregnancies/vaginal birth or caesarean, previous placenta praevia or placental abruption, miscarriages/TOP –– medicines and allergies • Perform standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Warning and Response Tools) • Perform physical examination: –– estimate amount and rate of blood loss - check loss on pad –– consider possibility of concealed bleeding - in uterine cavity –– FHR (if skilled) - needs confirming with USS if not heard –– palpate abdomen - is uterus soft, hard, tender, non-tender, contracting; check fundal height –– if minor bleed take blood for FBC, group and hold 4. Management2,5 • Consult MO on all occasions • All women with APH heavier than spotting and with ongoing bleeding require evacuation/ 536 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy hospitalisation • USS required to exclude placenta praevia - irrespective of previous imaging results • Keep nil by mouth • Administer analgesia as clinically indicated. See Acute pain management, page 35 • MO may request woman be catheterised • Continue to monitor blood loss, pain, and standard clinical observations • If Rh(D) negative with no pre-formed anti-D antibodies gestation offer Rh(D) immunoglobulin.6 See Rh(D) immunoglobulin (anti-D) prophylaxis, page 508 p lications • If at risk of preterm birth, corticosteroids may be considered. See Preterm labour, page 544 • Further management in accordance with MO 5. Follow up • Offer grief counselling for parents who have experienced antepartum haemorrhage with fetal death 6. Referral/consultation • Consult MO on all occasions of vaginal bleeding in pregnancy
HMP Preterm prelabour rupture of membranes
Recommend1,2 • Antibiotics are recommended to reduce the risk of neonatal and maternal infection, and delay the onset of preterm labour (prolong latency) and the need for indicated preterm delivery Background1 • PPROM refers to membrane rupture before the onset of uterine contractions < 37+0 weeks gestation • PPROM is associated with potentially serious infections - chorioamnionitis, septicaemia - and risks to the fetus including cord prolapse, abruptio placentae and fetal malpresentation • Genital tract infection is the single most common identifiable risk factor for PPROM • The majority of pregnancies with PPROM deliver within a week of membrane rupture • Diagnosis is generally based on visualisation of amniotic fluid in the vagina of a woman who presents with a history of leaking fluid, confirmed by laboratory tests if uncertain • Nitrazine test (Amnicator®) is generally not recommended as a diagnostic tool for PPROM3,4 • See Queensland Clinical Guideline: Early Onset Group B Streptococcal Disease: https://www. health.qld.gov.au/qcg/publications#maternity
1. May present with1,5 • Pregnant woman < 37+0 weeks gestation who reports: –– a gush of clear or pale yellow fluid from vagina –– intermittent or constant leaking of small amounts of fluid –– sensation of wetness within the vagina or on the perineum –– seeing or feeling umbilical cord protruding from vagina 2. Immediate management6 • If umbilical cord is protruding treat as an obstetric emergency. See Umbilical cord prolapse or presentation, page 569
Section 6: Obstetrics and neonatal | Pregnancy complications 537 • Auscultate FHR if skilled - normal is 110-160/min: –– if tachycardia or bradycardia: –– reposition woman and recheck –– check for cord prolapse –– contact MO urgently
p lications 3. Clinical assessment1 • Wherever possible a woman who is thought to have ruptured membranes should be assessed by a midwife or MO • Ask about this presentation: –– when did she first notice the fluid - date/time –– how much - gush, small leak, just wetness –– still leaking
Pregnancy com –– colour of fluid - clear, yellow, green, bloody –– any odour –– fetal movements - feeling as normal/decreased –– any abdominal or pelvic pain, contractions –– fever, nausea/vomiting –– any other symptoms/concerns • Ask about this pregnancy: –– antenatal history - check records –– gravida/para –– estimated gestation based on dating scan if available; or LNMP –– any concerns or problems - diabetes, hypertension –– STI tests performed, when, results • Assess Group B Streptococcus risk. See Group B Streptococcus prophylaxis, page 540 • Obtain past history: –– medicines, allergies –– reproductive, sexual history • Perform physical examination: –– standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Warning and Response Tools) –– check for obvious vaginal fluid loss (check pad) - colour, offensive odour –– urinalysis and collect MSU for MCS –– FHR –– abdominal examination - tenderness, fundal height, fetal lie and presentation, contractions (strength/length/frequency) • Digital vaginal examination should be avoided due to risk of causing infection • Perform sterile speculum examination if skilled to: –– exclude cord prolapse –– observe the cervix for dilation and/or effacement –– check for pooling of amniotic fluid: –– if fluid not immediately visible, ask woman to push on her fundus, Valsalva, or cough to pro- voke leakage of amniotic fluid from the cervical os –– if PPROM is not obvious after visual inspection, Amnicator® can be used however is associ- ated with false results (positive and negative) –– collect LVS for MCS + LVS for chlamydia, gonorrhoea and trichomonas PCR. See Sexually transmitted infections, page 615
538 | Primary Clinical Care Manual 10th edition | Pregnancy com Pregnancy • Obtain combined LVS-anorectal swab for GBS.2 See Group B Streptococcus prophylaxis, page 540 for technique 4. Management • If cord prolapse. See Umbilical cord prolapse or presentation, page 569 • Consult MO on all occasions • MO may advise:
–– evacuation/hospitalisation p lications –– antibiotics:2,9 –– erythromycin oral for 10 days OR –– ampicillin (or amoxicllin) IV 6 hourly for 48 hours (followed by oral amoxicillin and erythromy- cin for 7 days) –– betamethasone to accelerate fetal lung maturation.1 See Preterm labour, page 544 • Continue to monitor woman and fetus until evacuation as per MO instructions
Extended authority Schedule 4 Erythromycin ATSIHP/IHW/IPAP ATSIHP, IHW, IPAP, MID, RIPRN and RN must consult MO/NP Route of Recommended Form Strength Duration administration dosage Adult Capsule 250 mg Oral 10 days 250 mg qid Provide Consumer Medicine Information: Take on an empty stomach 1 hour before or 2 hours after food. May cause nausea, vomiting, diarrhoea, abdominal pain, cramps and candidiasis. Can be taken with food if causes stomach upset Note: If renal impairment seek MO/NP advice. Interacts with many drugs, including over the counter and herbal products. Use with caution in patients with myasthenia gravis. Contraindication: Severe or immediate allergic reaction to macrolides. Severe hepatic impairment Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 2,8
Extended authority Schedule 4 Ampicillin ATSIHP/IHW/IPAP ATSIHP, IHW, IPAP, MID, RIPRN and RN must consult MO/NP Route of Recommended Form Strength Duration administration dosage stat Powder 500 mg Inject over for IV 2 g 1 g 10-15 minutes injection Provide Consumer Medicine Information: May cause rash, diarrhoea, nausea, pain and inflammation at injection site Contraindication: Severe hypersensitivity to penicillins, carbapenems, and cephalosporin antibiotics. Do not mix with aminoglycosides e.g. gentamicin Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 7,9,10
Section 6: Obstetrics and neonatal | Pregnancy complications 539 5. Follow up • Evacuation/hospitalisation for ongoing management 6. Referral/consultation • Consult MO on all occasions of suspected prelabour rupture of membranes
Labour and birth Labour and birth HMP Group B Streptococcus prophylaxis
Recommend1 • Assess all pregnant women for risk factors for Group B Streptococcus (GBS) antenatally and in early labour - to identify if intrapartum antibiotic prophylaxis (IAP) is recommended • IAP should be given at least 4 hours prior to delivery where possible • Routinely provide information to women about GBS and early onset GBS disease including: risk factors, risks and benefits of IAP to themselves and baby. See Consumer information at https:// www.health.qld.gov.au/qcg/publications#maternity Background1 • GBS is the most frequent cause of early onset neonatal sepsis • Maternal colonisation of the lower genital tract of GBS increases the risk of neonatal infection • IAP given to at risk women can substantially reduce the rate of early onset GBS disease • Queensland recommends a ‘risk based approach’ for the identification of women for whom IAP is indicated • See Queensland Clinical Guideline Early Onset Group B Streptococcal Disease: https://www. health.qld.gov.au/qcg/publications#maternity
1. May present • Routine antenatal visit • Pregnant woman with urine pathology result of GBS • Preterm labour with or without rupture of membranes (ROM) • Term pre-labour rupture of membranes (PROM)
2. Immediate management Not applicable
3. Clinical assessment1 • Review GBS risk factors if woman presents: –– in labour –– with rupture of membranes –– for routine antenatal care • If in labour and/or ruptured membranes, check: –– gestation –– have membranes ruptured, when –– has woman reported a fever, when started, temperature - if known • Perform standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early 540 | Primary Clinical Care Manual 10th edition | Labour and birth Warning and Response Tools)
Group B Streptococcus (GBS) risk factors1 • Preterm labour < 37+0 weeks • Rupture of membranes ≥ 18 hours prior to birth • Maternal T ≥ 38°C intrapartum or within 24 hours of giving birth • GBS colonisation in current pregnancy • GBS bacteriuria in current pregnancy - any colony count • Previous baby with early onset GBS disease
All women with risk factors will require antibiotics in labour
4. Management1 • If risk factors are detected as part of routine antenatal care: –– document the presence of GBS risk factors in health record –– check allergy for penicillin and document –– advise woman she will need antibiotics during labour –– give information about GBS and intrapartum antibiotic prophylaxis (IAP) • If woman presents in labour and/or ROM and has GBS risk factors: –– always contact MO early for advice –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status • If risk factor is intrapartum maternal T ≥ 38⁰C (or T ≥ 38⁰c within 24 hours of birth): –– notify MO immediately –– this may affect neonatal management • If PRETERM pre-labour rupture of membranes (PPROM): –– take culture for GBS –– if imminent risk of birth - within 24 hours - give intrapartum antibiotic prophylaxis (IAP) –– otherwise for management. See Preterm prelabour rupture of membranes, page 537
Culture for GBS1 • Either vaginal-rectal swab OR vaginal perianal swab - woman may self-collect • Use one single dry swab stick - insert into vaginal opening and then: –– for vaginal-anorectal - insert into anus –– for vaginal-perianal - swab the perianal surface without penetration of the anal sphincter –– place into standard bacterial transport medium –– label ‘GBS screening in pregnancy’
• If TERM pre-labour rupture of membranes (PROM) irrespective of GBS status: –– only commence antibiotics at onset of established labour if: –– ROM duration is ≥ 18 hours at onset of established labour OR –– during established labour, the duration of ROM reaches or exceeds 14 hours AND –– birth is assessed as unlikely to occur before duration of ROM reaches 18 hours i.e. do not wait for the duration of ROM to equal 18 hours before commencing antibiotics
Section 6: Obstetrics and neonatal | Labour and birth 541 Antibiotics to give in labour i.e. Intrapartum Antibiotic Prophylaxis (IAP): • If 1 or more risk factors for GBS - give antibiotics to women in active labour • Commence after onset of labour - aim to give at least 4 hours prior to birth • If not allergic to penicillin give: –– benzylpenicillin 3 g IV once (loading dose) followed 4 hours later by: –– benzylpenicillin 1.8 g IV every 4 hours until birth • If allergic to penicillin give: lincomycin 600 mg IV 8 hourly Labour and birth ––
If antibiotics (IAP) are given < 2 hours prior to birth i.e. birth too quick: • Contact MO urgently • If baby < 37+0 weeks they will require: –– antibiotics within 30 minutes of birth –– FBC with differential + blood cultures –– see Queensland Clinical Guideline Early Onset Group B Streptococcal Disease: https://www. health.qld.gov.au/qcg/publications#maternity • If baby > 37+0 weeks they will require: –– FBC and observation for signs of infection for 48 hours
Extended authority Schedule 4 Benzylpenicillin ATSIHP/IHW/IPAP/MID ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP MID may proceed Route of Recommended Form Strength Duration administration dosage
IV stat (at onset of labour) Loading dose Reconstitute with Infuse over 30 minutes to 3 g Injection 600 mg 10 mL water for 1 hour (powder for 1.2 g injections, then 4 hours after loading dose reconstitution) 3 g dilute in Maintenance dose then 4 hourly until birth 100 mL sodium 1.8 g infuse over 30 minutes to chloride 0.9% 1 hour Provide Consumer Medicine Information: May cause diarrhoea and nausea Note: Rapid IV injection of large doses may cause seizures Contraindication: Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 2,3
542 | Primary Clinical Care Manual 10th edition | Labour and birth
Extended authority Schedule 4 Lincomycin ATSIHP/IHW/IPAP/MID ATSIHP, IHW, IPAP, RIPRN and RN must consult MO MID may proceed Route of Recommended Form Strength Duration administration dosage stat IV Give by infusion only over at Injection 600 mg/2 mL 600 mg Dilute in 100 mL sodium least 1 hour chloride 0.9% then 8 hourly on MO order Provide Consumer Medicine Information: May cause nausea, vomiting, diarrhoea, abdominal pain or cramps Contraindication: IV injection; severe cardiopulmonary reactions can occur. Must only be given by slow IV infusion. Severe or immediate allergic reaction to clindamycin or lincomycin Note: If renal or hepatic impairment seek MO advice Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 4,5
5. Follow up • Babies born to a woman at risk of GBS should be evacuated and have neonatal/paediatric review as soon as possible after birth • If birth occurs prior to evacuation request neonatal support/advice from retrieval team 6. Referral/consultation • Consult MO on all occasions of women presenting in labour or with ROM
Section 6: Obstetrics and neonatal | Labour and birth 543 HMP Preterm labour
Recommend1,2 • Accept risk of birth occurring en route when gestational age is 23-28 weeks unless such transfer puts the mother’s life at risk • If clinically appropriate, use tocolytics to delay birth to allow in utero transfer and enable administration of corticosteroids to accelerate fetal lung maturation • Corticosteroids are routinely recommended for women with a viable fetus who are at increased
Labour and birth risk of preterm birth before 35+0 gestation to accelerate fetal lung maturation • Magnesium sulfate is recommended for women between 24+0 and 30+0 weeks gestation where birth is expected or planned within 24 hours for neuroprotection Background1 • Preterm labour occurs at < 37+0 weeks gestation • Fetal fibronectin fFN is a glycoprotein thought to promote adhesion between the fetal chorion and maternal decidua. It is normally present in small amounts in cervico-vaginal secretions between 18 and 34-36 weeks, rising as term approaches • Quantitative fFN testing measures the likelihood of preterm birth (PTB). Be aware of false negative and positive results: –– fFN < 50 ng/mL (negative) suggests low risk of birth within 7-14 days –– fFN ≥ 50 ng/mL (positive) suggests increased risk of preterm birth • Transvaginal ultrasound of cervical length (TVCL) by a credentialed clinician can assist in assessing the risk of PTB • Antenatal corticosteroids are associated with a significant reduction in rates of neonatal death, respiratory distress syndrome and intraventricular haemorrhage • See Queensland Clinical Guideline Preterm Labour and Birth: https://www.health.qld.gov.au/ qcg/publications#maternity • If gestational age is < 26+0 weeks also refer to the Queensland Clinical Guideline Perinatal Care at the Threshold of Viability: https://www.health.qld.gov.au/qcg/publications#maternity
Related topics Group B Streptococcus prophylaxis, page 540 Imminent birth, page 552
1. May present with1 • Pregnant woman < 37+0 weeks gestation with: –– pelvic pressure –– lower abdominal cramping –– lower back pain –– vaginal loss - mucous, blood or fluid –– regular uterine contractions
544 | Primary Clinical Care Manual 10th edition | Labour and birth 2. Immediate management • If birth is imminent. See Imminent birth, page 552 and Neonatal resuscitation, page 565 • Send for help • Contact MO urgently 3. Clinical assessment1 • Wherever possible a woman who is thought to be in labour should be assessed by a midwife or MO • Use prompts in Labour 1st stage, page 548 to ask about: –– this presentation –– this pregnancy –– past history • Perform physical examination including: –– standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or Intrapartum or other local Early Warning and Response Tools) • Palpate abdomen - if skilled - to assess: –– uterine tone –– contractions –– fetal size –– presentation –– FHR + CTG if available and skilled • Obtain MSU for MCS • If MO advises, and skilled, perform sterile speculum examination to: –– visualise cervix/presenting part e.g. hair, feet or cord –– check if membranes have ruptured –– assess liquor - clear, meconium stained, bloody, pink • Perform fetal fibronectin test if indicated (see table): –– see test kit instructions –– obtain the sample from posterior fornix of vagina - prior to any examinations –– only use sterile water as lubricant –– take HVS for MCS • Obtain combined LVS-anorectal swab for GBS: –– see Group B Streptococcus prophylaxis, page 540 for technique • If MO advises, assess cervical dilatation by sterile digital vaginal examination unless contraindicated by ruptured membranes or suspected placenta praevia
Fetal fibronectin (fFN) testing1 Indications Contraindications • Symptomatic preterm labour between 22+0 • Cervical dilatation > 3 cm and 36+0 weeks • Ruptured membranes AND • Cervical stitch in situ • Intact membranes • Presence of soaps, gels, lubricants or AND disinfectants • Cervical dilatation ≤ 3 cm Relative contraindications • Visual evidence of moderate or gross bleeding • Within 24 hours of sexual intercourse
Section 6: Obstetrics and neonatal | Labour and birth 545 4. Management1,3,4 • Consult MO early who will: –– organise evacuation to an obstetrics facility with neonatal capability –– provide advice for ongoing management • Aim for in utero transfer wherever possible: –– if 23-28 weeks, accept a high level of risk for birth occurring en route - unless mother’s life at risk • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • MO may advise transvaginal USS of cervical length (TVCL) if resources/skilled clinician available Labour and birth • If woman has signs of uterine infection (chorioamnionitis) - maternal fever > 38⁰c, HR > 100, FHR > 160, uterine tenderness, offensive vaginal discharge: –– labour should not be stopped - MO will consider IV antibiotics • To delay birth if < 34 weeks gestation MO may order tocolysis: –– nifedipine 20 mg oral stat –– if contractions persist after 30 minutes, repeat nifedipine 20 mg –– if contractions persist after a further 30 minutes, repeat nifedipine 20 mg –– if BP stable, nifedipine may be ordered 6 hourly for 48 hours • Monitor: –– FHR after contractions, or CTG (if available and skilled) until contractions cease –– BP, HR and RR every 30 minutes –– T 4 hourly • To accelerate fetal lung maturation if < 35+0 weeks gestation MO may order: –– betamethasone 11.4 mg IM –– 2nd dose 24 hours later - or if preterm birth likely, consider giving 12 hours later –– if maternal diabetes, monitor BGL • Intrapartum antibiotic prophylaxis (IAP) will be required if: –– preterm labour continues OR –– there is imminent risk of birth within 24 hours. See Group B Streptococcus prophylaxis, page 540 • Continue to monitor woman and fetus until evacuation: –– maternal BP, HR and RR at a minimum every 30 minutes –– uterine contractions - every 15-30 minutes count number of contractions over 10 minutes –– check vaginal loss hourly –– FHR - every 15 minutes (at a minimum) –– continue to closely liaise with MO –– prepare woman for evacuation –– provide emotional support for woman
546 | Primary Clinical Care Manual 10th edition | Labour and birth Extended authority Schedule 4 Nifedipine ATSIHP/IHW/IPAP/MID ATSIHP, IHW, IPAP and RN and RIPRN must consult MO MID may proceed to a max. of 2 doses Route of Recommended Form Strength Duration administration dosage stat Oral Tablet Repeat dose after 30 minutes 10 mg crush or chew first (conventional 20 mg if contractions persist. 20 mg 2 doses to increase release) MO may order another dose rate of absorption If contractions persist for a further 30 minutes Provide Consumer Medicine Information: May cause nausea, headache, flushing, dizzinesss, hypotension, peripheral oedema Note: May increase effects of magnesium sulfate and risk of hypotension; use cautiously Tocolytics contraindicated in any condition where prolongation of pregnancy is contraindicated e.g. intrauterine fetal death, lethal fetal anomalies, suspected fetal compromise, maternal bleeding with haemodynamic instability, severe preeclampsia, placental abruption, chorioamnionitis Contraindication: Maternal hypotension or cardiac disease Management of associated emergency: Consult MO. See Anaphylaxis, page 102 1,3
Extended authority Schedule 4 Betamethasone ATSIHP/IHW/IPAP/MID ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP MID may proceed Route of Recommended Form Strength Duration administration dosage stat Injection 5.7 mg/mL IM 11.4 mg Further doses on MO/NP orders Provide Consumer Medicine Information: To accelerate fetal lung maturation Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 5
5. Follow up • Evacuation/hospitalisation for ongoing management 6. Referral /consultation • Consult MO on all occasions of suspected preterm labour
Section 6: Obstetrics and neonatal | Labour and birth 547 HMP Labour 1st stage
Recommend1 • Birth during transport should be avoided if possible • There is a high level of risk of birth occurring en route when gestational age is 23-28 weeks • Birth en route is to be avoided unless there is significant risk to the mother's life • Vaginal examinations should only be performed if clinician is skilled in doing so • Intrapartum Record Form available at: https://clinicalexcellence.qld.gov.au/resources/clinical Labour and birth -pathways/maternity-clinical-pathways ordered through local health service Background2,3 • This section of the PCCM is intended for facilities that do not have planned births • First stage of labour: –– latent phase - onset of painful contractions, not necessarily continuous with cervical dilatation ≤ 4 cm –– active phase i.e. established labour - regular painful contractions with cervical effacement and dilatation of at least 4-6 cm. In active labour, cervical dilatation of 2 cm in 4 hours is considered normal. Dilatation of 0.5 cm per hour is generally accepted • Second stage - time from full cervical dilatation to the delivery of the baby • Third stage - time from the birth of the baby to the expulsion of placenta and membranes
Related topics Preterm labour, page 544 Imminent birth, page 552
1. May present with3 • Pregnant woman with: –– contractions - abdominal pain and tightening that comes and goes –– rupture of membranes –– a show - passage of bloody mucous –– lower back pain 2. Immediate management • If birth is imminent - baby visible, vulval gaping/bulging perineum, anal dilation, urge to push/ need to open bowels. See Imminent birth, page 552 3. Clinical assessment2,3,4 • Wherever possible a woman who is thought to be in labour should be assessed by a Midwife or MO • It is important to establish the stage of labour, and if there are any complicating factors • Ask about this presentation: –– uterine contractions - when started, frequency, duration, strength –– have membranes ruptured, if so when –– any vaginal loss: –– discharge - colour, odour, consistency –– blood - amount, colour –– liquor - amount, odour, consistency, colour - clear, pink, green (meconium), blood –– fetal movements - normal or decreased
548 | Primary Clinical Care Manual 10th edition | Labour and birth • Ask about this pregnancy - check records if possible: –– gestation - how many weeks pregnant - most accurate via dating scan: –– preterm < 37 + 0 weeks –– full term ≥ 37 weeks –– has woman had antenatal care, where –– one baby or more –– hypertension and/or gestational diabetes –– any other pregnancy complications/concerns • Check investigation results: –– placental position –– Hb, syphilis –– blood group (check if negative) –– risk assessments. See Antenatal care, page 500 • Assess Group B Streptococcus risk. See Group B Streptococcus prophylaxis, page 540 –– if at risk, may need antibiotics during labour • Obtain past history: –– gravida/para - how many pregnancies and births –– normal vaginal births or caesareans –– medicines, allergies –– medical, gynaecological, surgical, social • Perform physical examination: –– general appearance, nutrition and hydration status –– standard clinical observations (full Q-MEWT Rural and Remote - Intrapartum or other local Early Warning and Response Tools) –– urinalysis • Palpate abdomen (if skilled) to assess: –– fundal height - measure suprapubic bone to umbilicus in cm - this may give an indication of gestation if unknown –– fetal lie - longitudinal, transverse, oblique –– presentation - vertex (head), breech (buttocks/bottom) –– position e.g. right occiput anterior –– descent into pelvic brim - 5ths of fetal head palpable above the symphysis pubis • Palpate contractions: –– rest hand on abdomen and feel tightening –– note strength, frequency and length of each contraction over 10 minutes • Check fetal (baby’s) heart rate (FHR) - if skilled: –– listen immediately after a contraction for 30-60 seconds –– normal range 110-160/min –– differentiate between maternal pulse - by taking radial pulse of mother concurrently –– if FHR shows bradycardia or tachycardia: –– change position of woman and recheck –– immediately contact MO • Assess vaginal loss: –– nil, discharge, blood, liquor –– colour, amount, odour, consistency • A vaginal examination (VE) may be performed (if skilled) to aid decision making: –– VE contraindicated if: maternal consent not obtained, antepartum haemorrhage, rupture of membranes and not in labour, placenta praevia, placental position unknown, suspected
Section 6: Obstetrics and neonatal | Labour and birth 549 preterm labour –– prior to VE, auscultate FHR, ensure bladder empty, perform abdominal examination. If needed, cleanse vulva with water –– auscultate FHR post VE –– Note: cord presentation or prolapse should be excluded at every VE in labour. See Umbilical cord prolapse or presentation, page 569 • If spontaneous rupture of membranes (SROM) consider speculum instead of digital examination
4. Management Labour and birth • In all cases, contact MO early for advice: –– a decision will need to be made as to whether there is time to evacuate or if the woman will birth at the community –– considerations will include: gestation, parity of woman, stage of labour on presentation, labour progression, staff availability/mix at the facility • If evacuation planned, ensure pregnancy health records/antenatal records go with woman • If birth is planned to occur in the community: –– prepare/check equipment, and ensure assistance available. See Imminent birth, page 552 • If preterm and ruptured membranes but NOT IN labour: –– see Preterm prelabour rupture of membranes, page 537 • If preterm and IN labour: –– see Preterm labour, page 544
Care of the woman in active 1st stage labour3 • i.e. regular painful contractions with cervical effacement and dilatation of at least 4-6 cm • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Ongoing monitoring of maternal and fetal wellbeing and progress of labour to be in close consultation with MO • Provide continued reassurance and support to the woman - ensure privacy, calmness • Involve support person/partner • Assist woman to select position(s) in which she is most comfortable • Encourage woman to drink to thirst, offer light food as desired • Monitor the FHR during labour:3 –– every 15-30 minutes –– after a contraction there should be no deceleration (slowing of FHR) –– if FHR slows after contractions, ask the woman to change her position and recheck –– advise woman not to lie flat on back due to potential supine hypotension –– check FHR immediately after membranes rupture –– if bradycardia or abnormal FHR urgently consult MO: 5 –– consider cord compression as a possible cause. See Umbilical cord prolapse or presentation, page 569 • Monitor contractions and maternal HR every 30 minutes • Check: –– vaginal loss hourly –– 4 hourly: –– BP, T - if elevated urgently consult MO –– abdominal palpation and as needed to monitor progress –– VE - assessment of cervical dilatation may need to be more frequent than would normally be undertaken in a maternity unit
550 | Primary Clinical Care Manual 10th edition | Labour and birth • Encourage to empty bladder every 2 hours • Signs of transition into 2nd stage of labour (7-10 cm dilated): –– shakiness, irritability, nausea and vomiting • Increase support for woman, continue to monitor progress, and prepare for birth
Offer pain management as required3,6 • Try non-pharmacological approaches as long as possible e.g. mobilisation, shower, massage, heat therapy, breathing techniques • Analgesia options if required:7,8
–– nitrous oxide and O2 (Entonox®) –– consider a single dose of morphine if pain relief not satisfactory after all other strategies, and birth not imminent. See Acute pain management, page 35 –– a non-midwife must obtain an MO order for analgesia/antiemetic for women in labour –– opioid may be more effective in early active labour; less effective after 7 cm dilatation –– aim to give the lowest possible dose for adequate pain relief to minimise side effects –– if birth is anticipated in 1-4 hours, consider the duration of action and effect on newborn during labour and following birth, assess for respiratory depression in mother and baby –– consider antiemetic if needed. See Nausea and vomiting, page 48
Nitrous oxide + oxygen Extended authority Schedule 4 (Entonox®) ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP MID may proceed Route of Recommended Form Strength Duration administration dosage nitrous oxide 50% Premix gas self administered as + Inhalation as required (clear) needed oxygen 50% Provide Consumer Medicine Information: Woman must self administer i.e. hold the mouthpiece or mask. Commence breathing Entonox® at early onset of contraction or 30 seconds prior if possibile, continue until contraction eases. May cause nausea, vomiting, dizziness, drowsiness or shivering Note: Monitor sedation score and respiratory rate. Use with caution if vitamin B12 deficiency or if opioid has been administered Management of associated emergency: Consult MO/NP. Give oxygen if overdose. See Oxygen delivery, page 64 7,9
5. Follow up • Consider evacuation prior to or after birth 6. Referral/consultation • Always consult MO
Section 6: Obstetrics and neonatal | Labour and birth 551 HMP Imminent birth
Recommend1,2 • Birth during transport should be avoided if at all possible • Wherever possible, the birth should be attended by a Midwife or MO • Encourage woman to birth in an upright position, if she feels comfortable with this • Modified active management of third stage labour is recommended to significantly reduce the risk of post-partum haemorrhage (using delayed cord clamping) Labour and birth Background1,4 • This section of the PCCM is intended for facilities that do not have planned births • Full term birth is ≥ 37 weeks gestation • Preterm birth is < 37 + 0 weeks and should generally be managed the same as a full-term birth • Episiotomy is only indicated if potential fetal compromise is evident. Prophylactic episiotomy for preterm birth is not associated with improved neonatal outcome • There is insufficient evidence in regards to: –– hands poised or hands on techniques to avoid perineal trauma –– guidance or flexion of the head to reduce perineal trauma • Intrapartum Record Form at https://clinicalexcellence.qld.gov.au/resources/clinical-pathways/ maternity-clinical-pathways (ordered through local health service) • Imminent Birth education program for rural and remote non-midwives is available at: https:// ilearnexternal.health.qld.gov.au/
Related topics Immediate care of the newborn, page 558 Neonatal resuscitation, page 565
1. May present with1,5 • Pregnant woman with: –– strong contractions that come close together - feeling more intense and painful –– urge to bear down/push –– need to open bowels –– bulging perineum and/or baby’s head on view –– anal dilation 2. Immediate management6 • Stay with woman • Send for help • Get Midwife or MO to assess the woman whenever possible • Stay calm • Ensure woman is in a safe, comfortable place, reassure and respect her privacy • Prepare equipment e.g. emergency birth kit • Put on protective glasses and gloves • Ask assistant to: –– contact MO for advice –– insert 2 x IV cannula - use the largest possible gauge given age and vascular status
552 | Primary Clinical Care Manual 10th edition | Labour and birth –– prepare oxytocin 10 units: –– draw up ready to give to mother IM immediately after baby born - kept in fridge –– get MO order if needed –– obtain consent from mother –– turn on/prepare incubator if available plus warm towels –– prepare neonatal resuscitation equipment and be ready to resuscitate the baby as needed. See Immediate care of the newborn, page 558 and Neonatal resuscitation, page 565 3. Clinical assessment1 • Obtain rapid history as able - in particular: –– gestation - how many weeks pregnant: most accurate via dating scan –– gravida/para - how many pregnancies and births –– have membranes ruptured - when/colour of fluid –– fetal movements - normal or decreased –– has woman had antenatal care - where/any problems/concerns –– diabetes, hypertension –– allergies, medicines –– any significant medical history 4. Management1
Preparing for birth • Encourage the woman to adopt a comfortable position for birth • Avoid lying flat - potential supine hypotension • If analgesia required: –– offer nitrous oxide and O2 (Entonox®). SeeLabour 1st stage, page 548 • Support the woman to use her own pushing instincts - do not tell her when/how hard to push • Encourage voiding • Continue to encourage/support mother
Monitor • FHR towards the end of each contraction, continuing for at least 30-60 seconds after the contraction has finished (or at least every 5 minutes) • maternal HR every 15 minutes, and as indicated to differentiate from FHR • contractions - continually note frequency, strength, length • vaginal loss - continually • use Q-MEWT Rural and Remote - Intrapartum (or other local Early Warning and Response Tool)
The birth5,7 • The head/presenting part will stretch the perineum as it comes down with contractions • Prevent faecal contamination from the anal area using a pad as needed8 • Encourage woman to breathe gently and/or pant her baby’s head out in a slow and controlled way if possible • Discourage active pushing at the time of crowning to reduce the risk of perineal trauma9 • Either have ‘hands poised’ or place ‘hands on’ during birth of the head:5 –– no need to place firm pressure/resistance to maintain flexion of head
Section 6: Obstetrics and neonatal | Labour and birth 553 If feet or bottom presenting instead of head see Breech birth, page 582
• Once head born: –– no need to check for cord around neck1 –– do not rush to deliver the body • Wait for next contraction and internal rotation of the shoulders and trunk: –– the head will turn sideways –– with the next contraction (or earlier) the shoulders should gently emerge Labour and birth –– usually the anterior (top) shoulder slips out under the symphysis pubis first
If shoulders do not spontaneously come out:7,10 • Place a hand on either side of the baby’s head and apply slow gentle axial traction i.e. traction in line with the baby’s spine - not in a downward direction or with force • If shoulders STILL not coming out. See Shoulder dystocia, page 579
• Support the baby and lift towards the mother’s abdomen: –– encourage skin to skin contact with mother7 –– dry baby and remove wet towel(s) –– cover baby with dry warm towel/blanket • Note time of birth
If fetal compromise/distress during birth and delivery is being blocked by perineal tissue, consider episiotomy to expedite delivery (if skilled).9 See Episiotomy and repair of perineum, page 562
• Ask assistant to quickly assess newborn:10 –– within 15 seconds of birth check: –– tone, breathing, HR –– assistant to continue to care for newborn. See Immediate care of the newborn, page 558 –– if preterm, especially < 35 weeks, will likely require resuscitation. See Neonatal resuscitation, page 565 • Immediately after baby born: 1,11 –– check the uterus for another baby - the top of the uterus (fundus) should be no higher than the umbilicus and firm THEN –– use modifiedactive management of 3rd stage of labour to deliver placenta and membranes
554 | Primary Clinical Care Manual 10th edition | Labour and birth
Modified active management of3rd stage of labour1 • Give IM oxytocin to mother - within 1 minute of birth and before cord clamped
Extended authority Schedule 4 Oxytocin ATSIHP/IHW/MID/RIPRN ATSIHP, IHW and RN must consult MO MID and RIPRN may proceed Route of Recommended Form Strength Duration administration dosage 5 units/mL Injection IM 10 units stat 10 units/mL Provide Consumer Medicine Information: May cause nausea and vomiting Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,12
• Clamp and cut cord - use delayed cord clamping:1 –– wait for 1-3 minutes after birth or for cord pulsation to cease –– do not clamp cord < 1 minute after birth unless baby needs immediate resuscitation away from mother –– 1st clamp about 10 cm from baby’s abdomen –– 2nd clamp about 5 cm from the 1st on the placenta side –– cut cord using sterile scissors between the two clamps - by the clinician, mother or other person • Use controlled cord traction (CCT) to deliver placenta if skilled1,11 –– see Controlled cord traction instructions on following page • If not skilled in CCT obtain MO advice
Section 6: Obstetrics and neonatal | Labour and birth 555 Controlled cord traction1,3 • Ensure oxytocin has been administered to the mother • Reclamp the cord closer to vaginal opening with metal forceps • Do not commence CCT until signs of separation are observed • Signs of placental separation - usually occurs within 2-3 minutes after oxytocin administration: –– uterus rises in the abdomen, becomes firmer and globular (ballotable) –– trickle or gush of blood from vagina lengthening of the cord Labour and birth –– –– woman may feel urge to bear down –– placenta may become visible at vagina • Avoid repeated palpation of uterus • Apply suprapubic counter pressure prior to CCT • Gently apply traction downwards on the cord while maintaining countertraction above the pubic bone • As placenta delivers, hold in both hands and gently turn to twist the membranes • Slowly tease out the membranes to complete birth
Guarding uterus
Placenta visible
Image reproduced with permission of the Queensland Ambulance Service Application of cord traction until the placenta is visible
• If the placenta does not descend during 20-30 seconds of CCT or there is resistance to CCT: –– do not continue to pull on the cord - risk of cord snapping or uterine inversion –– hold the cord loosely - without any pulling/traction and wait until the uterus is well contracted again –– with the next contraction, repeat controlled cord traction with counter traction on the uterus
Post-delivery of the placenta and membranes1,11 • Immediately assess tone of uterus - check fundus is firm and central • Massage the uterus if needed to ensure it remains contracted • Be aware massaging fundus may be uncomfortable/painful for woman
556 | Primary Clinical Care Manual 10th edition | Labour and birth • Note the time • Measure/estimate blood loss • If heavy or persistent ≥ 500 mL. See Primary postpartum haemorrhage, page 572 • If ≥ 350 mL MO may order misoprostol 800 micrograms as a secondary preventer of PPH3 (recommended in low resource areas). See Primary postpartum haemorrhage, page 572 • Observe maternal physical condition - colour, respirations, vaginal blood loss • Maintain a private, calming and relaxing environment • Examine the placenta and membranes for completeness promptly (if skilled):1,3 –– placenta - does it look complete, general shape and appearance, calcification or infarctions, evidence of abruptions, succenturiate lobe –– membranes - 1 amnion and 1 chorion, complete or ragged, presence of vessels –– cord - note cord insertion site, look for 3 vessels (2 arteries, 1 vein), any velamentous insertion (vessels noted in membranes) • If you are unsure of your placenta check - send placenta with woman when evacuated • If mother is RhD negative blood group (or unknown) - collect cord blood for group and direct antiglobulin test (Coombs) + maternal blood for Kleihauer1 • Dispose of placenta in accordance with mother’s wishes. Respect cultural and personal perspectives. Woman has right to take placenta home
Post-birth observations and care:1,3,13
Baby see Immediate care of the newborn, page 558
Mother for the first 2 hours post birth: • Do not leave the mother and baby alone • Continue skin to skin contact and encourage/support breastfeeding • Avoid unnecessary mother-baby separation or interruptions • Check using Q-MEWT rural and remote postnatal (or other local Early Warning and Response Tool): –– uterus is firm and central 15-30 minutely –– blood loss 15-30 minutely –– HR, BP, RR - once after birth of the placenta –– pain - initial assessment, review if indicated –– urine output - encourage women to void soon after birth (within 2 hours) –– T - within the 1st hour. If elevated contact MO promptly • If heavy or continuing vaginal blood loss. See Primary postpartum haemorrhage, page 572 • If RhD negative blood group, review indications for RhD immunoglobulin. See Rh(D) immunoglobulin (anti-D) prophylaxis, page 508 • Take bloods for syphilis serology if: –– syphilis infection in this pregnancy, OR –– no antenatal screening at 34-36 weeks, OR –– other high risk factors e.g. outbreak area: See Queensland Clinical Guideline Syphilis in Pregnancy: https://www.health.qld.gov.au/qcg/publications#maternity • Inspect for perineal/vaginal trauma after first maternal observations: –– maintain privacy, keep woman comfortable and warm –– offer pain relief prior to assessment as needed. SeeAcute pain management, page 35 –– keep nil by mouth until assessment completed
Section 6: Obstetrics and neonatal | Labour and birth 557 –– using good lighting, gently examine the vaginal walls and perineum for tears using a piece of gauze wrapped around your gloved fingers –– bleeding from tears can be controlled with direct pressure. If large blood loss from trauma. See Primary postpartum haemorrhage, page 572 –– discuss need for sutures with evacuating MO. See Episiotomy and repair of perineum, page 562 –– reassess perineum as indicated • Ensure comfort and personal hygiene needs, offer food and drink, pain relief • After 2 hours: –– continue observations as above once in 8 hours while waiting for evacuation Labour and birth 5. Follow up • MO will consider evacuation after birth 6. Referral/consultation • Always consult MO
HMP Immediate care of the newborn
Recommend • Routine suctioning of mouth, nose and pharynx not recommended even if exposed to meconium. Suctioning can delay normal rise in oxygenisation1,2,3 • Promote skin to skin contact where possible to assist thermoregulation and breastfeeding4,5 • Newborns are at risk of vitamin K deficiency bleeding (VKDB). Vitamin K prophylaxis is recommended for all babies (including preterm) as soon as possible after delivery. IM is the preferred route6,7 Background1,2,3 • It is normal for babies to be cyanotic at birth - pink colouring begins soon after onset of breathing. Persistent blue discolouration in extremities is normal after birth (acrocyanosis) • Normal values in a term baby: RR 30-60 rpm, HR 95-160 bpm, T 36.5-37.5⁰C
Related topics Neonatal resuscitation, page 565
1. May present with • Immediately following birth 2. Immediate management2 • If preterm, particularly < 28 weeks. See Neonatal resuscitation, page 565 • Bring baby up to mother’s chest • Dry, keep warm, promote skin to skin contact • Within 15 seconds of birth check: –– tone - is baby moving limbs and have a flexed posture –– breathing –– HR - listen with stethoscope • Establishment of breathing should maintain HR above 100 bpm within 1-2 minutes after birth
558 | Primary Clinical Care Manual 10th edition | Labour and birth • If breathing and responsive: –– maintain skin to skin contact, keep warm –– encourage breastfeeding • If weak or absent responses in term/near-term baby:1 –– perform brisk gentle drying with soft warm towel to stimulate breathing –– replace towel with warm one to prevent heat loss • If HR < 100 and baby remains apnoeic or ineffective respirations e.g. gasps:3 –– commence respiratory support within 1 minute of birth at a rate of 40-60 breaths per minute. See Neonatal resuscitation, page 565 • Consider further resuscitative efforts if: –– poor tone/floppy –– persistent retraction of lower ribs and sternum/expiratory grunting –– preterm < 35 weeks. See Neonatal resuscitation, page 565 • If skilled complete Apgar score at 1 and 5 minutes, then every 5 minutes until stable • 5-minute Apgar of 7-10 is considered normal2
Apgar Score1 Score Component 0 1 2 Colour cyanotic or pale blue extremities completely pink
Heart rate none 1-99 bpm ≥ 100 bpm Reflex irritability – response to no response grimace cry, cough, or sneeze mild stimulus active motion with Muscle tone flaccid some movement good flexion weak cry or Respiratory effort none good cry hypoventilation
3. Clinical assessment9 • If term baby and well record: –– every 15 minutes RR, colour, positioning for patent airway for first 2 hours –– T and HR within 1 hour of birth • Complete a brief head to toe examination within the first few minutes of life if skilled • Review antenatal history to identify problems that may impact the baby:1 –– chronic conditions e.g. diabetes –– Rh-negative blood group –– syphilis, HIV, hepatitis B –– maternal medications and/or substance use during pregnancy –– other concerns about fetal or maternal wellbeing • Assess for risk factors for Group B Streptococcus. See Group B Streptococcus prophylaxis, page 540 • Review labour history in particular:1 –– prolonged rupture of membranes > 18-24 hours - may increase risk of neonatal sepsis –– any meconium
Section 6: Obstetrics and neonatal | Labour and birth 559 • Assess for risk for hypoglycaemia. See Risk factors for hypoglycaemia • Note first urine and passing of meconium (stool) • After first feed and at least 1-2 hours of skin to skin contact:9 –– bare weigh baby –– measure length and head circumference
Risk factors for hypoglycaemia4 • < 37 weeks gestation Labour and birth • Maternal diabetes • Birth weight < 2500 g • Small or large for gestational age • Hypothermia • Labile temperature • For additional risk factors See Queensland Clinical Guideline Newborn Hypoglycaemia: https://www.health.qld.gov.au/qcg/publications#maternity
4. Management1 • Contact MO/NP early for advice • Work on the principle of keeping the baby pink, warm and BGL normal • Continue skin to skin contact for 1-2 hours post birth • Offer breastfeeding help as needed9 • Confirm the baby's identification arm and leg bands with the mother and secure them on the infant • Place a plastic cord clamp not less than 2 cm from the baby's skin • Administer Vitamin K as soon as possible after birth6 • Offer birth hepatitis B vaccination.10 See Immunisation program, page 768 –– best given in first 24 hours of birth as soon as baby is medically stable –– if mother is HBsAg-positive baby requires concurrent HBIG and a monovalent Hepatitis B vaccine on day of birth • If mother had syphilis in pregnancy OR if baby has a clinical suspicion of syphilis (rash, hepatomegaly, rhinitis, lymphadenopathy, other): –– further assessments and treatment required –– See Queensland Clinical Guideline Syphilis in Pregnancy: https://www.health.qld.gov.au/qcg/ publications#maternity
560 | Primary Clinical Care Manual 10th edition | Labour and birth
Schedule Unscheduled Vitamin K (Konakion®)
ATSIHP, IHW, IPAP must consult MO/NP MID, RIPRN and RN may proceed Route of Recommended Form Strength Duration administration dosage Newborn stat 2 mg/0.2 Injection IM 1 mg ≥ 1.5 kg As soon as possible mL 0.5 mg < 1.5 kg after birth Provide Consumer Medicine Information: May cause pain at the injection site Note: Ampoule may be given orally if skill set not available to give IM. IM more reliable Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 7
If assessed at risk of hypoglycaemia in an asymptomatic well baby4 • Keep warm and dry • Initiate early feeds within 30-60 minutes of birth • Discuss with MO/NP need for gavage feeds if < 35 weeks • If fed effectively: –– take BGL via heel prick prior to second feed - within 2-3 hours of birth –– aim for BGL > 2.5 mmol/L –– repeat BGL every 4-6 hours pre-feed –– aim for feeds at least 3 hourly or sooner if baby demanding –– check level of consciousness, tone, T, RR, colour/perfusion pre-feeds for minimum of 24 hours • If did not feed effectively, but baby well/asymptomatic: –– express/give colostrum –– check BGL at 2 hours of age • If BGL 1.5-2.5 mmol/L: –– feed immediately and contact MO/paediatrician promptly for further advice –– MO may consider 0.5mL/kg glucose gel 40% prior to feed if baby ≥ 35 weeks - if available and baby able to swallow/is well –– confirm BGL < 2 with iStat if available –– repeat BGL in 30-60 minutes • If BGL < 1.5 mmol/L urgently discuss with MO/neonatologist 5. Follow up • Newborn check of baby is required by Midwife/MO/paediatrician within 48 hours of birth 6. Referral/consultation • Contact MO early for all unplanned births in the community • If Aboriginal and Torres Strait Islander baby refer for BCG vaccine - only specially trained clinicians can give
Section 6: Obstetrics and neonatal | Labour and birth 561 HMP Episiotomy and repair of perineum
Recommend • Episiotomy should only be performed if there is a clinical need i.e. suspected fetal compromise to expedite birth1,2 • Episiotomy and perineal repair should only be performed by a skilled Midwife/MO2 Background • The routine use of episiotomy is not recommended to prevent perineal trauma1 Labour and birth • Continuous sutures are recommended over interrupted sutures for perineal repair for a reduction in short term pain and ease of technique4 • Leaving perineal trauma un-sutured is associated in poorer wound healing3
1. May present with1,2 • Perineal trauma post episiotomy or tear post birth • Episiotomy indicated - fetal distress during birth requiring expedited delivery, and where the perineum is obstructing the progress of the presenting part 2. Immediate management • Midwife/MO should only perform episiotomy – contact urgently if required 3. Clinical assessment2 • Post birth examination of the perineum: –– to be completed by Midwife/MO trained in perineal assessment –– ensure privacy, cultural sensitivity and comfort for mother. Encourage support person to be present if desired by mother
–– provide adequate pain relief prior to and during procedure e.g. nitrous oxide and O2 (Entonox®). See Labour 1st stage, page 548 and/or Acute pain management, page 35 –– undertake a systematic assessment of perineal structures. See Queensland Clinical Guideline Perineal Repair for detailed assessment: https://www.health.qld.gov.au/qcg/ publications#maternity –– if in doubt as to extent of injury, refer to MO/more experienced practitioner 4. Management • Until repaired, treat as an open wound • Obtain informed consent
Cutting an episiotomy3 • Ensure there is good vision/lighting at all times • Between uterine contractions infiltrate lidocaine (lignocaine) 1%: –– insert 2 fingers into vagina along the line of proposed incision –– separate the presenting part from the perineum –– infiltrate about 5 mL of lidocaine (lignocaine) 1% in perineum at a 45⁰ angle (right side at 7 o’clock) repeating twice either side of initial infiltration (up to 15 mL) –– apply pressure over injection site • Place two fingers in the vagina, position blades of episiotomy scissors between fingers • Make a cut 4-5 cm long through infiltrated area at the height of the contraction at which the birth is
562 | Primary Clinical Care Manual 10th edition | Labour and birth anticipated • Immediately prepare to control the birth of the head • Apply pressure to the episiotomy between contractions if there is a delay in the birth
Repair of the perineum2 • 1st and 2nd degree tears should only be repaired by an experienced Midwife or MO/NP trained in perineal/genital assessment and repair • 3rd and 4th degree tears should only be repaired by expert practitioner (Obstetrician) • Repair skin (1st degree tear) with continuous subcuticular suture or consider surgical glue • 2nd degree tears - use rapid absorbing synthetic suture e.g. 2.0 Vicryl Rapide® using continuous non- locking suture technique for all layers (vagina, perineal muscles) with a subcuticular stitch or glue for the skin • Undertake rectal examination post repair to exclude rectal penetration • Repairs can be left for the receiving hospital • Discuss care of perineum with woman:2 –– use cooling treatment (ice pack or cold gel pad) for 10-20 minutes for 24-72 hours as needed –– analgesia such as paracetamol may help with pain –– support perineal wound when defecating or coughing –– give advice on: –– positioning e.g. side lying for breastfeeding –– avoiding activities that increase intra-abdominal pressure e.g. straining/lifting –– wash and pat dry perineal area after toileting –– change perineal pads frequently and shower at least daily –– encourage 1.5-2 litres of water per day and healthy diet to prevent constipation
Section 6: Obstetrics and neonatal | Labour and birth 563 Extended authority Schedule 4 Lidocaine (lignocaine) MID MID may proceed Route of Recommended Form Strength Duration administration dosage 1% up to 3 mg/kg to a total max. of Injection subcut stat 50 mg/5 mL 200 mg Provide Consumer Medicine Information: Report any drowsiness, dizziness, blurred vision, vomiting Labour and birth or tremors Note: Use the lowest dose that results in effective anaesthesia Management of associated emergency: Ensure resuscitation equipment readily available. Consult MO/NP. See Anaphylaxis, page 102 5
5. Follow up • Advise woman to check the wound daily using a hand mirror for signs of infection, or wound breakdown • Advise to contact doctor or midwife if any concerns 6. Referral/consultation • Woman will likely be evacuated to a higher-level service post-delivery - discuss with MO • If a 3rd of 4th degree tear ensure woman has been referred to a physiotherapist6
564 | Primary Clinical Care Manual 10th edition | Em
Emergencies during labour and birth e rg
Neonatal resuscitation e nci
Recommend1 e
• Ensure neonatal resuscitation equipment and medicines are available for all births s durin • Provide a warm and draft free environment - aim for air temperature of 23-25⁰c or at least 26⁰c if baby < 28 weeks gestation • At least one person should be responsible for the care of the baby only g labour and birth • Resuscitate baby on resuscitation trolley with overhead heater if available - head towards clinician • Naloxone is rarely used for newborn babies. Positive pressure ventilation (PPV) is the priority for babies suspected of having respiratory depression as a result of maternal opioids Background1 • This section of the PCCM is intended for facilities that do not have planned births • Assessment of colour is an unreliable means of judging oxygenation. Cyanosis is difficult to recognise in newborns • Risk factors for neonatal resuscitation include but are not limited to: –– prematurity, particularly < 35 completed weeks; meconium in amniotic fluid; no/minimal antenatal care; reduced fetal movements at onset of labour; prolapsed cord; prolonged labour or precipitate/fast labour; opioid administration to mother within 4 hours of birth; maternal fever, diabetes, or substance use; prolonged rupture of membranes > 18 hours; shoulder dystocia • See Queensland Clinical Guidelines Neonatal Resuscitation and Neonatal Stabilisation for Retrieval: https://www.health.qld.gov.au/qcg/publications#maternity • Neonatal resuscitation education programs available at: https://ilearnexternal.health.qld.gov. au/
Related topics Immediate care of the newborn, page 558
1. May present with1 • Newborn who is/has: –– unresponsive to drying/tactile stimulation –– HR < 100 or absent HR –– poor colour - blue/white –– gasping, absent, laboured or poor respiratory effort –– poor muscle tone/limp 2. Immediate management1,3,4,5 • Call for help • Urgently contact MO/NP • Commence resuscitation. See Newborn Life Support flowchart, page 567 • If < 28 weeks resuscitate in polyurethane (plastic) bag for warmth - no need to dry first –– see Special considerations for preterm babies on following pages
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 565 • Establish airway: –– place baby on back with head in neutral or slightly extended position - sniffing position –– place a 2 cm thick roll of blanket or towel under the shoulders and/or support lower jaw and open baby’s mouth to improve airway patency as needed • Routine suctioning NOT recommended - even if exposed to meconium • Suction if obvious signs of obstruction to spontaneous breathing or PPV e.g. respiratory efforts with no audible air entry to lungs; course crackles audible: –– gently use a 10-12 F suction catheter passed no more than 5 cm from lips in term baby –– only for a few seconds • If HR < 100 AND remains either apnoeic or ineffective respirations (gasps): g labour and birth –– commence respiratory support within 1 minute of birth at a rate of 40-60 breaths per minute –– use room air unless advised by MO otherwise
• Place pulse oximeter sensor on baby’s right hand or wrist (pre-ductal) to monitor HR and SpO2: –– for targeted levels of SpO after birth see Newborn Life Support flowchart, page 567 s durin 2 e • Effective ventilation will almost always be enough to resuscitate baby: –– indicated by chest wall movement, improvement in HR and SpO nci 2
e • If little or no visible chest wall movement, improve the technique of ventilation:
rg –– check face mask fits well, with minimal leak e –– check neck and jaw position
Em –– occasionally an oropharyngeal airway/LMA may be useful if ≥ 34 weeks or > 2000 g • After 30 seconds of ADEQUATE assisted ventilation check HR: –– if HR < 60 commence chest compressions –– aim for 90 compressions per minute with ½ second pause every 3rd compression to deliver an inflation • Continue to resuscitate as per the Newborn Life Support flowchart, page 567 • MO may order adrenaline (epinephrine) if HR remains less than 60 bpm: –– umbilical vein is preferred route if skilled, otherwise consider intraosseous route. See Intraosseous infusion, page 69 and Newborn Life Support flowchart, page 567 for doses
566 | Primary Clinical Care Manual 10th edition | Em
2 Newborn Life Support flowchart e rg e nci e s durin g labour and birth
Australian Resuscitation Council Guideline 2016
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 567 Special considerations for preterm babies6 • Respiratory support will be required for most very preterm babies • Temperature: –– very premature babies are at particular risk of hypothermia –– if < 28 weeks resuscitate baby wrapped in polyethylene bag or under polyethylene sheet up to the neck (until alternative methods of thermal control available) e.g. zip lock bag, oven bag, NeoWrap® –– do not cover head with plastic –– no need to dry baby before placing in bag - head only needs drying. g labour and birth –– apply bonnet/folded bedding to head (pre-warmed if possible) –– provide tactile stimulation through bag –– using a radiant warmer if available –– do not remove the bag/wrap during resuscitation. Keep in place until temperature has been s durin checked and pre-warmed humidified incubator available e –– if possible, room temperature should be at least 26⁰C nci e rg e Em
• Handling and skin protection: –– handle gently - premature infants are at increased risk of damage to skin and internal organs –– ensure adherence to good infection control –– if using antiseptic for umbilical catheterisation, use sparingly and avoid pooling in groin/ flanks - particularly alcohol based which can cause serious damage to immature skin
3. Clinical assessment1,7 • Record Apgar score at 1 and 5 minutes after birth, and then every 5 minutes until HR and breathing are normal. See Immediate care of the newborn, page 558 • Post resuscitation:
–– continue to closely monitor SpO2, HR, RR and respiratory effort, tone –– after 10 minutes of age target SpO2 is: –– term babies 92-98% –– preterm babies 90-95% –– check BGL - infants who require resuscitation are more likely to develop hypoglycaemia. See Immediate care of the newborn, page 558 –– MO may consider further investigations/antibiotics as resuscitation may be a consequence of the onset of sepsis
568 | Primary Clinical Care Manual 10th edition | Em 4. Management7,8 e
• Post resuscitation: rg
–– keep warm and maintain T 36.5-37.5⁰ C e
–– continue routine newborn management including administration of Vitamin K nci –– prepare baby for retrieval in consultation with retrieval team and MO/NP e
–– maintain close monitoring of baby until evacuation occurs s durin –– provide support to the mother and family, and keep informed - resuscitation of a baby will be distressing for parents
5. Follow up g labour and birth • Mother and baby should be subsequently managed in maternity service7 6. Referral/consultation • Consult MO/NP on all occasions
Umbilical cord prolapse or presentation
Recommend
• Umbilical cord prolapse is an obstetric emergency - the cord can be compressed, cut off 2O to the baby and can result in asphyxia or death1 • Cord presentation or prolapse should be excluded at every vaginal examination in labour2 • Always listen to FHR after membranes rupture - suspect cord prolapse if bradycardia or abnormal FHR pattern2,3 • Speculum and/or digital vaginal examination should be performed if cord prolapse is suspected Background • Cord prolapse is where the umbilical cord is felt in front of the presenting part after rupture of membranes (ROM):2,3 –– ROM must occur for umbilical cord to prolapse. Most cases occur shortly after –– can occur in any situation where the presenting part (of the baby) does not fit well into the mothers pelvis e.g. prematurity –– can sometimes be difficult to confirm if the cord is not visible or palpable –– wrapping swabs soaked in warm saline around the cord exposed to air is of unproven benefit2 • Cord presentation occurs when the umbilical cord is felt in front of or near the fetal presenting part. If membranes rupture, cord will prolapse4
1. May present with • Cord prolapse:3 –– fetal bradycardia or abnormal FHR after rupture of membranes –– cord visible or palpable (smooth pulsating band) in vagina or on vulva after membranes rupture –– palpation of the cord below the presenting part during vaginal examination • Cord presentation:4 –– on digital vaginal examination cord is felt in front of presenting part of baby –– membranes intact –– fetal bradycardia or abnormal FHR
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 569 2. Immediate management1,2 • Call for help • Consult MO urgently • If abnormal FHR after membranes rupture: –– perform urgent speculum/digital vaginal examination to check for cord (if skilled) • Aim is to stop cord compression
If cord has prolapsed2,3,5
g labour and birth • Promptly: –– assist mother into the knee-chest face-down position (see diagram) –– put two gloved fingers into the vagina and gently push the presenting part of the baby upwards off the cord
s durin –– avoid putting pressure on cord e –– if the cord is outside of the vagina, attempt to replace it back into the vagina with a DRY pad: – minimise handling as can cause vasospasm nci
e • Insert urinary catheter:
rg –– run 500 mL of sodium chloride 0.9% into the bladder using an IV giving set: e –– check that the IV giving set is a good fit with the catheter and that fluid can be effectively squeezed into the bladder without undue leakage Em –– clamp the catheter - filling the bladder may hold the presenting part off the cord –– the fingers holding the presenting part of the baby can now be withdrawn –– discuss with MO the timing to release clamp and amount of urine to drain • Woman needs to stay positioned: –– knee-chest face-down (while waiting for transport) OR –– left lateral with head down and pillow(s) under left hip (during transport) until baby can be delivered safely via caesarean section • Monitor FHR closely to assess adequacy of measures above (normal is 110-160/min) • If FHR not heard, continue with above measures until an USS can be performed
If cord presentation suspected4 • Act promptly • Perform vaginal examination to confirm/exclude if not already done (and skilled) • Elevate the pelvis of the woman so that the presenting loop can slip back up, or if possible, knee- chest position as above, • Follow with lateral supine position - ask woman to lie on the opposite side to which the cord is presenting (if known), keep pelvis elevated with pillow(s) under hip • Monitor FHR to check if returns to normal after positioning - if remains abnormal try repositioning to other side • Be guided by MO for further management
570 | Primary Clinical Care Manual 10th edition | Em e rg e nci e s durin g labour and birth
3. Clinical assessment • Obtain rapid history of: –– this presentation, pregnancy history and past history –– see Preterm prelabour rupture of membranes, page 537 for prompts • Perform physical examination as able: –– standard clinical observations (full Q-MEWT Rural and Remote - Antenatal or other local Early Warning and Response Tools) –– FHR –– palpate contractions –– assess liquor - clear, meconium stained, bloody 4. Management2 • Urgently contact MO who may: –– order tocolytics to suppress labour. See Preterm labour, page 544 –– organise urgent evacuation for caesarean section • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status • Keep nil by mouth • Provide emotional support for woman and partner/support person. Keep informed • In isolated areas, if a woman presents with a cord prolapse, the baby may have already died. However, unless this is certain, it is best to act as above 5. Follow up2 • Offer ongoing support to woman/refer to perinatal mental health supports • After obstetric emergencies women can be psychologically affected by post-natal depression, post-traumatic stress disorder or fear of further childbirth • Women with cord prolapse and those requiring urgent transfer to hospital may be particularly vulnerable to emotional problems 6. Referral/consultation • Consult MO urgently on all occasions of umbilical cord presentation or prolapse
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 571 HMP Primary postpartum haemorrhage (PPH)
Recommend1 • Major blood loss can develop rapidly without warning in the absence of haemodynamic compromise. Close monitoring and rapid response is critical • Visual estimation of blood loss often leads to underestimation. Also consider nature and speed of blood loss, and clinical findings due to hypovolaemic shock to guide loss estimation • Use warm IV fluids if warming device available; do not use microwave • Give tranexamic acid in addition to uterotonics - reduces blood loss and death especially if given
g labour and birth within 3 hours of birth Background1,2,3,4 • Primary postpartum haemorrhage occurs within 24 hours of birth, generally > 500 mL and is a leading cause of maternal morbidity and mortality s durin
e • Common causes of PPH are referred to as the ‘Four T’s’: Tone - uterus not contracting (70%); Trauma e.g. of perineum/vagina (20%); Tissue - retained products/placenta/membranes (10%); nci and Thrombin - coagulation abnormalities (< 1%) e • Risk factors for PPH include (but not limited to): rg
e –– ≥ 35 years, BMI ≥ 30; parity > 3; gestational diabetes; anaemia; multiple pregnancy; previous PPH; fibroids; anaemia; antepartum haemorrhage; placenta praevia; prolonged labour; Em perineal trauma; non-cephalic presentation; polyhydramnios; premature rupture of membranes; T > 38 ⁰C in labour
Related topics Secondary postpartum haemorrhage, page 586
1. May present with1,5 • Bleeding ≥ 500 mL immediately post birth or up to 24 hours later: –– ≥ 1000 mL is severe –– ≥ 2500 mL is very severe • Slow steady trickle of blood after third stage of labour • Signs of shock: –– ↑ HR, ↓ BP, ↑ RR –– restlessness, sweating, cool, clammy skin –– decreased urine output • Tachycardia and narrow pulse pressure (systolic BP minus diastolic BP) may occur early in severe PPH4 • Amount of vaginal bleeding may look normal if intra-abdominal sources of bleeding e.g. ruptured uterus, haematoma, subcapsular liver rupture6
572 | Primary Clinical Care Manual 10th edition | Em
1 Clinical findings in PPH e rg Blood loss (mL) Systolic BP Signs and symptoms Degree of shock e
palpitations, dizziness, nci 500-1000 normal compensated tachycardia e
weakness, sweating, s durin 1000-1500 slight decrease mild tachycardia restlessness, pallor, 1500-2000 70-80 mmHg moderate oliguria g labour and birth collapse, air hunger, 2000-3000 50-70 mmHg severe anuria
2. Immediate management1 • Act quickly to resuscitate, treat shock and identify cause simultaneously • Send for help • DRS ABC as relevant. See DRS ABCD resuscitation/the collapsed patient, page 54 • Contact MO urgently • Assign person to care for baby • Ensure routine third stage oxytocin given. See Imminent birth, page 552
If placenta out • Rub fundus (top of uterus) until it is a hard ball • Expel clots from uterus if needed - cup fundus with palm of hand, compress uterus between thumb and fingers • Insert IDC to empty bladder • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status: –– 1 line for fluids, 1 for medicines –– use intraosseous if IV not obtained • If still bleeding: –– continue to rub fundus if boggy/not contracting –– give oxytocin 5 units IV over 1-2 minutes –– give rapid IV fluids (warmed if possible) - Hartmann’s or sodium chloride 0.9% 1000 mL –– repeat dose of oxytocin in 5 minutes if needed –– start oxytocin infusion 30 units in 500 mL sodium chloride 0.9% –– MO may order: –– ergometrine + antiemetic. See Nausea and vomiting, page 48 –– misoprostol - takes 1-2.5 hours to work (early administration may help sustain uterine tone)
If STILL BLEEDING excessively and uterus not firming - start bimanual compression
• If trailing membranes use sponge holder to remove: –– without traction, grasp membranes and roll forceps to create a rope –– use up and down motion and gentle traction to remove • Check placenta and membranes are complete
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 573 Look for other causes if placenta and membranes delivered and look intact, uterus well contracted and STILL BLEEDING1 • Trauma: –– examine perineum, cervix and vagina –– apply firm pressure to bleeding areas, or clamps to bleeding vessels until repair possible • Thrombin - look for: –– haematuria, petechial conjunctival and mucosa haemorrhage –– blood that no longer clots - look on bed or floor –– T < 35⁰C g labour and birth –– uterine atonia (not contracting)
s durin If placenta NOT out e • Reattempt controlled cord traction. See Imminent birth, page 552
nci • Insert IDC to empty bladder e • Encourage maternal pushing and repositioning rg
e • Insert 2 x IV cannula - use the largest possible gauge given age and vascular status: –– 1 line for fluids, 1 for medicines Em –– use intraosseous if IV not obtained • If still bleeding: –– give oxytocin 10 units IV or IM –– give rapid IV fluids (warmed if possible) - Hartmann’s or sodium chloride 0.9% 1000 mL –– do vaginal examination to check if placenta remains in uterus. If felt protruding through cervix or lying high in vagina gently attempt to remove –– if placenta not coming out or incomplete, will require transfer to appropriate equipped facility for manual removal –– as a life saving measure MO may advise manual removal of the placenta in the community. See Manual removal of the placenta box
If STILL BLEEDING excessively - start bimanual compression
In all cases • Assess rate and volume of bleeding - use caution with underestimation: –– weigh bloody linen, drapes, bluey's/pinkies if practical • Lie flat • If hypotensive position feet higher than head by 15-300
• Give O2 via face mask at 10-15 L/min regardless of SpO2. See Oxygen delivery, page 64 • Keep warm, aim for T > 36⁰C • Continuously monitor (or at least 15 minutely) standard clinical observations (full Q-MEWT Rural and Remote - Postnatal or other local Early Warning and Response Tools) • Continue fluid resuscitation: –– MO will order more IV fluids (up to 2 L crystalloids, up to 1.5 L colloids) –– early blood transfusion preferred for continued bleeding if available –– monitor fluid balance, aim for urine output ≥ 30 mL/hour • Give tranexamic acid on MO order as soon as possible (within 3 hours) 574 | Primary Clinical Care Manual 10th edition | Em • Take urgent bloods time permitting:
–– full chemistry profile (Chem20), FBC e rg –– coagulation profile, blood gas including calcium and lactate
–– consider blood cross match if no group or cross match sample available or woman has e nci significant antibodies
–– if intraosseous route used for bloods, make note on pathology form e • Administer analgesia as clinically indicated. See Acute pain management, page 35 s durin • Massive Haemorrhage Protocol may be activated by MO as per local policy if actively bleeding and ANY of the following: –– blood loss > 2500 mL g labour and birth –– anticipated 4 units of blood required in < 4 hours AND haemodynamically unstable –– evidence of coagulopathy
Bimanual compression1 Aortic compression2 (if MO advises) • With one hand: • Aim is to conserve blood by cutting off supply –– keeping fingers straight and thumb to pelvis via compression: tucked in palmar side of index –– place left fist just above and to the finger, insert hand into the vagina left side of the woman’s umbilicus with palm facing woman’s thigh –– before exerting pressure, feel femoral –– once fingers meet resistance artery for a pulse using right hand roll the hand so palm is upward, –– slowly lean over woman to and curl fingers into a fist increase pressure over aorta –– place fist in anterior fornix of the –– check pulse is now non-palpable vagina and apply upwards pressure in femoral artery - adjust • With the other hand: position of fist as needed –– locate the top of the uterus (fundus) –– keep monitoring femoral pulse –– deeply palpate to put the while aorta is being compressed fingers behind the fundus –– cupping the fundus, compress it firmly around the fist that is in the vagina –– keep compressed and evaluate effect
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 575 Extended authority Schedule 4 Oxytocin ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO MID and RIPRN may proceed Route of Recommended Form Strength Duration administration dosage
IM 10 units stat stat g labour and birth Inject over 1-2 minutes 5 units Repeat after 5 minutes if needed to a max. of 10 5 units/mL Injection units 10 units/mL IV s durin Infusion e 30 units
nci Dilute in 500 mL Infuse at
e sodium chloride 0.9% 83-167 mL/hour (Infuse 5-10 units/hour) rg e Provide Consumer Medicine Information: May cause nausea and vomiting Em Note: Rapid injection can hypotension, tachycardia, arrythmia and myocardial ischaemia Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,7
576 | Primary Clinical Care Manual 10th edition | Em
Extended authority e
Schedule 4 Ergometrine rg ATSIHP/IHW/IPAP/MID
ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP e nci ATSIHP, IHW and IPAP may not give IV
MID may proceed e s durin Route of Recommended Form Strength Duration administration dosage stat IM 250 microgram May be repeated once after 5 g labour and birth minutes on MO order 500 (For IV dilute 250 Injection microgram/mL micrograms to stat Give slowly over 1-2 minutes IV 5 mL with sodium chloride 0.9%) May repeat once after 2-3 minutes. Further doses on MO order Provide Consumer Medicine Information: May cause nausea and vomiting Note: Consider giving concomitant antiemetic Contraindications: Retained placenta, pre-eclampsia, eclampsia, hypertension/history of hypertension, severe/persistent sepsis, renal, hepatic or cardiac disease Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,8
Extended authority Schedule 4 Misoprostol ATSIHP/IHW/IPAP ATSIHP, IHW, IPAP, MID, RIPRN and RN must consult MO Route of Recommended Form Strength Duration administration dosage 800-1000 Tablet 200 microgram PR/Subling/Buccal stat microgram Provide Consumer Medicine Information: Buccal - put tablets in the mouth between the cheeks and gums. Let them dissolve over 30 minutes before swallowing what is left of the tablets Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 1,11
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 577 Schedule 4 Tranexamic acid Prescribing guide
MID, RIPRN and RN only. Must be ordered by an MO Route of Recommended Form Strength Duration administration dosage stat IV Infuse over 10 minutes 1 g/10 mL Injection 500 mg/5 Dilute in 100 mL 1 g If bleeding persists after 30 minutes, mL sodium chloride or stops and restarts within 24 hours g labour and birth 0.9% of the first dose, a second dose is recommended Provide Consumer Medicine Information: May cause hypotension and dizziness (particularly after rapid administration), thrombosis and visual disturbances
s durin Note: Initiate as soon as possible after onset of PPH, preferably within 3 hours e Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102
nci 1,9,10 e rg e
Em Manual removal of the placenta1,3 • As a life saving measure only on MO advice ®) • Give analgesia. See Acute pain management, page 35 plus nitrous oxide and O2 (Entonox during the procedure. See Imminent birth, page 552 • Ensure aseptic technique • MO may order a single dose of antibiotics - ampicillin or first-generation cephalosporin • Insert IDC to empty bladder • Use one hand to follow the path of the umbilical cord through the vagina, cervix and lower uterine segment to find the maternal-placental interface • The other hand maintains the uterine fundus in position through the mother's abdomen • If the opening of the cervix is too small to fit the clinicians hand, a uterine relaxant, such as glyceryl trinitrate may be ordered • Gently separate the placenta from the uterus with your hand using a side-to-side motion until the placenta has completely separated • If there is a small area where the placenta is very adherent to the uterus, use your fingers to slowly and persistently attempt to remove • When placenta removed massage fundus to promote uterine contraction
Uterine inversion1 • Contact MO urgently for advice • If inverted uterus to be corrected, to relax uterus MO may order: –– to stop oxytocin infusion –– glyceryl trinitrate 400 microgram spray, terbutaline 250 microgram subcut or IV, or magnesium sulphate 4 g IV infusion over 5 minutes • See Queensland Clinical Guideline Primary Postpartum Haemorrhage: https://www.health.qld. gov.au/qcg/publications#maternity
578 | Primary Clinical Care Manual 10th edition | Em 3. Clinical assessment e
• See Immediate management rg
1 e 4. Management nci As per Immediate management, until bleeding controlled
• e
• Administer analgesia as clinically indicated. See Acute pain management, page 35 s durin • Continue to monitor closely while collaborating with MO: –– standard clinical observations –– uterine tone g labour and birth –– vaginal blood loss –– fluid balance • Keep warm • Offer woman and family debriefing and provide emotional support • Support maternal and infant bonding, facilitate skin to skin contact under direct supervision • Facilitate infant feeding 5. Follow up • Evacuation is required to facility with equipment and expertise 6. Referral/consultation • Consult MO early on all occasions of PPH
Shoulder dystocia
Recommend1,2 • Shoulder dystocia is an obstetric emergency • An episiotomy should only be considered if the clinician’s hand is unable to enter the vagina for internal manoeuvres. It will not relieve the bony obstruction3 • Do not use downward and/or excessive traction of the baby’s head or apply pressure to the top of the uterus (fundal pressure) - associated with brachial plexus injury, and fundal pressure with uterine rupture4 • Only use slow and gentle axial traction, as you would with a normal birth i.e. in line with baby’s spine4 Background • Clinicians may find Eponyms such as Rubin I, Woods’ screw, and the mnemonic HELPERR confusing.4,5 If used HELPERR stands for: call for Help; Evaluate for episiotomy OR End pushing; Legs (McRoberts); suprapubic Pressure; Enter vagina (for internal maneuvers); Remove posterior arm; Roll onto hands and knees6 • Shoulder dystocia has a high perinatal morbidity and mortality rate. Maternal morbidity is also increased4
1. May present with1,4,7 • Difficulty with delivery of face and chin • Head remains tightly applied to vulva or retracts (turtle-neck sign/head bobbing)
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 579 • Baby’s head fails to restitute (turn) • Shoulders fail to descend • Routine gentle traction in an axial direction (in line with the axis of the fetal spine) fails to deliver shoulders
2. Immediate management1,2,3,4 • Call for help • Urgently contact MO • Stay calm
g labour and birth • Note time the head birthed • Ask mother to END (stop) pushing. Pushing may make the shoulder more impacted • Go to step 1 s durin
e Step 1 Position legs McRoberts • Lie woman flat, remove pillows, move nci buttocks to edge of bed so they hang off e • Bring woman’s thighs to abdomen and rg hyper-flex as far as they can go e • Position is effective if buttocks are lifted off
Em the bed • Get assistant(s) to hold legs in place • Apply routine axial traction: ––same degree of traction as applied during a normal birth in line with the axis of the fetal spine • If top shoulder NOT coming go to Step 2
• Do not continue to apply traction Image reproduced with permission of Remote Primary Health Care Manuals, 2017
Step 2 Apply suprapubic pressure • Maintain thighs to abdomen • Get assistant to stand on side of fetus’ back • Select most likely side if not sure where back is • If unsuccessful, can try other side • Put hand just above the mother’s symphysis pubis, over baby’s anterior shoulder • Assistant to apply strong suprapubic pressure in a downward and lateral direction (NOT pressure to top of uterus): ––use a continuous or a rocking ‘CPR-like’ motion • At the same time: ––apply gentle axial routine traction to baby’s head Image reproduced with permission of ––ask mother to push Remote Primary Health Care Manuals, 2017 If top shoulder NOT coming, go to Step 3
580 | Primary Clinical Care Manual 10th edition | Em
Step 3 Roll onto all fours e • Assist woman into ‘all fours’ position with hips and rg
knees flexed e • Like a reverse of the McRoberts position nci
• Apply gentle axial traction to baby’s head to deliver e
the top (posterior) shoulder s durin
If top shoulder NOT coming, go to Step 4 Image reproduced with permission of Remote Primary Health Care Manuals, 2017
Step 4 Enter hand into vagina g labour and birth • Position woman back in knees to chest position with buttocks at end of bed • Scrunch up your hand like trying to fit it into a tin of Pringles® or putting a tight bracelet over your hand (fingers compressed and thumb tucked into palm) • Insert whole hand into the vagina posteriorly via sacral hollow (buttocks side of the baby's head) • Will be a tight fit Try to remove posterior arm OR internal rotation. Try both manoeuvres if needed
Option 1 Remove posterior arm Option 2 Internal rotation
Image reproduced with permission of the Image reproduced with permission of the Queensland Ambulance Service Queensland Ambulance Service
• With hand in vagina, feel across the baby's • Keep hand in vagina chest • Apply pressure with hand in vagina behind • Feel for the hand and forearm of the either the front or back aspect of the posterior posterior arm (on woman’s buttocks side) (lowermost) shoulder • If baby's arm is felt flexed over its chest, take • If pressure in one direction has no effect try hold of wrist with fingers and thumb, and rotating in opposite direction by pressing on gently release the posterior arm in a other side of the baby: straight line ––change from pressing the back of the • Use action like putting your hand up in baby’s shoulder to the front or vice versa class • If you are struggling, try changing the hand you are using • Only try to rotate up to 20-300 • Ask assistant to apply suprapubic pressure to help rotation • Make sure you are both pushing in the same direction
If birth NOT achieved go back to Step 1 • Continue progressing through each step • Be guided by MO
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 581 3. Clinical assessment • See Immediate management 4. Management • A baby born with shoulder dystocia will require resuscitation. See Neonatal resuscitation, page 565 • Once baby delivered, continue to manage woman as per Imminent birth, page 552 • MO will arrange for evacuation to neonatal unit • Keep mother informed of what is happening • If outcome of shoulder dystocia results in neonatal injury or death, provide emotional support to g labour and birth mother and partner/family 5. Follow up As guided by MO
s durin • e 6. Referral/consultation nci e • Always consult MO rg e Breech birth Em
Recommend1,3 • A preterm breech should be managed the same as a term breech • Keep hands off wherever possible. Touching the baby may result in reflex extension of the arms or head • Avoid traction on the baby’s trunk. This can cause arms to get positioned around back of neck and make delivery difficult • Avoid handling the umbilical cord, as this increases vasospasm • If handling the baby is required, ensure that support is only provided over the bony prominences of the pelvic girdle to reduce soft tissue and internal injury Background1,3 • Breech presentation is where the presenting part of the baby is the buttocks or feet; the breech can be extended, flexed or footling • Routine episiotomy not recommended • Once the buttocks have passed the perineum, significant cord compression is common • The Burns-Marshall technique (grasping the feet of the baby who has delivered to the nape of the neck and sweeping up in a wide arc to deliver the head) is associated with overextension of the head and is not advised
1. May present with • 2nd stage of labour (birth) • Baby's buttocks and feet, buttocks, or foot presenting first from the vagina 2. Immediate management • Call for help • Urgently contact MO
582 | Primary Clinical Care Manual 10th edition | Em • Stay calm
• Conduct vaginal examination immediately after membranes rupture to rule out prolapsed cord4 e rg • If you can see or feel the cord, see Umbilical cord prolapse or presentation, page 569 e
• Aim for an unassisted HANDS OFF birth wherever possible nci • During birth:1 e
–– ensure baby’s back remains opposite to the mothers back s durin –– if the baby’s trunk looks like it is rotating to the sacro-posterior position (baby’s back to mothers back) controlled rotation may be needed –– only handle baby over bony prominences
–– keep mother’s bladder empty where possible g labour and birth
Unassisted breech birth1,4,5
Keep HANDS OFF • Assist woman into semi-recumbent or all-fours position depending on her preference and your experience • Place semi-recumbent if assistance needed • Await mothers spontaneous urge to push • When fetal buttocks present at vaginal opening note time and encourage mother to push during contractions • Allow baby to birth by maternal expulsions alone • Hands off • When umbilicus visible note time • In most cases the baby will birth spontaneously, and only gentle support of the body is needed as the head is born (particularly if preterm) • If the limbs and trunk do not birth spontaneously: –– release the legs by applying gentle pressure to the popliteal fossa (back of knee joint) • Birth the head very gently
Images reproduced with permission of Remote Primary Health Care Manuals, 2017
Assisted breech birth1 • Signs that the birth should be assisted: –– no progress once the umbilicus is visible e.g. arms and legs not releasing spontaneously –– delay of > 3 minutes from birth of umbilicus to head –– delay of 5 minutes between the birth of the buttocks to head –– poor fetal condition • If arms do not release spontaneously use Løvsett’s manoeuvre. See following page • After release of the arms:1 –– support the baby until the nape of the neck becomes visible –– using the weight of the baby to encourage flexion –– ensure the head is born very gently with the woman ‘breathing’ it out very slowly • If spontaneous birth of the head does not follow:1
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 583 –– an assistant may apply suprapubic pressure to the mother to assist flexion of the head –– if head still not birthing, use Mauriceau-Smellie-Veit manoeuvre –– do not allow the head to get de-flexed
Løvsett’s manoeuver to release arms1 • Gently hold the baby over bony prominences of the hips and sacrum • Rotate baby so that one arm is upper most • To release upper most arm, put your index finger over the baby’s shoulder and follow the baby’s arm to the antecubital fossa - Image 1 g labour and birth • Flex the arm for delivery • Following release of the 1st arm, rotate baby 180⁰, keeping back uppermost – the 2nd arm becomes upper most - Image 2
s durin • Release this arm as per the first e Image 1 Image 2 nci e rg e Em
584 | Primary Clinical Care Manual 10th edition | Em
1,2 Mauriceau-Smellie-Veit manoeuvre birth of the after coming head e rg
• Support baby’s body on the under surface of your dominant forearm: e –– place 1st and 2nd fingers of your hand on the cheekbones of the baby (no fingers in mouth) nci
• With your other hand: e
–– apply pressure to the occiput (back of baby’s head) with the middle finger s durin –– place the other fingers simultaneously on the baby’s shoulders to promote flexion of the head (keep the chin on the chest) –– this should reduce the baby’s head diameter
• Delivered baby in an arc towards the mother’s abdomen g labour and birth • Ask assistant may apply suprapubic pressure to the mother to aid flexion
Assistant pushes above the pubic bone as baby delivers
1st and 2nd fingers on cheek bones
Image reproduced with permission of the Queensland Ambulance Service
3. Clinical assessment • See Imminent birth, page 552 4. Management • A baby born via breech may require resuscitation. See Neonatal resuscitation, page 565 • Once baby birthed, continue to manage woman as per Imminent birth, page 552 5. Follow up • As guided by MO 6. Referral/consultation • Always consult MO
Section 6: Obstetrics and neonatal | Emergencies during labour and birth 585 Postnatal
HMP Secondary postpartum haemorrhage
Postnatal Recommend • Approximately 10% of cases of secondary postpartum haemorrhage (SPPH) will present as a massive haemorrhage.1 Resuscitation should be commenced promptly - rapid response is critical • Sepsis should be considered in all recently delivered women who feel unwell and have a fever or hypothermia2 Background • Secondary postpartum haemorrhage (SPPH):3 –– is any abnormal or excessive bleeding from the birth canal occurring between 24 hours and 12 weeks after birth –– usually occurs as a result of a tear, an infection, or by fragments of the placenta and/or membranes, remaining in the uterus and causing an infection or preventing the uterus from contracting • There is a lack of clear evidence on the management of SPPH1,3 • Most SPPH will settle without the woman requiring investigation or any specific treatment4
Related topics Primary postpartum haemorrhage, page 572
1. May present with5,6,7 • Vaginal bleeding in excess of what is expected 24 hours -12 weeks after birth • May also have signs of infection: –– pelvic pain, uterine tenderness –– fever –– malodorous vaginal discharge • Signs of shock due to either blood loss or sepsis. See Sepsis/septic shock, page 80 –– ↑ HR, ↓ BP, ↑ RR –– restlessness –– sweating –– cool, clammy skin –– decreased urine output –– T ≥ 38oc or < 36oc –– mottled or ashen appearance –– altered mental status 2. Immediate management8 • Estimate total blood loss, previous and ongoing: –– keep all pads/linen for weighing to help estimate • If severe haemorrhage/shock or blood loss > 1000 mL: –– call for help –– commence resuscitative measures PLUS look for and treat cause, as described in immediate management of Primary postpartum haemorrhage, page 572
586 | Primary Clinical Care Manual 10th edition | Postnatal –– urgently contact MO –– arrange evacuation –– IV antibiotics will also likely be ordered • If signs of sepsis, see Sepsis/septic shock, page 80 –– urgently contact MO 3. Clinical assessment8 • Obtain history of this presentation: –– bleeding - when did it start, how much, is it heavy and ongoing, colour –– feeling unwell/well –– fever –– pain/abdominal cramping - where, when did it start, severity –– offensive vaginal discharge (lochia) –– any other symptoms - rigors, nausea, vomiting –– consider other sources of infection - mastitis, UTI9 • Obtain obstetric history: –– parity, labour and birth details –– any complications: –– manual removal of placenta, prolonged rupture of membranes or prolonged labour, fever during labour –– completeness of placenta and membranes • Any relevant medical or family history - bleeding disorder, diabetes, hypertension, allergies, medicines • Perform standard clinical observations (full Q-MEWT Rural and Remote - Postnatal or other local Early Warning and Response Tools) • Perform physical examination: –– observe blood loss, clots, amount, colour –– palpate abdomen - assess uterine size/tenderness –– if uterus boggy, rub fundus • If skilled, perform sterile speculum examination: –– look for sores, bleeding source, infected tears on vulva/perineum –– visualise the cervix, any discharge –– note if cervical os is open or closed –– if products of conception protruding, use sponge forceps to remove gently –– take endocervical swab and vaginal swabs (including episiotomy or tear sites) for MCS, and gonorrhoea, chlamydia and trichomonas PCR. See Sexually transmitted infections, page 615 • Take pathology: –– if late postpartum haemorrhage > 6 weeks postpartum, perform point of care testing for pregnancy –– urine - dipstick and MSU for MCS –– Hb on iStat –– if T > 38oC take blood cultures –– consider additional pathology for suspected sepsis. See Sepsis/septic shock, page 80
Section 6: Obstetrics and neonatal | Postnatal 587 4. Management2,4,8 • If severe haemorrhage. See immediate management of Primary postpartum haemorrhage, page 572 If woman feeling unwell with fever > 38oc OR hypothermia < 36oc always consider sepsis. See Sepsis/septic shock, page 80 Consult MO who may order: Postnatal • –– antibiotics –– misoprostol. See Primary postpartum haemorrhage, page 572 –– evacuation/hospitalisation. May require USS/further investigations • Keep nil by mouth • Monitor amount and rate of blood loss • If evacuated/hospitalised, where possible keep mother and baby together 5. Follow up • If not evacuated/hospitalised, advise woman to be reviewed the next day • Advise woman to see MO at next clinic • Follow up test results 6. Referral/consultation • Consult MO on all occasions of secondary postpartum haemorrhage
HMP Mastitis/breast abscess
Recommend1 • Continue breastfeeding or expressing to reduce the risk of complications such as breast abscess • If the mother decides to cease breastfeeding weaning should wait until mastitis is resolved to reduce the risk of breast abscess Background1,2 • Mastitis is inflammation of the breast tissue • Risk factors include nipple damage, poor drainage of the breast, or a prior history of mastitis • More common in the first month after birth, but can occur later • It is difficult to confirm candidiasis as the cause of breast infection. Consider after considering all differential diagnosis • See Queensland Clinical Guideline Establishing Breastfeeding: https://www.health.qld.gov.au/ qcg/publications#maternity
1. May present with2 • Sudden onset of symptoms • Tender, hot swollen, wedge-shaped area of breast • Chills, fever and flu like myalgia • Difficulty breastfeeding • Nipple pain • Severely swollen, painful lump, and oedema in overlying skin suggesting breast abscess
2. Immediate management Not applicable
588 | Primary Clinical Care Manual 10th edition | Postnatal 3. Clinical assessment2 • Ask about: –– any fever, chills, flu like muscle aching –– breast pain, tenderness, redness, swelling - when did it start –– any other symptoms/concerns e.g. nausea, vomiting, fatigue –– current age of baby –– birth details - gestation, complications after delivery –– social and emotional wellbeing and availability of support –– use of restricted clothing/bras • Ask about infant feeding:3 –– is she breastfeeding –– any problems/concerns –– is baby attaching to the breast well –– cracked nipples –– is she still feeding from effected breast –– if expressing - by hand or a breast pump, how often –– how often is baby feeding - usual 8-12 times per day –– how many wet nappies in 24 hours - usual for ≥ 6 –– other methods of feeding if being used • Perform standard clinical observations (full Q-MEWT Rural and Remote - Postnatal or other local Early Warning and Response Tools) • Perform physical examination:2,4 –– examine breasts - look for localised wedge-shaped area of redness, that is tender, warm and firm –– a blocked milk duct may present as a hard lump, patch of redness and afebrile –– damage to nipples - sore, cracked, bleeding –– check for signs of breast abscess - severely swollen lump, red, hot oedema in overlying skin, may become fluctuant and with skin discolouration • Observe baby feeding. Check:3 –– for correct positioning and attachment of baby –– baby’s mouth is opened wide against breast, with nipple and surrounding breast in open mouth –– for deep jaw movements, cheeks are not sucked in –– milk transfer is evident and breast softens during feed • Signs baby getting adequate milk:5 –– alert and mostly happy –– at least 6 pale yellow, wet cloth nappies, or 5 heavily wet disposable nappies per day –– regular soft bowel motions (3-4 in 24 hour period if < 6 weeks, may be less if older) –– gaining weight: –– weigh baby bare –– plot weight on percentile chart - look for upward trend –– check against previous weights
Section 6: Obstetrics and neonatal | Postnatal 589 4. Management1,4 • Be alert to signs of sepsis. See Sepsis/septic shock, page 80
Breast abscess Postnatal • Consult MO/NP if breast abscess suspected • Woman may require USS, needle aspiration or surgical incision
Atypical mastitis in person not lactating • consult MO/NP
Mastitis • Initiate treatment promptly, as delay will more likely lead to infection and breast abscess • Offer analgesia. Ibuprofen is preferred or paracetamol. SeeAcute pain management, page 35 • Effective milk removal is most important management step • Encourage mother to breastfeed more frequently, starting on the affected breast • If pain interferes with letdown reflex, feeding may begin on unaffected breast, switching to the affected breast as soon as letdown is achieved • Position baby at breast with chin or nose pointing towards blockage to help drain the affected area • Prior to feeding: –– application of heat (shower/warm cloth) to the breast may help with letdown reflex • During feed/expression: –– gentle massage may help - direct massage from blocked area towards nipple • After feeds: –– apply cold pack for comfort –– express milk by hand or pump - may help milk drainage and hasten resolution • If breastfeeding is very painful, milk must be removed by expression (at least 8 times in 24 hours) • Seek breastfeeding and expression of milk advice from lactation consultant, midwife or child health nurse as needed • Provide support to the mother. Encourage her to: –– wear unrestrictive clothing/bra –– rest, have adequate fluids and nutrition • If symptoms of mastitis are mild and have been present for less than 24 hours: –– effective milk removal and supportive measures as described above may be sufficient treatment • Give antibiotics if:4,6 –– symptoms are not improving in 12-24 hours OR –– the woman is acutely ill with systemic symptoms: –– flucloxacillin if no allergies OR –– cefalexin if hypersensitive to penicillins (excluding immediate hypersensitivity) OR –– clindamycin if immediate hypersensitivity to penicillins • Continue to monitor baby for feeding and adequate weight gain • If any concerns seek advice from midwife, lactation consultant, child health nurse or MO
590 | Primary Clinical Care Manual 10th edition | Postnatal Extended authority Schedule 4 Flucloxacillin ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP MID and RIPRN may proceed Route of Recommended Form Strength Duration administration dosage 250 mg Adult Capsule Oral 5 days 500 mg 500 mg qid Provide Consumer Medicine Information: May cause diarrhoea, nausea and candidiasis. Take on an empty stomach ½ hour before or 2 hours after food. Safe in breastfeeding. May cause loose bowel actions in breastfeeding infants Note: Can cause cholestatic hepatitis. If renal impairment seek MO/NP advice Contraindication: History of cholestatic hepatitis with dicloxacillin or flucloxacillin. Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 6,7
Extended authority Schedule 4 Cefalexin ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP MID and RIPRN may proceed Route of Recommended Form Strength Duration administration dosage 250 mg Capsule Oral 500 mg qid 5 days 500 mg Provide Consumer Medicine Information: May cause rash, diarrhoea, nausea, vomiting, dizziness, headache and candidiasis. Safe in breastfeeding. May cause loose bowel actions in breastfeeding infants Note: If renal impairment seek MO/NP advice Contraindication: Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware of cross-reactivity between penicillins, cephalosporins and carbapenems Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 6,8
Section 6: Obstetrics and neonatal | Postnatal 591 Extended authority Schedule 4 Clindamycin ATSIHP/IHW/IPAP/MID/RIPRN ATSIHP, IHW, IPAP and RN must consult MO/NP MID and RIPRN may proceed Postnatal Route of Recommended Form Strength Duration administration dosage Adults Capsule 150 mg Oral 5 days 450 mg tds Provide Consumer Medicine Information: May cause rash, diarrhoea, nausea, vomiting and abdominal pain. Take with a full glass of water Note: Can cause severe colitis due to Cl. difficile. Safe in breast feeding, may cause loose bowel actions in breastfeeding infants Contraindication: Allergy to clindamycin or lincomycin Management of associated emergency: Consult MO/NP. See Anaphylaxis, page 102 6,9
5. Follow up • Advise woman to be reviewed next day, or sooner if breastfeeding support required: –– if no improvement start antibiotics if not already commenced –– check baby is feeding adequately • If antibiotics commenced and no improvement the next day consult MO/NP 6. Referral/consultation • Consult MO/NP on all occasions of breast abscess • Refer to lactation consultant, midwife or child health nurse for breastfeeding advice
Postnatal check
Recommend • Postnatal visits are recommended on day 3, between day 7-14 and 6 weeks after birth.1 Visits should be individualised to reflect the needs of mother and baby • The mother and infant should be seen as a unit particularly in the first few months of life2 • Concurrently complete the routine 6-week baby check and offer immunisations at the 6-week postnatal check • Child health check forms available at: https://publications.qld.gov.au/dataset/queensland- health-health-check-forms. Guidance for 6-week infant check in Chronic Conditions Manual available at: https://www.health.qld.gov.au/rrcsu • Post-natal checks to be performed by appropriately skilled practitioner3 Background • There is limited evidence available regarding the timing of visits, and maternal and infant examinations, which is often based on historical models of care2 • Abdominal palpation to assess the fundus is not needed, unless there are concerns3
592 | Primary Clinical Care Manual 10th edition | Postnatal 1. May present with • Mother presenting up to 6-8 weeks after birth
2. Immediate management Not applicable
3. Clinical assessment1 • Ask about/check: –– birth and pregnancy history (obtain discharge summary from hospital) –– gravida/para –– birth details/any problems - vaginal or caesarean delivery, gestation, PPH, perineal trauma –– any problems antenatally e.g. gestational diabetes, anaemia, hypertension/pre-eclampsia –– rubella antibodies - if not immune during pregnancy check MMR vaccine was given after birth –– any treatment(s) or tests for STIs that require follow up • Obtain relevant past medical history and family history: –– diabetes, hypertension, RHD, depression/postnatal depression, mental health illness –– last Cervical Screening Test (CST) or pap smear • Ask about: –– general wellbeing, birth experience, how is she coping3 –– any problems passing urine or urinary symptoms –– bowel function - any constipation –– headache, fatigue, back pain –– breast/nipple pain or concerns –– uterine tenderness –– lochia (vaginal discharge) - colour, amount, any odour –– healing of any perineal wound, perineal pain/hygiene. See Episiotomy and repair of perineum, page 562 –– caesarean wound - any pain/concerns –– infant feeding - breastfeeding progress, concerns/alternative feeding –– resumption of sexual intercourse/any dyspareunia –– alcohol/tobacco use and second-hand smoke –– availability of emotional/other support –– any other concerns • Complete Edinburgh Postnatal Depression Scale between 6-12 weeks post birth. Available at: www. blackdoginstitute.org.au/docs/CliniciansdownloadableEdinburgh.pdf • Evaluate risk of domestic violence: –– check antenatal screening tools. Re-administer appropriate. See Antenatal care, page 500 • Perform physical examination:3,4 –– standard clinical observations (full Q-MEWT Rural and Remote - Postnatal or other local Early Warning and Response Tools) –– observe general appearance –– look for signs of anaemia - pallor, fatigue, breathlessness - check Hb if concerned –– if dysuria/other urinary symptoms do urinalysis - if abnormal See Urinary tract infection (UTI) - adult, page 389 –– offer to assess the perineum if the woman has pain, discomfort or dysparunia –– if caesarean, check wound –– if concerns about breast feeding, breast, or nipple pain, offer to examine breasts/observe breastfeeding
Section 6: Obstetrics and neonatal | Postnatal 593 –– if woman was diagnosed with gestational diabetes complete OGTT at 6-12 weeks post-partum for screening of persistent diabetes5 –– if due for CST offer at around 6 week check 4. Management1,3,4
Postnatal • Advise woman of recommended checks at 1-2 weeks and 6 weeks post birth • Concurrently check baby if possible. See Health Check 1-6 weeks https://publications.qld.gov.au/ dataset/queensland-health-health-check-forms • Consult with MO/NP if: –– abnormal blood loss, offensive lochia, abdominal tenderness or fever. ConsiderSecondary postpartum haemorrhage, page 586 and/or Sepsis/septic shock, page 80 –– perineal or caesarean wound breakdown/not healing –– Hb ≤ 11 g/dl • If hypertension and/or preeclampsia diagnosed in pregnancy:6 –– follow up by MO 6 weeks post-partum to ensure resolution, and need for ongoing care • If gestational diabetes advise:5 –– lifelong screening for development of diabetes or pre-diabetes at least 3 yearly –– if planning another pregnancy, recommend having OGTT or HbA1c annually • If constipated: –– provide advice about diet and fluid intake. Gentle laxative may sometimes be required3 • Offer MMR if woman not immune to rubella and MMR has not been given post-delivery. See Immunisation program, page 768 • Discuss with woman as appropriate:3,7 –– infant feeding - assist/advise as appropriate; support continuance of breastfeeding –– support available e.g. parent groups –– contraception. See Contraception, page 597 –– after pains, fatigue, sleeping –– offer advice for perineal pain as applicable. SeeEpisiotomy and repair of perineum, page 562 –– pelvic floor exercises, particularly if experiencing incontinence –– resuming sexual activity - encourage to delay until perineum healed and bleeding has decreased (as guided by woman’s desire and comfort) –– smoking, nutrition, physical activity, alcohol and other substance use –– immunisations for baby, and offer during 6 week visit. SeeImmunisation program, page 768 • Plan continued postnatal care for the woman and baby based on their individual needs 5. Follow up • Follow up depending on woman’s individual needs 6. Referral/consultation • As required, refer to: –– Mental Health worker, Social Worker, Child Health Nurse, or Midwife
594 | Primary Clinical Care Manual 10th edition | 7
Sexual and reproductive health
595 4
Section 4 Page left intentionally blank General
596 | Primary Clinical Care Manual 10th edition | Contraception general 597 1,5
1,2 Contraception general Contraception and thereby the safety of an ) ontraception: An Australian Clinical Practice An Australian Clinical ontraception: http://ukmec.pagelizard.com/2016# coitus interruptus Please refer to this for comprehensive information for the safe safe the for information comprehensive for this refer to Please Not applicable Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,2,3 1 1 See up to date version at All clinicians should refer to The United Kingdom Medical Eligibility Criteria (UKMEC) system All clinicians should refer to The United Kingdom 1 1 individual’s contraceptive choice in the context of their personal medical history. individual’s contraceptive choice in the context gynaecological and cervical screening history obstetric history previous contraceptive use family history particularly VTE and hereditary thrombophilias sexual history menstrual history medical history particularly migraines, venous thromboembolism (VTE), liver disease, medical history particularly migraines, venous thromboembolism CVA or heart disease or arterial risk factors e.g. gynaecological cancer, breast cancer, history of smoking, diabetes, hypertension identify absolute and relative contraindications to contraceptives identify absolute and relative contraindications – – – – – – – Even methods with higher failure rates can help with birth spacing Even methods with higher MO/NP may consider using the “Quick Starting” method to commence contraception. This to commence Starting” method the “Quick MO/NP may consider using a woman’s next menses for than waiting commencing contraception immediately, rather involves is possible cycle when an early undiagnosed pregnancy if beyond day 5 of the menstrual Handbook 4th edition 2016. Handbook 4th supply of contraception methods for protection use of condoms and other contraception Recommend simultaneous when a risk of STI/HIV transmission exists against HIV and other STIs This section is based on Family Planning New South Wales (FPNSW), True Relationships and (FPNSW), True Relationships New South Wales is based on Family Planning This section Victoria (FPV) C Health, Family Planning Reproductive Properly used, contraception reduces the rate of fertility to between < 1% (sterilisation, implants reduces the rate of fertility to between < 1% Properly used, contraception and 25% ( and injectable progestogen)
– – – – – – – Take full history: Present to the clinic requesting contraception reason Subject raised during a consultation for another
to • • • • •
Sexually transmitted infections, page 615 Related topics • • •
Recommend Background IMPORTANT: 3. Clinical assessment 2. Immediate management 1. May present with
Contraception Contraception general Contraception 598 Contraception general | Primary Clinical CareManual 10th edition | Natural methods Barrier methods Sterilisation the lowestfailurerates Note: theseoptionshave contraception (LARC) Long actingreversible Hormonal contraception Contraception type • • • • – – and (full observations clinical standard Perform information. TrueRelationships&ReproductiveHealthfactsheetsareavailableat: Provide informationontypesofcontraceptionavailable,supportedwithappropriatewritten/verbal – – – – – – – – – – Discuss contraceptionneeds-methodofchoiceinfluencedby: Perform initialphysicalexaminationincludingcervicalscreeningtestandSTIscreenifindicated true.org.au/health-information – – – – – – – – – – urine pregnancytestwhereindicated weight/height -BMI need forprotectionagainstSTI personal choiceandpreviousexperiencewithcontraceptivemethods parity (primipara,completedfamily) socioeconomic status social orculturalfactors personal beliefs user friendliness health risks,sideeffects,pastandpresentmedicalfamilyhistory efficacy, accessibility,cost,age,relationshipstatus,reversibility Eligibility Criteria(UKMEC) absolute andrelativecontraindicationstocontraceptivesasperTheUnitedKingdomMedical Response Tools)+ 6 • • • • • • • • • • • • • • • • • •
Progestogen releasingintrauterinesystem(Mirena Progestogen releasingsubdermalimplant(ImplanonNXT Injectable progestogen(Depo-Povera Copper bearingintrauterinecontraceptivedevice(IUCD) Progestogen releasingintrauterinesystem(Mirena Progestogen releasingsubdermalimplant(ImplanonNXT Coitus interruptus(withdrawal) Fertility awarenessbasedmethods Lactational amenorrhoea Abstinence Diaphragm Condoms (maleandfemale) Vasectomy Tubal sterilization Emergency hormonalcontraception Progestogen onlyPill('MiniPill') Combined hormonalcontraception('ThePill',vaginalringNuvaRing Injectable progestogen(Depo-Povera Contraceptives (inorderofefficacy) ADDS/CEWT score or other local Early Warning Early local other or score Q-ADDS/CEWT ® ® , Depo-Ralovera , Depo-Ralovera 1,5 ® ® ) ) ® ® ) ) ® ® ) ) http://www. ® ) Long-acting hormonal contraception 599 requires storage at requires storage ® Child protection, page 760 Child protection, and
Not applicable 1,8 12 Long-acting hormonal contraception hormonal | Long-acting health reproductive and Sexual Section 7: 1 7 1,8 1,8 Sexually transmitted infections, page 615 infections, page Sexually transmitted Medroxyprogesterone acetate
For women not able to take combined hormonal contraception For women not able to take combined hormonal For women who choose a longer acting method For women seeking an undetectable method medroxyprogesterone acetate. It is therefore a good choice of contraception for women taking medroxyprogesterone acetate. It is therefore a good these medicines Works by preventing ovulation and changing the endometrial lining and cervical mucus Works by preventing ovulation and changing the do not affect the efficacy of Liver enzyme inducing medicines including antiretrovirals Side effects with other forms of contraception Request for contraception Request for administration of depot medroxyprogesterone acetate Referral to MO/NP/specialist with skills for contraceptive implants, IUCD and sterilisation with skills for contraceptive implants, IUCD Referral to MO/NP/specialist MO/NP for assessment and prescription MO/NP for assessment Information on what to do if contraceptive method fails Information on what to do to return for clinical follow up Provide advice on when See NuvaRing (e.g. patient the to available is device for the contraceptive Storage above 30°C) should be protected from sunlight and temperatures 25°C after dispensing and Attention needs to be paid to providing all young men and women who are sexually active with women who are sexually all young men and to be paid to providing Attention needs and child of pregnancy, STI prevention from the perspectives and appropriate support information protection Consult MO/NP if a medical condition is present in a patient who is currently using contraception using contraception is currently patient who present in a is a medical condition MO/NP if Consult method) each contraception against categories (Check UKMEC for its use contraindicated that is chosen method has been once the contraceptive for review and prescription Consult MO/NP
• • • • • Related topics Contraception, page 597 • • • • • • • • • • • •
Recommend Background
HMP HMP 2. Immediate management
1. May present with Depo-Provera®, Depo-Ralovera®
Long-acting hormonal contraception Long-acting hormonal contraception 6. Referral/consultation
5. Follow up 4. Management 4. 600 Long-acting hormonal contraception 4. Management 3. Clinicalassessment | Primary Clinical CareManual 10th edition | • • • • • • • – – – Prior toadministrationofmedroxyprogesteroneacetatecheckannually: Each subsequentdoseisgiven12weekly.Beyondweeksthereariskofpregnancy – – If givenatanyothertime: – – The firstdoseshouldbegivenday1-5ofanormalmenstrualcycle: prescription andinitiationoffirstdose Confirm that<12monthssincelastMO/NPreviewformedroxyprogesteroneacetate – – – – – – Clinical assessment.See Initial assessmentrequiredbyMO/NP – – – – – – – – – – – – – – – – – – ask aboutsideeffects:e.g.weightgain,breasttendernessandmoodchange (incidenceislow): – common): bleeding historyshouldbechecked before eachdoseisgiven (irregular vaginalbleedingisnot – if presenting>14weekssincepreviousinjectionexcludepregnancyprior togiving: a urinepregnancytestisonlynecessaryif>14weekssincethelastinjection BP, weight,menstrual/bleedingpatternandreviewmedicaleligibility advise additionalcontraceptionorabstinenceforthenext7days exclude pregnancyandparticularlyrecentconception it iseffectiveimmediatelyinthissituation day 1isfirstofmensesand54dayslater BP, weight,BMIandmenstrualpattern conception pregnancy testwhereindicated.Anegativedoesnotalwaysexcludeandrecent contraceptive use: check absoluteandrelativecontraindicationsasperUKMedicalEligibilityCriteria(UKMEC)for choice ofcontraception methods ofcontraceptionavailable contraception needs – – – if experiencingsideeffectsrecommendreviewbyanMO/NP if anydoubtaboutnormalityofbleedingpatternrefertoMO/NP the possibleriskofpregnancyifinjectionisnotgiven. if pregnancycannotbeexcludedtheriskofgivinginjectionneedsto beweighedagainst 1,8 http://ukmec.pagelizard.com/2016#
1,8 Contraception, page597 including: 2 ConsultMO/NP
Long-acting hormonal contraception 601 9,10,11 Duration once every 12 weeks Extended authority authority Extended /IHW/RIPRN/SRH ATSIHP 150 mg dosage Recommended Recommended IM Route of administration Not applicable shake injection Medroxyprogesterone acetate Medroxyprogesterone (Depo-Provera®, Depo-Ralovera®) (Depo-Provera®, 1 Long-acting hormonal contraception hormonal | Long-acting health reproductive and Sexual Section 7: Strength 150 mg/mL 4 1,8 1 1
Assessment, insertion, follow up and removal must be performed by a specifically trained Health Assessment, insertion, follow up and removal must pregnancy test and advise alternate method until Professional. If implant is not palpable conduct location is confirmed Failure rates < 0.1% Is easily reversible Long-acting contraceptive effect lasting 3 years Present to the clinic requesting contraception Subject raised during a consultation for another reason MO/NP as above Delayed return of fertility and amenorrhoea may occur after discontinuing treatment. This is normal Delayed return of fertility and amenorrhoea may and normal periods will return within a year. If in and in the vast majority of patients normal fertility doubt consult MO/NP Advise to be reviewed every 12 months by an MO/NP
Form • • • • • • • • • Injection
Recommend Schedule Background : Menstrual irregularity, prolonged bleeding, spotting, Information: Menstrual irregularity, Provide Consumer Medicine in bone mineral depression, acne, weight gain and reduction amenorrhoea, breast tenderness, density than 12 months since last assessed by an MO/NP. Confirm it is less Note: The patient must be initially bone mass not reached recommended for women > 50 years or < 18 if peak MO/NP assessment. Not emergency: Consult MO/NP Management of associated ATSIHP, IHW and RN must consult MO/NP must consult IHW and RN ATSIHP, has prescribed and this medicine has initially been assessed may proceed if patient RIPRN and SRH use has been AND continuous since MO/NP assessment AND it has been < 12 months by a MO/NP since last MO/ or 12 month period end of current prescription Administration not to exceed confirmed. NP assessment 2. Immediate management
1. with May present Sub-dermal progestogen implant
6. Referral/consultation 5. Follow up 602 Long-acting hormonal contraception 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup 4. Management • • • • • • • • • • • MO/NP asabove Implant remainseffectivefor3yearsandmustbereplacedatthattime Removal tobecarriedoutonlybyexperiencedclinician reaction totheimplant tenderness, lossoflibido,abdominalpain,functionalovariancystsandscarringorotherlocal Side effectsincludealteredbleedingpatterns,acne,headache,moodchanges,weightgain,breast carbamazepine Unsuitable forwomenduringand28daysaftertakingliverenzymeinducingmedicinese.g. Bent implantsremaineffective implant Insertion siteisintoinneraspectofnon-dominantarm,andimplantremainspalpableforlifetime days andthatafollowuppregnancytestisnecessary4weeksafterinsertion Otherwise patientshouldbeadvisedtoabstainorusecondomsconsistentlyforthefollowing7 Effective immediatelyifinsertedonday1-5ofthecycleorcurrentlyreliablecontraception. Consult MO/NPforassessment – – – – – – – – – Clinical assessment.See Initial assessmentbyrequiredMO/NP – – – – – – – – – contraceptive use: check absoluteandrelativecontraindicationsasperUKMedicalEligibilityCriteria(UKMEC)for history ofmalignancies breastfeeding history pregnancy history,excludecurrent BP, weight,BMIandmenstrualpattern pregnancy testwhereindicated choice ofcontraception methods ofcontraceptionavailable contraception needs 1 1 http://ukmec.pagelizard.com/2016# 1 Contraception, page597 including:
Long-acting hormonal contraception 603 standard) or ® ) and levonorgestrel intrauterine levonorgestrel ) and ® ® 1,13 and TT380A and ® including: short) ® Not applicable ) ® Contraception, page 597 1,13 and TT380 ® http://ukmec.pagelizard.com/2016# 1,13 Long-acting hormonal contraception hormonal | Long-acting health reproductive and Sexual Section 7: 1,13 very effective - failure rate < 1% and can be left in place for up to 10 years (TT380 < 1% and can be left in place for up to 10 years very effective - failure rate 5 years (Multiload until 12 months the age of 40 can be left in place as contraception copper IUCD inserted after years after LNMP if menopause at < 50 years after LNMP if menopause at > 50 years old or 2 is immediately effective intercourse contraception if inserted within 5 days of unprotected can be used as emergency very effective contraceptive with failure rate of 0.1% very effective contraceptive as well as for and can be used to treat heavy menstrual bleeding, reduces menstrual bleeding contraception contains levonorgestrel that is released continuously for at least 5 years contains levonorgestrel – – – – – – – contraceptive use: cardiac valve disease and valve surgical history if present will require specialist referral cardiac valve disease and valve surgical history history of malignancies check absolute and relative contraindications as per UK Medical Eligibility Criteria (UKMEC) for breastfeeding history STI and PID history fibroids, cervical damage gynaecological history, including PID, endometriosis, methods of contraception available choice of contraception BP, weight, BMI and menstrual pattern contraception needs
– – – – – – – – – – – Copper IUCD – – contraceptive device (Mirena contraceptive device - Mirena Progestogen-releasing intrauterine – trained health professional trained health Assessment, insertion, follow up and removal of an IUCD must be performed by a specifically must be performed by removal of an IUCD insertion, follow up and Assessment, – – – Two types of copper IUCD in Australia (Multiload Australia IUCD in types of copper Two – – – – – – – – – Initial assessment required by MO/NP Clinical assessment. See – Request for contraception During a consultation for another reason
• • • • • • • •
Recommend Background
3. Clinical assessment 2. Immediate management
1. May present with Intrauterine contraceptive device (IUCD) device contraceptive Intrauterine 604 Long-acting hormonal contraception 4. Management | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup • • • • • • • • • • • • • Complications • MO/NP asabove IUCD shouldberemovedbeforeexpirydate Sexually transmittedinfections,page615 visualisation ofthread,discharge,pain,tenderness,sideeffectsand forSTIriskassessment,see Advise tobereviewedin3-6weekspostinsertion Pregnancy isuncommon,pregnancywithanIUCDinsiturequiresspecialistreferral during intercourse Partner dyspareunia may require thread shortening by MO or use of a diaphragm to cover thread STIs andotherinfectionsshouldbetreated.See of PIDreflectsthewoman'sriskexposuretoSTI Pelvic inflammatorydisease(PID)-theriskofPIDis1:400infirst20days.Afterthat IUCD threadsareseenonspeculumexamination,consultMO/NPregardingremovalof Uterine pregnancy-thereisariskofearlymiscarriageand2ndtrimestersepticmiscarriage.If pregnancy butoveralltherateislessthanforwomennotusingcontraception Ectopic pregnancy-ifoccurswithanIUCDinplacethereisahigherriskofectopic is negative Unusual bleeding or lower abdominal pain - refer to MO/NP immediately, even if pregnancy test – – the uterushasenlarged.Performapregnancytest: IUCD hasbeenexpelled,theperforateduterinewallorwomanispregnantand examination. TheIUCDpresencecanbeconfirmedbyultrasound.Otherpossibilitiesincludethe Lost threads-theshouldbevisibleextrudingfromexternalcervicalosonspeculum emergency contraceptionoralternatecontraceptivemayneedtobeconsidered Perforation, expulsion,missingthreadrequiresspecialistreferral,andpregnancytesting, expulsion ofabout5%withthehighestriskwithinfirstyear Expulsion ordisplacementisthe commonest causeofIUDfailure.There is anoverallriskof Uterine perforationisrare-approximately2.3per1000insertions,butaseriouscomplication – – if positive,consultMO/NP the deviceisestablished if negative,refertonextMO/NPclinic,advisingadditionalcontraceptionuntilthelocationof 1,13 1,13 , symptomsofpregnancy,dyspareunia Sexually transmittedinfections,page615 13 orifanyconcernstoassessbleedingpatterns, 2 Combined hormonal contraceptives 605 3,4 Combined hormonal contraception hormonal Combined including: Not applicable
Contraception, page 597 1,14,15 http://ukmec.pagelizard.com/2016# 1,14,15 Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,14,15 1,14,15 Missed pill flowchart, page 608 Missed pill flowchart, contraceptive use: menstrual pattern smoking history per UK Medical Eligibility Criteria (UKMEC) for check absolute and relative contraindications as conception BP, weight, BMI breastfeeding at present methods of contraception available choice of contraception does not always exclude pregnancy and recent pregnancy test where indicated. A negative test contraception history/needs Combined oral contraceptive pill/vaginal ring pill/vaginal contraceptive oral Combined
– – – – – – – – – smoke ≤ 15 cigarettes a day or who stopped smoking < 1 year ago smoking < 1 year a day or who stopped smoke ≤ 15 cigarettes See smoke ≥ 15 ≥ 35 years of age who contraindicated in women contraception is Combined hormonal of age who in women ≥ 35 years of venous thromboembolism day. There is a high risk cigarettes a Combined hormonal contraception can take the form of oral contraceptive pill or vaginal ring can take the form of oral contraceptive Combined hormonal contraception Confirm that it is < 12 months since last MO/NP assessment for oral contraceptive pill prescription Confirm that it is < 12 months since last MO/NP – – – – – – – – Initial assessment required by MO/NP Clinical assessment. See – Request for repeat supply of oral contraceptive pill or vaginal ring Request for repeat supply Request for contraception reason Subject raised during a consultation for another
• • • Contraception, page 597 Related topics • • • • • •
Recommend Background
HMP HMP 4. Management
3. Clinical assessment 2. Immediate management
1. May present with Combined hormonal contraceptives hormonal Combined 606 Combined hormonal contraceptives | Primary Clinical CareManual 10th edition | Essential information:combined hormonalcontraception swelling oflegorincreasedshortness ofbreathandchestpain Management ofassociatedemergency: pagelizard.com/2016# Contraindication: loss ofsight,unexplainedtendernessorpainandswellinginoneleg Report immediately if: including overthecounterproductsandStJohn'sWort,vomingdiarrhoea BP, fluidretention,chloasma,acneandthrush.Effectivenessmay decreasebysomemedicines, vomiting, breastenlargementandtenderness,headache,moodchanges, changesinlibido,increased Provide ConsumerMedicineInformation: NP assessment SRH mayproceedifinitiallyassessedandprescribedbyMO/NPitis<12monthssincelastMO/ medication ordercurrent ATSIHP andIHWmayproceedif<12monthssincethelastMOconsultationMO/NPwritten RIPRN andRNmustconsultMO/NPORsupplyaspercurrentwrittenmedicationorder Tablet • Form Schedule – Starting combinedpillorvaginalring: – – – however, packagingvaries andhealthcareproviders needto be familiarwiththe waydifferent – – preferably startanactivepillorinsert thefirstringonday1-5ofanormalmenstrualcycle: – – it istheneffective immediately day 1isfirst of mensesandday5is4dayslater norethisterone +ethinylestradiol levonorgestrel +ethinylestradiol ethinylestradiol 30microgram+ 100 microgram+20 500 microgram+35 125 microgram+30 15o microgram+30 4 ethinylestradiol 20microgram ethinylestradiol 30microgram ethinylestradiol 30microgram ethinylestradiol 3omicrogram ethinylestradiol 35microgram 50 microgram+30 75 microgram+40 desogestrel 150microgram+ See gestodene 75microgram drosperinone 3mg+ drosperinone 3mg+ 1 mg+35microgram cyproterone 2mg+ Severeandsuddenpaininchest,severeheadache,blurredvision or dienogest 2mg+ UK MedicalEligibilityCriteria(UKMEC)forcontraceptiveuse: other OCPs Strength Combined oralcontraceptivepills(OCP) ConsultMO/NPifsignsofDVT/PEwithsuddenpainand Maycausebreakthroughbleeding,amenorrhoea,nausea, administration Route of Oral
Recommended 1tablet dosage daily Extended authority ATSIHP / IHW/SRH http://ukmec. not toexceed whichever is Max. supply presciption; OR 4 months Duration 1,12,15,16 sooner current
Combined hormonal contraceptives 607 Combined hormonal contraception hormonal Combined Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1 7 consecutive days of active pills is required before contraception is effective. If ulipristal If effective. is contraception before required is pills active of days consecutive 7 if commenced beyond day 5 will not be effective until 7 active pills taken or the ring insitu for 7 pills taken or the ring be effective until 7 active beyond day 5 will not if commenced days – severe prolonged headache migraines with aura sudden onset shortness of breath calf pain severe abdominal pain severe chest pain the pill can be recommenced 2 weeks after the surgery the pill can be recommenced 2 weeks after the combined pill or ring arranging another contraceptive method if ceasing abnormalities containing estrogen should be stopped 4 weeks combined hormonal contraceptives (pill or ring) the legs prior to major elective surgery and any surgery to other causes of abnormal bleeding, particularly pregnancy, cervical pathology (polyps, cancer) or other causes of abnormal bleeding, particularly before assuming bleeding is pill related infection related bleeding need to be considered in any patient presenting with bleeding chlamydia infection should always be excluded breakthrough bleeding in the first 2 months is common and is likely to settle spontaneously. breakthrough bleeding in the first 2 months is with breakthrough bleeding and it may However, some patients have a continuing problem instance consult MO/NP and refer the patient be necessary to change their prescription. In this to the next MO/NP clinic as necessary the last 7 active tablets of the packet, take the next packet without the pill free interval of the packet, take the next packet without the the last 7 active tablets used that obtains good cycle control as a general rule the lowest dose pill should be due to the risk of incomplete absorption, additional methods of contraception should be used absorption, additional methods of contraception due to the risk of incomplete diarrhoea occurs during 7 days following. If the vomiting and/or severe during the illness and for if more than 24 hours, a backup method of contraception or abstinence is required until seven backup method of contraception or abstinence if more than 24 hours, a have been taken consecutive active pills note: for 5 days is used active pills cannot be restarted acetate emergency contraception OCP should be taken at around the same time each day be taken at around the OCP should as soon as remembered 24 hours then still protected, take missed pill if taken late by less than start 'at risk' patients anytime in the cycle with active pills or the ring using 'the 7 day rule' where the ring using 'the 7 day cycle with active pills or patients anytime in the start 'at risk' for this first 7 days or abstinence are advised of contraception additional methods pills correctly recent or at risk of pregnant cycle if not any time of started at ring can be pills or the active conception: – combined pill packaging types are 'followed' to assist patients to commence and continue taking taking continue and to commence patients to assist 'followed' are types pill packaging combined – – – – – – – – – – – – – – – – – – – – – – – – – degree relatives, postpartum, history of current VTE, known thrombogenic mutations degree relatives, postpartum, history of current if any of the following occur: Advise the patient to consult MO/NP immediately – – – of venous thromboembolic event (VTE) in first Other risk factors include: obesity, age, family history Thromboembolic disease risk - major surgery with prolonged immobilisation considerations include: Thromboembolic disease risk - major surgery with – – – – Poor cycle control considerations include: Poor cycle control considerations – Vomiting or severe diarrhoea: – – – Missed pills: – – – – • • • • • • 608 Progestogen only pills | Primary Clinical CareManual 10th edition | Progestogen onlypills 6. Referral/consultation 5. Followup HMP Missed pillflowchart • • • • • • Background Recommend • • • Combined hormonal contraceptives,page605 Related topics unprotected sexin contraception if Consider emergency break last hormone-free Use condomsfor7days Any othermissedpillscanbediscarded This maymean2pillsinoneday Take thepillmostrecentlymissedstraightaway past 5days < 7pillstakensince • • M MO/NP Patients onthecombinedoralcontraceptivepillorringshouldbefollowedupevery12monthsbyan – – – – contraceptives: Patients shouldbereviewedafterthefirst3-4cyclesandthenyearlywhenusingcombinedhormonal medicine mustbetakenatthesame timeeachday Works bychangingcervicalmucus andendometrium.Doesnotsuppressovulationtherefore For womennotabletotakecombined hormonalcontraceptionwhowishtouseanoralmethod – – – – O/NP Progestogen onlypill discuss sideeffectsandreviewanyproblemsinpilltakingorringuse change inbleedingpatterns check fornewmedicalconditions,medicines check BP,weight 1 1 1,14,15 Is thepill≥24hourslatei.e.isit48sincelastwastaken 1,15 Yes
• • pills continue active Skip inactiveand break next hormone-free < 7pillsleftbefore • • • The pillwillcontinuetowork This maymean2pillsinoneday Take thepillstraightaway No Progestogen only pills 609 Progesterone only pills only Progesterone 1 including: , MO/NP/True Relationships and Reproductive Health/ 1 Not applicable Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7:
Contraception, page 597 1 http://ukmec.pagelizard.com/2016# 1 1
rifabutin can reduce the contraceptive effectiveness detailed information on medication interactions with hormonal contraceptives can be obtained from Australian Contraception Handbook the progestogen only pill is not recommended in those taking liver enzyme inducing medicines antibiotics do not affect the absorption of the progestogen only pill but rifamycins e.g. rifampicin, due to the risk of incomplete absorption, additional methods of contraception should be used due to the risk of incomplete absorption, additional pills) following during the illness and for 48 hours (3 consecutive and emergency contraception if any unprotected intercourse takes place and emergency contraception if any unprotected small and not found to affect milk quality, excreted in breast milk. Dosage to infant is extremely for breastfeeding women quantity or infant growth or development. Suitable taken) contraceptive efficacy will be lost for the next 48 hours so the pill is considered 'missed'. taken) contraceptive efficacy will be lost for the and the next one at the normal time. Advise If a pill is missed take it as soon as possible during the next 48 hours (3 consecutive pills) abstinence or additional methods of contraception or abstinence should be advised for the first 48 hours until contraceptive effect (3 consecutive or abstinence should be advised for the first 48 of existing pregnancy pills) is reliably established. Consider likelihood only pill (POP) (27 hours or more since last one if any more than 3 hours late with a progestogen start on day 1-5 of a normal menstrual cycle (day 1 is first day of menses and day 5 is 4 days later) start on day 1-5 of a normal menstrual cycle (day other time, additional methods of contraception as it is then effective immediately. If started at any patient requires previous assessment by an MO/NP and be prescribed hormonal contraception patient requires previous assessment by an MO/NP within the last 12 months method of contraception available method of contraception choice of contraception Criteria (UKMEC) for contraindications as per UK Medical Eligibility check absolute and relative contraceptive use: contraception needs – – – – – – – – – – – –
– Interactions - medicines which may render the pill less protective: Interactions - medicines which may render the pill – – Vomiting and/or severe diarrhoea: – Lactation: – Missed pills: – Starting progestogen only pill: – – Check last MO/NP consultation: – – – Initial assessment by MO/NP Clinical assessment. See – Side effects of combined hormonal contraception of combined hormonal Side effects pill for combined oral contraceptive has developed New contraindication Postnatal lactating woman lactating Postnatal pill contraceptive supply of oral for repeat Request contraception Request for
• • • • • • • • • • • • •
Essential information: progestogen only pill (POP) Essential information: progestogen only pill 4. Management 3. Clinical assessment 2. Immediate management 2. Immediate 1. May present with present May 1. 610 Progestogen only pills | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup RIPRN andRNmustconsultMO/NPORsupplyaspercurrentNP/MOwrittenmedicationorder swelling oflegorincreasedshortnessbreathandchestpain Management ofassociatedemergency: pagelizard.com/2016# Contraindication: contraceptive protectionmaybereduced.Maycauseamenorrhoea,breasttendernessoracne MID mayproceedtosupplylevonorgestrelonly(max.8weeks) NP assessment SRH mayproceedifinitiallyassessedandprescribedbyMO/NPitis<12monthssincelastMO/ medication ordercurrent ATSIHP andIHWmayproceedif<12monthssincethelastMO/NPconsultation Provide ConsumerMedicineInformation: • • • • • Tablet Schedule Form MO/NP asabove Ensure adequatesupplyofprogestogenonlypill Patients ontheoralcontraceptivepillshouldbefollowedupevery12months byMO/NP – – – Other causesofabnormalbleeding: – – Irregular vaginalbleeding: – – – – – infection relatedbleedingneedtobeconsidered cervical pathology(polyps,cancer) pregnancy patient tothenextMO/NPclinicasnecessary includes troublesomespottinginsomewomen.InthisinstanceconsultMO/NPandreferthe is aknownsideeffectofprogestogenonlypill org/news/updated-clinical-guideline-published-drug-interaction-with/ Pharmacist or 350 micrograme.g.Micronor 30 micrograme.g.Microlut 4 See Norethisterone Levonorgestrel Drug interactionswithhormonalcontraception UK MedicalEligibilityCriteria(UKMEC)forcontraceptiveuse: Strength (Progestogen onlypills) Oral contraceptivepills
ConsultMO/NPifsignsofDVT/PEwithsuddenpainand ® ® Mustbetaken±3hoursatthesametimeeachdayor administration Route of Oral
same timeeach Recommended 1 tabletdaily Taken atthe dosage day 12 availableat: ATSIHP Extended authority / exceed 4months whichever issooner current presciption; IHW/MID/SRH Max. supplynotto http://ukmec. https://www.fsrh. Duration 1,2,11,15,17
OR emergency contraception 611 5 Emergency contraception Emergency Rape and sexual assault, page 659 Rape and sexual assault, page 659 Not applicable Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,18,19 1,18,19 1,18,19 is not associated with foetal abnormality in pregnancy is not associated with foetal contraception does not provide ongoing administered after ovulation is ineffective administered after ovulation
– – – need for ongoing contraception and suitability for Quick Starting initiation of contraception emergency contraception STI risk medications, allergies, breastfeeding status, BMI menstrual, coital, contraceptive history to assess risk of established pregnancy and need to give menstrual, coital, contraceptive history to assess Emergency contraception Emergency – – – – Abstinence or barrier methods should be advised until their choice of contraception is effective should be advised until their choice of contraception Abstinence or barrier methods – – contraception patient’s suitability for QuickStart initiation of Consider the need for the Be aware of mandated reporting of suspected abuse under child protection legislation of suspected abuse under child protection Be aware of mandated reporting Oral emergency contraception: – UPSI contraception. If it can be team where very young people are requesting Contact a sexual health of the treatment and the patient will have an ongoing understanding demonstrated that the best interest, then consent can be given treatment is in the patient’s All methods of emergency contraception should be initiated as soon as possible after unprotected as soon as possible after should be initiated of emergency contraception All methods after days) (5 hours 120 to up used be may but effectiveness, optimise to (UPSI) intercourse sexual Oral Emergency Contraception previously referred to as the 'morning after pill' Oral Emergency Contraception previously referred – Perform standard clinical observations if required – – If history of sexual assault/rape, see Obtain patient history including: – Taking medicine that interferes with hormonal contraception and unprotected sex has occurred in Taking medicine that interferes with hormonal pill (ECP) appropriate time frame for emergency contraceptive Request for emergency contraception following unprotected sexual intercourse or contraception Request for emergency contraception following failure e.g. expelled ring, missed pills Sexual assault/rape with health history for other presentation Need for emergency contraceptive pill (ECP) found
• • • • • • • Sexually transmitted infections, page 615 Related topics • • • • • • •
Recommend Background HMP HMP
3. Clinical assessment 2. Immediate management
1. May present with Emergency contraception Emergency 612 emergency contraception | Primary Clinical CareManual 10th edition | 4. Management Ulipristal acetate(UPA) Levonorgestrel (Cu-IUD) Contraceptive Device Copper Intrauterine Contraception type Emergency • • • may besuggested.DiscusswithMO/NP Note: – – Advise woman: – – – – – Ensure thefollowing: – – – – – – – period delayedby>1weekorifunusuallylightheavy next periodoccurswithin3daysofexpectedtimein>50%women;advise returnforreviewif spotting canoccur levonorgestrel does not induce a withdrawal bleed, although sometimes irregular bleeding or and possiblyserology where relevantthewomanisofferedSTIscreening,urinetestingorlowervaginalswabforPCR if levonorgestrel1.5mgisnotavailablediscussalternativeswithMO/NP review forpregnancytestand/orongoingcontraceptionin3weeksifindicated MO/NP advise barriermethodsuntilthenextperiodorcommenceanothermethodimmediately-consult the womanisclearonhowtotaketablet(s) it isuncleariftheefficiencyoflevonorgestrelreducedinobese women.Anincreaseddose 1,18,19 • • • • • • • • • • • Considerations contraceptives reducetheefficacyofUlipristalAcetate contraception, howeverconcurrentprogestogen-containing Ulipristal acetateismoreeffectivethanlevonorgestrelemergency May beusedwithin120hoursofUPSI Proof ofagemayberequestedbysomePharmacists Not listedwithPBS May bepurchasedoverthecounterinpharmacies Reduced efficacyafter72hours Licensed forusewithin72hoursofUPSI Proof ofagemayberequestedbysomePharmacists May bepurchasedoverthecounterinpharmacies within 5daysofUPSI Limited accesstothisoptionasspecialistneedsinsertthedevice The mosteffectiveformofemergencycontraception emergency contraception 613
1,18,20,23,24 stat Duration intercourse IHW/IPAP/MID/SRH Emergency contraception Emergency / Extended authority Extended ATSIHP Within 72 hours (3 days) of the Within 72 hours first episode of unprotected sexual of unprotected sexual first episode Anaphylaxis, page 102 1.5 mg dosage Recommended Recommended
If vomiting within 2 hours, repeat dose. May cause nausea, If vomiting within 2 hours, Consult MO/NP. See Levonorgestrel Oral Route of Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: administration 3 No absolute contraindications when used as emergency contraception No absolute contraindications 1.5 mg Strength
Efficiency reduced if in the previous 4 weeks the woman has taken medicines that induce CYP3A4 induce that medicines taken has woman the weeks 4 previous the in if reduced Efficiency See MO/NP as above Advise to return in 3 weeks to exclude pregnancy, discuss contraception, and do STI check (if at risk) do STI check (if at and discuss contraception, pregnancy, exclude 3 weeks to in return to Advise Schedule Form
Tablet • • up 96-120 hours (4 days) however its efficacy is uncertain up 96-120 hours (4 days) Contraindication: emergency: Management of associated vomitting, breast tenderness, vaginal bleeding and headache vomitting, breast tenderness, Note: preferred in these cases. Wort (See AMH for detailed list). A copper IUD is e.g. rifamycins, St Johns sex. It can be considered Queensland LAM for up to 72 hours after unprotected Approved for use by the Provide Consumer Medicine Information: Provide Consumer Medicine ATSIHP, IHW and IPAP must consult MO/NP must consult IHW and IPAP ATSIHP, RN and SRH may proceed MID, RIPRN,
6. Referral/consultation 5. Follow up 614 Barrier methods of contraception Barrier methodsofcontraception | Primary Clinical CareManual 10th edition | Sterilisation -female Diaphragm (male andfemale) Condoms Lactational amenorrhoea Coitus interruptus methods Fertility awareness Sterilisation -male • contraceptive use: Check absoluteandrelativecontraindicationsasperUKMedicalEligibility Criteria(UKMEC)for Method http://ukmec.pagelizard.com/2016# • • • • • • • • • • • • • – – – following criteriaaremet: Effective whenallthreeofthe Least effectivemethod – – Calculating ovulation: contraception duringthistime 8-16 weeksuntileffective,usealternate local anaesthetic Vasectomy performedunder Regarded asapermanentprocedure under generalanaesthesia Tubal ligationperformedlaparoscopically Discard after2years Observe forsignsofdeteriorationindevice 6 hoursafterintercourse Should beleftinplaceforatleast Online condomsmaynotbeTGAapproved not beusedsimultaneously Male andfemalecondomsshould Protects againstbacterialandviralSTI – – – – – amenorrhoeic < 6monthspostpartum cervix andcervicalmucus temperature andobservationof sympto-thermal methods,using calendar methods hours betweenfeedingbynight between feedingbydayand<6 use betweenfeedsand<4hours fully breastfeeding,i.e.noformula Management Typical pregnancyrates after 1yearofuse(%)1 (female condom) (male condom) Uncertain 2.9-5.9 0.15 0.5 22 18 21 12 Sexually transmitted infections 615 1800 032 238 or email Sexually transmitted infections transmitted Sexually Low abdominal pain in female, page
1,5,6,7 https://www.health.qld.gov.au/__data/assets/ Do not wait for pathology results Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1 2,3,4
admission and parenteral antibiotics admission and parenteral pdf_file/0025/648061/sti-testing-to-under-16.pdf policy Queensland refer to local jurisdictions outside of For those in or multiple painful/ patient presents acutely ill and with single Consult MO/NP on any occasion require hospital disseminated gonococcal infection). Will urgently inflamed joints (possible Informed consent to be obtained prior to sexually transmitted infections (STI) testing to sexually transmitted to be obtained prior Informed consent guide at < 16 years review the For those aged regional and remote populations of north Queensland, and among men who have sex with men regional and remote populations of north Queensland, in remote areas especially in the context of Donovanosis is now rare but it should be considered genital ulcer disease There are increasing rates of HIV diagnosis in Aboriginal and Torres Strait Islander populations There are increasing rates of HIV diagnosis in Aboriginal areas across Australia particularly in rural and remote and Torres Strait Islander people in There is currently a resurgence of syphilis in Aboriginal Genital warts are no longer a common presentation due to high rates of HPV vaccination Genital warts are no longer a common presentation persist in remote regions, leading to psycho- Excessively high rates of chlamydia and gonorrhoea pregnancy, infertility and populations vulnerable social distress, gynaecological problems, loss of to HIV epidemic The presence of an STI increases the likelihood of transmission of HIV The presence of an STI increases genital herpes are seen notifiable STI in Australia. Chlamydia and Chlamydia is the most common in rural and remote regions in all areas. Gonorrhoea and trichomonas are common Every opportunity should be taken to test for STIs in priority populations Every opportunity should testing should be offered occurs in the 15-30 year olds age group and The highest rate of infection in this age group to people at all presentations Often STIs do not have any symptoms Often STIs do not have [email protected] or Asymptomatic screening is important and should be offered annually in high risk populations where prevalence rates are high, and when a risk is identified those < 25 years of age, who have new onset of pelvic pain. See those < 25 years of age, who have new onset of 635 For patients with genital sores contact the Syphilis Surveillance Centre patients will be reinfected for other common STIs, and for HIV, hepatitis B and If someone tests positive for an STI, offer testing hepatitis C be considered in all sexually active women, particularly (PID) should Pelvic inflammatory disease presentation (presumptive treatment). reinfection risk of the is essential to reduce partners and treatment of sex tracing contact Immediate need to be re-screened at 3 months as one third of People diagnosed with chlamydia or gonorrhoea Symptomatic cases and contacts of individuals with a positive STI result must be treated at first Symptomatic cases and contacts of individuals
• • • • • • • • • • • • • • • • • • • • •
Recommend Background 1. Important principles of treating STIs 1. Important principles of treating
Sexually transmitted infections general infections transmitted Sexually Sexually transmitted infections infections transmitted Sexually 616 Sexually transmitted infections 2. WhentotestforSTIs | Primary Clinical CareManual 10th edition | from: Chronic ConditionsManual:PreventionandManagementof inAustralia families ofthesegroups,orbasedonepidemologicaldiseasepatterns. Seethecurrenteditionof populations, migrants, refugees, international students, backpackers, first and second generation Regular screeningisrecommendedforothergroupsincludingculturally andlinguisticallydiverse Is pregnant genitalium ordonovanosisinfection or acontactofknownmycoplasma A patientwhopresentswithsymptoms • • • • • • A patientpresentswith/as: • • • • • • • to prioritisefortesting: Islander peopleandgeneralpopulation Other AboriginalandTorresStrait and regionalpopulations years inotherruralandremoteareas Sexually activeyoungpeople15-30 rates arehigh Islander settingsorwhereprevalence remote AboriginalandTorresStrait Sexually activepeople<34yearsin Health Serviceforadvice Requesting anSTIcheck or inconsistent/nocondomuse A recentchangeofsexualpartner Past STIpathology has testedpositiveforanSTI A sexualcontactofsomeonewho with symptomsofanSTI A sexualcontactofsomeone Symptoms ofanSTI Sex industryworkers People with hepatitis B or hepatitis C People livingwithHIV Sistergirls andtransgenderpeople Men whohavesexwithmen(MSM) current incarceration People whohavehistoryof/ People whoinjectdrugs https://publications.qld.gov.au/dataset/chronic-conditions-manual Who 2,3,8 At presentation Annually (ata minimum) When HIV Syphilis Trichomonas Gonorrhoea Chlamydia See Donovanosis Mycoplasma • • • • • • • A fullSTIcheck: Chlamydia Hepatitis C(ifatrisk) or notchronicallyinfected) Hepatitis B(ifnotimmune HIV Syphilis Trichomonas Gonorrhoea Chlamydia Antenatal care,page500 orcontactlocalSexual G What enitalium available Sexually transmitted infections 617 STI Specimen Low abdominal pain in and
Sexually transmitted infections transmitted Sexually including: Acute abdominal pain, page 238 : including: STI check STI
: Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: , no symptoms, on following page the abdomen for tenderness. See female, page 635 lymph nodes for swelling or tenderness examine mouth and skin including palms of hands, soles of feet for sores, ulcers, rashes and hair loss
exacerbating factors - does anything make it worse severity - of pain/symptom radiation - does it go anywhere else/are there other associated symptoms radiation - does it go anywhere else/are there other the symptom(s) alleviating factors - does anything help to relieve go or is it consistent timing - have you had it before, does it come and site - where is the pain/lesion/discharge located onset - when did the symptom start of discharge, odour character - size, appearance, distribution, description pain with sex (dyspareunia) lymph nodes fever, headache, muscle/joint pains, rashes, enlarged genital rashes, lumps and sores pubic region itching/discomfort in the perineum, perianal and low abdominal pain in women urethral (penile)/vaginal discharge - onset, colour, odour urethral (penile)/vaginal urine (dysuria) pain or burning on passing abnormal vaginal or rectal bleeding injecting drug use (IDU), tattoos, body piercing, prison term, cultural penile incisions tattoos, body piercing, prison term, cultural penile injecting drug use (IDU), condom use recent history of STI - do they have oral, vaginal, anal intercourse nature of sexual intercourse new partner, multiple partners, or partner has multiple partners, regular/casual partners or partner has multiple partners, regular/casual new partner, multiple partners, same sex partners obstetric contraceptive test history cervical screening menstrual – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – If asymptomatic an examination is not required. Proceed to test according to If asymptomatic an examination is not required. Collection on the history and may include: The extent and nature of the examination depends – – – – – – – – – – For each symptom ask about: – – – – – – Assess Blood Borne Virus (BBV) risk Assess Blood Borne Virus – Ask about symptoms – – – Take a sexual history and assess STI risk history and assess STI Take a sexual – – – – – Take a reproductive history reproductive Take a –
• • • • • • • How to perform an perform to How Examination: History: History: 3. 618 Sexually transmitted infections | Primary Clinical CareManual 10th edition | Tests/investigations forSTIs: • • • • • • Gel tube anal swabs(chlamydia/gonorrhoeaPCRandMCS) e.g. menwhohavesexwith(MSM),alsotakethroatswabs(chlamydia/gonorrhoea PCR)and STI testsshouldbeappropriatetothesymptomspresentandsexactsperformed(oral,anal,vaginal) See If thereisagenitalsore,inadditiontotheabove,collecttestsforulcerdisease(GUD). – – – – – – – A fullSTIcheckincludestests/investigationsfor: Consider urinepregnancytestinwomenofreproductiveage The localSexualHealthServicewillprovideadviceifneeded and discussionisparticularlyimportantinrelationtoHIVtesting.See All STI testing must be done with the patient's knowledge and informed consent. Pre-test information – – – – – – – – – – – – – – – hepatitis C(alsoofferedforsurveillancepurposes) – – – hepatitis B(ifnotimmune): HIV syphilis trichomonas gonorrhoea chlamydia bi-manual examinationfortendernessandmasses(ifpractitionerexperienced) women -vulva/vagina/cervixforinflammation,discharge,bleeding swelling men -urethralopeningfordischargeandinflammation.Testesepididymistendernessor the externalgenitaliaincludingperianalareaforrashes,lumps,ulcersorskinsplits – – – Genital sores/ulcers,page640 https://publications.qld.gov.au/dataset/chronic-conditions-manual Management ofChronicConditionsinAustralia if chronicallyinfectedseecurrenteditionofthe if immuneordocumentedtobefullyvaccinated,itisnotnecessaryrepeatateachSTIcheck chronically infected immune statusshouldbeestablishedandvaccinationofferedifnot Urine PCRpotortube
All specimenscan bestoredinfridgeandtransported cold Dry swab forrecommendedmonitoringavailableat Chronic ConditionsManual:Preventionand MCS swabplusslide HIV, page656
Sexually transmitted infections 619
AND Sexually transmitted infections transmitted Sexually 1800 032 238 Syphilis HIV if HBcAb) HBsAg, (HBsAb, B Hepatitis not immune Hepatitis C Ab if risk Syphilis HIV HBcAb) if Hepatitis B (HBsAb, HBsAg, not immune Hepatitis C Ab if risk Herpes, syphilis Call Syphilis Surveillance Centre • • • • • • • • • • 1 x dry swab for PCR Blood: 2 x serum gel tubes Blood: 2 x serum If lesion/genital sore: Blood: 2 x serum gel tubes If no symptoms discharge, dysuria, low abdominal pain, lesions discharge, dysuria, low ) - if unable + dry swabs ) ‡ + Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: If penile discharge If symptoms ‡ + OR OR Do not wait for pathology results for PCR
Check for allergies prior to treatment e.g. to penicillin, or other beta-lactam antibiotics (includes Check for allergies prior to treatment e.g. to penicillin, ceftriaxone), the macrolide group of antibiotics (includes azithromycin) or to metronidazole Once only treatment is highly effective for chlamydia/gonorrhoea however retesting is Once only treatment is highly effective for chlamydia/gonorrhoea reoccur recommended especially if symptoms persist or patient take the medicine and document this in the If single dose treatments are used, observe the medical record Symptomatic cases and contacts of individuals with a positive STI result must be treated at first Symptomatic cases and contacts of individuals presentation. 1 x Trichomonas 1 x Gonorrhoea, chlamydia only) 1 x Trichomonas (female (female only) 1 x Mycoplasma genitalium 1 x Gonorrhoea, chlamydia Chlamydia, gonorrhoea Chlamydia, (female only) Trichomonas Chlamydia, gonorrhoea Trichomonas Mycoplasma genitalium (female only)
• • • • • • • • • • • • • • First Catch Urine* for PCR (20 mL First Catch Urine* Medication management First catch urine for PCR (20 mL to obtain swabs or no penile discharge 1 x MCS charcoal swab plus slide 3 x self collected vaginal/penile 2 x pharyngeal (and if MSM, 2 x anal and swabs) (or if MSM, 2 x anal and 2 x pharyngeal x anal and 2 x pharyngeal (or if MSM, 2 swabs) 2 x self collected vaginal dry swabs for PCR vaginal dry swabs 2 x self collected STI specimen collection specimen STI
(roll swab onto slide before inserting into charcoal medium) 4. STI management *First part of stream of urine 620 Sexually transmitted infections | Primary Clinical CareManual 10th edition | Education andprevention Contact tracing/ • • • • • • • • • • How toperform Condoms andlubricantshouldbeavailable with24houraccessindiscreetlocations condoms Discuss safe sex practices, contact tracing/partner notification - explain why and how and provide www.qld.gov.au/health/staying-healthy/sexual-health/sti Give informationaboutthetransmission, symptomsandcomplicationsofSTI.Availableat: If treatmentisrequiredseerelevant HMPforabstinenceperiod Assure thepatientthatconfidentialitywillbeprotected For syphilisandHIVthereneedstobemorethan3attemptsatcontacttracing pathology results Contacts ofindividualswithaknownSTImustbetreatedonthedaypresentation.Donotwaitfor essential toavoidreinfection Timely i.e.immediate,ondayofpresentation,contacttracingandtreatmentsexpartnersis – – – – Confidentiality ofallpartiesmustbemaintained: – – – The aimsofcontacttracingare: – – – – – – – – – – – – – – – – – – – clinical-practice/guidelines-procedures/sex-health/contact-tracing for furthercontacttracinginformationsee South, GoldCoast,WestMoreton,DarlingDownsandSouth Bay, CentralQueensland,WestandMetroNorth 07 42264769Townsville,Mackay,NorthWest Support Officerifyouneedadviceorhelpwithcontacttracing:FarNorth Queensland consult theMO/NP,Men's,Women'sandSexualHealthProgramorContact Tracing region. RecordIndex(personwithSTI),URnumbersofcontactsandotherregisterdetails maintain anSTIregistertotracknotificationandtreatmentofcontactsasapplicableinyour area notify theappropriatehealthservicestaffifanamedcontactisoutsideyourcentre's made anddocumented if clinicstaffareinitiatingcontacttracing,3attemptsbytelephoneorhomevisitsshouldbe do this the patient may choose to inform their contact(s) themselves or may want the clinic staff to of thecontactinmedicalrecordindexcase do notwritethenameofindexcaseincontacts'medicalrecord, for thediagnosedSTIandtestingothercommonSTIs document inthecontactmedicalrecordthattheyneedimmediatetreatment the nameofindexcasemustneverbedisclosedtocontacts names ofallcontactsfromtheprevious6monthsorasrelevanttoSTI to interrupton-goingtransmissionofdisease to identifyindividualswhomaybeinfectedandwouldbenefitfromtreatment to preventreinfection partner notification contact tracing 1 1 https://www.health.qld.gov.au/ 0744339600SunshineCoast,Wide 0429340210BrisbaneMetro 0731767587
https://
Sexually transmitted infections 621 Sexually transmitted infections transmitted Sexually
® , Sylk ® , Glyde ® to assist in the selection of HMP based on the patient presentation to assist in the selection of HMP based on the patient Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: STI flowchart
used condoms should be tied in a knot and put in the rubbish, not down the toilet tied in a knot and put in the rubbish, not down used condoms should be a hot place as this can make the rubber perish do not store condoms in perish so it is not left of the condom should be held on during withdrawal when finished, the base inside the partner gently roll condom down the shaft of the erect penis before having sex of the erect penis before down the shaft gently roll condom Wet Stuff based lubricant e.g. use only water the rubber as this can make such as baby oil or vaseline based lubricants do not use paraffin squeeze the end of the condom to keep air out of the tip end of the condom to keep squeeze the – the following – – – – – – reinforce education and prevention information and check condoms supplied reinforce education and prevention information they get symptoms or are at risk of STI e.g. new encourage patient to present for a check any time partner check test results: STI results (especially HIV) should be given in person check test results: STI results tested/treated - contact and check if sexual partner(s) have been ask again about sex partner(s) tracing is essential to avoid reinfection check adherence with medication and symptom resolution check adherence with medication – follow up – – – – – Demonstrate how to use a condom: check expiry date when opening packet. Take care with Take care packet. when opening expiry date check to use a condom: how Demonstrate rings, etc. fingernails, sharp – – – – – –
For STI specific follow up see relevant topics Use – – – – Recommend follow up one week after presentation/treatment: Recommend follow up one – Condom education education Condom • • • • 5. STI 622 Sexually transmitted infections | Primary Clinical CareManual 10th edition | contact ofsomeonewith contact ofsomeonewith STI flowchart symptoms ofanSTI an STIconfirmedon symptom ofanSTI pathology test pathology test Has apositive Is asexual A sexual Has a OR
Genital herpesand/ordonovanosis Genital herpesand/ordonovanosis Urethral (penile)discharge/dysuria Urethral ( Signs and/orsymptomsofsyphilis Female withlowabdomimalpain Low abdominalpaininwomen Mycoplasma Genitalium Pain/swelling intestes Vaginal discharge Vaginal discharge penile) discharge/dysuria Genital sores Trichomonas Gonorrhoea Chlamydia Syphilis Syphilis HIV See See See Genital herpes simplex virus Genital herpessimplexvirus See
trichomonas/mycoplasma trichomonas/mycoplasma trichomonas/mycoplasma trichomonas/mycoplasma 643 gonorrhoea/trichomonas/ See or simplex virus (HSV), page simplex virus(HSV),page mycoplasma genitalium, mycoplasma genitalium, See See See
genitalium, page623 genitalium, page623 Epididymo-orchitis, page Epididymo-orchitis, page Donovanosis, page650 Chlamydia/gonorrhoea/ Chlamydia/gonorrhoea/ See
Low abdominal pain in Low abdominalpainin See female, page635 or Genital sores/ulcers, Genital sores/ulcers, See (HSV), page643 Syphilis, page646 Syphilis, page646 Syphilis, page646
Donovanosis, page Donovanosis, page Genital herpes Genital herpes page 640 HIV, page656 page 623 Chlamydia/ See 650 632 Sexually transmitted infections 623 , is in the presence of in the presence , Mycoplasma genitalium Sexually transmitted infections transmitted Sexually Mycoplasma genitalium are often asymptomatic or the are often asymptomatic mycoplasma genitalium mycoplasma can damage the fallopian tubes increasing can damage the fallopian Low abdominal pain in female, page 635 Mycoplasma genitalium Mycoplasma Mycoplasma genitalium Mycoplasma genitalium trichomonas/ hlamydia, gonorrhoea, trichomonas c Not applicable Mycoplasma genitalium
Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,2,3,4,5 gonorrhoea/ 1,2,3 1,2,3,4 labour, neonatal infection or postpartum infection labour, neonatal infection or postpartum infection may cause soreness or itching. White or green inflammation of the vulva and vaginal walls which has a 'fishy' odour (typical of trichomonas) vaginal discharge which is typically 'frothy' and a urethral (penile) discharge and/or pain or dysuria testicular pain or cervix bleeds easily when swabbed creamy yellow or blood stained vaginal discharge or post coital (after sex) bleeding (PCB) abnormal bleeding: intermenstrual bleeding (IMB) (acute abdomen) or pain with penetrative low abdominal pain (PID) which may be mild to severe sex rupture of membranes, preterm preterm threatened miscarriage, pregnancy: during bleeding PV – – – – – – –
– – women: – – – men: – – Mycoplasma genitalium named contact of someone with PID, epididymo-orchitis positive pathology result for chlamydia and/or gonorrhoea and/or trichomonas and/or positive pathology result for chlamydia and/or gonorrhoea Chlamydia/ – – – – Trichomonas is an STI that may persist in women for years, and in men for up to 4 months may persist in women for years, and in men Trichomonas is an STI that implicated in PID and Chlamydia, gonorrhoea and infertility the risk of ectopic pregnancy symptoms go unrecognised symptoms go unrecognised gonorrhoea a urethral discharge in men is chlamydia and/or The most likely cause of an upper genital tract chlamydia or gonorrhoea will develop 10-15% of women with untreated presents with low abdominal pain. infection (PID) which usually Immediate contact tracing and/or treatment of sex partners is essential to avoid re-infection of sex partners tracing and/or treatment Immediate contact trichomonas, Chlamydia, gonorrhoea, urethral or vaginal discharge or dysuria urethral or vaginal (presumptive at first presentation with a known STI, treat or a contact of a patient If symptomatic results not wait for pathology treatment). Do Treat for chlamydia, gonorrhoea, trichomonas and gonorrhoea, trichomonas Treat for chlamydia,
Occasionally may present acutely ill with single or multiple painful/inflamed joints - possible Occasionally may present acutely ill with single or multiple painful/inflamed joints - possible disseminated gonococcal infection – Symptoms: – – Asymptomatic: –
• • • • • • • • Sexually transmitted infections general, page 615 Epididymo-orchitis, page 632 Related topics • • •
Recommend Background HMP
2. Immediate management 1. May present with
624 Sexually transmitted infections 3. Clinicalassessment | Primary Clinical CareManual 10th edition | 4. Management • • • • • • • • • • • • See Provide education,preventionandcondoms Advise nosexwithpastcontactsuntil theyhavebeentestedandtreatedasabove For alltheseinfectionsadvisenosexual contactfor – – – Perform immediatecontacttracingand/ortreatmentofsexpartnerstoavoid reinfection: – – – – Medication management: – Contact MO/NPifpatientis: See known STI,offerfullSTIscreen If patienthasbeenrecalledduetopositivepathologyresultorisanamedcontactofwith – – – – If symptomatictestfor: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Obtain patienthistoryandofferanexamination. – – – – – – – – – – – – for chlamydiaand observe thepatienttakingmedication treat asperthefollowing treat allpeoplewithapositivepathologyresultaccordingly – – treat thefollowingatthispresentation.Donotwaitforpathologyresults: infection acutely illandhassingleormultiplepainful/inflamedjoints-possibledisseminatedgonococcal – – additionally forMSM: – – – – – additionally forwomen: also offertestingforsyphilis,HIV,hepatitisB,C chlamydia, gonorrhoea,trichomonas, for trichomonastreat for gonorrhoeaonlytraceback – – – – – – – – – Sexually transmittedinfectionsgeneral,page615 Sexually transmittedinfectionsgeneral, page615 contact(s) ofpatientwithchlamydia,gonorrhoea,trichomonas, symptomatic caseswithvaginalorpeniledischargedysuria encourage self-collectionifclientrefusesexamination ano-rectal andpharyngealswabsifsymptomspresentornot CST ifdue page 635 experiences painduringtheexaminationassessforPID.See if thewomencomplainsoflowabdominalpainorduringsexualintercourse urinalysis -ifnitritespositivesendMSUforMCS urine pregnancytestonallwomenofchildbearingage(12-52years) should beretestedinthirdtrimester for chlamydiaallpregnantwomenatfirstprenatalvisitandthose<25yearswithriskfactors 1,2,5
Mycoplasma genitalium all currentpartners 6
Treatment guide 2 months Mycoplasmagenitalium traceback table 7 days 6 months aftertreatmentisadministered Low abdominal pain in female, Low abdominalpaininfemale, Mycoplasmagenitalium
Sexually transmitted infections 625 give 1,2,6,7
OR stat Ceftriaxone Ceftriaxone on day 8 Duration
AND AND M. genitalium if If not allergic treat with treat If not allergic Metronidazole (or Metronidazole Sexually transmitted infections transmitted Sexually Extended authority Azithromycin Doxycycline 7 days Doxycycline 100 mg bd for THEN 8 Azithromycin 1 g on day Moxifloxacin (requires MO/NP order from pharmacy) Metronidazole (or Tinidazole) Azithromycin Azithromycin AND Tinidazole) Azithromycin ATSIHP/IHW/IPAP/RIPRN/SRH 1 g dosage Anaphylaxis, page 102 gonorrhoea) Recommended (2 g for pharangeal Treat for
Take with or without food. May cause rash, diarrhoea, Take with or without food. May cause rash, diarrhoea, Oral Azithromycin Consult MO/NP. See Chlamydia M. genitalium M. genitalium Trichomonas (If pregnant discuss with MO/NP ) Chlamydia and gonorrhoea and gonorrhoea Chlamydia and trichomonas Gonorrhoea Chlamydia Route of administration
Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: pelvic M. genitalium 4 500 mg Strength 1,2,3,5,6
Presents with Presents Form Schedule Tablet nausea, abdominal cramps and candidiasis Management of associated emergency: Provide Consumer Medicine Information: ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN and SRH may proceed Pathology results show trichomonas or a sexual contact of someone with trichomonas Pathology results show inflammatory disease due to M.genitalium Pathology results show a sexual contact of someone with a sexual contact of someone chlamydia ano-rectal Pathology results show chlamydia Pathology results show uncomplicated Pathology results show genital or pharyngeal chlamydia OR or epididymo-orchitis OR with a sexual contact of someone PID gonorrhoea, cervicitis or men show uncomplicated Pathology results ano-genital, pharyngeal gonorrhoea ano-rectal or Vaginal discharge or discharge Vaginal and/or dysuria in penile discharge Treatment guide Treatment 626 Sexually transmitted infections | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: metallic taste,dizzinessorheadache with foodtoreducestomachupset.Maycausenausea,anorexia,abdominal pain,vomiting,diarrhoea, Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution) Management ofassociatedemergency of cross-reactivitybetweenpenicillins,cephalosporinsandcarbapenems Contraindication Note candidiasis andpainatinjectionsite Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Schedule Tablet (powder for Schedule Form Injection : Cancauseseverecolitisdueto Form Strength : Severeorimmediateallergicreactiontoacephalosporinspenicillin.Beaware 200 mg 400 mg 4 4 Strength 1 g administration to giveaconcentrationof lidocaine (lignocaine)1% Reconstitute with3.5mL Cl. difficile. ConsultMO/NP.See Route of : ContacttheMO/NP.See Avoidalcoholwhiletakingandfor24hoursthereafter.Take Ceftriaxone administration Oral Metronidazole Maycausenausea,diarrhoea,rash,headache,dizziness, 1 g/4mL Route of IM
If renalimpairmentseekMO/NPadvice
Recommended dosage Anaphylaxis, page102 2 g Recommended Anaphylaxis, page102 ATSIHP 500 mg dosage (2 mL) ATSIHP Extended authority / Extended authority IHW/IPAP/RIPRN/SRH / IHW/IPAP/ Duration stat Duration RIPRN stat 2,6,8,12 /SRH
4,6,9 Sexually transmitted infections 627 4,6,10 1,3,5,11 /SRH
RIPRN stat Duration M. genitalium Duration 7 days for IHW/IPAP/ / up to 21 days for Extended authority Extended Extended authority Sexually transmitted infections transmitted Sexually 7 days for ATSIHP ATSIHP/IHW/IPAP/RIPRN/SRH symptomatic ano-rectal chlamydia asymptomatic ano-rectal chlamydia 2 g dosage Anaphylaxis, page 102 Anaphylaxis, page 102 Recommended Recommended dosage 100 mg bd
Recommended Tinidazole
Oral May cause diarrhoea, nausea, vomiting, epigastric burning May cause diarrhoea, nausea, vomiting, epigastric Avoid alcohol while taking and for 24 hours thereafter. Take 24 hours thereafter. Take while taking and for Avoid alcohol Doxycycline Route of Consult MO/NP. See Consult MO/NP. See administration Oral Route of administration 4 Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 4 Safe in the first 18 weeks of pregnancy Use metronidazole instead of tinidazole Use metronidazole instead 500 mg Severe or immediate allergic reaction to tetracyclines or treatment with oral retinoids. Severe or immediate allergic reaction to tetracyclines Strength 50 mg 100 mg Strength Sexually transmitted infections general, page 615 Schedule
Consult MO/NP as above if allergic or if symptoms have not resolved following treatment A longer course of metronidazole for Trichomonas is necessary for patients that relapse A longer course of metronidazole for Trichomonas See Follow up at 1 week and 3 months at least 4 weeks after treatment It is essential that treatment is followed by a rescreen Re-testing at 3 months to detect re-infection Form Form
Tablet Tablet Schedule • • • • • • Children < 8 years of age. After 18 weeks of pregnancy Use in pregnancy: Management of associated emergency: Provide Consumer Medicine Information: Medicine Consumer Provide not lie down for an hour after taking. Do not take iron, and photosensitivity. Take with food or milk. Do Avoid sun exposure calcium, zinc, or antacids within 2 hours of taking. Contraindication: ATSIHP, IHW, IPAP and RN must consult MO/NP ATSIHP, IHW, IPAP and RN RIPRN and SRH may proceed Use in pregnancy: emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer pain, vomiting, diarrhoea, upset. May cause nausea, anorexia, abdominal with food to reduce stomach or headache metallic taste, dizziness ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, may proceed RIPRN and SRH
6. Referral/consultation 5. Follow up 628 Sexually transmitted infections 1. Maypresentwith | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement HMP Background • • • • • • • • • • Related topics Sexually transmittedinfectionsgeneral,page615 • • • – – – Medication management: – – – Provide educationonbacterialvaginosis: Contact tracingisnotrequired Consult MO/NPifsymptomsarerecurrentorseverepatientispregnant See – – – – A diagnosisofBVisusuallymadeinclinicalsettingsif3or4thefollowingcriteriaarepresent: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Obtain relevantpatienthistoryandofferanexamination Can causemildvulvalirritation Offensive 'fishy'smelling,thingreywhitevaginaldischarge 30-75% ofcasesareasymptomatic Caused byanovergrowthofvaginalbacteriae.g. Bacterial vaginosisisnotconsideredanSTI – – – – – – – – – – Bacterial recurrence iscommon avoid vaginaldouching leave IUDinplaceandtreatasrecommended positive cluecellsonagramstainhighvaginalsmearslide vaginal fluidodourduringexaminationindicatesapositiveWhifftesti.e.genitalmalodour vaginal fluidraisedpH(pH>4.5)usingindicatorpaper thin white/greyhomogenousdischarge 7-day oralmetronidazole clindamycin isthepreferredtreatment inpregnantwomen.Ifclindamycinisnotsuitable,use treat withoralmetronidazoleORPV clindamycin stat dosemedicationsandshortduration regimensareassociatedwithhigherratesofrecurrence Sexually transmittedinfectionsgeneral,page615 1,2,3 1,2,3,4 vaginosis
1,2 1,2,3 1
Notapplicable genitalium, page623 Chlamydia/gonorrhoea/trichomonas/mycoplasma Gardnerella Sexually transmitted infections 629 1,2,3,5 1,2,3,4
/SRH /SRH
RIPRN stat 7 days RIPRN 7 nights Duration Duration OR IHW/IPAP/ / Extended authority authority Extended IHW/IPAP/ / Sexually transmitted infections transmitted Sexually Extended authority ATSIHP ATSIHP 2 g Anaphylaxis, page 102 Anaphylaxis, page 102 dosage 400 mg bd Recommended Recommended 1 full applicator nocte Recommended dosage
Oral Metronidazole Avoid alcohol while taking and for 24 hours thereafter. Take Avoid alcohol while taking
: Cream may damage condoms during treatment period and for : Cream may damage condoms during treatment Clindamycin Route of Consult MO/NP. See Consult MO/NP. See Cl. difficile administration PV Route of administration Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 4 4 400 mg 200 mg Strength 2% Strength Can cause severe colitis due to
Consult MO/NP if recurrent or severe Not required Schedule Form Form
Tablet Cream Schedule • • Management of associated emergency: Provide Consumer Medicine Information cause local irritation and candidiasis up to 72 hours after course has finished. May Note: Provide Consumer Medicine Information: Provide Consumer Medicine pain, vomiting, diarrhoea, upset. May cause nausea, anorexia, abdominal with food to reduce stomach or headache metallic taste, dizziness emergency: Management of associated ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, may proceed RIPRN and SRH ATSIHP, IHW, IPAP and RN must consult MO/NP ATSIHP, IHW, IPAP and RN RIPRN and SRH may proceed
6. Referral/consultation 5. Follow up 630 Sexually transmitted infections 1. Maypresentwith | Primary Clinical CareManual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement HMP Background • • • • • • • • • • • • • • • – Medication managementofapositive vaginalmicroscopyand/orcultureswabfor: Consult MO/NPifsymptomsarerecurrent orsevere pregnancy, immunosuppressione.g.HIV,diabetes If thepatientpresentswithrepeatedepisodesofvaginalthrush(>4episodes/year), consider resolves not duetotransferofthecandidalinfection.Whenfemalepartneris treated,themale'sitch Some mendevelopapostcoitalitchfromanuntreatedfemalepartnerwith candidias.Theitchis – Diagnosis isdeterminedby: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand Obtain patienthistoryandofferarelevantexamination Genital herpesmustbeexcluded.See – – – Males: – – – – – Females: – Rare inmen.Considerdiabetesmenwithcandidalbalanitis Candidiasis isnotsexuallytransmitted high bloodsugarlevels,antibiotictherapyandcombinedoralcontraceptives Can arisespontaneouslyorduetodisturbanceofthevaginalflorae.ghighoestrogeninpregnancy, It iscommoninhealthywomenandtreatmentnotrequiredifasymptomatic Candidiasis (thrush)iscausedbyanovergrowthofyeast – – – – – – – – – – – Candidiasis/ a positiveyeastmicroscopyandcultureofhighvaginalorpenileswab fissures orsuperficialerosionstoglanspenis(head) swelling offoreskinifsevere red rashongenitals,especiallyunderforeskin,mayornotbeitchy excoriation, erythema,fissures,swelling external dysuria(painfulurination) superficial dysparuenia(painfulsex) genital/vulval itch,discomfort white ‘curd'or'cottagecheese'likenormalvaginaldischarge recurrent (>4episodes/year) – uncomplicated – – – treat withlongercourse ofclotrimazole treat withPVclotrimazole 1,2,3 1,2,3 Candida albicans:
1,2,3 vaginal ( 1,3
Notapplicable Candida albicans: thrush) Genital herpessimplexvirus(HSV),page643 ( primarily Candidaalbicans) Sexually transmitted infections 631
1,2,3,4 6 nights 6 nights Duration IHW/IPAP/RIPRN/SRH / Extended authority Sexually transmitted infections transmitted Sexually ATSIHP 1 pessary nocte 1 full applicator nocte Anaphylaxis, page 102 Recommended dosage
OR Clotrimazole PV PV May damage condoms during treatment period. Complete May damage condoms during treatment period. Route of Consult MO/NP. See is uncommon: administration Authority to administer and supply medicines, page 9 Authority to administer and 3 Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1% Candida glabrata Candida 100 mg Strength Schedule discuss with MO/NP, who may consider PV boric acid 1 pessary nocte for 14 days. Boric acid Boric acid for 14 days. 1 pessary nocte boric acid consider PV who may with MO/NP, discuss on prescription pharmacies by specialist can be compounded pessaries – no evidence that specific diets, or use of probiotics influence recurrence of candidiasis use of probiotics influence that specific diets, or no evidence hygiene products soaps, spermicides, vaginal lubricants, vaginal avoid local irritants e.g. vaginal creams and cervical caps can be damaged by antifungal latex condoms, diaphragms – relief symptomatic provide 1% cream may of hydrocortisone the addition infection with infection
Using the applicator provided, fill with cream and insert deep into the vagina. Pessary should be should Pessary vagina. the into deep insert and cream with fill provided, applicator the Using – – – – – Consult MO/NP if symptoms are recurrent or severe i.e. four or more acute episodes per year Consult MO/NP if symptoms are recurrent or severe Not required – – – ointment plus clotrimazole ointment plus is not required Contact tracing on candidiasis (thrush): Provide education – hydrocortisone symptomatic relief with partners only requires of male sexual Medication management – Form
Cream Pessary • • • • • Management of associated emergency: course even if symptoms ceased Note: insertion of pessary may be preferable inserted with the applicator. In late pregnancy digital Provide Consumer Medicine Information: ATSIHP, IHW and IPAP must consult MO/NP ATSIHP, IHW and IPAP must RIPRN and SRH may proceed see RN may administer; for supply
6. Referral/consultation 5. Follow up
632 Sexually transmitted infections | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement May presentwith HMP Background Recommend • • • • • • • • • • Related topics Urinary tractinfection(UTI)-adult,page389 Testicular/scrotal pain,page257 Sexually transmittedinfectionsgeneral,page615 • • • • • – – – – – Diagnosis ismadeclinicallybasedoncompatiblephysicalexamfindings including: – – The followingtestswilldeterminethecauseofinfection: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – Obtain patienthistoryandofferrelevantexamination: 257 Torsion canresultinthelossoftestiswithinhours.Formanagementsee If veryacuteonsetorseverescrotal/testespainconsidertorsionandurgentsurgicalreferral Accompanied byurinaryfrequencyanddysuriasymptoms Acute, unilateralpainandswellinginthetestes/scrotumwithorwithoutfever See Consider USSforpatients whendiagnosisisunclearclinically Escherichia coli Men whoengageininsertiveanalsexareatriskofinfectionfromacquiredentericpathogensi.e. Urinary tractpathogensaregenerallythecauseinmen>35yearsofage In sexuallyactivemeninfectionisprimarilyaresultofanSTIin<35yearsage Testicular torsionismostcommoninyoungboys.See considerably, sixhoursaftersymptomscommence excluded. Promptdiagnosisandsurgicalinterventionareessentialastestisviabilitycandiminish If acuteonsetorseverepainconsidertorsionofthetestes;amedicalemergencythatmustbe – – – – – – – – Epididymo-orchitis gradual onsetofpain mycoplasma genitalium also offeropportunistictestingforsyphilis,HIV,hepatitisB, C, trichomonasand MSU forMCS,firstcatchurinechlamydiaandgonorrhoeaPCR determine exactsiteandnatureofswellingtenderness 257 intact cremastericreflex,otherwise consider testiculartorsion.See erythematous scrotumoroedematous testicle,typicallyinnormalposition tender, swollenorinduratedepididymis (foundatposterioraspectofthetesticle) localisation ofpainposteriortotestis, withoccasionalradiationtolowerabdomen Sexually transmitted infections general,page615 1,2,3 and 1,2,3 Proteus
spp 1 mycoplasma genitalium,page623 Chlamydia/gonorrhoea/trichomonas/ Testicular/scrotal pain,page257 Testicular/scrotal pain, page Testicular/scrotal pain,page Testicular/scrotal pain, page Testicular/scrotal pain,page Sexually transmitted infections 633 2,5,7 stat Duration IHW/IPAP/RIPRN/SRH / Extended authority Sexually transmitted infections transmitted Sexually (2 mL) dosage 500 mg ATSIHP Anaphylaxis, page 102 Recommended Urinary tract infection (UTI) - adult, page 389 infection (UTI) - adult, page Urinary tract
Acute pain management, page 35 Acute pain management,
If renal impairment seek MO/NP advice See IM . Route of 1 g/4 mL OR May cause nausea, diarrhoea, rash, headache, dizziness, May cause nausea, diarrhoea, rash, headache, administration Ceftriaxone : Contact the MO/NP. See PLUS Cl. difficile. Reconstitute with 3.5 mL lidocaine (lignocaine) 1% to give a concentration of PLUS EITHER: Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1 g Strength 4 1,2,3,4,5,6 : Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware or a penicillin. Be aware : Severe or immediate allergic reaction to a cephalosporins repeat state dose of azithromycin 1 week later dose of azithromycin 1 repeat state doxycycline starting the next day doxycycline
Sexually transmitted infections general, page 615 Sexually transmitted infections – – stat dose of azithromycin stat dose of – – an initial dose of IM ceftriaxone an initial dose Form – – : Can cause severe colitis due to
Provide education, prevention and condoms Provide education, prevention See Bed rest Scrotal support to avoid reinfection tracing and treatment of sexually active partners Perform immediate contact Observe the patient taking the medication Observe the UTI in men. See cause treat as per If UTI is the likely clinically indicated Administer analgesia as – Consult MO/NP on all occasions to exclude torsion of the testes torsion of to exclude all occasions MO/NP on Consult with: cause treat is the likely If STI management. Medication – Injection Schedule (powder for • • • • • • • • • • Provide Consumer Medicine Information: RIPRN and SRH may proceed ATSIHP, IHW, IPAP and RN must consult MO/NP ATSIHP, IHW, IPAP and RN Contraindication and carbapenems of cross-reactivity between penicillins, cephalosporins Management of associated emergency candidiasis and pain at injection site Note reconstitution) 4. Management 4. 634 Sexually transmitted infections | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup Management ofassociatedemergency: retinoids. Contraindication: iron, calcium,zinc,orantacidswithin2hoursoftaking.Avoidsunexposure and photosensitivity.Takewithfoodormilk.Donotliedownforanhouraftertaking.take Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: nausea, abdominalcramps Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP • • • • • • • Schedule Tablet Schedule Tablet Form In severecasestreatmentmayneed tobecontinuedforup3weeks.Seekspecialistadvice Consult MO/NPonalloccasionsepididymo-orchitis issuspected See Recommend patientreturnforfollowupat1weekand2-3months within 4-5days Complete resolution of the swelling may take several weeks but a substantial response should occur If thepatientisnotsignificantlyimproved,consultMO/NPandconsider evacuation Recommend patientreturnthenextdayforreview Form Sexually transmittedinfectionsgeneral, page615 Strength Severeorimmediateallergicreactiontotetracyclinestreatmentwithoral 500 mg 4 Strength 100 mg 50 mg 4 administration administration Doxycycline Route of ConsultMO/NP.See Azithromycin ConsultMO/NP.See Route of Maycausediarrhoea,nausea,vomiting,epigastricburning Oral Takewithorwithoutfood.Maycauserash,diarrhoea, Oral
Recommended Recommended 100 mgbd dosage Anaphylaxis, page102 Anaphylaxis, page102 dosage 1 g ATSIHP/IHW/IPAP/RIPRN/SRH ATSIHP/IHW/IPAP/RIPRN/SRH Extended authority Extended authority Repeat 1weeklater
Duration Duration 14 days stat
1,2,3,4 1,2,3,6 Sexually transmitted infections 635 Sexually transmitted infections transmitted Sexually . Response to treatment confirms the treatment confirms the . Response to PID) Urinary tract infection (UTI) - adult, page 389 in female in
Do not wait for pathology results wait for pathology not Do Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,3 Acute abdominal pain, page 238
be considered in the presence of low abdominal pain in sexually active women in whom of low abdominal pain in sexually active be considered in the presence 1,2,3 pelvic inflammatory disease ( disease inflammatory pelvic 1,2,3 must menorrhagia (heavy menstrual bleeding) of pregnancy, dilatation and curettage, post instrumentation of the genital tract - termination IUCD insertion or birth intermenstrual (outside normal menstruation) postcoital (after sex) quadrant like period pain in character typically bilateral, may worsen with movement, may localise to one side, may refer to upper right typically bilateral, may worsen with movement, Low abdominal pain abdominal Low
– – – – – – Diagnosis of PID is clinical. Diagnosis of Consult MO/NP urgently if patient has severe pain or board-like rigidity of the abdomen severe pain or board-like urgently if patient has Consult MO/NP vaginal with abdominal pain and/or all women who present (tubal) pregnancy in Consider ectopic suspects she is pregnant or not the woman bleeding whether PID in early pregnancy may present as a threatened miscarriage with pain ± bleeding present as a threatened miscarriage with pain PID in early pregnancy may PID is an important cause of infertility PID is an important cause number of cases caused by STIs and/or vaginal flora. In a significant PID is usually polymicrobial, no pathogen is identified PID is a syndrome comprising a variety of upper female genital tract inflammatory disorders, a variety of upper female genital tract PID is a syndrome comprising salpingitis, tubo-ovarian abscess and pelvic peritonitis including endometritis, diagnosis PID excluded other causes have been Consult MO/NP urgently. MO/NP will advise further management and arrange evacuation/ hospitalisation Keep nil by mouth Assess HR, temperature, BP If ill, with board-like rigidity of abdomen, insert 2 x IV cannula - use the largest possible gauge given age and vascular status In severe cases see – – Fever, nausea, vomiting Vaginal discharge or bleeding: – – – Dyspareunia (painful sex) Low pelvic pain: –
• • • • • • • • Acute abdominal pain, page 238 Ectopic pregnancy, page 511 Related topics • • • • • • • • •
Recommend Background
HMP HMP 2. Immediate management
1. May present with Probable Probable 636 Sexually transmitted infections 3. Clinicalassessment | Primary Clinical CareManual 10th edition | • • • • • • • See Use thefollowingtableasaguidetodifferentialdiagnosisoflowabdominal paininfemale Cervical screeningtestifdue – – – – – Test for: – – – – – – – – – Perform examination.Assessfor: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – Obtain patienthistory.Askabout: – – – – – – – – – – – – – – – – – – the presenceofSTIsupportsdiagnosisPID also offer:syphilis,HIV,hepatitisB,C diagnosis urinalysis indicatingnitrates,leucocyte,dysuriaandfrequencysuggests UTIasdifferential pregnancy urine pregnancytestonallwomenofchildbearingage(12-52years)to exclude ectopic endocervical swabforchlamydia,gonorrhoea,trichomonasand see the presenceofmucopurulentdischargefromcervixsupportsdiagnosisPID pelvic mass cervical friability cervical discharge tenderness) tenderness onbimanualexamofcervix,uterusoradnexa(cervicalmotionadnexal bilateral abdominaltendernessmaysuggestPIDoverappendicitis new onsetofpelvicpainamongwomen<25yearsishighlypredictivePID lower abdominaltendernessandrebound – – – – – procedures involvinguterineinstrumentationthatmaycausepostsurgicalPID,suchas: quality ofpain(absencemigrationmaysuggestPIDoverappendicitis) date oflastmenstrualperiodtoassessforpossibilityectopicpregnancy partner withSTIorsymptomsofanunprotectedsex sexual history,includingrisksforsexuallytransmitteddiseasesi.e.recentpartnerchange, – – – – – Sexually transmittedinfectionsgeneral,page615 in vitrofertilisation intrauterine insemination hysterosalpingography intrauterine deviceinsertionwithinprevious6weeks pregnancy termination Acute abdominalpain,page238 1,3 Mycoplasma genitalium Sexually transmitted infections 637 and are common
Sexually transmitted infections transmitted Sexually Clues to diagnosis Clues Acute abdominal pain, page 238 1,2,3 Mycoplasma genitalium Urinary tract infection (UTI) - adult, page 389 Urinary tract infection (UTI) Ectopic pregnancy, page 511 Ectopic pregnancy, 513 in early pregnancy, page Vaginal bleeding Acute pain management, page 35
urinary frequency/dysuria are present or urinary frequency/dysuria nitrites are positive low abdominal pain alone is present low abdominal pain alone of reproductive age the woman is sexually active, gonorrhoea, chlamydia and living in an area where and treatment antibiotic appropriate to quickly responds pain • • See with a typical history - pain Appendicitis usually presents fever, moves from umbilicus to RIF, associated low grade anorexia, nausea diagnosed Pelvic adhesions and endometriosis can only be by laparoscopy in women Uterine fibroids and diverticulitis are uncommon aged < 40. See If pregnant, an USS will confirm or exclude a viable an USS will confirm or If pregnant, pregnancy intrauterine miscarriage in early cause of threatened PID may be the pregnancy See See PID is likely if: • • • UTI is likely if: . Rapid response to treatment is highly predictive of PID . Rapid response to treatment is highly predictive OR Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,3,4,5 (may be multiple) (may be Sexually transmitted infections general, page 615
stress the importance of follow up explain the diagnosis, the importance of adherence to medicines and the need for early follow explain the diagnosis, the importance of adherence up for patient and partner(s) advise to abstain from sex until course of treatment is finished and 7 days after partner has been treated PLUS 14 days of doxycycline non-adherent to doxycycline, give a stat dose of for pregnant women or patients suspected to be later azithromycin followed by another stat dose 1 week stat dose of ceftriaxone PLUS 14 days of metronidazole – – – – – – – See – – Give analgesia as clinically indicated. See of sexual partners to avoid reinfection Perform immediate contact tracing and treatment Provide education, prevention and condoms: – – Do not wait for pathology results Medication management for mild to moderate infection: – PID is diagnosed clinically and should be suspected in sexually active women with abdominal pain PID is diagnosed clinically and should be suspected vomiting or high fever), is allergic to penicillin, is Consult MO/NP for severe infection (nausea and require IV inpatient treatment pregnant or has abnormal vaginal bleeding. Will
• • • • • • • • Possible causes of low abdominal pain low abdominal causes of Possible Uterine fibroids Urinary tract infection Appendicitis Diverticulitis Ovarian or pelvic abscess (PID) Ovarian or pelvic abscess Ovarian cyst or tumour Pelvic adhesions Endometriosis Pregnancy test negative PID Pregnancy test positive ± PV bleeding Pregnancy test pregnancy Ectopic (tubal) (PID) Threatened/incomplete/septic miscarriage Differential diagnosis of low abdominal pain in female abdominal of low diagnosis Differential 4. Management 638 Sexually transmitted infections | Primary Clinical CareManual 10th edition | Management ofassociatedemergency: metallic taste,dizzinessorheadache with foodtoreducestomachupset.Maycausenausea,anorexia,abdominal pain,vomiting,diarrhoea, Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution) Management ofassociatedemergency of cross-reactivitybetweenpenicillins,cephalosporinsandcarbapenems Contraindication Note candidiasis andpainatinjectionsite Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Schedule Tablet (powder for Schedule Form Injection : Cancauseseverecolitisdueto Form Strength : Severeorimmediateallergicreactiontoacephalosporinspenicillin.Beaware 200 mg 400 mg 4 4 Strength 1 g administration to giveaconcentrationof lidocaine (lignocaine)1% Reconstitute with3.5mL Cl. difficile. ConsultMO/NP.See Route of : ContacttheMO/NP.See Avoidalcoholwhiletakingandfor24hoursthereafter.Take Ceftriaxone administration Oral Metronidazole Maycausenausea,diarrhoea,rash,headache,dizziness, 1 g/4mL Route of IM
If renalimpairmentseekMO/NPadvice
Recommended 400 mgbd dosage Anaphylaxis, page102 Recommended Anaphylaxis, page102 ATSIHP 500 mg dosage (2 mL) ATSIHP Extended authority / Extended authority IHW/IPAP/RIPRN/SRH / IHW/IPAP/ Duration 14 days Duration RIPRN stat 1,2,4,8 /SRH
1,2,5 Sexually transmitted infections 639 1,2,6 1,2,7
stat 14 days Duration Duration doxycline MO/NP Extended authority authority Extended for pregnant women and for pregnant Repeat dose 1 week later Repeat dose for those non-adherent to for those non-adherent to Extended authority Sexually transmitted infections transmitted Sexually ATSIHP/IHW/IPAP/RIPRN/SRH ATSIHP/IHW/IPAP/RIPRN/SRH 1 g Anaphylaxis, page 102 dosage Anaphylaxis, page 102 dosage 100 mg bd Recommended Recommended Recommended
Take with or without food. May cause rash, diarrhoea, cause rash, diarrhoea, May Take with or without food. Oral Azithromycin May cause diarrhoea, nausea, vomiting, epigastric burning May cause diarrhoea, nausea, vomiting, epigastric Oral Route of Consult MO/NP. See Doxycycline Consult MO/NP. See Route of administration administration Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 50 mg 100 mg Strength 4 4 Safe in the first 18 weeks of pregnancy Severe or immediate allergic reaction to tetracyclines or treatment with oral Severe or immediate allergic reaction to tetracyclines 500 mg Strength adherence and symptom resolution. If pain not resolved consult adherence and symptom resolution. If pain not 1,3
contacts have been tested and treated test results have been given repeat pregnancy test if indicated treatment – – – – Form If treatment completed and symptoms resolved a test of cure is not needed Follow up at 2-3 months for repeat STI screen – – – If no improvement or if worse, consult MO/NP. Hospitalisation, IV antibiotics and additional If no improvement or if worse, consult MO/NP. Hospitalisation, diagnostic evaluation is required and check: Recommend to return for follow-up within 2 weeks – Recommend to return for follow-up daily within 72 hours Patients should have significant clinical improvement Tablet
Form Tablet Schedule • • • • • • Schedule Management of associated emergency: Contraindication: of pregnancy retinoids. Children < 8 years of age. After 18 weeks Use in pregnancy: Provide Consumer Medicine Information: not lie down for an hour after taking. Do not take iron, and photosensitivity. Take with food or milk. Do Avoid sun exposure calcium, zinc, or antacids within 2 hours of taking. ATSIHP, IHW, IPAP and RN must consult MO/NP ATSIHP, IHW, IPAP and RN RIPRN and SRH may proceed Provide Consumer Medicine Information: Provide Consumer Medicine and candidiasis nausea, abdominal cramps emergency: Management of associated ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, may proceed RIPRN and SRH 5. Follow up 640 Sexually transmitted infections Genital sores/ 6. Referral/consultation | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Background Recommend • • • • • • • • Related topics Genital herpessimplexvirus(HSV),page643 Genital warts,page653 • • • • • – – Perform examination: Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – Obtain patienthistory: Ulce Lumps, growths,wartsormolluscuminthegenitalskin/mucosa ultrasound andlaparoscopytoassessforovarianmasses,adhesionsendometriosis If painrecurs,reassessforPID.reinfectionisunlikely,referralmaybeneededpelvic pregnant orhasabnormalvaginalbleeding Consult MO/NPforsevereinfection(nauseaandvomitingorhighfever),isallergictopenicillin, – Test for: Aboriginal andTorresStraitIslandermenwhohavesexwith There Scabies andcandidiasismaycausegenitalsores Herpe and signs,laboratorytestsresponsetotreatment The diagnosisofgenitalsorescanbedifficultandisbasedonacombinationclinicalsymptoms [email protected] Always consultthePublicHealthNurse,SyphilisRegisteron – – – – – ask aboutfever,headache,muscleachesandpains,rashes has symptomsorsignsofanSTI obtain afullhistoryincludingpreviousepisodesofgenitalsoresandwhether thecurrentpartner urine pregnancytest inallwomenofchildbearingage (12-52years) groin forenlarged nodes examine thegenitalareafordischarge, nodules,soresandulcers,thearmpits,neck hair loss examine mouthandskinincludingpalms ofhands,solesfeetforsores,ulcers,rashesand ration (wheretheskinisbrokenor continuestobeasignificantsyphilisepidemicinremotepopulationsandamongnon- s isthemostcommoncauseofgenitalulcers 1,2,3 ulcers -adult 1,2,3 Notapplicable inflamed) Syphilis, page646 1800032238oremail North-Qld- Sexually transmitted infections 641
See . Syphilis,
See Donovanosis Commences as one or more sores or nodules and may join to form large destructive ulcers which are beefy red and bleed easily Usually painless No No, continues to become larger over time . For women - if sores are sores - if women . For Sexually transmitted infections transmitted Sexually or specialist MO/NP regarding the - (chancre) one Syphilis Secondary (condylomata lata) multiple, often perianal skin, symmetrical and flat Painful or painless Yes/No within sores primary Yes, 2-3 weeks, secondary sores may come and go over 12 months Primary - or few sores, 1-2 cm with well defined edges North-Qld-Syphilis-Surveillance-Centre@health. Mycoplasma genitalium Mycoplasma Surveillance Centre Surveillance Donovanosis, page 650 1,2,3 Genital herpes See 1800 032 238 or . to form small shallow ulcers, with irregular borders Surrounding skin may be inflamed Painful or itchy Yes/No Yes, within 1-2 weeks but usually recurs Painful skin splits or cluster of blisters, which break down Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1,2,3 Genital warts No No No Solid lumps, may be smooth or warty, asymmetrical, no ulceration and no inflammation of surrounding skin herpes serology is not useful in this context and should not be taken context and should not is not useful in this herpes serology Sexually transmitted infections general, page 615 Sexually transmitted infections
lesions typical of genital herpes, Consult MO/NP before starting treatment if pregnant lesions typical of genital herpes, Consult MO/NP Genital herpes simplex virus (HSV), page 643 lesions typical of Donovanosis page 646 check allergies and observe the patient taking oral medicine check allergies and observe the patient taking oral or if unsure, treat for syphilis. lesions not typical of herpes and syphilis is likely Syphilis Surveillance Centre qld.gov.au unit if outside Queensland contact the local public health Note: swab of any discharge for MCS swab of any and herpes for PCR dry swab syphilis non-responding lesions histology for chronic consider a biopsy multiple or painful do not do a speculum examination instead obtain a low vaginal swab or first swab a low vaginal instead obtain speculum examination do not do a or painful multiple urine catch serology for syphilis blood C hepatitis B, hepatitis also offer HIV, chlamydia, gonorrhoea, trichomoniasis and trichomoniasis gonorrhoea, chlamydia, – – – – – – – – – – – – – – – Medication management at time of presentation: Medication management at time of presentation: – – – – response to treatment If treating for genital ulcer consult Syphilis likely diagnosis and ongoing management: See the following Management guidelines for genital ulcer disease (GUD) flowchart See the following Management guidelines for genital of clinical findings, laboratory tests and The diagnosis of genital ulcers is based on a combination – See – – – – – –
• • • • • Possible causes of sores and ulcers Possible causes of sores Heals without treatment Painful Enlarged lymph nodes Typical sores 4. Management 642 Sexually transmitted infections | Primary Clinical CareManual 10th edition | Management flowchartforgenitalulcerdisease(GUD) • • • • • place inadrysterilecontainer around theedgeandacrosslesion, (e.g. PCRswab),rollthe using asterilecottontippeddryswab chloride 0.9%(notantiseptic)then Clean thelesionwithwaterorsodium • • • Painful oritchymultipleblistersshallowulcers:considerherpesespeciallyifrecurrent Raised, firm,painfulorpainless,punchedout:considersyphiliticchancre Painless ulcersorbeefyred/crustysores,smellydischarge,bleedseasily:considerdonovanosis See See and HerpesPCR Take swabforSyphilis, Provide education,preventionandcondoms Perform immediatecontacttracingandtreatsexualpartnerstoavoidreinfection Contact trace sexual partners
Genital herpessimplexvirus(HSV),page643 Syphilis, page646 check lesion,alllaboratoryresultsand thatcontactshavebeentracedandtreated GUD SyndromicManagement swab firmly See Additional testing for genital ulcer disease Note: Sexually transmittedinfectionsgeneral,page615 Patient presents with genital ulcer Advise tobereviewedin1week- Remembertheseinfectionsmaycoexist Offer afullSTIcheck Possible diagnosis (treatimmediatelydonotwaitforresults)
Syphilis andHerpesPCR Notify SyphilisNotify SurveillanceCentre Write onpathologyform 1800032 238
Sexually transmitted infections 643
North-Qld- 1800 032 238 or email 1800 032 238 or email Sexually transmitted infections transmitted Sexually 1800 032 238 or email
If outside Queensland contact your local public If outside Queensland contact your local public
. Syphilis, page 646 Syphilis Surveillance Centre Centre Surveillance Syphilis Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: herpes simplex virus (HSV) 1,2,3 1,2,3
women who are pregnant or breastfeeding women who are pregnant allergy to the recommended antibiotic patients with a history of do not respond to treatment sores, ulcers or lesions a child with an STI contacts have been tested and treated as appropriate been tested and treated contacts have been given test results have at initial visit is offered, if not done to include a HIV test if an STI, check patient adherence with treatment and symptoms and signs have resolved symptoms and signs with treatment and patient adherence For a patient with genital sores contact the For a patient with genital Genital – – – – – – – – Herpes simplex virus (HSV) is the most common cause of genital ulcer disease in Australia Herpes simplex virus (HSV) is the most common ulcers i.e. Herpes zoster or Epstein-Barr virus Other herpes virus infections can lead to genital The majority of patients with HSV infection are undiagnosed Sexual abuse should be considered in children with anogenital HSV infection, particularly HSV2. Sexual abuse should be considered in children Child protection, page 760 [email protected] health unit and in patients with a history of allergy STIs in children, women who are pregnant or breastfeeding to the antiviral, require specialist management Antiviral therapy for HSV is not curative, but it shortens the episode if started within 72 hours of Antiviral therapy for HSV is not curative, but it shortens the onset of symptoms Register on Always consult the Public Health Nurse, Syphilis [email protected] the local Public Health Unit If outside Queensland contact – – – Consult MO/NP or specialist if: Consult MO/NP or specialist – Consider non-infectious causes if treatments don't work e.g. autoimmune disorders, neoplasia, or autoimmune disorders, don't work e.g. causes if treatments Consider non-infectious trauma – – – See relevant STI section for condition specific follow up follow specific for condition STI section See relevant Check: –
• • • • • • • Genital warts, page 653 Genital sores/ulcers, page 640 Related topics • • • • • •
Recommend Background HMP HMP
6. Referral/consultation 5. Follow up Follow 5. 644 Sexually transmitted infections 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith | Primary Clinical CareManual 10th edition | 4. Management • • • • • • • • • • • • • • • • See – – – Provide education,preventionandcondoms: Partners shouldhaveanSTIcheckandcounselled,butdonotneedtobe treated Contact tracingisnotnecessary,howevercounsellingregardingherpes infectionisrequired – – – – Medication managementattimeofpresentationforadults: Can bepainful.Administerpainreliefasclinicallyindicated.See Consult MO/NPformedicationmanagementofgenitalherpesinchildren – – Surveillance CentreorSexualHealthUnitandtreat: If clinicallysuggestiveofherpesdiscussthelikelydiagnosisandongoingmanagementwithSyphilis See Take swabforsyphilisandherpesPCRastheseconditionsmaycoexist Perform examination Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – Obtain patienthistory: Recurring ano-genitalulcers,blistersorskinsplits Pain oritchiness with irregularborders Clusters ofpainfulblistersintheano-genitalarea – – – – – – – – – – – – suppressive therapy isindicated for frequent and severeepisodes to reducerecurrencesby 70% onset ofprodromalsymptomsorlesions for recurrentepisodes,shortcoursesoftherapyiseffectivewhenstarted concurrentlywiththe for aninitialinfectionstarttreatmentimmediately valaciclovir ORaciclovir(preferredinpregnancy) It isnotcurative antiviral therapyforHSVshortenstheepisodeifstartedwithin72hoursofonsetsymptoms. episodes treatment shouldnot be delayed for those presenting with severe episodes, particularly initial or buttocks,behindthekneeevenondorsumoffoot) lesions that haveoccurredatothersitesalongsacraldermatomes(such as thesurroundingskin recurrences thatoccurlessfrequently,arepainfulandhaveashorterduration ulcers thathealafter1-2weekswithouttreatmentthenrecur encourage condomusewithongoing partners treatment isnotcurative.Transmission canstilloccur keep lesionsdrywithsaltbaths Sexually transmittedinfectionsgeneral,page615 Sexually transmittedinfectionsgeneral, page615 1,2,3 1,2,3 1,2,3 Notapplicable which breakdowntoformsmallshallowulcers, Acute painmanagement,page35 Sexually transmitted infections 645 2,5 1,2,4
5 days 2 days Duration severe cases reassess at 6 months 3 days 5 days up to 10 days for Duration Extended authority Extended Extended authority Sexually transmitted infections transmitted Sexually ATSIHP/IHW/IPAP/RIPRN/SRH reassess at 6 months OR ATSIHP/IHW/IPAP/RIPRN/SRH Initial episode 5 days; up to 10 days for severe cases 5 days; up to Recurrent episodes Recurrent episodes Anaphylaxis, page 102 Anaphylaxis, page 102 Suppressive treatment Suppressive treatment Initial infective episode dosage 400 mg bd 400 mg tds 800 mg tds 400 mg tds Recommended dosage 500 mg bd 500 mg bd Aciclovir 500 mg daily Valaciclovir Recommended Recommended May cause nausea, vomiting, headache, diarrhoea, May cause nausea, vomiting, Drink at least 1.5 to 2 litres of water per day. May cause Drink at least 1.5 to 2 litres of water per day. May Consult MO/NP. See Consult MO/NP. See
Oral Oral Route of Route of Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: administration administration 4 4 Aciclovir is prefered. May be used from 36 weeks of pregnancy Aciclovir is prefered. May 500 mg 200 mg 800 mg Strength Strength and SRH may proceed If renal impairment seek MO/NP advice If renal impairment seek : If renal impairment seek MO/NP advice Form Form Schedule Schedule Tablet Tablet Management of associated emergency: Management of associated dizziness or confusion. Avoid driving or operating heavy machinery if affected. Drink plenty of fluids Avoid driving or operating heavy machinery if affected. dizziness or confusion. Note: Use in pregnancy: Provide Consumer Medicine Information: Provide Consumer Medicine ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, order treatment on MO/NP may proceed. Suppressive RIPRN and SRH vomiting, headache and/or diarrhoea Note Management of associated emergency: Provide Consumer Medicine Information: heavy machinery if affected. May cause nausea, dizziness or confusion: avoid driving or operating ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN 646 Sexually transmitted infections 6. Referral/consultation 5. Followup | Primary Clinical CareManual 10th edition | 1. Maypresentwith Reactive syphilis HMP Background Recommend • • • • • • • • • Related topics Genital sores/ulcers,page640 • • • – Symptomatic: symptoms No If outsideQueenslandcontactthelocalPublicHealthUnit Consult MO/NPifallergictomedications,pregnantorsymptomsdonotrespondtreatment Review suppressivetreatmentafter6months.Ifnoimprovementrefertospecialist – Follow upat2-3months: as furthermedicationmaybeindicated Refer toMO/NPifsymptomshavenotresolvedwithin1weekorthepatienthasrecurrentepisodes, – – – – Ask toreturnforfollowupwithin1weekcheck: – [email protected] Infection ofbabiesinpregnancycanleadtomiscarriage,neonataldeath orcongenitalsyphilis babies duringpregnancy(byblood),upto8yearsafterinfectioninmother Untreated syphiliscanbetransmittedtosexualpartnersup2yearsafter infectionandto regarding syphilis gov.au [email protected] Contact theQueensland – – – – – – – Syphilis Forapatientwithgenitalsorescontactthe offer afullSTIcheckincludingsyphilisserologyandHIVtest test resultshavebeensupplied contacts havebeencounselledasappropriate clinical evaluationofresponsetotreatment compliance withtreatment – secondary syphilis maypresentwith: – – – – primary syphilismaypresentwith: – – – – – skin andareoften symmetrical genital sores(condylomata lata)thataretypicallymultiple, painless,ongenitaland/orperianal if untreated,soreswillhealbythemselves within3-8weeks lymph nodesinthegroinmaybeenlarged lesions maybepainful,tenderorpainless and1-2cmindiameterwithwelldefinededges one orafewprimarylesions( orforthoseoutsideofQueenslandcontactyourlocalPublicHealthUnitanyadvice 1,2 1
1,2 SyphilisSurveillanceCentre chancre) oftheano-genital,oropharyngeal orsurroundingareas or [email protected]. Syphilis SurveillanceCentre 1800032238oremail
1800032238oremail Qld-syphilis-
Sexually transmitted infections 647
Sexually transmitted infections transmitted Sexually Not applicable Not applicable
1,2,3 Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: Genital sores/ulcers, page 640 a reactive syphilis serology history a reactive syphilis serology latent syphilis EIA, TPPA, TPHA or FTA) being reactive may indicate 2 specific tests (either (> 2 years) defined as early latent (< 2 years) or late latent latent syphilis is further may be reactive or non-reactive non-specific tests for RPR management should always be in consultation with a specialist MO/NP with a specialist should always be in consultation management rash may be generalised and include the palms of the hands or soles of the feet of the soles or the hands of palms the include and be generalised may rash swollen glands hair loss and and pains, aches headache, muscle fever, to 2 up and sometimes of 12 months over a period and go may come symptoms if untreated, years is rare and skin signs cardiovascular or bone neurological, – – – – – – – – – –
of treatment a new infection requiring treatment is usually indicated by a 2 titre (four fold) rise e.g. 1:4 to 1:16 the titre usually rises in early infection and falls, with or without treatment, over a period of 2 the titre usually rises in early infection and falls, years an adequate response to previous treatment is usually indicated by a 2 titre (four fold) fall within 3-6 months e.g. 1:128 to 1:32, depending on the stage of syphilis and the titre at the time treatment non-reactive at a serial dilution titre e.g. 1:1, 1:2, non-specific tests for RPR are either reactive or 1:4, 1:8, 1:16 etc. specific tests for EIA, TPPA, TPHA and FTA are either reactive or non-reactive specific tests for EIA, TPPA, TPHA and FTA are either patient has acquired syphilis, but not when or if 2 specific tests are reactive, this indicates the will remain reactive for life irrespective of whether they have been treated. Specific tests See trichomonas, HIV and hepatitis B offer further STI screen for chlamydia, gonorrhoea, urine pregnancy test on all women of childbearing age (12-52 years) urine pregnancy test on all women of childbearing syphilis serology syphilis and herpes PCR. if genital sores are present also collect a swab for and groin for enlarged nodes for patches of hair loss examine for rash on face, palms, soles of feet and examine mouth for mucous patches examine the genital area for discharge, nodules, sores and ulcers as well as the armpits, neck examine the genital area for discharge, nodules, – fever, headache, muscle aches and pains, rashes ask about other symptoms: results and treatment: – – – obtain a full history including whether the current partner has symptoms of an STI whether the current partner has symptoms obtain a full history including syphilis serology and the Syphilis Surveillance Centre for previous check patient's clinical records – – – – – syphilis: late (tertiary) – – – – – – – – – – – – – – – – – –
– – – – – – – Syphilis results: – – – – – Test for: Response Tools) Perform examination: – – score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Obtain patient history: – – – • • • • •
3. Clinical assessment 2. Immediate management 2. Immediate 648 Sexually transmitted infections 4. Management | Primary Clinical CareManual 10th edition | • • • • • • • See – – – – Jarisch-Herxheimer reaction: – – – – – – Treatment ofsyphilisinpregnancy: – – – – Medication management: – – Provide educationonpreventionandcondomsuse: – – Perform immediatecontacttracingandtreatmentofsexpartnerstoavoidreinfection: syphilis management au [email protected] Contact theQueensland – – – – – – – – – – – – – – – – – – orforthoseoutsideofQueenslandcontactyourlocalPublicHealthUnitanyadviceregarding can normallybemanagedwithparacetamol for24hours hypotension andflareupoflesions lasting 12-14hours symptoms mayoccur6-12hoursaftertreatmentandinclude fever, chills,headache, result inmiscarriage,stillbirthandcongenitalsyphilis may causepretermlabour,butthisshouldnotpreventordelaytreatment becausesyphiliscan common andmayoccurwithtreatmentofearlysyphilis 2 titre(fourfold)fallinRPRbythetimeofdelivery treatment is adequate if completedatleast 30 days priorto delivery, ideally with a documented up maybeneeded diagnosis andtreatmentisthesameasfornon-pregnantwomen,although morefrequentfollow testing forsyphilis-see congenital syphiliscanbepreventedthroughappropriatetestingandmanagement syphilis inpregnancycanresultmiscarriage,neonataldeathandcongenital consultation withaspecialistMO/NP treatment ofpregnantwomenandtheircontactsshouldbecarriedouturgentlyin local PublicHealthUnitforalternativetreatmentoptions note: have risen.Repeatthesyphilisserologyonfirstdayoftreatment(baselineRPR) if treatmentiscommencedmorethan2weeksafterperformingsyphilistesting,theserologymay (Bicillin LA late latentsyphilis(morethan2yearsorunknownduration)treatwithbenzathinebenzylpenicillin benzylpenicillin (BicillinLA primary, secondaryandearlylatentsyphilis(lessthan2yearsduration)treatwithbenzathine syphilis) untilthepartnershavebeentestedandtreated(asappropriate) advise nosexwithpartnersfromthelast3months(primarysyphilis)and6(secondary advise nosexualcontactfor7daysaftertreatment all contactsofsyphilisshouldbefollowedupuntiltreated – – contacts ofprimary,secondaryandearlylatentsyphilis(syphilis<2yearsduration): – – Sexually transmittedinfectionsgeneral, page615 treat atpresentationwithbenzathinebenzylpenicillin(BicillinLA obtain alistofthenamessexualcontactsupto12months,ifpractical if allergytopenicillin,seekadvicefromtheQueenslandSyphilisSurveillanceCentre,or ® ) 1.8gonceweeklyfor3weeks 1,2,3,4
Syphilis SurveillanceCentre Antenatal care,page500 ® ) 1.8gstat or [email protected].
1800032238oremail ® ) 1.8g Qld-syphilis- Sexually transmitted infections 649
1,2,3,4,5
Duration stat dose
Administration tips for Late latent syphilis Early latent syphilis Early latent Primary, Secondary or Primary, Secondary Once a week for 3 weeks IHW/IPAP/RIPRN/SRH / Extended authority authority Extended Sexually transmitted infections transmitted Sexually ATSIHP Anaphylaxis, page 102 Adult (1.8 g) dosage injections Recommended Recommended Give 2 separate 2.4 million units 2.4 million units ) ®
May cause diarrhoea, nausea and pain at injection site May cause diarrhoea, nausea IM (Bicillin LA (Bicillin Consult MO/NP. See Route of administration Benzathine benzylpenicillin benzylpenicillin Benzathine Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 4 Strength (900 mg) 1.2 million Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity of aware Be penicillin. a to reaction allergic immediate or Severe units/2.3 mL repeat RPR and offer full STI check adequate response to treatment a 2 titre or fourfold fall in RPR by 6 months indicates test results have been provided to patient consult MO/NP if symptoms have not resolved treatment completed and symptoms have resolved contacts have been tested and treated
– – – – – – : Stop injection immediately if patient shows signs of severe pain. See if patient shows signs of severe pain. See : Stop injection immediately Schedule Management of the babies of women needing treatment in pregnancy should be done in consultation in pregnancy should be done needing treatment of women of the babies Management with a specialist MO Always consult an MO/NP syphilis for: – – – – and 12 months for primary, secondary, early latent Recommend client to return for follow-up at 3, 6 Recommend client to return for follow-up at 1-2 weeks to check: Recommend client to return for follow-up at 1-2 – – Form
syringe) Injection (pre-filled • • • • benzathine benzylpenicillin, page 787 benzathine benzylpenicillin, Contraindication: and carbapenems between penicillins, cephalosporins emergency: Management of associated Provide Consumer Medicine Information: Provide Consumer Medicine Note RIPRN and SRH may proceed RIPRN and SRH ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP,
6. Referral/consultation 5. Follow up 650 Sexually transmitted infections | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend • • • • • • • • • Related topics Genital sores/ulcers,page640 • • • • • • – Collect STIspecimen: – – – Suspect donovanosisinpatientswithcombinationof: Perform examination Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – Obtain patienthistory: Past historyofdonovanosis Patient maycomplainoflesionssmellingoffensive,duetosecondarybacterialinfection Painless hardano-genitalulcerswithirregularraisededgesthatbleedoncontact Raised, beefynodulesorsores.Canbelargeanddisfiguring Microscopy ofscrapings,sniporpunchbiopsy,PCRcanconfirmthediagnosis Donovanosis isachronic,progressivelydestructiveinfection Very rare,eveninruralandremoteareasofAustralia azithromycin -seekexpertadvice Children bornviavaginaldeliverytowomenwithactivedonovanosisshouldreceiveprophylactic Follow-up isessentialasresolutionslowandrecurrencecanoccur contact fromcentralandnorthernAustralia(rare),PapuaNewGuinea,IndiaorsouthernAfrica indicated i.e.aknowncontactofdonovanosiscaseORruralandremoteresidentwithnamed There isnoneedtotestfordonovanosisoninitialpresentationofgenitalulcersunlessclinically – – – – – Donovanosis exclusion ofothercauses(especially herpessimplexvirusinfection,syphilis,andgonorrhoea) high risksexualbehaviours(particularlyinendemicregions) painless genitalulcer donovanosis. Discusswithaspecialist if previousserologyisnegativeforothergenitalulcersorunresponsive totreatments,consider in adrysterilecontainer tipped dryswabe.g.PCRswab,rollthe swabfirmlyaroundtheedgeandacrosslesion,place clean the lesion withwater or sodium chloride0.9%(not antiseptic) then using a sterilecotton 1,2 1,2 1,2 1,2,3 Not applicable Syphilis, page646 Sexually transmitted infections 651
1,2,3,4
7 days occurs Duration 1800 032 238 1800 032 238 Extended authority Sexually transmitted infections transmitted Sexually ATSIHP/IHW/IPAP/RIPRN/SRH For at least 4 weeks until healing or specialist MO/NP regarding the regarding MO/NP or specialist Anaphylaxis, page 102 dosage OR 500 mg daily Recommended 1 g once a week Surveillance Centre Surveillance Azithromycin Take with or without food. May cause rash, diarrhoea, nausea, Take with or without food. May cause rash, diarrhoea, Consult MO/NP. See
Oral Oral Route of administration Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 4 500 mg 500 mg Strength
condom use for 7 days after treatment is administered advise no sexual contact been reviewed and from the last 6 months until the partners have advise no sex with partners treated as necessary contacts should be examined and have a complete STI check contacts should be examined treat with azthromycin OR doxycycline treat with azthromycin [email protected] – – – – – – – – Perform immediate contact tracing: Perform immediate contact – and prevention: Provide patient education – be organised to a biopsy needs to 6 weeks after therapy, not completely healed If lesions have exclude alternative diagnoses or public health unit contact the local If outside Queensland presentation: management at time of Medication Treat immediately Syphilis ulcer consult for genital If treating Centre Syphilis Surveillance and ongoing management: likely diagnosis
Form • • • • • • • Schedule Tablet Tablet abdominal cramps and candidiasis Management of associated emergency: Provide Consumer Medicine Information: ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN and SRH may proceed 4. Management 4. 652 Sexually transmitted infections | Primary Clinical CareManual 10th edition | 6. Referral/consultation 5. Followup Management ofassociatedemergency: Use inpregnancy: retinoids. Children<8yearsofage.After18weekspregnancy Contraindication: calcium, zinc,orantacidswithin2hoursoftaking.Avoidsunexposure and photosensitivity.Takewithfoodormilk.Donotliedownforanhouraftertaking.takeiron, Provide ConsumerMedicineInformation: RIPRN andSRHmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP • • • • • Schedule Tablet If outsideQueenslandcontactthelocalPublicHealthUnit Consult MO/NPasaboveifallergic,pregnantorsymptomsdonotrespond totreatment months Relapse/re-infection mayoccur.Advisepatientstoseekreviewatcompletion oftreatmentandat3 – – – – and symptomswhichcanbeslow;recurrenceoccur: Follow-up weekly(duringdirectobservationofmedicationadministration)untilresolutionsigns Form [email protected] – – – – Forapatientwithgenitalsorescontactthe check contactshavebeenexaminedandtreated epithelialisation longer durationoftherapymayberequireduntilcompleteulcergranulationandre- by 6weeks consult MO/NPifsoreshavenotsignificantlyrespondedtotreatmentwithin4weeksorhealed check toensurepatientwascompliantwithtreatment 1,2,3 Severeorimmediateallergicreactiontotetracyclinestreatmentwithoral Safeinthefirst18weeksofpregnancy 4 Strength 100 mg 50 mg administration Doxycycline ConsultMO/NP.See Route of Maycausediarrhoea,nausea,vomiting,epigastricburning Oral Syphilis SurveillanceCentre
Recommended 100 mgbd dosage Anaphylaxis, page102
ATSIHP/IHW/IPAP/RIPRN/SRH Extended authority For atleast4weeksuntil 1800032238oremail healing occurs Duration
1,2,3,5
Sexually transmitted infections 653 Sexually transmitted infections transmitted Sexually Syphilis, page 646
Not applicable HPV)
1,2,3
Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 1 warts 1,2,3
small, nondistinctive 1-2 mm flesh-colored papules frequently found in large clusters on external genitalia exclude normal anatomical variants and other causes of lumps before treating solitary keratotic papule or plaque (initially) examine the genital area for discharge, nodules, sores and ulcers and the groin for enlarged the groin sores and ulcers and examine the genital area for discharge, nodules, nodes STI's - any symptoms; previous history of STIs pregnancy whether partner has genital warts/other STI symptoms test any HPV changes detected on cervical screening immunosuppression Genital Genital – – – – – – – – – – The diagnosis of genital warts is clinical. Syphilis must be excluded of genital warts is clinical. The diagnosis lesions and cervical cancer lesions and of cervical cancer has resulted in a decrease in the incidence HPV vaccination in Australia after initial exposure (not always sexual) Usually form up to 18 months HPV is associated with genital warts, abnormal cervical screening tests, squamous intraepithelial tests, squamous abnormal cervical screening with genital warts, HPV is associated – – Diagnosis is usually based on visual appearance: – – Response Tools) Perform an examination: – – – score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT – – – Obtain patient history including: Bleeding or irritation upon contact with clothing or during sexual intercourse, especially with larger Bleeding or irritation upon contact with clothing lesions PR bleeding after passage of stools Perianal itch Burning sensation Warts may be papillomatous, pedunculated or sessile growths (elongated stalk), with either a pedunculated or sessile growths (elongated Warts may be papillomatous, and do not cause are usually the same colour as surrounding skin smooth or rough surface, of the skin ulceration or inflammation Large clusters of lesions (warts) on genital skin that may or may not be painful (warts) on genital skin that may or may not be Large clusters of lesions
• • • • Genital sores/ulcers, page 640 Genital sores/ulcers, page Related topics • • • • • • • • • •
Recommend Background HMP HMP
3. Clinical assessment 2. Immediate management
1. May present with Human papilloma virus ( virus papilloma Human 654 Sexually transmitted infections 4. Management | Primary Clinical CareManual 10th edition | • • • • • • – – – – – – Provide patienteducationandprevention: Contact tracingisunnecessaryasthemajorityofthosewithHPVareinfectedsubclinically Female partnersofmaleswithgenitalwartsshouldhaveacervicalscreeningtestifdue – – – Consult withMO/NPorSexualHealthNursewhomaytreatwith: See – – – – Tests toconsider: – – – – – – – – – – – – – – – – – – – chlamydia, gonorrhoea,trichomonasand urine pregnancytestforallwomenofchildbearingage(12-52years) cervical warts histology biopsytoexcludecancerifthereisvariablepigmentation,raisedplaque-likelesionsor appearance canbeflat,domeorcauliflowershaped colour rangesfromwhitetopink,purple,red,orbrown may growaslargeseveralinchesindiameter encourage HPVvaccine topical treatmentsonnormalskincancauseerythemaandulceration recur in thepresenceofHIV,genitalwartsmayrequirelongercyclestreatmentandaremorelikelyto treatment iscosmeticratherthancurative if wartsinthepubicregionavoidshavingorwaxingwhichmayfacilitatelocalspreading condom use specialist excisionorothertherapiesformeatal,intra-analcervicalwarts liquid nitrogenornitrousoxidecryotherapy – – self administeredpodophyllotoxin: also offertestforsyphilis,HIV,hepatitisC,B – – Sexually transmittedinfectionsgeneral,page615 cream isbestusedfortheperianalarea,vaginalopeningandunderforeskin paint issuitedforuseonexternalskin 1,2,3 Mycoplasma genitalium (only ifclinicallyindicated) Sexually transmitted infections 655 1,2,4,5
3 days 4 days Duration above for up to 4-6 Repeat treatment as cycles until resolved then no treatment for Extended authority Extended Sexually transmitted infections transmitted Sexually ATSIHP/IHW/IPAP/RIPRN/SRH ATSIHP/IHW/IPAP/RIPRN/SRH Anaphylaxis, page 102 bd Adult dosage Apply to wart Recommended Recommended (avoid normal skin)
May cause local irritations: burning, inflammation, pain, May cause local irritations: Consult MO/NP. See Podophyllotoxin Topical Route of administration Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: 4 Contraindicated o.5% o.15% Strength 1,3
: Clinician to apply the first treatment and instruct the patient in proper use treatment and instruct the patient in proper : Clinician to apply the first Follow up is unnecessary but is beneficial to assess response to treatment and to reassure client Follow up is unnecessary but is beneficial to assess or do not respond to treatment Consult MO/NP or specialist if lesions are atypical All women with genital warts or partners of men with genital warts should have a regular cervical All women with genital warts or partners of men screening test in accordance with NHMRC guidelines Schedule
Form Paint Cream • • • Management of associated emergency: applied. May weaken latex condoms and should be washed off before used condoms and should be washed off before applied. May weaken latex Note Use in pregnancy: Provide Consumer Medicine Information: Provide Consumer Medicine applying, wash affected on broken skin. Avoid contact with eyes. Before erosion or itch. Do not use after use; avoid bathing or water and allow to dry. Wash hands before and area with mild soap and or wash it off if already If you have sex, apply the treatment afterwards showering after application. ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, may proceed RIPRN and SRH
6. Referral/consultation 5. Follow up 656 Sexually transmitted infections Human immunodeficiencyvirus( | Primary Clinical CareManual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Background Recommend • • • • • Related topics Sexually transmittedinfectionsgeneral,page615 • • • • • • • – – – – – Obtain patienthistory: MO/NP Consult skin infections deficient i.e.oralthrush,herpeszoster,diarrhoea,weightloss,pneumonia, Karposi'ssarcomaor Opportunistic infectionsthatoccurwithsignificantlyincreasedfrequency duetobeingimmune mouth ulcers,muscleachesandpains,enlargedlymphnodes Flu likesymptomscanoccur2-6weeksafterinfectionsuchasfever,headache, rashes,sorethroat, Asymptomatic follow-upafterpositivescreeningtestofundiagnosedHIVinfection – risk ofsexualtransmission transmission tobabiesduringpregnancy(from30%-<1%).Antiviralmedicinealsoreducesthe Antiviral medicinecanimprovethequalityandlengthoflife,aswellsignificantlyreducing and non-occupationalexposuretoHIV.SeeManagement HIV postexposureprophylaxis(PEP)isavailableinselectedcasestheeventofoccupational people whoshareinjectingequipment people, peoplefromacountrywithhighHIVprevalence,sexuallyactiveoverseastravellersand People atriskincludemenwhohavesexwith(MSM),sexualpartnersofHIVinfected if exposed The presenceofotherSTIssignificantlyincreasestheriskbothacquiringandpassingonHIV, Outside ofQueenslandcontactyourlocalSexualHealthUnit 3328 9797 au/clinical-practice/guidelines-procedures/sex-health/services/find-service#hiv For assistance:inQueenslandcontacttheHIVPublicHealthTeam: discussing withapatient Any positiveresult – – – – – – injecting practices (PEP orPrEP) any priortreatment withantiretroviraltherapy(ART)including preorpostexposureprophylaxis options chronic medicalandpsychiatricconditions orcurrentmedicationsthatmayaffecttreatment has beenidentifiedoncontacttracing sexual contactwiththosefromahigh HIVprevalentcountrye.g.Africa,CentralAmerica,Europe sexual practices 1,2 onapathologytestmustbediscussedwithspecialistMO/NPbefore 1,2 1,2,4 HIV) infection
https://www.health.qld.gov. orphone 07
Sexually transmitted infections 657 or receptive anal Sexually transmitted infections transmitted Sexually http://www.testingportal. Consideration 1,2,3 1,2,3 OR http://conditions.health.qld.gov.au/ at: HIV Pathology Standard Pathology High during HIV primary illness Marker of immune function, usually > 500 if on Maker of HIV level in serum, should be undetectable treatment Usually lab will perform a combination HIV Ag/Ab test, usually Usually lab will perform a combination HIV Ag/Ab longer reactive within 6 weeks of infection but occasionally Confirmatory test hout a condom Blood Blood Blood Blood Blood Section 7: Sexual and reproductive health | health reproductive and Sexual Section 7: Site/Specimen 4 HIV post-exposure prophylaxis - HIV Test
intercourse by MSM wit See HealthCondition/condition/14/116/520/Post-exposure-Prophylaxis--HIV needle stick injury from a known HIV positive source or a person from a high HIV prevalent country needle stick injury from a known HIV positive source sexual exposure, in particular sexual assault by multiple assailants of unknown HIV status or in the event of a sexual assault by a person from a high HIV prevalent country, national informed consent for HIV testing guidelines available at national informed consent ashm.org.au/hiv/informed-consent-for-testing your local HIV public health team rectal exam gynaecological exam abnormal subcutaneous fat redistribution abnormal subcutaneous examination of lymph nodes neuropsychiatric evaluation body mass index oral cavity, and teeth abnormalities of skin, infections or any issues related to disclosing HIV status to others to disclosing HIV any issues related history of sexually transmitted infections (STIs), such as syphilis, gonorrhea, or chlamydia gonorrhea, as syphilis, (STIs), such infections transmitted of sexually history hepatitis C B or (TB), hepatitis as tuberculosis such co-infections, any known and emotional health and social supports, including housing, financial social history any ongoing risk factors for transmission, such as sexual habits and illicit drug use illicit and habits sexual as such transmission, for factors risk ongoing any – – – – – – – – – – – – – – – – – – – – Contact the Director of Sexual Health or Infectious Diseases Physician, the local HIV Public Health Public HIV local the Physician, Diseases Infectious or Health Sexual of Director the Contact presents immediately following possible exposure: Team or an MO/NP, to discuss HIV PEP if a patient On advice of your local HIV public health team take appropriate HIV pathology. See HIV Pathology On advice of your local HIV public health team take table – – – – taking any pathology tests and gain consent with patient before Ensure to have pre-test discussions in accordance with: – – – – – include: MO/NP examination should – Warning and or other local Early (full Q-ADDS/CEWT score clinical observations Perform standard Response Tools): – – – –
• • • • • HIV RNA (viral load) Western blot HIV p24 antigen CD4 lymphocyte HIV Ag/Ab Glucose, eGFR, LFTs, FBC, lipids, urinalysis, and hepatitis A, hepatitis B and hepatitis C serology. Glucose, eGFR, LFTs, FBC, lipids, urinalysis, and Consider screening for tuberculosis 4. Management 658 Sexually transmitted infections 5. Followup | Primary Clinical CareManual 10th edition | 6. Referral/consultation • • • • • • • • For moreinformationgoto HIV positivepeopleshouldbemanagedinconsultationwithaspecialistMO cover thewindowperiod If thepatienthasbeenexposedtoHIVinprevious3months,serologyshouldberepeated – Medication management: – – Post HIVtestresultdiscussionsshouldbeinaccordanceto: – – HIV pathologyresults: the resultwithpatientasfalsepositivetestorindeterminateresultscanoccur Discuss withtheHIVPublicHealthTeamorMO/NPanyresultinterpretation – – – – – made availableforthepatientto discussions withthelocalHIVPublicHealthTeamandspecialistwillensuremedicationsare your localHIVpublichealthteam au/hiv/conveying-hiv-test-results a positiveHIVresultmeansthepatienthasbeeninfectedwith a negativeHIVresultmeansthepatienthasnotbeeninfectedwith national conveyingHIVtestresultsguidelinesavailable HIV isanotifiabledisease start treatmentassoonpracticalafterthedayofdiagnosis
OR
at
http://www.testingportal.ashm.org. before discussing Rape and sexual assault Rape and sexual assault
Rape and sexual assault - adult/child
Recommend1 • Evacuation may be required in some areas for forensic examination. Check local protocol • Initial management of a client presenting in the acute phase of an alleged rape or sexual assault is to assess and manage any injury or medical problem • Sexual health assistance is part assessment and management • The priority is to ensure the safety and welfare of the client • For clients < 14 years of age seek phone advice from a specialist Paediatrician • If the client is < 18 years of age there may be a mandatory reporting obligation. See Child protection, page 760 • Documentation must be accurate, objective and specific. Clearly state the facts as reported by the client as notes may be subpoenaed if the client reports the assault to police. The use of diagrams can be useful to detail bruises, cuts, abrasions, bites • The role of Queensland Health is to provide medical care, forensic medical examinations, sexual health assistance, information and support. See Response to sexual assault Queensland Government Interagency Guidelines for Responding to People who have Experienced Sexual Assault. Available at https://publications.qld.gov.au/dataset/victims-assistance-sexual- assault/resource/3b3958c9-504f-4698-a64d-e56ca7e5248e
Related topics Emergency contraception, page 611 Traumatic injuries, page 163 Sexually transmitted infections general, page 615 Unintended pregnancy, page 498
1. May present with Adult • Reported sexual assault, family violence, physical assault • Loss of consciousness/episode of amnesia/alcohol blackout • Other minor complaint which does not correspond to patient's psychological state • Self-harm/attempted suicide/eating disorders • Report from within community that an adult is being sexually assaulted. Report incident to the police • Request for forensic evidence collection by Queensland Police Service Child • PV/PR bleeding, abdominal pain, behavioural change • Sleep disturbance, bed wetting • Other non-accidental injury • Report from within community that a child is being sexually assaulted. Report incident to police • Sexually transmitted infection in child which needs to be followed up with extreme care and confidentiality
Section 7: Sexual and reproductive health | Rape and sexual assault 659 2. Immediate management • Assess and attend to life threatening conditions,2 which may include: –– strangulation –– blunt trauma to head, face and torso –– penetrating injuries2,3 • Consult MO/NP/Forensic Nurse Examiner (FNE)/Forensic Medical Officer (FMO) • See the client in a private area to ensure confidentiality, dignity and safety1 • If a preference for female or male clinician is expressed, take all reasonable steps to accommodate this1 • Ensure client has an opportunity to arrange a support person such as relative, friend or appropriate Police Officer
Rape and sexual assault and sexual Rape • Adult victim/survivor: –– consult MO/NP/FNE/FMO if available –– follow local protocols for forensic examination and evacuation of victim • Child victim/survivor:1,4 –– consult MO/NP who will arrange evacuation for examination by experienced MO/NP or Paediatrician 3. Clinical assessment1 • Forensic examination: –– clients may require evacuation for forensic examination - check local protocol • Non-forensic examination:2,5 –– gain client’s consent to perform non-forensic examination • Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) • Perform physical examination: –– perform head to toe physical examination –– observe for bleeding and injuries to genitals, anus, breasts –– observe for trauma to thighs, upper arms and face/neck –– document and/or record on body diagram any physical injuries that have occurred as a result of being held, pushed, punched etc • Offer STI screening and blood tests for: –– syphilis (as baseline) –– hepatitis B to check immune status. This is urgent if offender is known IV drug user, or possible hep B carrier or is tattooed (higher risk profile for HBV) –– HIV test (as baseline) with appropriate pre-test information and consent. See HIV, page 656 –– offer point of care pregnancy testing for women of reproductive age 4. Management1 • Adult victim/survivor: –– consult MO/NP/FNE/FMO –– ensure client feels safe and supported - proceed at their pace. It is important that the client can retain control of the process –– provide emotional and psychological support as necessary5
660 | Primary Clinical Care Manual 10th edition | Rape and sexual assault –– provide information on options and encourage the client to make their own decision regarding legal action, giving them space and time: –– they may change their mind –– consider the role of telephone counselling to assist the patient in making these decisions: –– 24 hour National Sexual Assault, Domestic and Family Violence Counselling Line 1800 737 732 • Child victim/survivor:1 –– follow local protocols for child safety referral. See Child protection, page 760 –– if a medical examination is required it should be conducted by an experienced MO/NP/ Paediatrician/FNE/FMO, or in consultation with one 5. Follow up3,5 • Ensure the client, if not evacuated, has a safe place to go after clinical examination and/or police contact • Continue to provide comfort and support • Contact your local/regional Sexual Assault Centre to arrange counselling and ongoing support if required. It is not uncommon that some clients do not wish to access counselling immediately following sexual assault. The information can be used in the future • Review next day if not evacuated • Offer to provide pathology results to patient’s normal health care provider • Advise to see MO/NP at next clinic as appropriate • Offer the following reviews: –– 2 weeks post assault - with results of pathology tests taken or if no tests done, perform STI screening and pregnancy test (if indicated) –– 1 month post assault - hepatitis B vaccination, pregnancy test (if indicated) –– 3 months post assault - HbsAg, HIV, syphilis –– 6 months post assault - hepatitis B vaccination 6. Referral/consultation • Consult MO/NP/Paediatrician/FNE/FMO on all occasions of rape/sexual assault • Paediatrician through MO/NP/FNE/FMO or Child Safety Officer • Forensic Nurse for assistance and advice at nearest district/regional facility • Police if indicated or requested • Sexual assault service/counselling service/Social Worker as per availability • Other useful resources include: –– National Sexual Assault, Domestic and Family Violence Counselling Line 1800Respect on 1800 737 732 (free and anonymous) –– For men and women (free and confidential) Queensland Sexual Assault Helpline 1800 010 120 –– Child Safety (Queensland) After hours 07 3235 9999 –– True Relationships & Reproductive health (previously known as Family Planning Queensland) available at: www.true.org.au 3250 0240 • If outside of Queensland contact local support services/resources
Section 7: Sexual and reproductive health | Rape and sexual assault 661 4
Section 4 Page left intentionally blank General
662 | Primary Clinical Care Manual 10th edition | 8
Paediatrics
663 664 Paediatric presentation History andphysicalexamination Paediatric presentation | Primary Clinical Care Manual 10th edition | Background Recommend • • • • • • • • emergency-department-patient-information-sheets Patient informationsheetsavailable at – – – – – – – – – – – – – – – – – – – Risk signsforseriousillnessinchildrenare Small children,especiallyyoungbabies,getsickveryquickly dataset/chronic-conditions-manual Management ofChronicConditionsinAustralia For scre Opportunistic healthpromotionandscreeningshouldoccurduringvisitwheneverappropriate. right thinginbringingthechild-regardlessofconcern Regardless of the time of day or night or thecircumstances always reassure theyhavedone the Pay particularattentiontohistoryfromparent/carerwhereavailable are concernedaboutorwithanabnormalCEWTscore Consult MO/NP immediately about any baby < 3 months of age who is febrile or any child who you and ResponseTool- Always useageappropriateCEWTruralandremote-ifnotavailableotherlocalEarlyWarning – – – – – – – – – – – – – – – – – – – a historyofrepeatedorprolongedseparations fromtheirprimarycaregiver(s) at home where socialconditionsareconcerningand/orparentsmayhave difficultymanaging congenital orchronicdiseasee.g.cardiac,gastrointestinal,neurological abdominal distension uses eyes,ratherthantheirhead,tofollowyou central capillaryrefill>2seconds cold extremities sunken eyes < 4wetnappiesin24hours persistent vomitingand/orlotsofdiarrhoea:>8waterystoolsin24hours breathing fast/noisy,respiratorydistress,apnoea reduced feeding drowsiness, decreasedactivity high pitchedcryorweak irritability unexplained pain/restlessness fever orhypothermia-T>38°C<35.5°C CEWT score≥4 intellectual disabilityormentalhealth problems psychosocial riskfactorsincludingfamily violence,poverty,homelessness,parentswith ening toolsandchecks,seethe document andactonCEWTscore https://clinicalexcellence.qld.gov.au/resources/ Chronic ConditionsManual:Preventionand
: - child availablefrom: https://publications.qld.gov.au/ Paediatric presentation 665 16-25 90-149 12 years ≥ ≥ 60 - < 120 Systolic range Paediatric Paediatric presentation C 16-30 85-129 o 5-11 years ≥ 80 - < 130 80 Systolic range Nil C - 37.9 ≥ 94% o ≤ 2 secs CEWT range CEWT 35.5 AVPU tool - alert Glasgow coma scale 15 16-35 80-124 1-4 years Section 8: Paediatrics | Section 8: Paediatrics ≥ 90 - < 140 3-8 mmol/L (random capillary) Systolic range 1 Sepsis/septic shock, page 21-45 75-119 < 1 year ≥ 100 - < 160 Systolic range Early Warning and Response Tool. in all children if: Have score ready when consulting the MO/NP 2 RR BP HR BGL SpO Level of (mmHg) distress refill time Respiratory (beats/min) (beats/min) Temperature (breaths/min) (breaths/min) consciousness Central capillary (0) values on the Queensland Children's Early Warning Tool (CEWT) Tool Early Warning Children's Queensland on the (0) values Parameter Zero could this be sepsis altered behaviour or ↓ level of consciousness re-presentation within 48 hours fever or hypothermia unexplained pain or restlessness signs of deterioration during current illness CEWT score ≥ 4 looks sick you suspect they may have sepsis patient, family or carer/parent has concerns clinical signs if Standard If any of the above, screen for sepsis. See Think indicated Other vital Always document clinical observations on an age appropriate CEWT rural and remote or other local Always document clinical observations on an age observations 666 Paediatric presentation | Primary Clinical Care Manual 10th edition | • • Step 1:Obtainhistoryofthepresentingconcern/problem • • • intake/output during Presenting concern/ activity duringthis The historyisthemostpowerfultoolforidentifyingdiagnosisincases – Obtain afullhistoryinconjunctionwithexaminingthechild: For eachsymptom medicine givenby Appetite andfluid Treatment and/or carer duringthis Use closedendedquestioningtohelp confirmoreliminatevariouspossibilities Consider possibledifferentialdiagnosis Ask ifthereareanyotherconcerns – Behaviour and in asickchildthisentailsfullassessmentofallsystems (as relevant) this illness Associated symptoms ask about problem illness illness • • • • • • • • • • • • • • • • • Muscle tonenormaloraretheyfloppy Active/alert, sleepyorirritable,easy/difficulttowake Beware ofvomitingwithoutdiarrhoea – E.g. nausea,vomiting,photophobia,headache: – Severity Exacerbating factors Timing Alleviating factors Radiation Character – – – Onset Site Use openendedquestions Ask theparent/carerwhatproblemis What, howmuch,when,often, howeffective Amount/type bowelmovements;presenceofbloodinstool – – – – Try tobeasprecisepossiblewithquantities.How: – – – – – – – – – many wetnappiesortimespassedurineinpreceding24hours long betweenintakeandvomit/diarrhoea alert duringfeeds many drinks/breastfeeds breathing, diarrhoeaand/orweightloss,rash always askspecifically see what weretheydoingwhenitstarted continuous orintermittent gradual orsuddenonset History ofpresentingconcern/problem -whereisthepain/symptom : Acute painmanagement,page -whendiditfirstbegin,howlonglast,havetheyhadbefore -mild,moderateorseverepain: ofpainordiscomfort e.g.sharp,dullorburning -whatmakesitbettere.g.sittingup,medicines -doesanythingmakeitworsee.g.movement
about fever,pain,shortnessofbreath,rapid 35 forpainassessmenttools 2 2 2
Paediatric presentation 667
used
Paediatric Paediatric presentation ® 778 2 768 Section 8: Paediatrics | Section 8: Paediatrics Past history 2 Immunisation program, page Medication history and reconciliation, page anaphylaxis, skin reaction, bronchospasm, other e.g. shoe tag, may look like normal jewellery or other accessory anklet, watch taken correctly medicines food other allergies e.g. honey bee stings, sticking plaster, generic name dose, frequency ask about diabetes, asthma, epilepsy, RHD ask about diabetes, asthma, – – – – – – – – If adverse medication reactions/allergies ensure documented as per local If adverse medication reactions/allergies ensure policy Check if up to date Documented evidence of immunisations received should be obtained Offer opportunistic immunisation at visit if appropriate. See Specific reaction: – EpiPen Is an adrenaline (epinephrine) autoinjector e.g. Check for medical alert jewellery and accessories: – Check clinical records – home the child may May need to ask about other medicine(s) in the have taken See Ask about adverse reactions/allergies to: – – Household smokers Recent contacts or trips away If medicines are given, will they be taken alternative, bush Regular and prn medicines: prescribed, complementary, medicines, over the counter: – – Hospital admissions. Why/when when Operations or injuries. What/ drug history during pregnancy Mother's alcohol, smoking, - especially siblings and parents Health problems in the family what is the social situation Who looks after the child, presenting with child/relationship to child Record name of person in carers/child Mental health problems Was birth normal. Any immediate neonatal problems Any immediate neonatal Was birth normal. and development Any problems with growth the past. What/when: Significant illnesses in – • • • • • • • • • • • • • • • • • • • • • • • • • past history past allergies and medicines allergies and history Allergies Medications Immunisations surgical history Past medical and Family and social Always ask about Always ask about Review and update past history in clinical records each visit records each in clinical past history and update Review visit this diagnosis with differential that may assist past history relevant Consider Step 2: Ask about about 2: Ask Step • • • 668 Paediatric presentation | Primary Clinical Care Manual 10th edition | Step 3:Perform • • Offer opportunistichealthchecks(asappropriate) Offer, orreferforhealthchecksasappropriate dataset/chronic-conditions-manual ManagementofChronicConditionsinAustralia Check ifdueforroutinehealthcheck.See • • • – – – – Tips forexaminingchildren – – – In achildwhoisnotsick – – In asickchild – – – – – – – – – examination all ofthechild’sclothingwillneedtoberemovedatsomestageduringcomplete a thoroughandcompleteexaminationisrequired leave themostdisruptivepartsuntillaste.g.earsandthroat you can if thechildisirritableperformexaminationopportunisticallyi.e.dowhatyoucanwhen may bebestdonewiththechildoncarer'sknee use distractiontechniques symptoms andsigns this isparticularlyimportantwhenexaminingchildrenwhooftenpresentwithgeneralised be guidedbythehistoryandpreparedtoexamineothersystemsasnecessary history andyourfindings examine therelevantsystemfirstandproceedtofurtherexaminationasguidedby physical examination : : : Chronic ConditionsManual:Preventionand availablefrom: https://publications.qld.gov.au/
Paediatric presentation 669
785 7 (continued) Paediatric Paediatric presentation
2,3,4,5 floppy/limp and listless floppy/limp OR Glasgow Coma Scale/AVPU, page Calculate score Section 8: Paediatrics | Section 8: Paediatrics for tips in taking BP in children
Early Warning and Response Tool 700 - feel gently. Ask the older child to put their chin - feel gently. Ask the older child to put their chin : : : Always document on CEWT rural and remote or other local Always document on CEWT rural and remote or other Physical examination - child examination Physical APSGN, page 2 peech/cry - strong and vigorous, weak, hoarse, high pitched peech/cry - strong and vigorous, onsolability - can child be comforted by the care giver onsolability - can child be one - moving around and active one - moving ook/gaze - does the child fix their gaze on a face or is there a glassy ook/gaze - does the child nteractiveness - reaching for toys/interacting, or disinterested in or disinterested - reaching for toys/interacting, nteractiveness see for 5 seconds - how press on skin of sternum or a digit at level of heart long does it take for the colour to return listen for audible wheeze, snoring, grunting, stridor listen for audible wheeze, - are they blue look at lips tongue and fingers colour to parents if unsure compare lips and tongue skin colour - pink/pallor, mottling, cyanosis does the child look well or sick does the child alert or drowsy T I interacting/playing C L eyed stare S flaring, gasping, increased RR look for retractions, nasal – – – – – – – – – – – – – – Conscious state - AVPU ± GCS. See ill BGL - if altered level of consciousness/seriously HR SpO of upper arm): BP - use correct sized cuff (wider than 2/3 the length – Central capillary refill time: – – Any neck stiffness stiffness on their chest - if they can, they do not have neck Do they look well nourished RR T – Work of breathing – – Circulation – – – – – – – Watch before you examine before you Watch child between carer and Observe interaction Appearance – • • • • • • • • • • • • • • • 6 care) (All children Perform standard presenting for acute clinical observations General appearance 670 Paediatric presentation | Primary Clinical Care Manual 10th edition | Cardiovascular Hydration system Weight Skin • • • • • • • • • • • • • • • If trainedinauscultationlistentoheart sounds – – – – Palpate: – – Inspect skincolour: Any palpable/tenderlymphnodesintheneck,axillaeandgroin – – – Skin lesionsorsores: – – – – Inspect for: Always checkthewholebody,particularlyinasickchild See indicates aseriousillness A bulgingfontanellearisesfromraisedintracranialpressureandusually Fontanelle -normalordepressed.Ifdepressedmayindicatedehydration. or staysaggy Skin turgor-pinchaloosepieceofskin.Doesitreturntonormalimmediately Mouth andtongue-wetordry Eyes -normalorsunken.Tearsabsentpresent Any weightloss – – If appropriate,alsomeasure: – – Weigh allchildren – – – – – – – – – – – – – – – – – thesternumwithyourthumb Central perfusion-asperperipheralperfusion,butblanchtheskinover how longittakesforthecolourtoreturn peripheral perfusion-'blanch'theskinonafingerortoefor5seconds. Time peripheral pulses-weakorstrong with limbs skin temperature-hot,warm,cool,cold,sweating.Comparethetrunk any oedema-checkhands,feet,shins,lowerlegs,face pink, white,greymottling.Comparethetrunkwithlimbs any familymembers/closecontactwithsimilarlesions exudate e.g.clear,pus,bloody colour, shape,size,location,distributiononbody signs ofinfection-redness,swellingortenderness bruising, unexplainedorunusualmarks colour -unusuallypale,mottledorcyanotic rash -non-blanching,petechiae,purpura head circumferenceif<2years,orindicatedinolderchild length if<2yearsold,height>andabletostand plot ongrowthchartsappropriateforageandgender compare againstmostrecentweights Acute gastroenteritis/dehydration-child,page Physical -bareweightif<2years: examination -child(continued) 730 (continued)
Paediatric presentation 671
758
(continued)
785 Paediatric Paediatric presentation Bone and joint infections, page and 705 Section 8: Paediatrics | Section 8: Paediatrics Glasgow Coma Scale/AVPU, page : transmitted sounds from the upper respiratory tract are very : transmitted sounds from Acute rheumatic fever, page 2 Physical examination - child (continued) - child examination Physical conscious state. See for the child's age. orientation to time, place and person if appropriate to tell you the time, Ask the child their name, age, location. Ask them date and year pupils - size, equality, shape, reactivity to light any rebound tenderness - press down and take your hand away very any rebound tenderness - press down and take quickly - is the pain greater when you do this any redness, swelling or tenderness discolouration; prominent veins; obvious masses discolouration; prominent soft or firm any obvious masses and exact area tender to touch - identify which abdominal quadrant any guarding/rigidity - even when the child is relaxed wheezes or crackles - on inspiration or expiration wheezes or crackles - on Note may mask other signs common in children and distension/hernias, bruising or other any scars or abdominal mild, moderate or severe; nasal flaring; head bobbing or severe; nasal flaring; mild, moderate or absent equal, adequate, decreased equal chest movement equal chest - rib retraction/recession; muscles of respiration use of accessory – – – – – – – – – – – – – – – Test touch sensation using cotton wool child walking, looking Test finger nose coordination. If possible, observe around and using hands Full range of movement in limbs, joints and muscles - active and passive Pain in limbs, joints or muscles Any redness, pain, swelling, heat over joint(s); observe gait See – – – each side of the face and Assess asymmetry of tone and power i.e. compare limbs – Question about change in bowel habits Percuss and feel for bladder Check the testes in boys - are they both in the scrotum: – A brief assessment is all that is needed. Assess: Auscultate bowel sounds - present or absent Palpate abdomen - if pain, palpate with extra care: – – – – – – Will the child lie flat SpO Inspect for: – Can child talk continuously, only in words/sentences or unable to talk at all words/sentences or unable continuously, only in Can child talk depth and effort of breathing over 1 minute - rhythm, Measure RR cough, ± sputum, wheeze, stridor, grunt, snore, Listen for extra noises - hoarse speech/cry lung fields: Auscultate air entry in both – Most information is gained through inspection is gained through Most information chest for: Inspect anterior/posterior – – • • • • • • • • • • • • • • • • • • • • • • Musculo- skeletal system Nervous system Respiratory system Gastro-intestinal and reproductive systems 672 Paediatric presentation | Primary Clinical Care Manual 10th edition | Step 5:Select Step 4:Considerdifferentialdiagnosis Ears, noseandthroat • • • • • Always considerriskfactorsforchildren inconsideringyourdiagnosis/management If unsure,collaboratewithMO/NP page See decisionmakingflowchartstoassist withclinicalimpressionin Document thepage numberoftheHMP/CCGreferred to intheclinicalrecord To guidefurtherassessment andmanagement Urinalysis Eyes 673 HealthManagementProtocol • • • • • Throat • • Nose • • • • Ears • • • See – – – – Inspect: – If indicated,testthevisualacuityofeacheye: – – – Inspect: Is thereanydischargeorobviousforeignbody Feel forfacialswelling/inflammation Examine theurineofallsickchildren,childrenwithabdominalpain or See Check behindtheear(mastoid)forredness/swelling – – Look insidecanalwithanotoscope: – – Inspect: – Perform urinalysis+ Does itsmellnormal Inspect thecolour-isitnormal,dark,bloodstained urinary symptomsandallchildrenwithunexplainedorsigns – – – – – – – – – – – – – Physical examination-child(continued) presentation (withparentalconsentifageappropriate) point ofcarepregnancytestifchildbearingageandappropriateto eye movements-askthechildtofollowmovementofyourfinger check pupillaryreflextolight pupils -aretheyequalinsizeandregularshape swelling eyes andsurroundingstructures-anyredness,dischargeor use ageappropriateSnellenchartat6metresingoodlight condition ofteeth any redness/swelling/rash lips, buccalmucosa,gums,palate,tongue,throat air bubbles,perforationsordischarge eardrum-normal,redness,dullness,bulgingorretraction,fluid canal-anyredness,swelling,discharge looking withanotoscopewillbepainful ear canal-anyobviousswellingorrednesstooutercanal,ifthereis the pinna-anyredness,swelling Assessment oftheeye,page Ear andhearingassessment,page or Clinical CareGuideline 358
for detailedassessment 708 fordetailedassessment Differential diagnosis - child, Differential diagnosis-child,
Paediatric presentation 673 first Paediatric Paediatric presentation 28 always consult an MO/NP consult an always for Queensland contacts 20 Section 8: Paediatrics | Section 8: Paediatrics Clinical consultation, page - child pathology if indicated if indicated pathology 8 History and physical examination - adult, page https://www.health.qld.gov.au/healthsupport/businesses/pathology-queensland/ see see healthcare pathology test list request forms rural and remote pathology if RIPRN orders pathology, they are responsible for following up the result for following pathology, they are responsible if RIPRN orders if results are abnormal consult MO/NP may order pathology as per a HMP may order pathology protocol for form or follow local RIPRN must be on request of the MO, NP or name and signature electronic ordering
– – – – – – – – The following flowcharts can be used as a guide to assist with differential diagnosis in a child The following flowcharts can be used as a guide judgment, expertise or experience They are not intended to be a replacement for clinical to a MO/NP as needed Aways work within your individual scope and refer Always consult with the MO/NP if you are not sure who to contact - during and after hours Check your local facility guidelines to find out – Have CEWT score completed Use ISOBAR to guide your communication. See – If outside Queensland refer to local pathology services See Pathology Queensland for: See Pathology Queensland – – the director of the clinical unit and Pathology Queensland/local health service unit and Pathology Queensland/local health the director of the clinical pathology form as RFDS/other collaborative health provider on the Write ‘copy of report to…’ appropriate in some facilities e.g. iSTAT Point of care testing is available – – agreement in place between be able to request pathology if there is a local Other clinical staff may – – If child is unwell enough to require a blood test beyond BGL and Hb BGL and Hb test beyond a blood to require is unwell enough If child may other tests that for blood collection ‘additional’ unnecessary testing, or unnecessary to save be required RIPRN:
• • • • • • • • • • • • • • Recommend Step 7: Collaborate with MO/NP as required Step 6: Order/collect 6: Order/collect Step Differential diagnosis 674 Paediatric presentation Child with | Primary Clinical Care Manual 10th edition |
Fever is usually an indicator of infection. Two or more infections may co-exist, e.g. URTI plus meningitis Consult MO/NP for babies < 3 months of age, a fever with no obvious source of infection, a fever that is persistent despite measures taken, or at any time you are unsure
Clinical assessment performed fever
Child unwell Child unwell Child unwell Child unwell Basically well Basically well Basically well Basically well child child child child History of URTI Rapid onset high Dysuria, Cough like illness fever frequency, smelly Joint pain +/- Vomiting and URTI type Sore throat, ears, Rapid breathing, urine swelling diarrhoea symptoms may nasal discharge, Neck stiffness Stridor, drooling, chest recession be present cough, cervical or bulging unable to eat, Positive Murmur, chest No other Tachycardia lymphadenopa- fontanelle drink or talk urinalysis pain significant Bulging ear drum thy, red inflamed No other features on examination Headache, Reluctant to No other Jerky movements throat, tonsillar significant photophobia move neck significant No other enlargement features Rash ± rash features significant No other signifi- Nodules features cant features
Consider Consider Consider Consider Consider Consider Consider Consider Meningitis, page epiglottis. See Urinary tract Pneumonia - Acute rheumatic Acute gastroen- Acute otitis media Upper respiratory 91 Croup/epiglottitis, infection - child, child, page697 fever, page705 teritis/dehydra- (AOM) with/with- tract infection page 691 page 754 tion - child, page out perforation, (URTI) - child, 730 page 712 page 682
Always consider Sepsis, see Sepsis/septic shock, page80 Note: If child has received chemotherapy within 14 days, and has T ≥ 38.5oC x 1 OR ≥ 38oC x 2 one hour apart suspect febrile neutropenia. Urgently contact MO/NP
Paediatric presentation
675
Always consider Sepsis consider Always 80 page shock, Sepsis/septic see ,
695 page child, page 682 page child,
Bronchiolitis, Bronchiolitis, infection (URTI) - - (URTI) infection 682 page 99
and 691 page respiratory tract tract respiratory (URTI) - child, child, - (URTI) (choking), page page (choking),
Croup/epiglottitis, Croup/epiglottitis, 119 page Upper and 685 tract infection infection tract child, page 697 page child, obstruction airway 689
Croup. See See Croup. Upper respiratory respiratory Upper Acute asthma, asthma, Acute - Pneumonia page throat, Sore body Foreign Pertussis, page page Pertussis,
Paediatric Paediatric presentation
Consider Consider Consider Consider Consider Consider Consider
features
significant significant
something
features features
No other other No
choking on on choking pressure
significant significant significant significant
Section 8: Paediatrics | Section 8: Paediatrics
ingesting or or ingesting or pain Facial pus
No other other No No other other No
history of of history
enlargement ± ± enlargement
Sneezing Sneezing
stridor Usually there is a a is there Usually abdominal pain abdominal Tonsillar Tonsillar
Mild/moderate Mild/moderate Chest or or Chest
features drainage drainage
compromised
inflamed throat inflamed
significant significant Post-nasal Post-nasal features
Tachycardia Mild fever Mild Airway Airway
Fever, red red Fever,
No other other No Nasal itching itching Nasal significant significant
recession symptoms ± Wheeze ± No other other No
lymphadenopathy lymphadenopathy
breathing watery) watery)
with chest chest with Mild URTI URTI Mild
Cervical Cervical
Cough ± Stridor Stridor ± Cough Wheeze, rapid rapid Wheeze, (mucoid or or (mucoid Apnoea
Rapid breathing breathing Rapid
Barking cough Barking Nasal discharge discharge Nasal Whoop
Sore throat Sore
well child well cough
Fever Fever
in previously previously in exercise induced induced exercise child and/or ears ears and/or cough
child
Sudden onset onset Sudden Child unwell Child Nocturnal or or Nocturnal Basically well well Basically Sore throat throat Sore Paroxysmal Paroxysmal Basically well well Basically
cough
Clinical assessment performed assessment Clinical Contact MO/NP if significant features of assessment unclear or you are unsure of cause of unsure are you or unclear assessment of features significant if MO/NP Contact Babies < 3 months of age contact MO/NP immediately MO/NP contact age of months 3 < Babies Child with with Child 676 Paediatric presentation Child with | Primary Clinical Care Manual 10th edition |
Stridor is a harsh vibrating sound originating from the large upper airways and occurring on inspiration. It occurs due to upper airway obstruction. Consider the following causes: croup (common), inhaled foreign body, epiglottitis (rare but important), trauma, angioedema, mass (tumour or abscess). • Contact MO/NP immediately forbabies < 3 months of age with acute stridor stridor
Obtain full history, including Hib immunisation status. Limit examination. Do not examine mouth or throat
Significant features of assessment unclear or you are unsure of cause? Yes Consult MO/NPurgently In the meantime, consider No epiglottitis
Rapid onset Slow onset Sudden onset in previously well Gradual swelling of face, neck child and throat • Weak or no cough • Croupy (barking) cough • Temp > 38.5°C • Temp < 38.5°C • Cough or wheeze may be present • Usually there is a history of • Septicaemia • No systemic disturbance • Usually there is a history of exposure to allergen: • Drooling saliva ingesting or choking on –– an injection of a medicine • Unable to eat or drink • Severe stridor less common something e.g. peanut or blood product • Doesn't talk • Able to swallow –– ingestion of oral • Any age • Will usually drink • Reluctant to move neck medicine/food • Normal voice • As the condition deteriorates the –– bites/stings < 6 years stridor may decrease • • More prominent at night
Consider Consider Consider Consider Croup/epiglottitis, Croup/epiglottitis, Foreign body airway Anaphylaxis, page page 691 page 691 obstruction (chok- 102 and Sepsis/septic ing), page99 shock, page80
Paediatric presentation
677
Always consider Sepsis consider Always 80 page shock, Sepsis/septic see ,
80
urgently septic shock, page page shock, septic child, page 730 page child,
Consult MO/NP MO/NP Consult Sepsis/ and 91 tis/dehydration - - tis/dehydration 697 page 747 page 746 754 page child, -
- gastroenteri Acute Diabetes. Diabetes. Pneumonia - child, child, - Pneumonia page Meningitis, Intussusception, Intussusception, page stenosis, Pyloric infection tract Urinary
Consider Consider Consider Consider Consider Consider Consider
Paediatric Paediatric presentation
features
features
Rash features
No other significant significant other No
No other significant significant other No Neck stiffness ± ± stiffness Neck features urinalysis significant other No
features gain significant other No Ketones on on Ketones
Tachycardia
photophobia stool | Section 8: Paediatrics
No other significant significant other No Weight loss or poor poor or loss Weight
Headaches, ± ± Headaches, Fever High BGL High jelly currant Red
Chest recession Chest
Fever feed
URTI like illness like URTI Positive urinalysis Positive dehydration intermittently
Rapid breathing Rapid Hungry following following Hungry
May have history of of history have May Diarrhoea signs of of signs pain Abdominal
urine
Cough Projectile vomits vomits Projectile With or without without or With
child frequency smelly smelly frequency years Fever
Child unwell Child Basically well well Basically unwell Child 2-6 weeks old weeks 2-6 Dysuria Child unwell Child 3 to months 3
No
Significant features of assessment unclear or you are unsure of cause, or if bile stained vomit stained bile if or cause, of unsure are you or unclear assessment of features Significant Yes Consult MO/NP Consult Yes
Clinical assessment performed assessment Clinical
metabolic (diabetic ketoacidosis, poisoning) ketoacidosis, (diabetic metabolic
r tumour), tumour), r o abscess (trauma, pressure intracranial raised oesophagitis, reflux hernia), appendicitis, intussusception, stenosis, (pyloric
edia), bowel obstruction obstruction bowel edia), m otitis meningitis, UTI, (pneumonia, infection causes: following the consider - diarrhoea without vomiting Beware child. young
ess especially in a very very a in especially ess illn serious indicate may which symptom, important and common a is Vomiting immediately. MO/NP contact age of months 3 < Babies Child with vomiting vomiting with Child 678 Paediatric presentation Child withabdominalpain | Primary Clinical Care Manual 10th edition | History ofconstipationorinfrequentstools • Firm stoolpalpableinlowerabdomen? – – – Contact MO/NPimmediatelyfor: Any historyofsignificanttrauma – – – Inguinal-scrotal painorswelling or anychildwithaCEWTscore≥4(orotherearlywarningandresponsetooltrigger) any childwithsignificantpain<3years babies <3monthsofage leukocytes, nitritesorblood Diarrhoea ±vomiting/fever or bacteriaonmicroscopy Positive urinedipstickfor Bile-stained vomiting Localised tenderness Rebound tenderness Consult MO/NP Palpable mass Bloody stool Tachypnoea Chest pains Distension Recession Guarding Fever ± and/or Cough No No No No No No
Yes Yes Yes Yes Yes Yes Consider 754 Consider Consult MO/NP interfacility transfer(insidefrontcover) Criteria forearlynotificationoftrauma See Consider tion -child,page Consider Traumatic injuries,page
Pneumonia -child,page Urinary tractinfection-child,page Constipation, page
Acute gastroenteritis/dehydra 730 163 743 and 697 - Paediatric presentation 679
or 10 days 10 days Bloody at least at least diarrhoea, diarrhoea, Mucous in Paediatric Paediatric presentation Consult MO/NP Abdominal pain Consult MO/NP No
736 lactose page Consider Suspected intolerance Section 8: Paediatrics | Section 8: Paediatrics Lactose intolerance, Yes 738 directed by the MO/NP directed by the Nausea Consider Flatulence Foul smelling, watery diarrhoea Giardiasis, page faeces sample for MCS and OCP and other tests as for MCS and OCP and faeces sample For children presenting with chronic diarrhoea obtain presenting with chronic For children features of assessment are clear features of assessment chronic diarrhoea chronic 740 Clinical assessment performed and significant Clinical assessment performed
Consider in faeces
Perianal itch
Sighting of worms Intestinal worms, page Babies < 3 months of age contact MO/NP immediately. Diarrhoea every day for every day for Diarrhoea MO/NP immediately. of age contact < 3 months Babies require investigation periods over longer of loose stools episodes recurrent • Child with with Child 680 Button battery Button batteryingestion/insertion Button battery | Primary Clinical Care Manual 10th edition | 1. Maypresentwith Background Recommend • • • • • • • • • • • • • • • Related topics Corrosive substanceingestion,page • • • • • • • • • Vomiting Constipation Unexplained bleedingfromthemouth, anus,vagina,noseorear Abdominal pain Refusal toeat Decreased appetite Difficulty swallowing Discharge fromear,noseoreye Drooling Chest pain Inspiratory stridor Coughing, chokingorgaggingwitheatingdrinking Airway obstructionorwheezing Non-specific symptomswithnodefinitehistoryofabatteryingestion Fever Children <5yearsofagearemorelikelytohaveabuttonbatteryingestion Batteries intheoesophagusmaybeasymptomaticearlybutsevereburnscanoccurwithin2hours produces alocalisedalkalineinjury moisture. Thisproducesanexternalelectricalcurrentcausingachangeintissuefluidswhich The mechanism of injury is related to pressure from the battery combined with contact with Button batterieswithadiameterofmorethan20mmcaneasilylodgeintheoesophagus or airway.Buttonbatterieslodgedinearsandnosescanalsocausesignificantinjury Button (disc)batteriescancauselife-threateninginjuries,particularlyiflodgedintheoesophagus required If x-ray facilities are not available urgent evacuation to appropriately equipped facility may be Poisons InformationCentre(PIC) Consult MO/NPfirstforallchildrenwithingestion/insertionofbuttonbatteries.Contactthe there isnoindicationofsignificantgastrointestinalinjury If the battery is found within or distal to the stomach, it may be allowedtopassspontaneously if Witnessed ingestion/insertionisassociatedwithgoodoutcomes 1,2,3 1 1,2 273 131126 (24hours)
- child Foreign bodyairwayobstruction(choking),page 99 Button battery 681
airway, ear , Button battery Button 35 Toxicology (poisoning and Section 8: Paediatrics | Section 8: Paediatrics 99 Acute pain management, page
259 1,2 1,2 2 . This may require evacuation of the patient Foreign body airway obstruction (choking), page (choking), page obstruction body airway Foreign
13 11 26 (24hrs)
Community education on the prevention of button battery injuries especially safe storage Community education on the prevention of button If the battery is to be passed spontaneously, follow up to ensure battery passage within 4 days If the battery is to be passed spontaneously, follow or nose Close attention to airway and breathing is essential Administer analgesia as clinically indicated. See Consult MO/NP who will discuss with clinical toxicologist via the Poisons Information Centre (PIC) discuss with clinical toxicologist via the Poisons Consult MO/NP who will found to be lodged in the oesophagus Urgent removal of battery is required if battery Perform standard clinical observations (full CEWT score or other local Early Warning and Response observations (full CEWT score or other local Early Perform standard clinical Tools) Complete a risk assessment using Toxicology risk assessment in Complete a risk assessment page overdose) - general approach, If available, urgent x-ray of the entire oesophagus, neck and abdomen to identify position of abdomen to identify position oesophagus, neck and urgent x-ray of the entire If available, mm in to be larger than 20 and if a battery is known in patients < 12 years battery, especially x-ray if possible obtain an anteroposterior and lateral diameter. If battery in oesophagus Do not induce vomiting or give cathartics (e.g. laxative) as both are ineffective (e.g. laxative) as both vomiting or give cathartics Do not induce battery or definite button the patient has a suspected are not available and If x-ray facilities equipped facility to an appropriately evacuation is required ingestion, urgent See for be required may x-ray as anaesthesia by position excluded oesophageal mouth until Nil by battery removal
• • • • • • • • • • • • •
5. Follow up 4. Management
3. Clinical assessment 2. Immediate management Immediate 2. 682 RespiratorY 1. Maypresentwith Acute Respiratory problems | Primary Clinical Care Manual 10th edition | HMP Background Recommend • • • • • • • • • • • • • Related topics Croup/epiglottitis, page Bronchiolitis, page Acute asthma,page • • • • • • • • Halitosis Ear pain,fullnessorpressure Low-grade fever,headache,general malaise,slightbodyaches Decreased, orlossof,senseofsmell Facial painorpressure Sneezing Watery eyes Post-nasal drainage Nasal itching Nasal congestion – – – Nasal discharge: Irritability Sore throat have immunedisordersorcysticfibrosis,maydevelopacutebacterialsinusitis.Therecanbe Children withexposuretotobaccosmoke,abnormalitiesofthenasalpassagesorsinuses, causes arerare Most URTIsarecausedbyvirusese.g.commoncoldanddonotrequireantibiotics.Bacterial pneumonia, requiringantibiotics A viralURTIcanbecomplicatedbysecondarybacterialinfectionsuchasotitismediaor typically diagnosedasURTI Infections oftheupperairwaywhereneithersorethroatnorcougharepredominantfeature Comfort isusuallythegoaloftreatment Consider nasalobstructionbyaforeignbodyespeciallyifsymptomsareunilateral serious illnessessuchasmeningitis The symptomsandsignsofanupperrespiratorytractinfection(URTI)maybeaprecursortomore Other complicationsincludeexacerbationofasthma severe complicationssuchasmeningitis – – – Upper the characteristicsofnasaldischargedoesnotdifferentiateviralfrom bacterialinfection mucoid typical tohaveseveraldaysofpurulentnasaldischargewhichresolves orbecomesclear generally clearandwateryinitially,thenthickermucoidlater rhinosinusitis/common 1,2,3 1 respiratory tractinfection(URTI) 695 119 3 691 cold Urticaria/allergic rhinitis,page Sore throat,page -child 685 320 Respiratory 683 Pneumonia - child, Respiratory Respiratory problems 375
3 768 Acute otitis media (AOM) with/without Section 8: Paediatrics | Section 8: Paediatrics 91 697 Orbital cellulitis/periorbital cellulitis, page Meningitis, page 673 Not applicable Not Immunisation program, page Immunisation program, page 4 712 : petechiae and purpura do not fade on pressure : petechiae and purpura Pneumonia - child, page 3,6,7,8 Note 5
697 diplopia or impaired vision mental status deterioration periorbital oedema. Consider severe headache. Consider – – – – educate patients and parents on appropriate use of antibiotics – – – has a cough productive of mucopurulent sputum, may need further investigations for possibility has a cough productive of mucopurulent sputum, of chronic respiratory disease symptoms of: acute bacterial sinusitis. In particular, any associated – respiratory distress or apnoea looks sick, not alert or interactive any rash < 1 year with RR > 45/min 1-4 years with RR > 35/min 5-11 years with RR > 30/min ≥ 12 years with RR > 25/min < 3 months of age auscultate the chest for air entry and any added sounds - crackles or wheezes auscultate the chest for and under nappies and for any skin rash especially at pressure points inspect all skin surfaces clothing. respiratory effort e.g. chest recession, nasal flaring, grunting (noisy breathing), abdominal recession, nasal flaring, grunting (noisy breathing), respiratory effort e.g. chest breathing throat inspect the ears, nose and for enlarged lymph glands palpate the head and neck overall appearance e.g. smiling, agitated, lethargic overall appearance e.g. – – – – – – – – – – – – – – – – –
– Advise patient and parents that the basis of treatment is rest and fluids Antibiotics and antihistamines have no role for treating the common cold (viral rhinosinusitis): – – – – – – – – – Consult MO/NP if: – If child has evidence of secondary ear infection, see If child has evidence of secondary ear infection, perforation, page If child has cough as the main feature, consider other diagnoses. See Child with cough flowchart in If child has cough as the main feature, consider Differential diagnosis - child, page consider other diagnoses. See If child has an increased RR or any chest findings page If child has an increased RR, increased respiratory effort or any chest findings consider other RR, increased respiratory effort or any chest findings If child has an increased diagnoses. See See Check vaccination status. – – – – – causes including: Perform physical examination – Perform standard clinical observations (full CEWT score or other local Early Warning and Response local Early Warning (full CEWT score or other clinical observations Perform standard Tools) and chemical viral, bacterial, allergic, can be caused by history: be aware that rhinitis Take patient Reduced oral intake of food and/or fluids and/or food of oral intake Reduced
• • • • • • • • • • • •
4. Management
3. Clinical assessment 3. Clinical 2. Immediate management 2. Immediate 684 RespiratorY | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup Management ofassociatedemergency: between penicillins,cephalosporinsandcarbapenems Contraindication Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution • • • • • • • • • • • to oralliquid Schedule Powder for Capsule follow up If arashdevelopstellhealthprofessional asitmayindicateanunderlyingconditionthatrequires If notimprovingconsultMO/NP Advise tobereviewedthenextday Contact MO/NPifallergictopenicillin Give amoxicillinifnotallergictopenicillin – – – infection: Consider antibiotictherapyforpatientswhohaveanyofthefollowingindicatorsbacterial – – – – – Provide hygieneeducationtopreventspreadofrespiratorydiseaseby: Sodium chloride0.9%nosedropsmaybehelpful tions, agitation,irritability,insomnia.Nottobeusedinchildren<6yearsage Oral andtopicaldecongestantsarenotindicatedmaycauseadversereactionse.g.palpita aspirin inchildren.See Symptomatic treatmentincludesanalgesia/antipyreticse.g.paracetamoloribuprofen.Donotuse Consult MO/NP asabove Form – – – – – – – – worsening symptomsafterinitialimprovement(‘doublesickening’) 3 days severe symptomsandhighfever(39°Corhigher)attheonsetofillnesslastinglongerthan tenderness (particularlyunilateral)ormaxillarytoothache symptoms ofrhinosinusitislastinglongerthan7days,withpurulentnasaldischarge,sinus keep contaminatedhandsawayfromeyesandnose wash handsandfacesregularlyaftercontactwithrespiratorysecretions keep childrestingathome if notissuesavailable-coughorsneezeintotheinnerelbowratherthanhand blowing nosesandthenputusedtissuesinthebin cover thenoseandmouthwithdisposabletissueswhencoughing,sneezing,wiping
: Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity 500 mg/5mL 250 mg/5mL Strength 4 500 mg 250 mg Acute painmanagement,page
administration Route of Oral ConsultMO/NP.See Maycauserash,diarrhoea,nauseaandcandidiasis Amoxicillin
to amax.of500mg/dosetds 15 mg/kg/dosetds 35 Child <12years Recommended Anaphylaxis, page dosage ATSIHP/IHW/IPAP/RIPRN Extended authority 102
Duration 5 days
- 7,8 Respiratory 685
pyogenes . 705
S Respiratory Respiratory problems include acute post streptococcal include acute post streptococcal Acute rheumatic fever, page pyogenes
Section 8: Paediatrics | Section 8: Paediatrics 682 Streptococcus infection quinsy streptococcal child 1 - tonsillitis, tonsillitis, C 700 o 1,2 3,4,5 posturing: fixed, upright, leaning forward, torticollis i.e. twisted or wry neck torticollis i.e. twisted upright, leaning forward, posturing: fixed, airway patency: stridor, drooling, muffled or absent voice stridor, drooling, muffled airway patency: mental status air hunger, altered lethargy, poor perfusion, toxic appearance:
– – – Sore throat Sore considerations need to be applied for populations at high risk of RHD considerations need to be due to Complications of throat infections Pay careful attention to care giver in order to clarify the exact nature of the complaint care giver in order to clarify the exact nature of the Pay careful attention to however special in origin and do not require antibiotic treatment Most sore throats are viral Strait Islander children is IM LA®) (Bicillin benzylpenicillin benzathine of dose one or antibiotics oral of days (10) Ten A Streptococcus required to eradicate group – throat and ARF/APSGN. between group A streptococcal sore Always be alert to the relationship in Aboriginal and Torres common and serious but potentially avoidable These complications are Life-threatening sore throat requires rapid assessment and intervention. Features of airway and intervention. assessment rapid sore throat requires Life-threatening include: or impending airway compromise compromise – – Epstein-Barr virus (glandular fever) or Cytomegalovirus (CMV) Epstein-Barr virus (glandular fever) or Cytomegalovirus infection in high risk patients, although antibiotics have not been proven to prevent APSGN infection in high risk patients, although antibiotics (limited opening of mouth), severe unilateral Peritonsillar abscess (quinsy) presents with trismus requires aspiration or drainage in hospital throat pain, high fever, and/or change in voice. Usually mimic tonsillitis. Consider other causes such as There are a number of viral conditions that can With the exception of scarlet fever type rash there is no individual clinical feature to make a With the exception of scarlet fever type rash there definitive diagnosis of non-suppurative complications of Antibiotics are recommended to prevent the glomerulonephritis (APSGN), acute rheumatic fever (ARF), rheumatic heart disease, streptococcal disease, heart rheumatic (ARF), fever rheumatic acute (APSGN), glomerulonephritis toxic shock syndrome, and pancreatitis Headache Malaise Enlarged tender anterior cervical (neck) lymph nodes Mouth breathing or voice change Fever > 38 imply tonsillitis. Lymphoid tissue in the pharynx is relatively more prominent under 5 years of age imply tonsillitis. Lymphoid tissue in the pharynx Difficulty or pain on swallowing Irritability and reduced oral intake Painful throat yellow exudate on tonsils. Large tonsils may not Bright red oropharynx ± swollen tonsils ± white or
• • • • • • • • • • APSGN, page Upper respiratory tract infection (URTI) - child, page Related topics • • • • • • • • •
Recommend Background HMP HMP
1. May present with Pharyngitis, Pharyngitis, 686 RespiratorY 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical Care Manual 10th edition | 4. Management • • • • • • • • • • • • • • • If childhasanincreasedRRoranychest findingsconsiderotherdiagnosessee Differential diagnosis-child,page If childhascoughasthemainfeature, considerotherdiagnoses.SeeChildwithcoughflowchartin – – – – – – – Consult MO/NPifchild: Check vaccinationstatus.See – – – – – – – Perform physicalexaminationincluding: Collect throatswabforMCS – Tools) + Perform standardclinicalobservations(fullCEWTscoreorotherlocalEarlyWarningandResponse – – – – Take patienthistoryincluding: management Any patientwithimpendingairwayobstructionshouldbereferredearlyfordefinitive Assess andmaintainairway.See Scarlet feverrash-istheonlyindividualclinicalfeaturetodiscriminatestreptococcalinfection Halitosis Nausea andvomiting Abdominal pain perforation, page If childhasevidence ofsecondaryearinfection.See 695 – – – – – – – – – – – – – – – – – – – has tonsillitisandissystemicallyunwell has anyrash still lookssickwhenTreduced looks sick,notalertorinteractiveandhasT>38°C < 3monthsofage clothing. inspect allskinsurfacesforanyrashespeciallyatpressurepoints and undernappies breathing respiratory efforte.g.chestrecession,nasalflaring,grunting,noisybreathing,abdominal auscultate thechestforairentryandanyaddedsounds-cracklesorwheezes inspect theears,noseandthroat palpate theheadandneckforenlargedortenderlymphglands tonsillar swellingorexudateabsentpresent overall appearancee.g.smiling,agitated,lethargic urinalysis -haematuriaand/orproteinuriamayindicateAPSGN ask aboutjointpain-considerARF history offever cough presentorabsent past episodes,complicationssuchasARF/APSGN CEWT scoretriggersaclinicalreview has/or issuspectedtohavequinsy or epiglottitis.See , and Pneumonia -child, page Note 3,6 : petechiaeandpurpuradonotfadeonpressure 712 1 Tetanus immunisation,page
697 673 DRS ABCDresuscitation/thecollapsedpatient,page Acute otitis media (AOM) with/without Acute otitismedia(AOM) with/without Croup/epiglottitis, page 773 Bronchiolitis, page Bronchiolitis, page 691 54 Respiratory 687 3,7
10 days Duration S. pyogenes S. pyogenes . Symptomatic . Symptomatic IHW/IPAP/RIPRN / 35
Respiratory Respiratory problems 102 Extended authority ATSIHP
Child dosage to a max.of Recommended 500 mg/dose bd 15 mg/kg/dose bd Anaphylaxis, page Section 8: Paediatrics | Section 8: Paediatrics
Acute pain management, page page management, pain Acute Oral Route of administration May cause diarrhoea, nausea and candidiasis. Food has little May cause diarrhoea, nausea and candidiasis. Food Consult MO/NP. See Phenoxymethylpenicillin 250 mg 500 mg Strength 125 mg/5 mL 250 mg/5 mL 4 Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity Severe or immediate allergic reaction to a penicillin. cefalexin azithromycin oral phenoxymethylpenicillin if not allergic OR oral phenoxymethylpenicillin oral medicine is (Bicillin LA®) if a lack of adherence with IM benzathine benzylpenicillin of oral therapy anticipated or intolerant due to streptococcal infection. Rash usually starts after the sore throat and lasts a week Rash usually starts after the sore throat due to streptococcal infection. and Torres Strait Islander communities in central and northern Australia, Maori and Pacific Australia, Maori and in central and northern Islander communities and Torres Strait Islander people with existing RHD and strawberry tongue a characteristic and striking red blanching rash who have scarlet fever - aged 2-25 years with sore throat in communities with a high incidence of ARF e.g. Aboriginal incidence of ARF e.g. Aboriginal with a high with sore throat in communities aged 2-25 years throat lozenges for older children but not for young children at risk of choking at risk for young children but not older children lozenges for throat milkshakes ice cream, cold liquids, foods, soft bland Form – – – – – – – – – Capsule – If immediate hypersensitivity to penicillin use: – – – hypersensitivity) use: If hypersensitive to penicillin (excluding immediate If an alternative diagnosis to tonsillitis is being considered e.g. Epstein-Barr virus or CMV, consult to tonsillitis is being considered e.g. Epstein-Barr If an alternative diagnosis of blood specimens MO/NP prior to collection treatment give: If indicated for antibiotic Additionally it is reasonable to prescribe antibiotics for patients who are particularly unwell and/or to prescribe antibiotics for patients who are Additionally it is reasonable suggestive of streptococcal infection with severe clinical features – – Antibiotic treatment is recommended to prevent nonsuppurative complications of to prevent nonsuppurative is recommended Antibiotic treatment risk patients: ARF and APSGN for high infection e.g. – relief can also be provided by: also be provided relief can – – indicated of antibiotics is no longer Routine use Administer analgesia as clinically indicated. See indicated. as clinically analgesia Administer oral liquid Powder for • • • • • • • • Schedule reconstitution to Management of associated emergency: effect on absorption Contraindication: between penicillins, cephalosporins and carbapenems Provide Consumer Medicine Information: ATSIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed 688 RespiratorY | Primary Clinical Care Manual 10th edition | RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: between penicillins,cephalosporinsandcarbapenems Contraindication: benzathine benzylpenicillin,page Note Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: of cross-reactivitybetweenpenicillins, cephalosporinsandcarbapenems Contraindication Note: headache andcandidiasis Provide ConsumerMedicineInformation: reconstitution (pre-filled to oralliquid Injection syringe) Powder for Schedule Schedule Form Capsule : Stopinjectionimmediatelyifpatientshowssignsofseverepain.See Form IfrenalimpairmentseekMO/NPadvice units/2.3 mL 1.2 million : Severeorimmediateallergicreaction toacephalosporinsorpenicillin.Beaware (900 mg) Strength Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity 125 mg/5mL Strength 500 mg 250 mg 4 4 administration 787 Benzathine benzylpenicillin administration Route of Route of IM Oral ConsultMO/NP.See ConsultMO/NP.See (Bicillin LA Maycausediarrhoea,nauseaandpainatinjectionsite Maycauserash,diarrhoea,nausea,vomiting,dizziness,
Cefalexin
15 -<20kg 10 -<15kg 6 -<10kg ® 3 -<6kg Weight ≥ 20kg ) Recommended dosage to amax.1g/dosebd 25 mg/kg/dosebd Recommended dosage Anaphylaxis, page Anaphylaxis, page Child 337.5 mg 900 mg 450 mg 225 mg 675 mg Dose ATSIHP Extended authority ATSIHP Extended authority / IHW/IPAP/RIPRN / 0.76 mL 102 1.52 mL Volume Administration tips for Administration tipsfor 102 0.5 mL 2.3 mL IHW/IPAP/RIPRN 1 mL
Duration 10 days
Duration
stat 3,8,9 3,10 Respiratory 689 - 3, 11
5 days Duration
Respiratory Respiratory problems 102 or if abnormal Extended authority authority Extended 705 ATSIHP/IHW/IPAP/RIPRN ATSIHP/IHW/IPAP/RIPRN daily Child dosage daily to a . Also known as the '100 day cough' Recommended Recommended 12 mg/kg/dose 12 mg/kg/dose Anaphylaxis, page max. of 500 mg Section 8: Paediatrics | Section 8: Paediatrics
682 Acute rheumatic fever, page Oral Take with or without food. May cause rash, diarrhoea, Take with or without food. Bordetella pertussis Route of Azithromycin - adult/child administration Consult MO/NP. See 700 500 mg APSGN, page Strength 4 200 mg/5 mL 1 1,2
urinalysis, see ask about sore joints, chest pain, breathlessness and check urinalysis ask about sore joints, chest pain, breathlessness consult MO/NP if symptoms persist. See review in 2 weeks – – – Common respiratory illness caused by is on average 7-10 days Pertussis is highly contagious. Incubation period by apnoea in infants, pneumonia, hypoxic Pertussis is a prolonged illness and can be complicated brain injury, seizures or lead to chronic lung disease Coughing may continue for 6-8 weeks after treatment and may recur with the next URTI Coughing may continue for 6-8 weeks after treatment If adults and teenagers present with pertussis ask about young babies at home as pertussis is a If adults and teenagers present with pertussis ask of age particularly severe disease in infants < 6 months Form Tablet tic penicillin or referral to ENT specialist for consideration for tonsillectomy/adenoidectomy tic penicillin or referral to ENT specialist for consideration Consult MO/NP as above or if symptoms persist despite symptomatic treatment Consult MO/NP as above or if symptoms persist may consider prolonged course of prophylac If recurrent tonsillitis > 6 episodes per year, MO/NP – – Request to return for review the next day, if not improving consult MO/NP Request to return for review given for sore throat: If antibiotics have been –
• • • • • Powder for Upper respiratory tract infection (URTI) - child, page Related topics • • • • to oral liquid Schedule
reconstitution Recommend Provide Consumer Medicine Information: Provide Consumer Medicine and candidiasis nausea, abdominal cramps emergency: Management of associated ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed Background Pertussis (whooping cough)
6.Referral/consultation 5. Follow up 690 RespiratorY 1. Maypresentwith | Primary Clinical Care Manual 10th edition | 5. Followup 4. Management 3. Clinicalassessment 2. Immediatemanagement • • • • • • • • • • • • • • • • – – – – – – Consult MO/NP(astherearepublichealthimplications)ifpertussissuspected, whomayadvise: Check vaccinationstatus.See is ofasickchild in periodsbetweenparoxysmsofcoughing,withfewclinicalsigns,howevertheoverallimpression The ‘whoop’canbecharacteristicbutmaynotalwayspresent.childdistressed See If severeconsultMO/NPimmediately Pertussis cancausepneumonia investigation Children particularlythose>3yearsofagemaypresentwithaprolongedcough-consider weeks duration,thatisworseatnight,inanadult,pertussisuntilprovenotherwise Adults usuallyhaveapersistenttroublesomecoughonly,withoutwhoop.Aofseveral coughing bout.Apnoeamayoccurwithoutprecedingbouts coughing andvomiting.Theycandevelopapnoea(stopbreathing)becomecyanosedduringa Young babiesusuallydonothavethecharacteristicwhoopbutarelikelytobeverydistressedby Absence offever Bradycardia ortachycardiaifsevere Cyanosis, typicallyduringanepisodeofcoughing Vomiting, typicallyafteranepisodeofcoughing characteristic inspiratory‘whoop’asthechildcatcheshis/herbreath Cough typicallyparoxysmali.e.intermittentepisodesofprolongedcoughingfollowedbythe symptoms URTI If notevacuated/hospitalised advisetobereviewed daily,atleast initially – – – – – – household andchildcarecontactsmay requireprophylacticantibioticstopreventfurther recurrence willnotlastlong to explainthatcoughingwillcontinuefor6-8weeksandmayrecurwith thenextURTI.The others. Patientcanbeconsiderednolongerinfectiousafter5daysoftreatment. Itisimportant antibiotics mayshortenthelengthofillnessifgivenearlyandwillalso reduceinfectivityto – – – appropriate teststoconfirmdiagnosis: evacuation/hospitalisation ifyoungchild<6monthsorsymptomsare significant condition/14/33/150/whooping-cough-pertussis pertussis factsheetavailableat: of antibioticshavebeenreceived advise toavoidcontactwithothers, especiallyyoungchildrenandinfantsuntilatleast5days clinical casesofpertussis – – – Upper respiratorytractinfection(URTI)-child,page gel swabforMCS throat swab dry nasopharyngealswaboraspirateforPertussisPCR Testing.Canusedry blood serumforIgA 3,4 2 3 Immunisation program,page http://conditions.health.qld.gov.au/HealthCondition/ 682
to guideassessment 768 Respiratory 691
Respiratory Respiratory problems 2 685 Croup Sore throat, page Section 8: Paediatrics | Section 8: Paediatrics Inspiratory stridor No systemic disturbance Able to swallow Will usually drink Normal or hoarse voice Croupy (barking) cough T < 38.5°C (however viral croup often has a high temperature) • • • • • • • 99 3 - child epiglottitis Acute epiglottitis 1 2 http://disease-control.health.qld.gov.au/Condition/755/pertussis Pertussis requires immediate notification to the local Public Health Unit based on clinical on clinical Unit based Public Health to the local notification immediate requires Pertussis do not lie the child flat consult MO/NP as soon as circumstances allow do not examine mouth or throat - this can cause airway spasm and complete obstruction gain IV/intraosseous access and maintain airway Croup/
– – – – Keep the child as calm as possible, with and in the arms of parent if possible Keep the child as calm as Epiglottitis (supraglottitis) is a life-threatening bacterial infection characterised by rapidly is a life-threatening bacterial infection characterised Epiglottitis (supraglottitis) of and around the epiglottis progressive inflammation vaccination the epiglottis) is rare since introduction of the Hib Epiglottitis (cellulitis of Croup usually follows 3 or 4 days after a mild URTI when the infection spreads to the upper airways. 4 days after a mild URTI when the infection spreads Croup usually follows 3 or It is usually mild and self-limiting Do not examine the mouth or throat and do not lie the child flat Do not examine the mouth – – If epiglottitis is suspected: – – at: Consult MO/NP on all occasions pertussis suspected pertussis all occasions MO/NP on Consult Available pathological diagnosis. and symptoms and/or clinical history, signs evidence including
Reluctant to move neck Unable to eat or drink Doesn't talk Any age T > 38.5°C Septicaemia Looks sick Drooling saliva Decreased level of consciousness Hypotonia, cyanosis and pallor Weak or no cough Restlessness
• • • • • Foreign body airway obstruction (choking), page Related topics • • •
• • • • • • • • • • • • Recommend Background
HMP HMP 2. Immediate management
1. May present with 6. Referral/consultation 6. 692 RespiratorY 4. Management 3. Clinicalassessment | Primary Clinical Care Manual 10th edition | • • • • • • • • • • • • Occasional snoring tachypnoeic) agitated, excited,or only beheardwhilecrying, Inspiratory stridor(may Good airentry be hoarse)orhoarsecry Ability tospeak(voicemay – – – If croup: – – – – – – If epiglottitissuspected: MO/NP Consult table The degreeofairwayobstructioncanbeestimatedbaseduponphysicalfindingsinthefollowing Inspect fordroolinginasicklookingchild.Thisalongwithhighfeverissuggestiveofepiglottitis Tools). Perform standardclinicalobservations(fullCEWTscoreorotherlocalEarlyWarningandResponse Obtain patienthistoryincludingonsetandprecedingURTI – – – – If severerespiratorydistress,lethargicorcyanosed: – – – – – – – – – – – – – insert IVcannulaorintraosseouscannula. See assess andmaintainairway MO/NP willorganiseurgentevacuation handle thechildaslittlepossible have theparents/carerstaytocomfortchild if O a calmatmosphereisbeneficial consult MO/NPimmediately give O – for humidified airor steam inhalationsareofnoadditional benefit symptomatic treatmentasperURTI. See – – MO/NP mayorder: – – – nebulised budesonide IV ceftriaxone IV dexamethasone(repeatedat24hours ifrequired) mild tomoderate 2 therapynottolerated,avoidagitatingchild.HoldtheO Note 2 tomaintainSpO Mild inparticularTandRR(whenthechildisquiet) 2,5
casesMO/NPmay advise: 1,4 2
≥94%.See OR • • • • • • • • Decreased mentalalertness to maintainanopenairway Adopts 'tripod'positioning Presence of'sniffing' cyanosis Hypoxaemia (SpO Decreased airentry nasal flaring,orgrunting) (suprasternal retractions, tory effort Signs ofsignificantrespira Prolonged inspiratorytime stridor) witheverybreath (and possiblyexpiratory Audible inspiratorystridor Moderate/severe Oxygen delivery,page
Upper respiratorytractinfection(URTI) -child,page
Intraosseous infusion,page 2 91%),
- 64 2 tubing/maskclosetoface • • • • • • • loss ofconsciousness Rapid deteriorationand airway in anattempttoclearthe Silently gaggingorcoughing supraclavicular retractions Marked suprasternalor Grunting Nasal flaring Struggling tobreathe movement Marked reductionofair Complete 69
682
Respiratory 693 5,9
5,6,7,8 stat Duration If IV inject Cl. difficile. slowly over 3-5 minutes stat Duration over 30 minutes 102 Inject over at least IHW/IPAP Respiratory Respiratory problems 3 minutes OR infuse / 102 ATSHI/IHW/IPAP Extended authority ATSIHP Extended authority 1 month > dosage OR dosage Recommended max. of 1 g Child Anaphylaxis, page to a max. of 12 mg 50 mg/kg to a Recommended Child > 1 month Anaphylaxis, page 0.15 to 0.3 mg/kg/dose up 0.15 to 0.3 mg/kg/dose Section 8: Paediatrics | Section 8: Paediatrics
Dexamethasone Route of May cause nausea, diarrhoea, rash, headache, dizziness, May cause nausea, diarrhoea, rash, headache, May cause mood or sleep disturbances May cause mood or sleep Ceftriaxone administration IV/Intraosseous IV or IM) Route of Consult MO/NP. See : Contact the MO/NP. See IV/IM/Oral ATSIHP, IHW and administration Note: ( OR IPAP may NOT administer IPAP may NOT administer OR 4 1 g Strength 4 4 mg 0.5 mg Severe or immediate allergic reaction to sulfites. Any serious concern of Severe or immediate allergic reaction to sulfites. : Severe or immediate allergic reaction to a cephalosporins or a penicillin. Be aware or a penicillin. Be aware : Severe or immediate allergic reaction to a cephalosporins 4 mg/mL Strength cases MO/NP may advise: MO/NP may cases 8 mg/2 mL severe oral dexamethasone (or IM or IV if vomiting) oral dexamethasone oral prednisolone with a second dose the following evening evening following dose the a second with prednisolone oral oral dexamethasone solution 1:1,000 (epinephrine) adrenaline nebulised nebulised budesonide oral prednisolone – – – – – – – – – – for – plus either – – Form : Rapid IV injection of large doses may cause seizures. Can cause severe colitis due to due colitis severe cause Can seizures. cause may doses large of injection IV Rapid : MO/NP will consider evacuation/hospitalisation MO/NP will – Schedule Form Injection Tablet Schedule (powder for • Injection Management of associated emergency If renal impairment seek MO/NP advice Contraindication and carbapenems of cross-reactivity between penicillins, cephalosporins Provide Consumer Medicine Information: and candidiasis Note ATSIHP, IHW, IPAP, RIPRN and RN must consult MO/NP reconstitution) encephalitis Management of associated emergency: Provide Consumer Medicine Information: Provide Consumer Medicine Contraindication: ATSIHP, IHW, IPAP, RN and RIPRN must consult MO/NP ATSIHP, IHW, IPAP, RN and 694 RespiratorY | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency: Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RNandRIPRNmustconsultMO/NP Management ofassociatedemergency: with foodtohelpreducestomachupset Provide Consumer Medicine Information: ATSIHP, IHW,IPAP,RIPRNandRNmustconsultMO/NP Management ofassociatedemergency: than amasktoreduce risk offacialirritation.Rinsemouthwith water, gargleandspitout after nebuliser Note: facial skinirritation Provide ConsumerMedicineInformation: ATSIHP, IHW,IPAP,RNandRIPRNmustconsultMO/NP Oral liquid Inhalation Injection Schedule solution Tablet Schedule Schedule Form Form Form Covereyesduringnebulisationandwashfaceafterwards.Ifpossibleuseamouthpiecerather 0.5 mg/2mL 1 mg/2mL 1mg/1mL Strength Strength Strength 5 mg/mL 1:1,000 25 mg 5 mg 4 1 mg 3 4 oxygen 8L/min oxygen 8L/min administration administration administration Nebulise with Nebulise with Adrenaline (epinephrine) Route of Route of Route of Oral ConsultMO/NP.See ConsultMO/NP.See ConsultMO/NP Maycauserestlessness,anxiety,headache andpalpitations May cause dysphonia, oropharyngeal candidiasis,bruising, MaycauseincreasedBGLandaffectmoodsleep.Take Budesonide Prednisolone
Child >1month Recommended Recommended Recommended 5 mL(5mg) undiluted Anaphylaxis, page Anaphylaxis, page 1 mg/kg dosage dosage dosage 2 mg Extended authority Extended authority ATSIHP ATSIHP Extended authority ATSIHP 102 102 / / IHW/IPAP IHW/IPAP Repeat after30 improvement / minutes ifno IHW/IPAP Duration Duration Duration stat stat stat
2,12,13
2,10 2,11 Respiratory 695 682 Respiratory Respiratory problems www.predict.org.au/download/ Section 8: Paediatrics | Section 8: Paediatrics Upper respiratory tract infection (URTI) - child, page Upper respiratory tract infection (URTI) - child, page 329 5 3 119 - child , cyanosis (severe), apnoea (sometimes apnoea is the only sign) 2 1,2,3 1,4 adrenaline (epinephrine) except in an arrest scenario adrenaline (epinephrine) nebulised hypertonic saline antibiotics including azithromycin beta 2 agonists e.g. salbutamol if ≤ 12 months of age beta 2 agonists e.g. salbutamol corticosteroids – – – – –
Australasian-bronchiolitis-bedside-clinical-guideline.pdf – – – Do not administer: – – Bronchodilators are not recommended Bronchodilators are not More significant in babies < 10 weeks of age, those with underlying heart or lung problems and More significant in babies < 10 weeks of age, those those exposed to cigarette smoke at A bedside guideline for health professionals is available Aboriginal and Torres Strait Islander children are diagnosed with bronchiolitis and other lower Aboriginal and Torres Strait Islander children are than others respiratory tract infections at a much greater rate In southern Australia more common in winter Can occur throughout the year in north Queensland. - spring illness gets better within 5 days Mild cases can be managed at home and the child Australia Bronchiolitis is a major cause of morbidity in regional Bronchiolitis is a condition that affects the lower respiratory tract caused by a virus that affects the lower respiratory tract caused Bronchiolitis is a condition severe cause sometimes can but days, few a for last only may and mild usually are Symptoms Poor feeding Dry nappy > 12 hours Rapid breathing, chest wheezes and crackles, chest recession (‘sinking’ chest when breathing) Rapid breathing, chest wheezes and crackles, chest Nasal flaring, grunting respirations and sternal or intercostal recession Low SpO Looks very unwell profuse Cough night and day, fever, nasal discharge is often Consult MO/NP as above Consult MO/NP If child with croup is not evacuated/hospitalised, advise to be reviewed next day and consult MO/ day and consult next to be reviewed advise is not evacuated/hospitalised, with croup If child improving NP if not
• • • • • • • • • • Acute asthma, page Pneumonia - adult, page Related topics • • • • • • • • •
Recommend Background
1. May present with Bronchiolitis
6. Referral/consultation 5. Follow up Follow 5. 696 RespiratorY 3. Clinicalassessment 2. Immediatemanagement | Primary Clinical Care Manual 10th edition | 5. Followup 4. Management • • • • • • • • • • • • • Consult MO/NPif not improving If notevacuated/hospitalisedadvise toberevieweddaily Children receivingHFNCshouldbeimmediately evacuated – – In Queensland: If respiratorysupportisrequired,organiseevacuationassoonpossible – – – – Consult MO/NPwhowillconsidertreatingsimilarto: – – – – Perform physicalexamination: Tools) Perform standardclinicalobservations(fullCEWTscoreorotherlocalEarlyWarningandResponse – – – – – – Obtain completepatienthistory.Ofparticularimportanceis: – – – – – Urgent evacuationwillberequiredifanyofthefollowingarepresent: 64 Give O Consult MO/NPurgentlyifsevere – Instruct toreturnimmediately ifanyofthefollowingsigns areobserved: – – – – – – – – – – – – – – – – – – – – – –
HFNC shouldnotbeusedforchildren >24monthsofage age followingconsultationwithaPaediatricianatLevel4facility high flowO If child/infantisnotfeedingwell,fluidsmayberequiredbyNGTorIV monitor SpO acute asthmaifwheezeisprominent.See listen tochestforpresenceofwheezes/crackles inspect forcyanosisoflips,tongue,extremities,presentinseverecases inspect middleears subcostal recession inspect forsignsofrespiratorydistresse.g.grunting,nasalflaring,sternaland/orintercostal/ how wellisthechild/infantfeedingandhydration if childhasstoppedbreathing(apnoea)forshortperiodsoftime if wheezeispresent premature birth history ofchestconditionssuchasasthma,pneumonia,congenitalheartorlungproblems a historyofURTIsymptomsinchildthatisbasicallywell persistent lowSpO cyanosis severe respiratorydistress,includinggrunting,chestrecession,RRof>70breaths/min child appearsseriouslyunwelltohealthprofessional apnoea (observedorreported) breathing ismore difficult, grunting,flaringnostrils, chest‘suckingin’betweenribsand using pneumonia iffeverandrapidbreathingisprominent.See 2 tomaintainSpO 1,3,5 2 viaHighFlowNasalCannula(HFNC)canonlybeinitiatedforachild<24 monthsof 2 6 3,5
2 2 3,5 >95%.If95%notmaintained,consultMO/NP,see 3,5
Acute asthma,page
Pneumonia -child,page 119 Oxygen delivery, page Oxygen delivery,page 697 Respiratory 697 682 Respiratory Respiratory problems 64 695 Section 8: Paediatrics | Section 8: Paediatrics Bronchiolitis, page Upper respiratory tract infection (URTI) - child, page Upper respiratory tract infection (URTI) - child, page Oxygen delivery, page ≥ 94%. See 2 80 1,2 - child 695 1 1 to maintain SpO 2 feeding falls to less than half of normal amount, and no wet nappy for 12 hours wet nappy and no of normal amount, than half falls to less feeding (apnoea) breaths between > 10 seconds (cyanosis) under tongue lips or blue around hard to wake up) irritable, floppy, exhaustion (sleepy, stomach to breathe stomach Pneumonia
– – – – pneumonia Children with severe pneumonia living in the tropics (north of Mackay, Tennant Creek and Port living in the tropics (north of Mackay, Children with severe pneumonia to the time of year antibiotic regimen. The regimen will vary according Hedland), require a different 70% of pneumonia is viral age when presenting with should be considered in children < 18 months of Acute viral bronchiolitis distress. See a cough and respiratory and chronic lung disease, are at more risk of Children with co-existing illnesses e.g. bronchiolitis Give O Complete rapid assessment score or other local Early Warning and Response Perform standard clinical observations (full CEWT Tools) Lethargy Poor feeding and dehydration Cyanosis and apnoea in infants pneumonia Abdominal pain associated with right lower lobe Chest pain Cough - dry or with sputum, fever, tachycardia and chest recession in infants Rapid breathing, nasal flaring, grunting respirations Consult MO/NP on all occasions bronchiolitis is suspected Consult MO/NP on all occasions Instruct parents/carers that nobody should smoke in house as it increases the risk of more severe as it increases the risk should smoke in house that nobody Instruct parents/carers bronchiolitis symptoms of – – – –
• • • • Bronchiolitis, page Sepsis/septic shock, page Related topics • • • • • • • • • • • •
Recommend Background
HMP HMP 2. Immediate management
1. May present with 6. Referral/consultation 698 RespiratorY 3. Clinicalassessment | Primary Clinical Care Manual 10th edition | • • • • • • recession ≥ 40/min cyanosis grunting apnoea and/or the clinicalsetting,todeterminepneumonia The followingflowchartcanbeusedasaguide,inconjunctionwiththeageappropriateCEWTfor Check vaccinationstatus.See Auscultate thechestforairentryandanyaddedsounds(cracklesorwheezes) – – – – Perform physicalexaminationincludinginspectionof/for: – – Obtain pasthistory,including: – – – – – Obtain patienthistoryincluding: RR – – – – – – – – – – – <3months subtle inbabiesandinfants respiratory distresse.g.grunting,nasalflaring,sternal/intercostal/subcostalrecession.Maybe skin surfaceforanyrash signs ofdehydration-moisttongue,skinelasticity.Severeisunusual lips, tongue,extremitiesforcyanosis asthma, bronchiolitisorchroniclungdisease past episodesorcomplications medicines taken feeding, fluidintakeandoutputincludingwetnappies,passingurine,diarrhoea signs ofhypoxia-agitation,cyanosis if childhasstoppedbreathing(apnoea)forshortperiodsoftime length oftimesignsorsymptomshavebeenpresent < 40/min RR ≥40/min ≥ recession cyanosis grunting apnoea and/or Mild pneumoniaorconsiderotherdiagnosis 1,2 3 months-1year RR Immunisation program,page Moderate orseverepneumonia < 40/min RR severity recession 30/min ≥ cyanosis grunting apnoea and/or RR 1-4 years 768 < 30/min RR recession ≥ 25/min cyanosis grunting apnoea and/or RR > 4years < 25/min RR Respiratory 699 35 Respiratory Respiratory problems Section 8: Paediatrics | Section 8: Paediatrics Acute pain management, page Acute pain management, 1,2 ≥ 94%. If unable to maintain ≥ 94% consult MO/NP ≥ 94%. If unable to maintain 2 to maintain SpO 2
IV fluids - sodium chloride 0.9%. MO/NP will advise quantities and rate IV fluids - sodium chloride IV antibiotics insert IV/intraosseous cannula - if possible take blood cultures prior to commencing antibiotics - if possible take blood cultures prior to insert IV/intraosseous cannula chest x-ray if available chest x-ray if oral or IM antibiotics bronchiolitis of viral infection or not be indicated if typical antibiotics may – – – – – – Consult MO/NP on all occasions pneumonia is suspected referral Some children with pneumonia will require a paediatric Advise to see MO/NP at next clinic If not evacuated/hospitalised advise to be reviewed daily If not evacuated/hospitalised advise to be reviewed Consult MO/NP if not improving Give oral fluids as tolerated clinically indicated. See Administer analgesia as – – Evacuation/hospitalisation Give O MO/NP may advise: – Encourage rest and increase oral fluids Encourage rest to make more comfortable Treat fever with regular paracetamol – – – Consult MO/NP for any suspicion of pneumonia any suspicion MO/NP for Consult advise: MO/NP may
• • • • • • • • • • • • • •
Moderate/severe pneumonia Mild pneumonia 6. Referral/consultation
5. Follow up 4. Management 4. 700 post streptococcal diseases child Post streptococcaldiseases | Primary Clinical Care Manual 10th edition | 2. Immediate management 1. Maypresentwith HMP Background Recommend • • • • • Related topics Scabies, page Impetigo, page • • • • • Recent historyofskinsoresand/or sore throat Skin sores/infectedscabies – – – – – – – – – Acute nephritis- Asymptomatic -microscopichaematuriae.g.detectedonroutinescreening If fittingsee infection Latent periodbetweenrespiratoryinfectionandnephritisis7-10days,2-4weekspostaskin – – – APSGN: – – – To helppreventAPSGN: intervention responserequired The PHUwilldeclareifacommunityoutbreakisidentifiedandprovidethenecessary The PHUwillmonitorandadviseonpublichealthinterventions – – – – – – – – – Acute in severecasesrespiratorydistress due topulmonaryoedema-fluidoverload hypertension -variesmildtosevere ↓ urineoutput;oliguria proteinuria macroscopic (frank/gross)haematuria-urinelookssmoky,andteaorcola coloured microscopic haematuriaOR oedema -puffyface,eyes,limbs uncommon: hypertensiveencephalopathy -severeheadache,convulsions,coma lethargy, generalweakness,oranorexia – – – – – – AllsuspectedcasesofAPSGNshouldbenotifiedbyphonetothelocalpublichealthunit(PHU). most commonlyimpactschildrenfrom2-17yearsofage,butcanoccuratanyage communities withhighlevelsofscabies,skinsores,andovercrowdedlivingconditions is commonamongAboriginalandTorresStraitIslanderchildreninnorthernAustralia resulting inacompleximmuneresponseandglomerulonephritis is causedbypriorinfectionwithspecificstrainsofGroupA treat skinsores/sorethroatspromptly regular washing,particularlyofchildren,todecreasespreadthebacteria community controlofscabiesandskinsores 1,2 5 post streptococcalglomerulonephritis(APSGN) 415 Fits/convulsions/seizures, page 392 typical presentation: 1 2 3
2,3,4
109 Sore throat,page 685 Streptococcus (GAS)infection -adult/ post streptococcal diseases 701 table (next page): Post streptococcal diseases Post streptococcal diseases
See How to collect a wound swab/culture in 2 Section 8: Paediatrics | Section 8: Paediatrics 2 2 427 Screening BP values requiring further evaluation 6
ASOT, antiDNAase B titres, C3, C4, FBC, film, CHEM20 on the pathology form, include clinical information ‘suspected APSGN’ – – – urine microscopy for RBC, culture, albumin creatinine ratios Chronic wounds, page for identification of GAS otherwise, take a throat swab if indicated on history, blood for: – swabs from 2 different sites if skin sores present. skin for sores/infected scabies face, hands and feet for oedema throat - any redness if BP elevated see instructions in table to determine BP percentile based on child’s height if BP elevated see instructions in table to determine if unsure, consult MO/NP Response Tools) to trigger referral if suspected APSGN do not rely on CEWT BP ranges standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and (full Q-ADDS/CEWT score or other local Early standard clinical observations when, how treated do any close contacts have similar symptoms contacts have similar symptoms do any close skin sores sore throat urine colour urine colour - has it decreased urine output off food of breath, feeling unwell, e.g. shortness any other symptoms puffiness of face or eyes, legs or arms of face or eyes, legs or arms puffiness If the initial BP is elevated, perform 2 more BP measurements at the same visit and average If the initial BP is elevated, perform 2 more BP measurements them Differs with age, gender and height Measure on right arm for consistency, with appropriately sized cuff Measure on right arm for consistency, with appropriately visits Can vary considerably during the same visit or across – – – – – – – – – – – – – – – – – – –
– – – Listen to chest for crackles or wheezes - may indicate fluid overload/pulmonary oedema Listen to chest for crackles or wheezes - may indicate Take pathology: – – – – Urinalysis - check for blood and protein recent weights Weight - bare weight if < 2 years. Assess against Examine: Check BP against the – – – Social history e.g. crowded living conditions Social history e.g. crowded including: Perform physical examination – – Previous medical history or close contacts with APSGN Previous history of APSGN – of: Any recent history – – – – – Take complete patient history history patient Take complete Ask about: – BP in children • • • • • • • • • • • • • • • • • 3. Clinical assessment Clinical 3. 702 post streptococcal diseases | Primary Clinical Care Manual 10th edition | • • If theBPis≥valuesonthistable,measurechild’sheight,then: If BPis
1 7 Post streptococcal diseases Post streptococcal diseases
other symptoms: of APSGN Renal biopsy suggestive Renal biopsy Laboratory definitive evidence Laboratory definitive only NO clinical evidence clinical evidence
•
but
3 AND R
O
take bloods first only 2 Section 8: Paediatrics | Section 8: Paediatrics 415 Diagnosis of APSGN Diagnosis clinical evidence laboratory suggestive evidence suggestive laboratory Scabies, page D ND : Reduced C3 level Laboratory definitive evidence Laboratory definitive evidence Laboratory suggestive on microscopy Haematuria (RBC > 10/ul) AN infection Evidence of recent GAS skin or e.g. positive culture from titre or throat, or elevated ASO Anti-DNase B A Laboratory suggestive evidence Laboratory suggestive • • • • Requires Requires Requires either: • :
percentile is elevated and requires further investigation percentile requires aggressive treatment th th of the : see information under clinical assessment about BP percentiles in children : see information under clinical assessment about oped in conjunction with a paediatrician outstanding check care plan is in place and follow up anything obtain urine microscopy for RBC, culture, albumin creatinine ratios advise to come to next MO/NP clinic children with a history of APSGN should be monitored through an individual care plan devel children with a history of APSGN should be monitored if allergic to penicillin give oral azithromycin – – – – –
If there is no history of APSGN in last 6 months: – – If prior history of APSGN - haematuria can persist for up to 3-6 months post resolution If prior history of APSGN - haematuria can persist – – get contacts from previous 2 weeks - adults and children staying in house get contacts from previous 2 weeks - adults and if hypertension and/or heart failure, MO/NP may order furosemide (frusemide) if hypertension and/or heart failure, MO/NP may give benzathine benzylpenicillin (Bicillin LA®) - – treat scabies if present. See MO/NP will likely consult with paediatrician for specialist advice MO/NP will likely consult with paediatrician for evacuation/hospitalisation required BP > 90 BP > 95 note all suspected cases of APSGN fulfil the clinical evidence criteria for APSGN) any child with oedema or hypertension (but do not – – – – – – – – – – – – – least 2
Clinical evidence – – – on management of contacts Notify local public health unit for further advice urinalysis If microscopic haematuria incidentally found on – – – If clinical evidence suggests probable APSGN: – – – – – Always consult MO/NP for – – If BP is elevated Hypertension Peripheral oedema ≥ moderate haematuria on dipstick Facial oedema At following: • • • • • • • • • Confirmed APSGN Confirmed Possible APSGN Possible Probably APSGN
4. Management 704 post streptococcal diseases | Primary Clinical Care Manual 10th edition | RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: nausea, abdominalcrampsandcandidiasis Provide ConsumerMedicineInformation: Management ofassociatedemergency: between penicillins,cephalosporinsandcarbapenems Contraindication: benzathine benzylpenicillin,page Note Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP reconstitution Schedule (pre-filled to oralliquid Injection syringe) Powder for Form Schedule Tablet : Stopinjectionimmediatelyifpatientshowssignsofseverepain.See Form units/2.3 mL 1.2 million (900 mg) Strength Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity 200 mg/5mL 4 Strength 500 mg 4 administration 787 Benzathine benzylpenicillin Route of IM ConsultMO/NP.See ConsultMO/NP.See administration (Bicillin LA Maycausediarrhoea,nauseaandpainatinjectionsite Azithromycin Route of Take withorwithoutfood.Maycause rash,diarrhoea,
Oral 15 to<20kg 10 to<15kg 6 to<10kg 3 to<6kg ® Weight ≥ 20kg
) Recommended dosage Child 6months- max. of500mg Anaphylaxis, page 12 mg/kg/dose Adult andchild Anaphylaxis, page Recommended 500mgdaily ≥ 12years < 12years daily toa dosage 337.5 mg 900 mg 450 mg 225 mg 675 mg daily Dose ATSIHP Extended authority ATSIHP/IHW/IPAP/RIPRN / Extended authority IHW/IPAP/RIPRN 0.76 mL 102 102 1.52 mL Volume 0.5 mL 2.3 mL Administration tips for Administration tipsfor 1 mL
Duration 5 days
Duration stat
10, 11 2,8,9 post streptococcal diseases 705 http://www. (GAS) in the throat, and Post streptococcal diseases Post streptococcal diseases Streptococcus (2nd edition) available from 442 Section 8: Paediatrics | Section 8: Paediatrics - adult/child ARF) : this resource refers to benzathine penicillin as benzathine penicillin : this resource refers to benzathine penicillin as Australian guideline for prevention, diagnosis and management of Australian guideline for prevention, diagnosis and Note 1 . rheumatic fever ( rheumatic fever 1 1
Aboriginal and Torres Strait Islander people living in rural and remote areas Aboriginal and Torres Strait Islander people living recurrent episodes into their 40’s children aged 5-14 years; however adults can have ARF is a notifiable disease – – usually resolves quite rapidly assuming concurrent resolution of infection concurrent resolution quite rapidly assuming usually resolves months can persist for up to 3-6 haematuria to 3 years or more increase sometimes up persist longer - mild proteinuria may Acute – – – G (BPG) - these are the same Recommended resource: acute rheumatic fever and rheumatic heart disease RHDaustralia.org.au People at most risk: – – ARF is an auto-immune response to infection with Group A ARF is an auto-immune response to infection with skin and the nervous system possibly the skin. ARF affects the heart, joints, ARF is difficult to diagnose - an incorrect diagnosis, either positive or negative, can have significant ARF is difficult to diagnose - an incorrect diagnosis, consequences treat sore throat and skin infections early to In Aboriginal and Torres Strait Islander communities prevent the initial case of ARF ARF should always be considered in the differential diagnosis of patients presenting with arthritis ARF should always be considered in the differential in high risk populations (swollen and hot joint, with pain on movement) arthritis to be considered until proven otherwise If mono-arthritis (inflammation of 1 joint) septic paediatric review ARF should be admitted to hospital for a specialist All patients with suspected and echocardiography
APSGN is not a notifiable condition. However, to enable follow up of close contacts, clinicians condition. However, to enable follow up of close APSGN is not a notifiable the local public health unit should notify by phone to Consult MO/NP on all occasions of suspected APSGN Consult MO/NP on all occasions Resolution of APSGN: Resolution of – – – Follow up close contacts in collaboration with local public health unit health with local public in collaboration up close contacts Follow care plan individualised through an monitored should be of APSGN with a history Children a paediatrician with in conjunction developed
• • • • • • • • • Secondary prophylaxis for acute rheumatic fever, page Secondary prophylaxis for acute rheumatic fever, page Related topics • • • • • Recommend
Background HMP
6. Referral/consultation 5. Follow up Follow 5. 706 post streptococcal diseases 1. Maypresentwith | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement Extremely rare-erythemamarginatum Rare -subcutaneousnodules Sydenham’s chorea Fever ≥38⁰C Heart murmur Arthritis-mostcommonpresentation • • • • • • • • • • • • • • • • • • • • • • – – – – – – Obtain historyaboutpresentingsymptoms,inparticular: Difficult todetectin Circular patternsof Highly specificsy and vertebrae Crops ofsmall Note Relatives andteachersmaydescribethemas‘jumpykids’ Very commoninAboriginalandTorresStraitIslanderchildren(28%ofpresentations) May affect1sideonly Disappears duringsleep Especially affectshands,feet,tongue,face Jerky, unc Indicates possiblecarditis Joints maybepai Problems weight-bearingorwalkingunaided Pain respondsverywelltoNSAIDs May beextremelypainful-oftenoutofproportionwithclinicalsigns Large jointsusuallyaffected-especiallykneesandankles May involve Usually asy Swollen h – – Obtain pasthistory. Askabout: – – – – – – – – jerky/uncoordinated movements pain orswellinginlimb(s)joint(s) history of penicillininjections forARF/RHD: past episodesofARF orprevioussymptomssuggesting ARF recent historyofsorethroat,painful joint(s)orskininfectionsandwhethertreated history fromarelativeorteachere.g. strangemovements – measures takentotreatpresenting symptoms: recent fever – : chorea have theytriedibuprofenforjointpain; howeffective -common oordinated movements ot jointwithpainonmovement mmetrical andmigratory-1jointbecominginflamedasanothersubsides multiple joints withnootherpossibleneurologicalcausewillbeconsideredARF round painlessnodulesoverelbows,wrists,knees,ankles,achillestendon,occiput nful butnotswollen mptom ofARF;stronglyassociatedwithcarditis brightpinkmaculesorpapulesontrunkandproximalextremities AboriginalandTorresStraitIslanderpeople,buthighlyspecificforARF 1,2,3 1 Notapplicable post streptococcal diseases 707 1
3 e.g. septic 1 35 Post streptococcal diseases Post streptococcal diseases 778 1 how to take a swab
for , 0.16 0.18 0.20 427 Seconds (preferably before antibiotics) Acute pain management, page Section 8: Paediatrics | Section 8: Paediatrics https://www.rhdaustralia.org.au/queensland streptococcus
Chronic wounds, page 17+ 3-12 12-16 Upper limits of normal P-R interval Upper limits of normal P-R Group A Age (years) Medication history and reconciliation, page and reconciliation, history Medication 1 rather than ibuprofen until diagnosis made - culture for 1 1 1 : hospitalisation should occur as soon as possible after onset of symptoms : hospitalisation should occur as soon as possible
have any injections been missed missed been injections any have QLD to assist: contact RHD if unsure – – etc. note thorough investigations for alternative diagnoses should always be undertaken arthritis, disseminated gonococcal infection, gout, innocent murmur, congenital heart disease, refer for baseline echocardiogram paediatric/physician/cardiology review and arrange evacuation/hospitalisation for specialist diagnosis give paracetamol to disappear complicating the diagnosis NSAIDs are very effective - can cause joint symptoms anti-streptococcal serology - both ASO and anti-DNase B titres anti-streptococcal serology - both ASO and anti-DNase blood cultures if T ≥ 38°C FBC, ESR, C-reactive protein (CRP) skin for old or infected sores throat for inflammation and limbs for any jerky movements of the face, tongue, trunk swelling, tenderness and mobility swelling, tenderness and of proportion to the joint signs does the pain seem out Response Tools) Response Tools) note any fever P-R interval ECG - note prolonged – See medicines. current and local Early Warning score or other observations (full Q-ADDS/CEWT standard clinical – – – – – – – – – – – – – – – – – – –
If probable ARF give a single dose of benzathine benzylpenicillin (Bicillin LA®) if not allergic Contact local public health unit for advice/support for suspected ARF – – Consult MO/NP who will: – – Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See – – Swab any skin sores for MCS. See – – Do throat swab Look for indications of heart failure e.g. ↑ or irregular HR, ↑RR, basal crackles in chest Look for indications of heart failure e.g. ↑ or irregular Take bloods: – – – – sounds e.g. whooshing sound Auscultate the heart if skilled - listen for a murmur/abnormal – – Inspect: Inspect and palpate joints for: Inspect and palpate joints – – – including: physical examination, Perform – • • • • • • • • • • • • 4. Management 708 Ears | Primary Clinical Care Manual 10th edition | Ear andhearing Ear problems 6. Referral/consultation 5. Followup This presentationaskabout Management ofassociatedemergency: between penicillins,cephalosporinsandcarbapenems Contraindication: benzathine benzylpenicillin,page Note Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP (pre-filled • • • • • • • Injection syringe) Form Schedule History ofrecentURTI, exposuretopassivesmoking/smoker, swimming(especiallyindirty damor Details ofpastmedicaltreatmentand response – – – Ear symptoms: Obtain acompletepatienthistory ver-acute signs andsymptoms.See Consult MO/NPonalloccasionsofsuspectedARF Follow uptobeunderguidanceofspecialistMO of otitismedia(OM) andhearingloss creek), dustyenvironment, overcrowding/closeproximity tootherchildren,poordiet,family history : Stopinjectionimmediatelyifpatientshowssignsofseverepain.See
onset andseverity a youngchildmaybeunsettledorpulling attheirears pain, fever,discharge,itchy ARFrequiresimmediatenotificationtothelocalPublicHealthUnitbased onclinicalhistory, 1 units/2.3 mL 1.2 million (900 mg) Strength Severeorimmediateallergicreactiontoapenicillin.Beawareofcross-reactivity 4 assessment http://disease-control.health.qld.gov.au/Condition/804/rheumatic-fe 1 administration 787 Benzathine benzylpenicillin Route of IM ConsultMO/NP.See -adult/child (Bicillin LA Maycausediarrhoea,nauseaandpainatinjectionsite
® ) Recommended dosage 1.2 millionunits Anaphylaxis, page 600,000 units Child <20kg child ≥20kg Adult and (900 mg) (450 mg) ATSIHP Extended authority / IHW/IPAP/RIPRN 102 Administration tips for Administration tipsfor
Duration stat 4,5 - Ears 709 Ear | Ear Section 8: Paediatrics problems 1 1 https://publications.qld.gov.au/dataset/chronic-conditions-manual Chronic Conditions Manual: Prevention and Management of Chronic Conditions in and Management of Manual: Prevention Chronic Conditions Examples of positioning of children for examination of throat and ears Examples of positioning of children for examination available at: mastoid bone - swollen, hot, tender occiput, around ears, both sides or neck for lymph glands ear - warm to touch, pain on moving pinna, tender – – – – – Inspect - any inflammation Palpate: – Position infant/toddler on parent/carer’s knee. Can use front hugging position. Older children can parent/carer’s knee. Can use front hugging position. Position infant/toddler on stand while adult sits gently Often very painful - approach appointments/care Examine ear at eye level Hearing screening and assessment commences from birth across the life span. Refer to current the life span. Refer commences from birth across and assessment Hearing screening edition of the Australia they are up to date with care of an ENT Specialist or Audiologist ensure If a patient is under the Under care of ENT Specialist/Audiologist Under care of issues in children learning and behavioural or language development, Delayed speech First episode or previous episodes - acute otitis media with or without perforation; chronic ear chronic perforation; with or without otitis media - acute episodes or previous First episode treatments and when; 0perations discharge; tests hearing loss and any Hearing • • • • • • • • • • • Outer ear Examination Hearing screening and assessment Hearing screening Past history of ear problems ear of history Past 710 Ears | Primary Clinical Care Manual 10th edition | Chest Nose andthroat Tympanic membrane(TM)(eardrum) Ear canal • • • InspectTM(eardrum)for: • • • • • Attic perforation Note otherinjuriesifpresente.g.cause oftraumaticrupturetheeardrum Auscultate thechestforairentryand anyaddedsounds(cracklesorwheezes) Any dischargefromnoseorredness ofthethroat – – – – – 11 o’clock Sections ofhandlemalleusvisiblethroughtranslucentdrum-rightear1o’clock,left left earat7o’clock Normal TMisshiny,translucent,pearl/greycolour,coneoflightvisible-rightearat5o’clock, Clean theearcanal.See lumps orbonygrowths,foreignbody,extrudinggrommets,wax,lesions If painlevelsallowlookinsidewithotoscope-inspectcanalforswelling,redness,fungus,debris, Inspect foranyobviousdischarge,redness/swelling – – – – – any perforationintheatticregionrequiresanurgentreferraltoENTspecialist discharge perforations -documentthesizeandpositiononadiagramincasenotes fluid orbubblesbehindtheeardrum intact, pink,pearly,red,dull,bulging,retracted Left Chronic suppurativeotitismedia(CSOM),page 719 Other perforation Right
Ears 711
Australian Immunisation Ear | Ear Section 8: Paediatrics problems Recommendations for Clinical Care Guidelines
- adult/child - about importance of prevention, early detection and treatment of otitis detection and treatment of prevention, early about importance http://www.health.gov.au/internet/main/publishing.nsf/Content/ - encourage children to wash face and hands regularly, especially after nose - encourage children to wash face and hands regularly, - should be performed in an upright position. Bottle feeding children laying down, - should be performed in an upright position. Bottle - encourage mothers to continue breastfeeding http://www.careforkidsears.health.gov.au/internet/cfke/publishing.nsf/Content/Home - age appropriate vaccinations as per current edition of the - age appropriate vaccinations as per current edition is a risk factor and is strongly discouraged around children is a risk factor and is strongly discouraged around 1 - use of a dummy after 6 months of age can increase the risk of OM - use of a dummy after 6 months of age can increase 1,2 high risk of developing AOM discharge with some degree of hearing loss all forms of OM can be associated fragile X syndrome and Downs syndrome are at babies with cleft palate, fetal alcohol syndrome, life other upper risk of acute otitis media (AOM) when they have children are at increased respiratory infections ear pain or to the health centre when any child develops encourage early presentation ensure effective communication strategies for people with hearing loss ensure effective communication the first months of and Torres Strait Islander infants may occur within onset of OM in Aboriginal
– – – – – – at an early age, can have lifelong impacts on children's development can have lifelong impacts at an early age, Ask about speech, language, learning and behaviour because ear disease and hearing impairment impairment hearing ear disease and and behaviour because learning language, speech, about Ask Aboriginal and Torres Strait Islander resources are available from the national ‘Care for Kids Ears’ Aboriginal and Torres Strait Islander resources are campaign at: on the Management of Otitis Media in Aboriginal and/or Torres Strait Islander Populations on the Management of Otitis Media in Aboriginal resources are available from the national ‘Care for available at: Aboriginal and Torres Strait Islander Kids Ears’ campaign at: indigenous-otitismedia-clinical-care-guidelines non-Aboriginal and Torres Strait Islander people the advantage of antibiotics is small unless non-Aboriginal and Torres Strait Islander people systemic features are present see Dosing in this area is complex, for more details prop fed or in children’s bed while going to sleep, increases the incidence of ear infections prop fed or in children’s bed while going to sleep, significantly recommended in rural and remote Aboriginal and Higher dose and longer duration antibiotics are and complications from OM, while in Torres Strait Islander children due to higher incidences Dummy Smoking Bottle feeding especially if nasal discharge is present Vaccination Handbook Breastfeeding Personal hygiene and encouraged to blow their noses regularly, blowing or coughing. Children should be taught – – – – Encourage early interventions: – – Tell all expectant mothers Tell all expectant and education should be loss. The potential effects on language media (OM) to prevent hearing emphasised
• • • • • • • • • • • •
Recommend
Prevention of otitis media and hearing loss in Aboriginal and Torres Strait Islander and Torres Strait loss in Aboriginal of otitis media and hearing Prevention children: Ear infections (general) infections Ear 712 Ears | Primary Clinical Care Manual 10th edition | HMP Background Recommend Otitis mediawitheffusion(OME,glueear) Recurrent acuteotitismedia(rAOM) Acute otitismediawithacuteperforation Acute otitismedia(AOM)withoutperforation Otitis externa Dry perforation Chronic suppurativeotitismedia(CSOM) Related topics Chronic suppurativeotitismedia(CSOM), page • • • • • • dramatically reducetheincidenceof chronicsuppurativeotitismedia(CSOM) AOM withperforationoccursmainlyinthefirst18monthsoflifeand effectivetreatmentwill Infection behindtheeardrummaycausedrumtoperforate otitis media(CSOM),page If dischargecontinuesthroughaperforationafter14daysoftreatment see Always followupacuteperforationstoensuretheyhavehealed Consider higherdoseand/orlongercourseofantibioticsifpersistentor recurrentperforation criteria outlinedatthebeginningofpaediatricsection Consult MO/NPimmediatelyifchildis<3monthsofage,sick,febrile or meetsanyoftheother Acute 1 1 otitis media(AOM)with/withoutperforation Condition Ear conditions 719 differential diagnosistable-definitions 719 'swimmer's ear'and'tropical pain, swellinganddischarge.Othertermsinclude Inflammation oftheearcanalassociatedwith or fluidbehindtheeardrum A holeintheeardrumwithoutanysignsofdischarge the middleear large enoughtoallowthedischargeflowoutof is onlyappropriateiftheperforationseenand the eardrum≥twoweeks.ThediagnosisofCSOM Persistent dischargeofpusthroughaperforationin persistent signs ofacuteotitismedia.OMEmaybeepisodicor Fluid behindtheeardrumwithoutanysymptomsor months period orfourmoreepisodesinthelasttwelve Three ormoreepisodesofAOMinasixmonth eardrum <2weeks Discharge ofpusthroughaperforationinthe pain orirritability following: bulgingeardrum,redfever,ear Fluid behindtheeardrumandatleastoneof Ear andhearingassessment,page Definition 1 -adult/child Chronic suppurative Chronic suppurative 708 Ears 713 80 35 719 Sepsis/septic shock, page Ear | Ear Section 8: Paediatrics problems Acute pain management, page 708 Not applicable Chronic suppurative otitis media (CSOM), page Chronic suppurative otitis 1,2
Ear and hearing assessment, page required) request to return in 4-7 days for review the correct storage, dose and method to give antibiotics (give first dose to demonstrate if the correct storage, dose and method to give antibiotics the beginning of the paediatric section - consider sepsis. See the beginning of the paediatric section - consider < 3 months of age T > 38°C or < 35.5°C meets any of the other criteria as outlined at any rash, increased RR or respiratory distress or document the size and position of any perforation on a diagram in the case notes of any perforation on a diagram in the case document the size and position gently clean any discharge from the ear canal with a tissue spear before examining the ear drum from the ear canal with a tissue spear before gently clean any discharge with an otoscope. See eardrum look for a red and/or bulging – – – – – – – –
in children - regular nose blowing and washing of hands and face in children - regular nose blowing and washing of – to other children encourage personal hygiene To prevent recurrent OM and transmission of bacteria If unilateral disease and no systemic features treat symptomatically and consult MO/NP if If unilateral disease and no systemic features treat concerned Discuss with family/client: – For indications for antibiotics and for selection of recommended antibiotics. See following For indications for antibiotics and for selection of or without perforation) flowchart - Management of acute otitis media (with Consult MO/NP if child is/has: – – – Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See – perforation has been present Document how long the See – – Obtain a complete patient history Obtain a complete patient local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) Perform physical examination: Fluid behind the eardrum, a red and/or bulging eardrum the eardrum, a red and/or Fluid behind within the last 6 weeks Ear discharge Irritability Irritability Fever Ear ache
• • • • • • • • • • • • • • • •
4. Management 3. Clinical assessment 2. Immediate management management 2. Immediate 1. May present with present May 1. 714 Ears | Primary Clinical Care Manual 10th edition | Islander Torres Strait and/or Aboriginal Management ofacuteotitismedia(withandwithoutperforation) Islander Torres Strait and/or Aboriginal Non Antibiotic selectionforacuteotitismedia Yes Yes • Recent antibioticuseorfailureto within 1weekorinregionswith respond tostandardtreatment Give antibiotic known penicillinresistance to penicillin to penicillin to penicillin to penicillin Torres StraitIslander Not allergic Not allergic Allergic Allergy Aboriginal and • Child Yes OR ing factors No perforationandnocomplicat • recentantibioticuse factors i.e. No perforationandcomplicating Adult andchild>3months Child Adult andchild>3months Child Adult andchild>3months Child <3months Perforation resistance • inregionswithknownpenicillin dosagewithin1week • failuretorespondstandard Systemically unwell? e.g.fever,vomiting,lethargy < 3months < 3months Yes
1,2,10 Yes No • OR • • Age <6monthswithbilateralAOM or historyofAOMwithdischarge No > 6monthsreviewin48hours ≤ 6monthsreviewin24hours Improvement onreview Torres StraitIslander Non Aboriginaland -
Watch andwait
No furthertreatment Amoxicillin Trimethoprim +sulfamethoxazole Consult MO/NP Amoxicillin Consult MO/NP Trimethoprim +sulfamethoxazole Consult MO/NP 14 days High doseamoxicillin 7 days High doseamoxicillin No 1 Yes
Ears 715
1,2,4,9 5 days 5 days 7 days 7 days Duration (if perforation give for 14 days) IHW/IPAP/RIPRN /
102
Extended authority Extended ATSIHP 2 years or Ear | Ear Section 8: Paediatrics problems dosage Anaphylaxis, page 500 mg tds HIGH DOSE hild < 1 years - Aboriginal and years - non-Aboriginal Recommended Recommended C max. of 1 g/dose bd max. of 1 g/dose bd max. of 1 g/dose bd Torres Strait Islander max. of 500 mg/dose tds Adult and child ≥ 12 years Adult and child and Torres Strait Islander and Torres Strait Islander 45 mg/kg/dose bd up to a 25 mg/kg/dose bd up to a 25 mg/kg/dose bd up to 30 mg/kg/dose bd up to a 30 mg/kg/dose bd up to 15 mg/kg/dose tds up to a 15 mg/kg/dose tds up to Child < 12 Child < 12 Amoxicillin
May cause rash, diarrhoea, nausea and candidiasis Consult MO/NP. See Oral Route of administration 4 250 mg 500 mg Strength : Severe or immediate allergic reaction to a penicillin. Be aware of cross-reactivity : Severe or immediate allergic reaction to a penicillin. 250 mg/5 mL 500 mg/5 mL Schedule Form Capsule Powder for to oral liquid between penicillins, cephalosporins and carbapenems Management of associated emergency: Provide Consumer Medicine Information: Contraindication ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed reconstitution 716 Ears | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup and, soremouth.Takewithfoodtoreducestomachupset.Avoidsunexposure.Reportthroat, Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency: Use inpregnancy: severe hepaticimpairment,elderlyandpregnancy Contraindication: taken inconjunctionwithanACEIandARB Note fever, rash,cough,breathingdifficulties,jointpain,darkurineorpalestools Tablet • • • • • • • • • • • • • liquid Form Oral Schedule for formalhearingassessmentifnot donerecently If thereareconcernsaboutchild’shearing, speechdevelopment,behaviour,schoolprogress.Refer Any patientwithanatticperforation requiresurgentreferraltoENTSpecialist refer toENTSpecialist Where prolongedmedicaltherapyfails i.e.>6weeks,orfrequentpainfulAOM,theMO/NPmay If otitismediaisrecurrenttheMO/NP mayconsiderantibioticsforprophylaxis Consult MO/NPasabove Review at3monthstoidentifythosewithchroniceardisease Australia edition ofthe If perforationhealsreviewin6weeksandcontinuetomonitorhearingaccording tothecurrent suppurative otitismedia(CSOM),page If dischargecontinuesafter2weeksoftreatmentcheckfamily’sability tocleantheear.See vomiting itupafterwards If failingtoresolveensurethechildisbeinggivenantibiotics,whetherthey arespittingitoutor Then reviewweeklyuntilthesignsofAOMand/orperforationhaveresolved If redorbulgingeardrumpersistsafter7daysincreasedoseofamoxicillin Request toreturnforreviewin4-7days(orearlierifindicated) systems and studentplacement (seating)in the classroom as educators/staff canimplementmeasurestoassist thechilde.g.soundfieldamplification If ahearinglossis identified,ensuretheschool/kindy/day careisinformed,withparental consent, : IfrenalimpairmentseekMO/NPadvice.Mayincreaseriskofhyperkalaemiaespeciallywhen 160 mg+800 80 mg+400 200 mg/5mL availablefrom: 40 mg/5mL 1 Strength Chronic ConditionsManual:PreventionandManagementof in Severeorimmediateallergicreactiontosulfonamides,megaloblasticanaemia, Donotuse + 4 https://publications.qld.gov.au/dataset/chronic-conditions-manual administration Trimethoprim +sulfamethoxazole 1 Route of Oral ConsultMO/NP.See 719 Maycausefever,nausea,vomiting,diarrhoea,itch,rash
max. of160mg+800mg/dosebd 4 mg+20mg/kg/dosebduptoa 160 mg+800mg/dosebd Child ≥1month Recommended Anaphylaxis, page dosage Adult ATSIHP/IHW/IPAP/RIPRN Extended authority 102
Duration 5 days
2,6,10 Chronic Chronic
Ears 717 708 Ear | Ear Section 8: Paediatrics problems Ear and hearing assessment, page 712 Not applicable 1,2 1 fluid or bubbles behind the eardrum retraction of eardrum past history of recurrent otitis media development concerns about speech, learning, behaviour or language
– – – – If hearing, speech, development or language is impaired refer to ENT Specialist, Audiologist, refer to ENT Specialist, language is impaired development or If hearing, speech, Speech Pathologist are not recommended Decongestants and antihistamines where significant but inhaled steroids may be trialled in children Steroids are not recommended etc. suggests allergic rhinitis nasal obstruction, sneezing Review children with bilateral OME at 3 monthly intervals and refer if required 3 monthly intervals and with bilateral OME at Review children washing is regular nose blowing, the spread of ear infections method to prevent The most effective of nasal discharge and keeping face clear hands and face Risk factors for OME include strong family history for OM, attending child care, frequent exposure strong family history for OM, attending child Risk factors for OME include of Aboriginal and Torres Strait Islander descent to other children and being OME results in thick glue-like material filling the middle ear which may take many months to material filling the middle ear which may OME results in thick glue-like age of language will have impaired hearing, which at the critical resolve. Children with OME and educational impacts 5 years), may result in significant developmental development (the first Otoscopy may reveal: – – a In conjunction with history and otoscopy, diagnosis is confirmed by tympanometry which shows type B pattern (limited or absent movement of the eardrum) Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Response Tools) Obtain a complete patient history and physical examination. See Ear and hearing assessment, pageObtain a complete patient history and physical 708 – – Diagnosis may also be suspected at routine ear examination, in a child being followed up after Diagnosis may also be suspected at routine ear after a routine child health check AOM, or a child referred for medical assessment Child may have: No symptoms Reported hearing concerns from parents/carers/educators
• • • • • • • Acute otitis media (AOM) with/without perforation, page Acute otitis media (AOM) with/without perforation, Immunisation program, page 768 Related topics • • • • • • • •
Recommend Background
3. assessment Clinical 2. management Immediate
1. with May present - adult/child (OME) effusion with media Otitis ear glue ears, non-discharging Painless 718 Ears 5. Followup 4. Management | Primary Clinical Care Manual 10th edition | 6. Referral/consultation • • • • • • • • • • system andstudentplacement can takemeasurestosupportthechild'slearningenvironment.e.g.sound fieldsamplification For hearingimpairedschoolchildrenensure(withparentalconsent)the schoolisnotified,sothey If thereisspeechdelayrefertoSpeechPathologist – – – – – Refer toENTSpecialist: tions-manual Conditions inAustralia See thecurrenteditionof service available arrange foradiagnosticaudiologyassessmentorearandhearinghealthcheckifno If thereareconcernsabouthearing,speech,learningdifficultiesorOMEispersistentfor>3months Advise toseeMO/NPatnextvisit Advise tobereviewed3monthly if required.See Check immunisationstatusparticularlypneumococcalvaccinationandoffercatchup als andearlyeducators: Use thenational'CareforKidsEars'websiteandresourcestosupportfamilies,healthprofession developing CSOM 25-50 mg/kg1-2timesdailyfor3-6months)areanoptioninfantswhoathighriskof Antibiotics arenotroutinelyrecommendedforOME.However,longtermantibiotics(e.g.amoxicillin – – – – – has severeretractedeardrum antibiotic therapyhasfailed any concernsabouthearingorspeech effusion persists>3months if hearingtestshowsimpairmentinbothearsfor>3months
for ongoingchildhealthchecks 1,2 Immunisation program,page availablefrom: http://www.careforkidsears.health.gov.au Chronic ConditionsManual:PreventionandManagementof https://www.publications.qld.gov.au/dataset/chronic-condi 768
- - Ears 719 - - Ear and hearing assess - adult/child Cleaning techniques for ears with Ear | Ear Section 8: Paediatrics problems 712 http://www.careforkidsears.health.gov.au/internet/cfke/ Not applicable
using tragal pumping using tragal
discharging for ≥ 2 weeks for ≥ 2 discharging 708 1 1,2 Chronic suppurative otitis media (CSOM) (CSOM) media otitis suppurative Chronic
Document the duration of ear discharge and size and position of perforation and size and position duration of ear discharge Document the Consult MO/NP for immediate ENT referral if perforation of the eardrum found in the attic region eardrum found in the if perforation of the for immediate ENT referral Consult MO/NP and instilling with a tissue spear pus from the canal ears actively by cleaning Treat discharging drops antibiotic ear CSOM is diagnosed in people who have discharging ears for more than 2 weeks who have discharging ears for more than CSOM is diagnosed in people
Avoid swimming unless ears can be kept dry Consult MO/NP if perforation found in attic region of the eardrum Encourage regular nose blowing, hand and face washing and keeping face clear of nasal discharge Encourage regular nose blowing, hand and face Use the national ‘Care for Kids Ears’ website and resources to support families, health profession als and early childhood educators: publishing.nsf/Content/Home times daily members to adequately clean the ears and instil the In young children it may be difficult for family daily for 7 days drops - clinic staff are advised to assist with this Teach patient/carer cleaning technique and instillation of drops Teach patient/carer cleaning technique and instillation ear canal, followed by ciprofloxacin ear drops 2 Twice daily dry mopping of pus and debris from Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) a diagram in the case notes Document the size and position of perforation on ment, page Ask about hearing, learning, speech and language Document length of time discharge has been present Dry mop pus and debris from ear canal prior to assessment. See Dry mop pus and debris from ear canal prior to assessment. chronic discharge below assessment. See Obtain a complete patient history and perform physical Decrease in hearing learning or speech and language development Concerns with behaviour, Ear discharge for > 2 weeks
• • • • Acute otitis media (AOM) with/without perforation, page Acute otitis media (AOM) Related topics • • • • • • • • • • • • • • • •
Recommend Background
HMP 4. Management
3. Clinical assessment 2. Immediate management
1. May present with Ear has been been Ear has 720 Ears | Primary Clinical Care Manual 10th edition | Followup 5. RIPRN mayproceedforAboriginalandTorresStraitIslanderpersonsonly ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency:ConsultMO/NP.SeeAnaphylaxis,page102 restrictions forotherpopulations Note: ForuseinAboriginalandTorresStraitIslanderpersonsonly.MO/NPnoteadditionalPBS chronic discharge Provide ConsumerMedicineInformation: Ear dropadministrationwithdrymopping Suction • • • Tissue spearmethod-drymopping Ear drops Schedule • • • • • • • • • • • • • Children <5yearsofage,advisetobe reviewedandtreateddailyfor7days If notdryinginolder childrenconsiderdailytreatment intheclinic.Suctionunderdirectvision is dry startsdischarging again Encourage parents/carers toreturnaclinicearlyifdischarge becomesworseoranear that was Form drops havebeeninstilledtoassistthethroughperforation Use ofcottonwoolasa‘plug’isnot advisedasitjustsoaksupthemedicine.Letexcessrunout Keep thepatientinpositionforseveral minutes Apply Instil theeardrops Clean anddrytheearcanalwithtissuespears The patientshouldbesittingorlyingdownwiththeaffectedearupwards and training.Significantdamagecanoccurifuntrainedstaffperform suctioning Suction underdirectvisionisthemosteffectivetechniquebutthisrequires specialequipment Perform atleasttwiceperdayuntiltheearisdry Leave inplacefor30secondsthenremoveandrepeatwithafreshtissueuntiltipisdry Insert intoeargently,twistingslowly Make aspearbytwistingcorneroftissuepaper Tissue spearsshouldbeusedformanagingchronicsuppurativeotitismedia ear discharges.Thetissuepaperactivelyabsorbsthemoisture This canbedonesafelybyachildontheirownortheparent.Itshouldwhenever 3 tragalpressurebypressingseveraltimesontheflapofskininfront ear canalafterthe Strength 0.3% 4 Cleaning techniques administration Route of Ear Foradministrationtips Ciprofloxacin 1,3 forearswithchronicdischarge Instil 5dropsinaffected Child ≥1month Recommended dosage ear bd see Cleaningtechniquesforearswith ATSIHP/IHW/IPAP/RIPRN Until theearhasbeendry Extended authority Max. 9dayssupply for atleast3days Duration 1,2,3,4 Ears 721 -
- 712 Ear | Ear Section 8: Paediatrics problems - child https://publications.qld.gov.au/dataset/chronic-condi 708 Acute otitis media (AOM) with/without perforation, page Acute otitis media (AOM) with/without perforation, http://www.careforkidsears.health.gov.au/internet/cfke/ Not applicable Chronic Conditions Manual: Prevention and Management of Chronic and Management of Manual: Prevention Chronic Conditions available from: available from: 1 1 ’ ® for ongoing child health checks for ongoing 1
attic retraction or perforation, suspicion of cholesteatoma or non-resolving discharging ear suspicion of cholesteatoma or non-resolving attic retraction or perforation, Ear and hearing assessment, page
Consult MO/NP as above Where prolonged medical therapy fails i.e. > 6 weeks, or frequent painful AOM, the MO/NP may As per MO/NP instructions can be custom built or made from silicone putty, cotton wool with petroleum jelly or adhesive putty can be custom built or made from silicone putty, e.g. ‘Blu-Tack Use the national ‘Care for Kids Ears’ website and resources to support families, health profession Use the national ‘Care for Kids Ears’ website and als and early childhood educators: publishing.nsf/Content/Home ear plugs with a swimming cap. Effective ear plugs Advise no swimming. If this is not possible use Treat as per acute otitis media. See treatment Consult MO/NP as per AOM if not responding to Document the size and position of grommet on a diagram in the case notes Document the size and position of grommet on See Perform standard clinical observations (full CEWT score or other local Early Warning and Response Perform standard clinical observations (full CEWT Tools) Perform physical examination Obtain a complete patient history Recent history of swimming (water immersion) without earplugs Recent history of swimming grommet, fever or URTI Discharge of pus from a History of insertion of grommet in 1 or both ears History of insertion of grommet Refer to a Speech Pathologist if speech, language, learning or behaviour issues exist if speech, language, learning or behaviour Refer to a Speech Pathologist Note: an ENT Specialist requires urgent referral to See the current edition of the See the current Australia Conditions in tions-manual Review weekly thereafter until ear is dry until weekly thereafter Review antibiotics for IV admission MO/NP. Consider consult an to discharge continues If the ear dries review at 3 months When the ear very useful to clear the ear if clinics have the equipment and staff have experience and training and experience have and staff equipment the have if clinics ear the to clear useful very
• • • • • • • • • • • • • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management
3. Clinical assessment 2. Immediate management 1. May present with Ear discharge in the presence of grommets Ear discharge in 6. Referral/consultation 722 Ears 2. Immediatemanagement 1. Maypresentwith Dry perforation | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management 3. Clinicalassessment • • • • • • • • • • • • • • • • • • • measures aretakentosupportthechild’s learningenvironment.e.g.soundfieldsamplification For hearingimpairedschoolchildren ensure(withparentalconsent)theschoolisnotified,so Speech Pathologistforallpatientswith language,learning,speechorbehaviouralproblems Full audiologyassessment-otoscopy, tympanometryandaudiometrytodeterminelevelofhearing – – – Refer toENTSpecialist: Follow upasperAudiologist/ENTSpecialistcareplan Advise patientstoattendtheclinicforantibioticsifanyepisodesofdischarge occur Consult MO/NPifperforationintheatticregion of waterorbyusingproofearplugs Discuss withparent/carer/patienttokeepearsdry,especiallywhenbathing,bykeepingheadout See Document thesizeandpositionofperforationonadiagramincasenotes Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand Document lengthoftimeperforationhasbeenpresent Ask abouthearing,learning,behaviour,speechandlanguage Obtain acompletepatienthistoryandperformphysicalassessment Concerns withbehaviour,listening,learningorspeechandlanguagedevelopment Decrease inhearing Perforated eardrum(hole)withoutanydischarge student placement measures tosupportthechild’slearningenvironment.e.g.soundfieldsamplificationsystemand For hearingimpairedschoolchildrennotify(withparentalconsent)theschool,sotheycantake ment, learningdifficultiesorthechildhashadrecurrentAOM Refer foraudiologyandspeechpathologyifconcernsabouthearing,speech,languagedevelop refer toENTSpecialist system andstudent placement – – – those withsignificantconductivehearing loss(>20dB)orrecurrentinfections all children>6yearswithadryperforationpersistingformonths perforation inatticregionoftheeardrum Ear andhearingassessment,page 1 1 -adult/child 1 1
1
Notapplicable
708 - Ears 723 Ear | Ear Section 8: Paediatrics problems 708 2,3 - adult/child 1,2,3,4 Ear and hearing assessment, page
focal granulation on the surface of the drum, especially at the periphery focal granulation on the surface of the drum, especially perforation in the attic region white mass behind an intact eardrum and skin debris a deep retraction pocket with or without granulation dizziness, ache behind the ear especially at night dizziness, ache behind face - requires urgent management muscle weakness of the discharge associated with a foul odour from the ear discharge associated with of the eardrum history of chronic perforation in a previously operated ear new onset of hearing loss white mass behind eardrum on otoscopic examination white mass behind eardrum – – – – – – – – – – diagnosed early may have no symptoms. Otherwise may present with: diagnosed early may have If suspected refer immediately to ENT Specialist immediately refer If suspected dysfunction and the on early recognition and success is highly dependent is treated surgically Cholesteatoma extent of the lesion Cholesteatoma is a keratinised mass in the middle ear or mastoid usually acquired in those with usually acquired in the middle ear or mastoid is a keratinised mass Cholesteatoma tube perforation or eustachian and/or chronic middle-ear acute otitis media a history of recurrent Refer to ENT Specialist. Paediatrician may assist in getting early ENT appointment If confirmed, surgical treatment is required If suspected refer immediately to ENT Specialist – – See Otoscopic examination may reveal: – – Obtain a complete patient history and perform physical examination Obtain a complete patient history and perform physical score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) Consult MO/NP for referral to Paediatrician or ENT Specialist Consult MO/NP for referral to Paediatrician or ENT – – – – – If –
• • • • • • • • • • • •
Recommend Background 6. Referral/consultation
5. Follow up 4. Management
3. Clinical assessment 2. Immediate management
1. May present with Cholesteatoma Cholesteatoma 724 Ears .Maypresentwith 1. | Primary Clinical Care Manual 10th edition | Referral/consultation 6. Followup 5. Management 4. Clinicalassessment 3. Immediatemanagement 2. HMP Acute mastoiditis -adult/child Background Recommend • • • • • • • • • • • • • • • • • • and ResponseTools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarning Urgent referraltoPaediatricianand/or ENTSpecialist As perdischargeorders First doseofantibioticsmayneedtobeadministeredpriorevacuation – – Consult MO/NPwhowillarrange: Administer analgesiaasclinicallyindicated.See See Earandhearingassessment,page Palpate theocciput,aroundearsandbothsidesofneckforlymphglands Note anyswellingorwarmtharoundthemastoidbone-describe Palpate behindtheear.mastoidtipnotinganytenderness Obtain acompletepatienthistoryandperformphysicalexamination Consult MO/NPimmediately Dizziness ortinnitus(ringingintheears)maybepresent The earmaybepushedawayfromtheheadbyswellingofmastoidarea behind theear) Pain, swellingandtendernessabovebehindtheearovermastoid(bonyprominence Systemic featureswithfeverandrigors Mastoiditis isinflammationinthemastoidaircellsandtypicallyoccursafteracuteotitismedia Urgent referraltohospitalwithPaediatricianand/orENTSpecialistformanagement – – discuss antibioticregimenwithInfectiousDiseaseSpecialist urgent referraltohospitalwithPaediatricianand/0rENTSpecialistformanagement 1 1 1 708 Acute painmanagement,page35 Ears 725
35
OR Ear | Ear Section 8: Paediatrics problems
OR Acute pain management, page ®
708 Not applicable - adult/child tropical ear tropical
1,2 1 Ear and hearing assessment, page flumetasone 0.02% + clioquinol 1% ear drops/wick triamcinolone compound ointment ear wick to prevent further acute bacterial infection dexamethasone + framycetin + gramicidin ear drops/ear wick Otitis externa Otitis
– – – Otitis externa can become chronic or recurrent, especially in hot humid climates recurrent, especially in can become chronic or Otitis externa The ear canal should be kept as dry as possible. Remove discharge or other debris from the ear or other debris as possible. Remove discharge should be kept as dry The ear canal with water not by syringing dry aural toilet (tissue spear), canal with a
– – built-up wax with a wax softener e.g. Waxsol Gently dry mop the ear canal followed by: – Using drying acetic acid ear drops e.g. Aquaear®/Vosol®, after swimming and showering will help Using drying acetic acid ear drops e.g. Aquaear®/Vosol®, present prevent recurrence. Do not use if grommets or perforation buds out of their ears. If necessary remove Advise patient to keep foreign objects such as cotton Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See dry for at least 2 weeks after treatment and General prevention involves keeping the ear canal protected by a lining of wax Advise not to swim until healed Consult MO/NP if fever, cellulitis or enlarged pre/post auricular lymph nodes Consult MO/NP if fever, cellulitis or enlarged pre/post be seen with fungal hyphae looking like wet blotting paper or dry like cotton wool or the infection be seen with fungal hyphae looking like wet blotting and normal but is itchy may be suspected even if the canal looks clean See Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Perform standard clinical observations (full Q-ADDS/CEWT Response Tools) gently Movement of the pinna is often very painful; approach chronic fungal infection present. This infection may Patients with recurrent infections often have a Obtain a complete patient history and perform a physical examination Obtain a complete patient history and perform a Foreign body/debris may be present Foreign body/debris may Ear pain (sometimes severe) or itch Ear pain (sometimes severe) Discharge not always present or fullness Ear blockage, deafness Tender, swollen outer ear and ear canal Tender, swollen outer ear Pain if outer ear manipulated Canal redness and peeling
• • • • • • • • • • • • • • • • • • • • •
Recommend Background
HMP 4. Management
3. Clinical assessment 2. Immediate management 2. Immediate management
1. May present with Swimmer’s ear or ear Swimmer’s 726 Ears | Primary Clinical Care Manual 10th edition | Note: Ciprofloxacineardropsarepreferredifeardrumperforationcannotbe excluded balance; stopusingthismedicationandreport.Allergicdermatitisafter prolongeduseiscommon Provide ConsumerMedicineInformation: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency:ConsultMO/NP.SeeAnaphylaxis,page 102 Schedule Technique Materials • • drops • • • • • • • Form suppurative otitismedia(CSOM),page719 For eardropadministrationtips,seeCleaningtechniquesforearswithchronicdischargein See Earwicktechniqueforotitisexternabelow Ear If usingcommercialearwickfollowmanufacturer’sinstructions OR should becomfortable.Ifthepatienthasincreasedpain,wickremoved If thereistoomuchribbon,theexcesstrimmedwithscissors.Onceinplace,patient gently pullingtheearbackwards upwards. Theearcanalis2.5cmlonginanadult.Forchildren,thestraightenedby 1 cmatatime.Foradults,theearcanalisstraightenedbygentlypullingbackwardsand The endoftheimpregnatedstripisgraspedwithforcepsandgentlyfedintoearcanal, ointment alongitslength The ribbongauzeislaidalongawoodentonguedepressorandimpregnatedwithdropsor Non-toothed forcepse.g.nasalpacking Ribbon gauzeapproximately10cminlengthforanadultorcommercialearwick Ear drops/earointmentaspermanagement
Dexamethasone 0.05% 4 Gramicidin 0.005% Framycetin 0.5% Strength Dexamethasone +framycetingramicidin Ear wicktechniqueforotitisexterna (Otodex®, Sofradex®) administration Affected ear May causeringing in the ears, hearing loss and difficulty with Route of Soak earwickin Recommended (severe cases) 3 dropstds dosage drops OR 1,2 ATSIHP/IHW/IPAP/RIPRN Continue untilafewdays (no longerthan2weeks) after symptomshave Extended authority disappeared Duration Chronic 1,3 Ears 727 1
1,4
RIPRN RIPRN Duration IHW/IPAP/ then review Duration / IHW/IPAP/ disappeared / ear canal for 1-3 days Leave wick in affected Extended authority Extended 102 102 after symptoms have after symptoms Extended authority ATSIHP (no longer than 2 weeks) Continue until a few days Continue until ATSIHP dosage ointment Ear | Ear Section 8: Paediatrics problems Recommended Soak ear wick in OR Anaphylaxis, page Anaphylaxis, page )
years ) ® ® 3 drops bd
(severe cases) Adult and child > 2 Adult and child Soak ear wick in drops Recommended dosage Recommended Route of
Affected ear administration (Kenacomb Otic Allergic dermatitis after prolonged use is common Allergic dermatitis after May cause ringing in the ears, hearing loss and difficulty with May cause ringing in the ears, hearing loss and Triamcinolone compound Triamcinolone compound Consult MO/NP. See Consult MO/NP. See (Locacortin vioform (Locacortin Route of Flumetasone + clioquinol Flumetasone Affected ear administration 4 Strength 4 Neomycin 0.25% Gramicidin 0.025% Triamcinolone 0.1% Coprofloxacin ear drops are preferred if ear drum perforation cannot be excluded are preferred if ear drum perforation cannot be Coprofloxacin ear drops Strength Nystatin 100,000 units/g Clioquinol 1% Flumetasone 0.02% Flumetasone
Ear : Ciprofloxacin ear drops are preferred if eardrum perforation cannot be excluded : Ciprofloxacin ear drops are preferred if eardrum As per MO/NP orders Advise to see MO/NP at next visit if ear canal not back to normal at 1 week or if recurrent Advise to see MO/NP at next visit if ear canal not Advise to be reviewed in 2 days and in 1 week Advise to keep ears dry until healed Form Ear Schedule Form
drops ointment • • • • Schedule Management of associated emergency: Management of associated ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed Management of associated emergency: RIPRN may proceed ATSIHP, IHW, IPAP and RN must consult MO/NP Provide Consumer Medicine Information: Provide Consumer Medicine Contraindication: Provide Consumer Medicine Information: Medicine Consumer Provide Allergic dermatitis after prolonged use is common balance; stop using this medication and report. Note
6. Referral/consultation 5. Follow up 728 Ears 2. Immediatemanagement 1. Maypresentwith | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management 3. Clinicalassessment HMP • • • • • • • • • • • • • • • Related topics Head injuries,page Consult MO/NPonpresentationand ifperforationnothealedin2weeks If perforationnothealedin2weeks, consultMO/NP Ask toreturnforreviewin2daysandthenweekly patients requiresurgicalintervention The majorityoftraumaticperforationshealspontaneouslywithoutany intervention, andonlyfew Antibiotic eardropsarenotnecessaryifholewascausedbydrytrauma (blowtohead) The earshouldbekeptdryuntilhealed water Consult MO/NPwhowilladviseantibioticeardropsifwaterpenetrated theperforatione.g.fallinto Administer analgesiaasclinicallyindicated.See See Response Tools) Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorotherlocalEarlyWarningand – – – – Obtain acompletepatienthistoryandperformphysicalexamination: Manage anylifethreateninginjuries Dizziness andnausea Pain intheear,reducedhearingand/orbleedingfromear – – – A historyoftheinjuryforexample: – – – – – – – Traumatic note otherinjuriesifpresent does thepatienthavedecreasedhearing time, dateofoccurrenceandwhenfirstnoticed ask aboutthecircumstancesandmechanismofinjury water forcedintoeare.g.afallfromheight penetrating injurye.g.asharpstick a blowtothesideofheadoranexplosione.g.pressurewave Ear andhearingassessment,page
1,2 175 rupture oftheeardrum 1 1 708 Acute painmanagement,page -adult/child 35 Ears 729 35 Dexamethasone + framycetin + Ear | Ear Section 8: Paediatrics problems 708 Acute pain management, page - adult/child Not applicable insect in ear insect Ear and hearing assessment, page Ear and hearing assessment, 1 See 725 1,2 ear drops 1
Foreign body/ Foreign The main danger of a foreign body in the ear lies in its careless removal the ear lies in its careless of a foreign body in The main danger
gramicidin drops or cooking oil introduced by the blunt end of a syringe or via a cut-off ‘butterfly’ needle, or drops or cooking oil introduced by the blunt end water other plastic tubing. Then gently syringe with warm complication of foreign body removal and Ear canal abrasion or laceration is the most common consider occurs in up to 50% of patients. If ear canal is traumatised Larger foreign bodies and those further down the canal require special equipment and training for Larger foreign bodies and those further down the Send to hospital with ENT facilities removal and may even require a general anaesthetic. by first instilling lidocaine (lignocaine) 1% 2-3 Live insects in the ear canal should be immobilised Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See can be easily removed using e.g. nasal packing Small objects seen to be near external ear opening forceps Examine the ears. Obtain a full history including circumstances: accidental, purposeful, incidental finding circumstances: accidental, purposeful, incidental Obtain a full history including local Early Warning and observations (full Q-ADDS/CEWT score or other Perform standard clinical Response Tools) Foreign body in ear canal such as an insect, gravel or a twig Foreign body in ear canal
• Otitis externa, page Otitis externa, Related topics • • • • • • • • •
Background
HMP 4. Management 3. Clinical assessment 2. Immediate management 2. Immediate management 1. May present with 730 GastrointestinaL | Primary Clinical Care Manual 10th edition | Maypresent with 1. Vomiting anddiarrhoea Gastrointestinal problems Referral/consultation 6. Followup 5. HMP Acutegastroenteritis/dehydration-child suppurative otitismedia(CSOM),page Ear dropadministrationtips:SeeCleaningtechniquesforearswithchronicdischargeinChronic balance; stopusingthismedicationandreport.Allergicdermatitisafterprolongeduseiscommon Provide Consumer Medicine Information: RIPRN mayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociatedemergency:ConsultMO/NP.SeeAnaphylaxis,page102 Note: Ciprofloxacineardropsarepreferredifdrumperforationcannotbeexcluded Schedule Recommend • • • • • Related topics Giardiasis, page738 • • drops Form osl MO/NP Consult See If foreignbodyorinsecteasilyremoved,asktoreturnforreviewin2days Lethargy oraltered levelofconsciousness,floppy,unresponsive orfitting Diarrhoea andvomiting; considerotherdiagnosesifpersistent/bilious vomitingandnodiarrhoea Ear – – – High riskchildreninclude: Contact MO/NPimmediatelyifinfantis<3monthsofage – – – managing athome where socialconditionsareconcerningand/ortheparentsmayhave difficulty those withcongenitalorchronicconditionse.g.cardiac,gastrointestinal orneurological excessive diarrhoeawith>8waterystoolsin24hours Otitis externa,page725ifsecondaryinfectionoccursafterremoval Dexamethaxone 0.05% 1,2 4 Gramicidin 0.005% Framycetin 0.5% Strength Dexamethasone +framycetingramicidin (Otodex®, Sofradex®) 719 administration Lactose intolerance,page736 Affected ear May causeringingintheears,hearinglossanddifficultywith Route of Recommended 3 dropstds dosage ATSIHP/IHW/IPAP/RIPRN Extended authority Duration 3-7 days 3 Gastrointestinal 731 785 54 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems Glasgow Coma Scale/AVPU, page Glasgow Coma Scale/AVPU, 1,2,3,4 DRS ABCD resuscitation/the collapsed patient, page DRS ABCD resuscitation/the
recent travel overseas blood or mucous in the stool, severe prolonged diarrhoea (> 7 days) suspicion of septicaemia degree of dehydration. See Clinical assessment of hydration in child table below degree of dehydration. See Clinical assessment abdominal distension, guarding, rigidity contact with other sick people and children day care attendance past history of diarrhoea or other illnesses or infections abdominal pain contacts similar household illnesses or with other social recent antibiotic use weight loss urine output if known, number of wet nappies has any home treatment/medicine been given vomiting - how much and for how long, is there bile vomiting - how much and for how long, is there fluid intake - how much and what type eaten and what, changes in appetite recent diet history - how much food has the child weight - bare weight if < 2 years. Assess against recent weights weight - bare weight if < 2 years. Assess against or semi formed, is there blood or mucous diarrhoea - how much and for how long, is it watery < 1 year with > 45 respirations/min < 1 year with > 35 respirations/min 1-4 years with > 30 respirations/min 5-11 years with > 25 respirations/min ≥ 12 years with – – – – – – – – – – – – – – – – – – – – – – –
– Consider a faeces specimen for MCS and ova, cysts and parasites (OCP) and viral studies if: Consider a faeces specimen for MCS and ova, cysts – – Perform a complete physical examination with particular attention to: Perform a complete physical examination with particular – – – – Did the child receive rotavirus vaccine – – – – – – – – – – Tools) + – Obtain a complete history including: – Perform standard clinical observations (full CEWT score or other local Early Warning and Response Perform standard clinical observations (full CEWT Monitor conscious state closely. See Monitor conscious state of age if any risk factors present or child is < 3 months Consult MO/NP immediately according to MO/NP advice Commence rehydration See Fever or rash Dehydration Abdominal distension – – – – High pitched or weak cry or weak High pitched well Not feeding Increased RR: Irritability • • • • • • • • • • • • • • • •
3. Clinical assessment 2. Immediate management 732 GastrointestinaL | Primary Clinical Care Manual 10th edition | 4. Management Management Urine output Extremities Capillary return Pulse Respiratory rate Thirst Skin turgor Mental state Mouth andtongue Eyes andfontanelle Clinical assessmentof • • • • • • need topresentearlycliniciftheir childdisplaysanygastrointestinalsymptoms Alert otherparentsofyoungchildren inthecommunityofcurrentgastrointestinalillnessand and familysituation Place childoncareplanwithindividualisedreview,fluidbalanceandweighs accordingtoseverity – – Avoid using: Consider ondansetronifvomitingishinderingoralrehydration.See electrolytes. Takebloodsearlierifindicated Children andbabieswithwaterydiarrhoealasting>2-3daysshouldhave bloodstakenfor – – – Consult MO/NPimmediatelyforchildrenwith: Clinical feature – – – – – antibiotics (rarelyindicated) anti-diarrhoeal agents < 3monthsofage moderate/severe dehydration risk factors 2,3,5 hydration inchild thirsty, mayrefusefluids Drinks normally,maybe Clear tostrawcoloured Can usuallybetreated at homeorwithclose monitoring byPHCor Warm handsandfeet rural/remote facility Normal toreduced Minimal <3% (≤ 2seconds) Normal Normal Normal Normal Normal Moist Alert 4
Yellow/orange coloured Mild tomoderate3-9% Cool handsandfeet urgent rehydration urgently. Requires Normal toirritable Recoil <2seconds Consult MO/NP nasogastric/IV Mildly sunken (> 2seconds) Increased Reduced Delayed Thirsty Fast Dry
Nausea andvomiting,page Cold, mottled,cyanosed Irritable, lethargic,or Dark orange/brown urgently. Requires decreased levelof Recoil >2seconds Minimal toanuric Consult MO/NP hands andfeet consciousness Deeply sunken resuscitation Drinks poorly (> 3seconds) Very delayed Severe >9% Fast, weak Fast/deep Parched
48 Gastrointestinal 733 Consider ondansetron Severe Consult MO/NP urgently Organise evacuation IV/intraosseous insertion mL/ Commence bolus of 20 kg sodium chloride 0.9% ® • • • • Yes , Pedialyte ® 2,4,5 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems No , Hydralyte ® Mild to moderate Assess dehydration Requires urgent rehydration - NG/IV MO/NP may organise evacuation Consult MO/NP urgently Vomiting prominent? Vomiting • • • 736 - Lactose intolerance, page Minimum reconstitute oral rehydration fluids with cooled boiled water reconstitute oral rehydration fluids with cooled aim to resume usual full-strength formula/diet within 24 hours offer age appropriate foods at meal times if diarrhoea is present see continue to offer bland solids i.e. rice cereal, potato or pumpkin if diarrhoea is present continue to offer bland solids i.e. rice cereal, potato fluid if child still vomiting replace formula and usual drinks with oral rehydration continue breastfeeding on demand or at least every 2 hours continue breastfeeding on demand or at least every breast feeds offer water or oral rehydration solution between avoid solids if the child is vomiting 24 hours offer solids when vomiting has stopped or after breastfeeding/bottle feeding and lemonade (1:5) with water if oral diluted commercial cordials (1:20), fruit juice drinks rehydration fluids not available oral rehydration fluids e.g. Gastrolyte – – – – – – – – – – – – – frequently Continue breastfeed ing/bottle feeding Assist carers to give child small amounts of oral fluids – – – – – For bottle-fed infant and older child: – – – – – Consider early NG rehydration in these children if oral replacement is not successful Consider early NG rehydration in these children staff or family Maintain a record of fluid intake and output - by For breastfed infants: Continue to offer fluids even if the diarrhoea seems to get worse Continue to offer fluids even if the diarrhoea seems if significant ongoing vomiting and/or diarrhoea Can be monitored and cared for at home, however the MO/NP occurs, child should return and be reviewed by – – Keep child drinking small amounts of fluids often. Use: Keep child drinking small amounts of fluids often. – Management of dehydration in children flowchart in children of dehydration Management • • • • • • • • • Minimal dehydration < 3% loss of body weight 734 GastrointestinaL | Primary Clinical Care Manual 10th edition | Severe dehydration>9%lossofbodyweight Mild tomoderatedehydration3-9%lossofbodyweight • • • • • • • • Weight kg Ongoing fluidinputshouldbemanaged inconsultationwithaPaediatrician – – – – – Consult MO/NPurgentlywhomayconsider: Evacuation required Monitor consciousstateclosely Continue tobreastfeed,formulafeedand/oroffersolidsaspermilddehydration Discuss ongoingmanagementwithMO/NPafter4hours – – – Consult MO/NPwhomayconsider: If notbeingevacuatedchildmustbemanagedinappropriatelyequippedandstaffedfacility – – – – – – – – if hypoglycaemicgivingIVglucose10%. See monitor fluidbalance commencing afluidresuscitationregimeaccordingtofollowingtable taking bloodsforUE,glucose,acidbase inserting IV/intraosseous.See monitoring child’sobservationsclosely commencing afluidbalancesheet 50-100mL/kg overthefirst4hours commencing oral/NGrehydrationtherapy.Seebelowtableforvolumes 20 30 10 12 15 8 6 9 4 3 7 5 Guide fororal/NGfluidreplacementmildtomoderatedehydration3-9% mL/hour forthefirst6hours 200 300 100 120 150 80 60 90 40 30 70 50 Intraosseous infusion,page Hyperglycaemia, page mL/hour from6hoursonwards 69 113 60 90 20 40 30 70 85 50 65 45 35 55 6 OR provide Gastrointestinal 735
2,4,5 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems Fluid resuscitation regimen for severe > 9% dehydration severe > 9% regimen for Fluid resuscitation baked beans lean meat and fish eggs fruit and vegetables peanut paste – – – – – – – – for children > 6 months of age encourage parent/carer to offer extra healthy foods until normal for children > 6 months of age encourage parent/carer weight is regained. Healthy foods that replace lean body tissue after weight loss include: – – continue to breastfeed, bottle feed and offer solids as per normal age-related recommendations continue to breastfeed, bottle feed and offer solids weight loss an episode of acute gastroenteritis may result in breastfeeding should be maintained during the acute phase and through any subsequent breastfeeding should be maintained during the lactose intolerance avoiding fatty or high sugar foods if the child has an appetite, eating should be encouraged, and drinks acute gastroenteritis can result in transient lactose intolerance. Formula fed babies may need acute gastroenteritis can result in transient lactose sufficiently to digest and absorb lactose lactose free formulas until the baby’s gut recovers fed babies get sufficient fluids it is particularly important to ensure that formula poor appetite is normal during the acute phase of the illness - during this time, ensure fluid poor appetite is normal during the acute phase intake is sufficient will want to feed more often when they are babies and young children who are breastfeeding more frequently sick - this is normal. Support mother to breastfeed has green vomit you are worried for any other reason is dehydrated e.g. not passing urine or reduced urine output, is pale and has lost weight, is dehydrated e.g. not passing urine or reduced up sunken eyes, cold hands and feet or is hard to wake has stomach pain has any blood in the faeces is not drinking and still has vomiting and diarrhoea
sodium chloride 0.9% + 5% glucose sodium chloride – – – – – – – – – – – – – – – – Nutrition after gastroenteritis: – – – – – – – – – – Nutrition during gastroenteritis: – – – vomiting has stopped for at least 24 hours vomiting has stopped for Return to clinic if child: – Avoid medicines to reduce vomiting and diarrhoea Avoid medicines to reduce drink e.g. cup, ice block, bottle, syringe Use methods to help children until the diarrhoea and children, including child care and/or school, Keep child away from other Discuss hand washing, personal hygiene, avoiding food preparation and public swimming pools personal hygiene, avoiding food preparation and Discuss hand washing, has settled until diarrhoea and vomiting to normal for 2 weeks Bowel actions may not return
Contact MO/NP for ongoing fluid orders Contact MO/NP Reassess shocked bolus of 20 mL/kg if still Give second sodium chloride 0.9% fluids in children include or replacement Ongoing maintenance OR 20 mL/kg bolus sodium chloride 0.9% 20 mL/kg bolus • • • • • • • • • • • • Initial treatment: Initial •
Advice to parent/carer(s):
736 GastrointestinaL 6. Referral/consultation 5. Followup | Primary Clinical Care Manual 10th edition | 2.Immediate management 1. Maypresentwith Lactose intolerance Background Recommend • • • • • • • • • • • Related topics Acute gastroenteritis/dehydration-child, page • • • • • • Stool maybe‘frothy’ Chronic diarrhoea,bloating,vomiting, irritability https://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-communic-1 dataset/chronic-conditions-manual and ManagementofChronicConditionsinAustralia Refer toPoorgrowthinchildrenthecurrentedition nurse ornextMO/NPclinic Children withweightlossorpoorgainwhoarenotacutelyunwell-refertochildhealth can resultinpoorappetiteandgrowthfailure Refer toMO/NPifhealthygrowthisnotresumedwithin4weeks-repeatedorchronicinfections Monitor weeklytoensurehealthygrowthisresumed 673 If diarrhoeacontinuesbeyond10days,seechronicin Babies mayrequirethisearlier Children withwaterydiarrhoealastinglongerthan2-3daysshouldhavebloodstakenforUE. concerned thatthechildisworse If notevacuated,allchildrenshouldbereviewedthefollowingdayorearlierifparent/careris Excoriated perianal area(duetodiarrhoea) when causedbyrotavirus.Itisusuallyofshortduration In youngchildrenlactoseisacommontransientcomplicationofgastroenteritis, inparticular pain, bloating,diarrhoeaand/orvomiting Any incompletelyabsorbedlactoseisfermentedbybacteriainthelarge bowel causingabdominal deficiency ofthelactaseenzyme Lactose intoleranceoccurswhenthegastrointestinaltractisunable to absorblactosedue Consider othercausesofchronicdiarrhoea Use lactose-freeformulasforartificiallyfedinfants Continue breastfeedingbreastfedinfants – – ConsidernotificationtoyourPublicHealthUnit.RefertheCommunicableDiseaseswebsite: – – wholegrain cerealslikeWeet-Bix cheese andyoghurt 1,2 1,2 1,2,3,4 -child
Notapplicable ® 730 availablefrom: Chronic ConditionsManual:Prevention Differential diagnosis - child, page Differential diagnosis-child,page https://publications.qld.gov.au/ Gastrointestinal 737 ® or O-Lac ® 730 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems Acute gastroenteritis/dehydration - child, page Acute gastroenteritis/dehydration 1,2
cheese; cottage, cream, any soft cheeses cream ice-cream custards milk; cow, goat, full cream, low fat, skim, powdered yoghurt breast milk advice from MO/NP need to be used as a short-term measure on a low lactose formula may in some breastfed children lactose intolerance can continue longer because of the lactose in lactose intolerance can continue longer because in some breastfed children inspect the perianal area for signs of excoriation inspect the perianal area hydration status. See or guarding palpate abdomen for tenderness weight - bare weight if < 2 years. Assess against recent weights weight if < 2 years. Assess weight - bare symptoms reoccur upon reintroduction of dairy products after a trial of a lactose-free diet of a lactose-free after a trial dairy products of upon reintroduction reoccur symptoms – – – – – – – – – – – – –
Consult MO/NP on all occasions lactose intolerance suspected Consult MO/NP on all occasions lactose intolerance Dietitian if available Consult MO/NP if diarrhoea persists clinic Advise to see next Child Health Nurse or MO/NP If symptoms recur, revert to lactose free formula and try again in 2-4 weeks If symptoms recur, revert to lactose free formula lactose free formula Ask to return for review 1-2 days after starting on For formula fed infants consider lactose free formulas such as De-Lact For formula fed infants consider lactose free formulas with 1/3 normal to 2/3 lactose free and Reintroduce normal formula after 2-4 weeks starting 3-4 days increasing the proportion of normal formula over – – – Temporarily avoid or reduce lactose based formulas and dairy products: Temporarily avoid or reduce lactose based formulas – – – – the child continues to have diarrhoea Encourage extra fluids if Discuss with the MO/NP or child health nurse if lactose intolerance is suspected Discuss with the MO/NP continue to be breastfed: Breastfed infants should – – (unabsorbed sugars) to rule out other causes of symptoms sugars) to rule out other (unabsorbed with emphasis on: physical examination Perform a complete – – Tools) + – (OCP) and reducing substances ova, cysts and parasites specimen for MCS, Collect a faeces Obtain a complete patient history: a complete Obtain – and Response local Early Warning (full CEWT score or other clinical observations Perform standard
• • • • • • • • • • • • • • • •
6. Referral/consultation 5. Follow up
4. Management 3. Clinical assessment Clinical 3. 738 GastrointestinaL | Primary Clinical Care Manual 10th edition | 4. Management 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend • • • • • • • • • • • • • Related topics Acute gastroenteritis/dehydration-adult,page Acute gastroenteritis/dehydration-child,page • • • – with: Treat allpatientsoncelaboratoryresults confirmspresenceofcysts,whethersymptomaticornot, Encourage oralfluids Discuss withMO/NP – – – Perform acompletephysicalexaminationwithemphasison: Collect 2faecesspecimenforMCSandova,cystsparasites(OCP) – Response Tools)+ Perform standardclinicalobservations(fullQ-ADDS/CEWTscoreorother localEarlyWarningand – – If prolongeduntreatedasymptomaticepisodesthen: Nausea, poorappetite Abdominal distension,flatulence Abdominal cramps Chronic diarrhoea,frequentlooseandpalegreasystool Foul smellingwaterydiarrhoea – – If symptomsdonot resolvethenreassessanddiscuss withMO/NPwhomayconsider: Giardiasis isoneofthemostcommoncausesdiarrhoeaworldwide of transmissionbutperson-to-personmayoccur Ingestion of Giardia protozoan cystsfromcontaminated water or foodis the most common route smelling diarrhoeaifsymptomsdon'tsettleaftertreatment Consider otherdiagnosesforabdominalpainandcrampinglarge-volume,watery,foul- – – – – – – – – – Giardiasis inspect theperianalareaforsignsofirritation palpate theabdomenfortendernessorguarding assess fordehydration.See weight -bareif<2years.Assessagainstrecentweights weight loss/poorgrowth anaemia a differentialdiagnosis repeat treatmentafter 24-48hours tinidazole 1,2,3 OR metronidazole -adult/child Acute gastroenteritis/dehydration-child,page Notapplicable OR 730 243 730
Gastrointestinal 739
1,2,3,4 1,2,3,5
RIPRN once 3 days Duration Duration IHW/IPAP/RIPRN / IHW/IPAP/ 102 102 / Extended authority Extended authority Extended ATSIHP ATSIHP
Anaphylaxis, page Anaphylaxis, page 2 g Child Adult Adult dosage 2 g daily hours for child Recommended Child > 1 month Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems Recommended dosage Recommended 50mg/kg to a max. of 2 g Tinidazole May need to repeat after 24-48 May need to repeat after 30 mg/kg to a max. of 2 g daily Metronidazole Avoid alcohol while taking and for 72 hours thereafter. Take Take thereafter. hours 72 for and taking while alcohol Avoid Avoid alcohol while taking and for 24 hours thereafter. Take Avoid alcohol while taking and for 24 hours thereafter. Consult MO/NP. See Consult MO/NP. See
Oral Oral Route of Route of 4 administration administration 4
Use metronidazole instead of tinidazole Use metronidazole instead 400 mg 200 mg 500 mg Strength Strength 200 mg/5 mL Schedule
Tinidazole tablets should be taken whole. If necessary, peel and crush the tablets, then weigh be taken whole. If necessary, peel and crush Tinidazole tablets should Consult MO/NP as above Consult MO/NP if diarrhoea not settling Provide education and advice concerning handwashing before handling food, eating and after toilet and avoid food preparation and public swimming pools until diarrhoea has settled Ask to return for review next day Schedule
Oral Form Form liquid Tablet Tablet • • • • the appropriate dose and mix with flavouring the appropriate dose and emergency: Management of associated metallic taste, dizziness or headache metallic taste, dizziness Use in pregnancy: Note: Provide Consumer Medicine Information: Provide Consumer Medicine pain, vomiting, diarrhoea, upset. May cause nausea, anorexia, abdominal with food to reduce stomach ATSIHP, IHW, IPAP and RN must consult MO/NP and RN must IHW, IPAP ATSIHP, RIPRN may proceed cause nausea, anorexia, abdominal pain, vomiting, diarrhoea, metallic taste, dizziness or headache cause nausea, anorexia, abdominal pain, vomiting, Management of associated emergency: Provide Consumer Medicine Information: liquid 1 hour before food for better absorption. May tablet with food to reduce stomach upset. Take oral RIPRN may proceed ATSIHP, IHW, IPAP and RN must consult MO/NP
6. Referral/consultation 5. Follow up 740 GastrointestinaL | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend • • • • • • • • • Related topics Anaemia, page • • • • • • • • • • – – – – Obtain acompletepatienthistory: Itchy skinwithredorpinktrackmarkssomestrongyloidesinfections Mild fever Abdominal pain,nausea,vomiting(highwormburden) Poor growth-strongyloidescancontribute Acute diarrhoea-strongyloides Anaemia - Presence ofwormsorwormsegmentsinfaecesaroundanus diarrhoea orpoorgrowth Perianal/perineal itch-pinworm(threadworm).Smallthreadlikewormmaybeseen.Doesn’tcause – – Intestinal Factsheet: Medicines fortreatmentofworminfectionsareusuallywelltolerated Strongyloides istransmittedthroughsoil Tapeworms aretransmittedbyfoode.g.undercookedpork Pinworms (threadworms)arecausedbypoorhygiene Strongyloides andotherwormsarecommoninNorthernAustralia Threadworm infectioniscommoninAustralia and intensityoftheexposuretoeggslarvae Disease fromwormsisdependentonthewormburden,locationofandduration Exclusion ofinfectedpatientsisnotusuallyrequired – – – Routine dewormingwithoutevidenceisnotrecommended.Indicatedin3situations: childhood – – – – – – have theybeenpreviously treatedforworms,ifsowhen andwithwhat is thechildonmedication do anyothermembers ofthefamilyorclosecontacthave signsorsymptoms length oftimesignsandsymptoms have beenpresent previous weights past episodes – – – loss/poor growth on thebasisoffaecesspecimenresult,sentaspartinvestigationforanaemiaorweight symptomatic children as partofacommunityeradicationprogram 1 hookworm http://conditions.health.qld.gov.au/HealthCondition/condition/8/121/661/worms-in- 749 worms 3 -adult/child Notapplicable 2 4 Gastrointestinal 741 5,8 once Duration Whipworm threadworm bd for 3 days Extended authority daily for 3 days Strongyloidiasis ATSIHP/IHW/IPAP/RIPRN treatment unsuccessful Hookworm, roundworm,
Repeat course after 7-14 days if
2 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems dosage 400 mg 200 mg Child < 10 kg Albendazole Recommended Adult and child > 10 kg Tablets may be crushed, chewed or swallowed whole. May swallowed or chewed crushed, be may Tablets Oral Route of 2,6 4 administration 5 400 mg 200 mg Strength
palpate the abdomen for tenderness or guarding abdomen for tenderness palpate the signs of irritation (if indicated) area for inspect the perianal/perineal weight - bare weight if < 2 years. Assess against recent weights recent Assess against if < 2 years. - bare weight weight Hb check (OCP) and OCPPCR ova, cysts and parasites specimen for MCS and collect a faeces albendazole OR mebendazole - if ≥ 6 months and not pregnant albendazole OR mebendazole pyrantel - if pregnant – – – – – – infection in immunocompromised patients Consult MO/NP for strongyloides Treat household contacts and carers at the same time to reduce risk of relapse and carers at the same time to reduce risk of Treat household contacts Reassurance, education and advice regarding handwashing, wearing shoes and personal hygiene and advice regarding handwashing, wearing shoes Reassurance, education and prevent reinfection should be cleaned well to destroy the ova Advise that house and clothing laboratory confirmation use: If treating worms without Acute abdominal pain, page 238 pain present. See Acute abdominal pain, page Consult MO/NP if abdominal Perform physical examination: Perform physical – – – – – – Perform standard clinical observations (full Q-ADDS/CEWT score or other local Early Warning and Warning Early local or other score (full Q-ADDS/CEWT observations clinical standard Perform Tools) + Response Schedule
Form Tablet • • • • • • • • Anaphylaxis, page 102 Management of associated emergency: Consult MO/NP. See ASTIHP, IHW, IPAP and RN must consult MO/NP RIPRN may proceed Provide Consumer Medicine Information: fever and abdominal pain cause nausea, vomiting, diarrhoea, headache, dizziness, for 1 month after treatment Note: Women should use contraception during, and Contraindicated: Ocular cysticercosis Use in pregnancy: Avoid during first trimester of pregnancy 4. Management 742 GastrointestinaL | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency: and headache.Tabletsmaybecrushed andmixedwithjam Provide ConsumerMedicineInformation: RN mayadminister;forsupplysee ATSIHP, IHW,IPAPandRIPRNmayproceed Oral liquid Use inpregnancy: cause nausea,vomiting,diarrhoea,headacheandabdominalpain Provide Consumer Medicine Information: RN mayadminister;forsupplysee ASTIHP, IHW,IPAPandRIPRNmayproceed Management ofassociatedemergency: Oral liquid Schedule Tablet Schedule Form Tablet Form 50 mg/mL Strength 100 mg/5mL 250 mg 125 mg Strength 100 mg Avoidduringfirsttrimesterofpregnancy 2 2 administration Route of administration Oral Route of Authority toadministerandsupplymedicines,page Authority toadministerandsupplymedicines,page Oral
ConsultMO/NP ConsultMO/NP.See Cancausenausea,vomiting,diarrhoea, abdominalcramps, Tabletsmaybecrushed,chewedorswallowedwhole.May
toamax.of1g Adult andchild Mebendazole Recommended Pyrantel 10 mg/kg > 1year dosage Child >6months child >6months Recommended and <10kg and >10kg Adult and dosage 100 mg 50 mg Anaphylaxis, page Repeat after7daysifheavyinfestation Consider repeatingdoseafter2weeks
Repeat doseafter2weeksif Repeat courseafter3weeks if treatmentunsuccessful daily for3days treatment unsuccessful Whipworm, hookworm, Threadworm Roundworm Extended authority Hookworm Extended authority ATSIHP ATSIHP Duration 102 once once bd for3days Threadworm roundworm Duration 9 9 once / / IHW/IPAP IHW/IPAP
5,7 5,6 Gastrointestinal 743 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems Not applicable 1,2,3 1,2,3 - child 1,2 1,2,3,4 social history including family routine, recent school or day-care entry, change in child’s behaviour and physical activity levels current stage and methods of toilet training current diet including food allergies, recent introduction of solids, cow’s milk or medicines fluid intake i.e. breastfed, formula fed or drinking from cup and how formula is prepared usual bowel pattern, stool colour, consistency and size, past episodes of constipation or usual bowel pattern, stool colour, consistency bowel motion encopresis (faecal incontinence), time since last parental expectations of ‘normal’ stool pattern urinary incontinence) urinary output including new enuresis (day or night medical history including delayed passage of meconium at birth (can indicate conditions such medical history including delayed passage of meconium early childhood) as Hirschsprung’s disease which can present throughout
– – – – – – – – Initial simple measures such as increasing dietary fibre and fluid intake, and encouraging regular such as increasing dietary fibre and fluid intake, Initial simple measures toileting may be sufficient Dietary and bowel habit discussions should be part of routine child health check visits for children discussions should be part of routine child health Dietary and bowel habit of all ages cycle of worsening constipation Faecal retention and stool withholding behaviour, low fibre diet, reduced fluid intake and Faecal retention and stool withholding behaviour, malnutrition are the most common causes painful bowel movements contributes to a Continued voluntary withholding of faeces to avoid Breastfed babies may defaecate once a week. This is not constipation Breastfed babies may defaecate soft stools. This is not of age can strain and cry before passing Healthy infants < 6 months constipation and will self-resolve Constipation is a delay or difficulty in defecation for ≥ 2 weeks that is characterised by infrequent, difficulty in defecation for ≥ 2 weeks that is Constipation is a delay or colon preventing a complete evacuation of the lower large, and/or painful stools in children < 4 years of age Constipation is common – – – – – – – Obtain a complete patient history including: – Hard painful stools - often small pellets Excessive straining at stool Soiling (encopresis) Consult MO/NP as above Consult MO/NP Advise to see MO/NP at next clinic if anaemia or weight loss/poor growth loss/poor or weight if anaemia at next clinic to see MO/NP Advise
• • • • • • • • • • • • • •
Recommend Background
3. Clinical assessment 2. Immediate management
1. May present with Constipation
6. Referral/consultation 5. Follow up Follow 5. 744 GastrointestinaL | Primary Clinical Care Manual 10th edition | 4. Management • • • • • • • • • • – School entry: – – – – – Toilet training: Encourage physicalactivity – – – – – – – Dietary interventions: – – – The mainprinciplesofconstipationmanagementareto: If faecalimpactionissuspected,alwaysconsultMO/NPorspecialist – – – – – – Consider possibleorganicproblemandreferforfurtherworkupif: – – – Perform acompletephysicalexaminationwithemphasistoinspect: – – Tools) + Perform standardclinicalobservations(fullCEWTscoreorotherlocalEarlyWarningandResponse If simple measures forconstipation areineffective considerstarting alaxative – – – – – – – – – – – – – – – – – – – – – – – – – – – – – smiling, laughing,cuddlingand/ora rewardforsittingonthetoiletisbeneficial,whethera this processshouldbefun,unhurriedandfreeofanxietyfortheparent and child encourage thechildtositroutinelyontoiletaftereachmealandattempt topassamotion eating ameal,especiallybreakfast take advantageofthegastrocolicreflex.Mostpeoplehaveurgetopass amotionafter of foodsandfluidsthatpromotesoftstools avoid excessiveamountsofcow’smilkwhichcanslowintestinalmotility anddiminishesintake dehydration andconstipation formula preparationmustbeinaccordancewiththemanufacturersrecommendations toavoid excessive dietaryintakecancauseconstipationinchildren pears (freshorpureed)pruneswillstimulatethegutgentlyandsoftenstools encourage drinkingplentyofwater encourage ahealthydietwithfruitandvegetableswholegraincereals transitioning tosolidsorfrombreastfeedingformulafeedingcanbrieflytriggerconstipation encourage goodtoiletingbehaviour empty therectum,ifimpacted,andkeepit adequately softenstoolstoeliminatefearofpainfulevacuation constipation doesnotimprovewithsimplemeasures there ismorethanjustastreakofbloodonthestool the childisnotgrowingwell there isanybilevomiting child hasvomitingandabdominaldistension child hasconstipationfrombirth sensation, skintags,analfissuresandbleeding anus andperianalarea-positionoftheanus,pressurestoolaroundperineal palpate abdomenformasses mouth, lookformouthulcer(s)andstateofteeth/gums plot growthandheight/length weight -bareif<2years.Assessagainstrecentweights teachers encourage parents todiscussmonitoringofanyconcerning bowelhabitswithcarersand changes todailyscheduleorembarrassment transitioning toschoolcantriggerconstipation duetoreluctanceusetheschooltoilet, children shouldavoidsittingonthe toiletforlongerthan10minutesatatime stool ispassedornot,toreinforcegood behaviour 1,2,3 on MO/NP advice
Gastrointestinal 745 , Movicol ® 1,2,3 Administration Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems ® : 10-15 mL orally, once daily : 20 mL orally, once daily : 20 mL orally, once daily Laxatives for children Laxatives for , OsmoLax ® If no regular stooling after 2-3 months 1-6 years > 6 years as required. Must remain upright for 2 hours Adjust the dose by 5 mL after the dose Junior divided doses (max. daily dose 60 mL) If 1-3 mL/kg orally, daily in to improve taste needed, mix with other drinks divided doses (max. daily dose 60 mL) If 1-3 mL/kg orally, daily in to improve taste needed, mix with other drinks 0.7-1 g/kg orally, daily for preparation e.g. Clearlax See individual product CMI Laxative OR a short course daily for 3 days of a lubricant laxative if stools are hard to pass for 3 days of a lubricant laxative if stools are hard OR a short course daily Initial treatment with a stool softener for up to 3 months with one of the following stool softener for up to 3 months with one of the Initial treatment with a titrate dose until the stool has the consistency of porridge the consistency stool has dose until the titrate dosing less frequent or to intermittent is preferable daily dose nerves to enteric or damaging addictive use is not harmful, laxative long-term
– – – MO/NP may consider referral to a Paediatrician If constipation persists, refer to the next Child Health Nurse or MO/NP clinic or Continence Advisor If constipation persists, refer to the next Child Health is unwell in any way Consult MO/NP if constipation is severe or the child Once the problem settles continue with dietary improvement and increased water intake to prevent Once the problem settles continue with dietary recurrence Children with constipation are advised to be reviewed regularly to assess progress Children with constipation are advised to be reviewed – – – with these measures in children will resolve Most constipation See Laxatives for children table: children for Laxatives See
• • • • • • • Contact MO/NP who may order stimulant laxative Liquid paraffin 50% Sorbitol Lactulose glycols (PEGs) Macrogol or polyethylene Macrogol or polyethylene
6. Referral/consultation 5. Follow up 746 GastrointestinaL Pyloric stenosis | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith Background Recommend • • • • • • • • • Related topics Acute gastroenteritis/dehydration-child,page • • • • – – Perform acompletephysicalexamination withemphasison: – Tools) + Perform standardclinicalobservations (fullCEWTscoreorotherlocalEarlyWarningandResponse – – – – – – Obtain acompletepatientandfamilyhistory: Consult MO/NPimmediately Dehydration Poor weightgainorloss Always hungry – – – Vomiting which: Assess degreeofdehydration. See – Infants usuallypresentbetween2-8weeksofageandis5timesmorecommoninmales obstruction andsubsequentforcefulvomiting Caused by a thickening of the pylorus (gastric outlet at the bottom of the stomach) causing Requires evacuationforfurtherinvestigationandsurgicalintervention – – – Due toongoingvomiting,childrequirescorrectionof: – – – – – – – – – – – – – maternal smoking postnatal exposuretomacrolideantibiotics,especiallyerythromycin bottle feeding positive familyhistoryforpyloricstenosisespeciallytwinorsibling infant iseagertofeedfollowingthevomitingepisode progressive increaseinprojectilevomitingafterfeeds non-bilious butbloodstainedin10%ofcases occurs soonafterfeeds is recurrentandprogressivelygetsworse,sometimesprojectile abdominal ultrasound ifavailable.Thiscanconfirm diagnosis visible peristalsis which ismoreobviousfollowingafeed inspect andpalpateabdomen weight -bareif<2years.Assess againstrecentweights – – – electrolyte abnormalities metabolic alkalosis significant volumedepletion 1,2,3 1,2,3 -child 1,2,3 1,2,3 Acute gastroenteritis/dehydration -child,page 730 Intussusception, page 747 730 Gastrointestinal 747
69 Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems Intraosseous infusion, page Intraosseous 1,2,3 1,2,3 - child 1,2,3
1,2,3 1,2,3
intermittent, severe, cramping, progressive abdominal pain arrange evacuation/hospitalisation for surgery arrange evacuation/hospitalisation insert IV/intraosseous cannula. See cannula. See insert IV/intraosseous or venous blood gas UEC, LFT, BGL, capillary bloods for FBP, fluid resuscitation nil by mouth – – – – – – ages 5-9 months Intussusception is telescoping of the proximal segment of intestine into a distal segment of Intussusception is telescoping of the proximal congestion, and bowel wall oedema intestine that may result in bowel obstruction, venous 3 months-3 years with peak incidence between It is most common in infants and children aged with drawing up of the legs and has blood and/or mucus in the stools with drawing up of the legs and has blood and/or and perforation Treat without delay due to risk of bowel ischaemia Suspect in a young child who has intermittent severe abdominal pain which may be associated Suspect in a young child who has intermittent Obtain a complete patient history: – Consult MO/NP Diarrhoea is common red currant jelly stool is a late sign Bowel motions may have blood and/or mucus. Classic facial redness rather than pallor Poor feeding Vomiting is common. Bile stained is a late sign Intermittent severe abdominal pain typically 2-3 times an hour and may increase over the next Intermittent severe abdominal pain typically 2-3 12-24 hours Other causes of infant crying are associated with Inconsolable crying where child may look pale. Consult MO/NP on all occasions of suspected pyloric stenosis Consult MO/NP on all occasions All babies with suspected pyloric stenosis must be managed in an appropriately resourced hospital pyloric stenosis must be managed in an appropriately All babies with suspected – Monitor closely until evacuated – – – – Consult MO/NP who may advise: MO/NP who Consult Assessment of electrolyte and acid base abnormalities i.e. hypokalaemia i.e. abnormalities base acid and electrolyte of Assessment
• • • • • • • • • • • • • • • • •
Recommend Background 3. Clinical assessment
2. Immediate management 1. May present with
Intussusception 6. Referral/consultation
5. Follow up 4. Management 748 GastrointestinaL | Primary Clinical Care Manual 10th edition | 6. Referral/consultation 5. Followup 4. Management • • • • • • Consult MO/NPonalloccasionsofsuspectedintussusception Monitor childonreturntocommunity – – – – Consult MO/NPwhomayadvise: All childrenwithsuspectedintussusceptionshouldbeevacuated – – – – – – Perform completephysicalexaminationwithemphasison: – – Tools) + Perform standardclinicalobservations(fullCEWTscoreorotherlocalEarlyWarningandResponse – – – – – – – – – – – – – – – – – – – – keep nilbymouth analgesia resuscitation fluid insert IV/intraosseouscannula.See assess degreeofdehydration.See abdominal ultrasoundifavailable(thiscanconfirmdiagnosis) palpable “sausage-shaped”massintherightmidorupperabdomen right lowerquadrantthatisscaphoid(empty)(Dance’ssign) focal tendernessespeciallyintherightmidorupperabdomen initially noabdominaltendernessordistension weight -bareif<2years.Assessagainstrecentweights fever maybealatesign recent rotavirusvaccination pallor, lethargy.Oftenepisodicandmaylookwellbetweenepisodes rectal bleeding,grossoroccult vomiting 1,2,3 Acute gastroenteritis/dehydration-child,page Intraosseous infusion,page 69 730 Gastrointestinal 749 Average 740 Intestinal worms, page Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems table Not applicable
1,2,3,4 ® - child 738 1,2,3 1,2,3 providing children a diet high in iron rich foods a diet high in iron providing children milks and drinks other non-iron-fortified excessive cow's milk or discouraging
– – prematurity Anaemia Accurate point-of-care testing should be maintained by regular calibration of haemoglobinometer calibration of haemoglobinometer be maintained by regular testing should Accurate point-of-care e.g. HemoCue Parental dietary education and understanding is the key to improving childhood anaemia, improving childhood anaemia, is the key to education and understanding Parental dietary namely: – – Aim to achieve haemoglobin (Hb) level within normal range within normal range haemoglobin (Hb) level Aim to achieve Anaemic children may be of normal weight, be underweight or overweight Anaemic children may be of normal weight, be underweight anaemia include maternal iron deficiency Antenatal risk factors for the development of childhood pregnancy, small for gestational age, and and anaemia during pregnancy, diabetes during Many children will have iron deficiency without symptoms of anaemia Many children will have development, breath with reduced psychomotor and cognitive Iron deficiency is associated attention-deficit hyperactivity disorder (ADHD), holding episodes, restless legs syndrome (RLS), Tourette syndrome and stroke Iron deficiency is the most common nutritional deficiency worldwide and the most common cause common nutritional deficiency worldwide and Iron deficiency is the most years and Torres Strait Islander children aged 6 months-4 of anaemia in Aboriginal of iron deficiency Anaemia is a late indicator Anaemia is defined as Hb less than the lower limit of the reference ranges for age. See Hb less than the lower limit of the reference ranges Anaemia is defined as ranges for age and lower limit haemoglobin stores is low Hb or haematocrit due to insufficient iron Iron deficiency anaemia
(spoon nails), hair loss Recurrent infections chalk, paper and dirt) Pica (eating non-food substances such as sand, glossitis (inflammation of tongue), koilonychia Angular chelitis (inflammation of corner of mouth), Poor growth Pale conjunctivae Recent bleeding episodes No symptoms health check Low capillary Hb detected during routine well child Tiredness, lethargy, irritability, pallor
• • • • • • • • • • • Giardiasis, page Related topics • • • • • • • • •
Recommend Background HMP
2. Immediate management 1. May present with 750 GastrointestinaL 3. Clinicalassessment | Primary Clinical Care Manual 10th edition | Infants bornatterm andofnormalbirthweightusually havesufficientironstoresfor4-6 months • • • • • • • • • – Perform acompletephysicalexaminationofallsystems: – – – – – Tools) + Perform standardclinicalobservations(fullCEWTscoreorotherlocalEarlyWarningandResponse Family historyofmemberswithanaemia,thalassaemiaorotherconditions – – – Social history: – – – Dietary history: – Medications: – Antenatal history: – Systems review: – Obtain acompletepatientpastmedicalhistory: – – – – – – – – – – – – – – – – heart murmur tachycardia record length/heightandheadcircumferenceforchildren<2years weight -bareif<2years.Assessagainstrecentweights point ofcarecapillaryHbcheck urinalysis carer orfamilysupport who providesandcooksfood primary caregiver eating ofnon-foodsubstancessuchassand,chalk,paperanddirt types andamountofmilkconsumedwhentheywereintroduced types ofironrichfoodsconsumedandwhentheywereintroduced past andcurrentmedicationsincludingsupplements maternal diabetes including maternalirondeficiencyoranaemia,IUGR,birthweight,gestationalageatbirth, blood lossincludingepistaxis,urinaryandstoollosses,menstrualpatternsinadolescentgirls history ofinfections 1-3 days(capillary) Birth (cordblood) > 12yearsboys > 12yearsgirls 6 -24months 2 -6months 6 -11years 2 -6years 2 months 2 weeks 1 month 1 week Age Average andlowerlimit 1,2,3,4 Average Hbg/L haemoglobin rangesforage 120 140 140 185 165 165 125 135 175 155 115 115 Lower limitHbg/L 4,5,6 100 120 130 105 125 145 135 135 115 115 90 95 Gastrointestinal 751 : : 740 Intestinal worms, page
Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems should be avoided which are iron poor or inhibit absorption should be avoided which are iron poor or inhibit table on following page table on following encouraging foods that are iron rich or improve iron absorption encouraging foods that 8,9 1,2,3,4,5,6,7
once anaemia is diagnosed via haemoglobinometer once anaemia can tolerate oral medications for those that for intestinal parasites. See faecal sample is positive Anaemia Management – – – iron should be stored safely away from reach of children iron should be stored safely away from reach of will be difficult at home, administer at the if safe storage is a concern or administering doses clinic only give iron as directed soft drinks or cordial iron overdose can be fatal large amounts of cow’s milk > 1 years of age (> 500 mL/day) large amounts of cow’s milk > 1 years of age (> 500 milks coconut milk, goats milk, powdered milks or soy caffeinated drinks such as tea or coffee fresh or dried fruit and green vegetables such as spinach, silverbeet, broccoli fresh or dried fruit and green vegetables such as nuts (in children > 2 years) lentils, beans, grains, whole wheat, brown rice, cow’s milk < 1 years of age chicken, fish, egg yolks iron fortified baby cereal fruit juice which improves iron absorption breastfeeding exclusively to around 6 months breastfeeding exclusively age appropriate infant formulas red meat, beef/lamb liver or kidneys, bush meat decide to administer IM/IV elemental iron after consultation with specialist paediatric services elemental iron after consultation with specialist decide to administer IM/IV anaemia B12 supplements to treat rare cases of megaloblastic order folic acid and vitamin 3 mg/kg elemental iron for mild to moderate anaemia 3 mg/kg elemental iron for severe anaemia (Hb ≤ 80 g/L) on MO/NP order 6 mg/kg elemental iron – if: single dose of mebendazole – oral elemental iron for 3 months in the first instance: iron for 3 months in the oral elemental – all babies < 6 months of age with Hb below normal range Hb below of age with < 6 months all babies Hb of < 80 g/L with a all children – – – – – – – – – – – – – – – – – – – – – – – – –
– – – – Provide medication information to parents: – – – – – – Provide information on foods that – – – – – – – The MO/NP may: – – Provide nutritional advice Iron doses (see drug box): – – – See may order: The MO/NP – Consult MO/NP immediately for: MO/NP immediately Consult – – • • • • • • • • 4. Management 4. 752 GastrointestinaL | Primary Clinical Care Manual 10th edition | MCS +OCP,urine MCS (3) FBC/film,reticulocytecount(retics), ironstudies,vitaminB12andfolate,coeliacserology,faecal MCS (2) FBC/film,reticulocytecount(retics), ironstudies,vitaminB12andfolate,faecalMCS+OCP,urine (1) FBC/film,reticulocytecount(retics), eLFTs,ironstudies,vitaminB12andfolate 0 -<6months 6-12 months > 12months Age group All cases 80 -<90 Hb (g/L) 80- <90 normal 90-105 90-110 below range < 80 < 80 • • • • • • • • • • • • • • • • • • • • • • • • • – Recheck Hbin1month: Ensure seenatnextMO/NPclinic 740 Give asingledoseofmebendazole.See Commence ironsupplements advise toinvestigatefurtherasper(3)below Ensure childseenatnextMO/NPclinic. Recheck Hbin1month 740 Give asingledoseofmebendazole.See Commence ironsupplements Recheck Hbin1month further investigationsguidedbyresultsandclinicalscenario Initial investigationsasper(1)belowandMO/NPwillinform Consult MO/NPimmediatelytodeterminetreatment – Recheck Hbin1month: Ensure childseenatnextMO/NPclinic 740 Give asingledoseofmebendazole.See Commence ironsupplements Recheck Hbin1month vise toinvestigatefurtherasper(2)below Ensure childseenatnextMO/NPvisit. 740 Give asingledoseofmebendazole.See Commence ironsupplements Recheck Hbin1month further investigationsguidedbyresultsandclinicalscenario Initial investigationsasper(1)belowandMO/NPwillinform Consult MO/NPimmediately results scenario andpathology MO/NP willinformfurtherinvestigationsguidedbyclinical Initial investigationsincludeFBC/film Consult MO/NPimmediately – – NP clinicforfurthermanagement/investigations if notimprovingwithironsupplementsrefertoMO/ further management/investigations if notimprovingwithironsupplements refertoMO/NPclinicfor Anaemia management
Management MO/NP mayad
MO/NP may Intestinal worms, page Intestinal worms,page Intestinal worms,page Intestinal worms,page Intestinal worms, page Intestinal worms,page -
Gastrointestinal 753 1,2,6,7,8,9 months by MO/NP then review For at least 3 Duration ATSIHP/IHW/IPAP Extended authority Extended . Keep out of reach of children. ) ) ® OR ® doses) > 40 kg < 10 kg 10-19 kg 30-39 kg 20-29 kg 5 mL daily 10 mL daily < 6 months 0.5 mL/kg daily 1 month-18 years weekly supervised anaemia (3mg/kg) Authority to administer and supply medicines,Authority to administer Daily dose given twice 15 mL OR 1 tablet daily (May be divided into 2-3 max. of 100-200 mg/day 20 mL OR 1-2 tablets daily Gastrointestinal | Gastrointestinal Section 8: Paediatrics problems MO/NP on individual patient basis) MO/NP on individual patient Quick dose guide for mild-moderate Quick dose guide for mild-moderate with water, drink through a straw, and follow each MO/NP 3-6 mg of elemental iron/kg/day to a iron/kg/day to 3-6 mg of elemental 1 mL daily (dose in collaboration with 1 mL daily (dose in collaboration Recommended Recommended dosage ®
Consult Ferrous fumarate (Ferro-Tab fumarate Ferrous Ferrous sulfate (Ferro-Liquid Ferrous Oral Route of administration 2 iron) 325 mg 105 mg) Strength elemental 30 mg/mL 6 mg/mL of (equivalent to (equivalent to elemental iron Ferrous sulfate Ferrous sulfate
Hb level should increase by about 10 g/L every 2-3 weeks Hb levels should start to respond to treatment within a week – – 9 Therapeutic Guidelines state continue for 3 months after Hb returned to normal to replenish Therapeutic Guidelines state continue for 3 months Follow-up all cases monthly to evaluate response to treatment: – Follow-up severe cases in 1 week: –
Oral Schedule liquid Tablet • • page Form ATSIHP, IHW and IPAP must consult MO/NP must consult IHW and IPAP ATSIHP, for supply see RN may administer; RIPRN may proceed. stores. If these preparations of oral iron are not tolerated consult MO/NP stores. If these preparations of oral iron are not Management of associated emergency: should be swallowed whole. Dilute Ferro-Liquid of teeth dose with plain water to prevent discolouration Note: Provide Consumer Medicine Information: overdose of iron can be fatal Provide Consumer Medicine Information: overdose Better absorbed with orange juice. Tablets May cause dark, tarry stools, diarrhorea or constipation. 5. Follow up 754 Urinary tract 6. Referral/consultation | Primary Clinical Care Manual 10th edition | 1. Maypresentwith Urinary tractproblems HMP Background Recommend • • • • • • • Related topics Child protection,page • • • • • • • – – – – Infant <3months: Refer toChildHealthNurse/Child-Worker Refer toDietitianfordiethistory,feedinghistoryandnutritionadvice Consult MO/NPorseenextclinicasabove – – If noresponsetooralirontherapyafter1monthconsider: for providingongoingsupportandmonitoring Place childonindividualisedcareplanwithtreatmentgoalsandclearlydefinewhoisresponsible – – – – Infants andchildren 3months-1year: Up to30%ofchildrenwhoexperienceaUTIwillhaverecurrencewithin oneyear children UTI maypresentwithnon-specificsymptomsandsigns,particularlyin infants andyoung meningitis, pneumoniaorevenviralinfections Finding aUTIinsickchilddoesnotruleoutothersourcesofinfection so keeplookinge.g. IV antibiotics and childrenwithknownkidney/urinarysystemabnormalitiesshouldbeadmittedtohospitalfor Any childwhoisunwell,childrenpresenting<6monthsofage,notrespondingtotherapy recommended Collection ofurinefordiagnosisUTIisbestusingasterilemethod.Bagsamplesarenot Dipstick testingofurineforleukocytesandnitritesisasusefulculture Any childpresentingwithanunexplainedfeverof>38°Cshouldhavetheirurinetested – – – – – – – – – – Urinary tractinfection(UTI) further investigations other causes check Hb repeat FBCtoconfirmresponsetreatment ferritin levelmaytakeupto4monthsreturnnormal fever may beirritable,have smellyurine,failtogainweight poor feedingandvomiting unwell -lookssick fever 3 1 4,5 760 1,2,4 -child Sepsis/septic shock,page 80 2 2 Urinary tract 755 1 Urinary tract problems problems tract Urinary 760 1 80 5 Child protection, page Section 8: Paediatrics | Section 8: Paediatrics Sepsis/septic shock, page Sepsis/septic shock, page
2 5 2,3,4 give the child a feed clean genital area with saline soaked gauze for 10 seconds and collect a midstream sample infections. In older children there will usually be urinary symptoms infections. In older children there will usually be genitalia in pyelonephritis palpate for loin tenderness which may be present with fever, vomiting or unwell, but it is often UTI should be considered in all babies and children including meningitis, pneumonia or even viral not possible to differentiate from other infections assess growth and plot against chart for age and sex assess growth and plot against chart for age and - ears, throat, skin, chest, abdomen, head to toe examination looking for signs of infection weight - bare weight if < 2 years. Assess against recent weights weight - bare weight if < 2 years. Assess against growth history child’s appetite, feeding, sleeping, waking, level of irritability child’s appetite, feeding, history of constipation problems history of kidney problems, urinary reflux, genital when did symptoms start, what has the progression been when did symptoms start, diarrhoea, vomiting fever, cough, fast breathing, may be unwell with fever, smelly urine, cloudy or blood-stained urine cloudy or blood-stained with fever, smelly urine, may be unwell abdominal or loin pain dysuria haematuria or new bed wetting loss of continence poor feeding gain weight fail to smelly urine, irritable, have may be frequency abdominal pain abdominal – – – – – – – – – – – – – – – – – – – – – –
Method: – Method: – hospital. If possible collect clean catch urine and blood culture before starting antibiotics. Giving hospital. If possible collect clean catch urine and sample if the child is unwell antibiotics is more important than waiting for a Children who are unwell and most children < 6 months of age will usually need management in Children who are unwell and most children < 6 months – – – Perform physical examination: – unexpected in children or other vulnerable people. See unexpected in children or other vulnerable people. score or other local Early Warning and Response Perform standard clinical observations (full CEWT Tools) + – – use of barrier contraception For sexually active girls, history of sexual activity, or presentation is inconsistent with history or is Always consider non-accidental injury where injury – – – Obtain a complete patient history, including: Obtain a complete patient – – Screen for sepsis/septic shock. See Screen for sepsis/septic – – – – – – – children: Older – –
• • • • • • • • • • Clean catch - younger children who cannot cooperate Midstream sample - children old enough to pass urine on demand Midstream sample - children old enough to Collection of urine sample
3. Clinical assessment 2. Immediate management 756 Urinary tract | Primary Clinical Care Manual 10th edition | Republished, withpermission,fromresourcesatTheRoyalChildren’sHospital,Melbourne, Australia Interpretation ofdipstickurinalysis Suprapubic aspirateorcatheterspecimen • • • • • • • • • • If nitritesarepositive, commenceantibioticswhileawaiting confirmationonpathologyculture indicator ofaninfection Negative dipstickresultisastrongpredictor ofnoinfection.Positivedipstickresultisapoor Only lookatnitritesandleukocytes. BloodandproteinarenotusefultodiagnoseUTI Use specimenfordipstickurinalysis culture. Alwayswritethemethodofcollectiononpathologyform After collectingacleansampleonchildwhereUTIissuspected,send sampletopathologyfor antibiotics (unlessthechildistoosicktowait).Onlycleancatchshould besentforculture If dipstickshowsleukocytes,nitritesorblood,acleancatchMUSTbeobtained beforestarting A bagurineshouldonlybeusedasalastresort.Culturesfrom aremostlyfalsepositives hospitalisation These shouldonlybedonebystaffwhohavebeentrainedotherwisechild willneedevacuation/ – – used: Bladder stimulationmayassistayounginfantprovidingsample. – – – culture resultsbefore startingantibiotictreatment If leukocytesarepositive butnitritesnegative,UTIispossible butlesslikely.Waitforpathology – – – – – – – – – ‘ – – – – – Paravertebral massage: catch aurinesampleinsterilecontainer wait forthechildtopassurine clean genitalareawithsalinesoakedgauzefor10seconds Quick wee’: – – – – – – – – – Figure 1:Clean capture urineinsterilecontainer.SeeFigure3 cold water.SeeFigure2 gently rubthelowerabdomenforafewminutesusingcircularmotionwithgauzesoakedin clean genitalareawithsalinesoakedgauzefor10seconds.SeeFigure1 give thechildafeed capture urineinsterilecontainer for30seconds,followedbygentlemassageofthelowerbackseconds a secondpersongentlyfingertapsoverthesuprapubicareaatfrequencyof100taps/min one personholdstheinfantunderarmswithlegsdangling clean genitalareawithsalinesoakedgauzefor10seconds give thechildafeed 7 5,6 Figure2:Rub 5,6,7 Twotechniquesthatcanbe Figure3:Catch
Urinary tract 757 35 Urinary tract problems problems tract Urinary will usually need management in will usually Section 8: Paediatrics | Section 8: Paediatrics Acute pain management, page Acute pain management, children < 6 months of age children < 6 organism or when there is recurrent UTI E. coli
1
hospital with IV antibiotics and may need a full sepsis work-up. Older children who appear well Older children who need a full sepsis work-up. IV antibiotics and may hospital with with oral antibiotics may be treated children who are unwell and most children who –
All children < 3 years of age with UTI should be discussed with a paediatrician; Children > 2 years of All children < 3 years of age with UTI should be discussed age if the infection is a non- with a paediatrician Suspected pyelonephritis should be discussed Consult MO/NP on all occasions of suspected UTI in children Consult MO/NP on all occasions of suspected UTI results may be required treated successfully or urine culture 1 week after treatment to indicate Follow up with urinalysis See next MO/NP clinic If not evacuated advise to be reviewed daily for next 2 days - if not improving, consult MO/NP to be reviewed daily for next 2 days - if not improving, If not evacuated advise on interpreting culture (24-48 hours) and discuss with MO/NP - advice Check results of urine MCS Administer analgesia as clinically indicated. See Administer analgesia as Consult MO/NP who will arrange/refer/discuss: Consult MO/NP – sample to pathology if there are reasons to exclude UTI - such as child is failing to thrive or has to thrive or child is failing - such as exclude UTI reasons to if there are to pathology sample be should not a bag, culture is from If the specimen ruled out. causes other common fever with attempted If both leukocytes and nitrites negative including from a bag urine, then UTI is unlikely. Only send Only is unlikely. UTI then bag urine, a from including negative nitrites and leukocytes If both
• • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management 758 Bone and joint Osteomyelitis and Bone andjointproblems | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend • • • • • • • Related topics Cellulitis, page Acute rheumaticfever,page • • • • • • • Can besystemicallyunwell Usually fever May besofttissueswelling,heatandredness Localised painandtenderness Pain, limp,refusaltoweightbear – – Obtain completepatienthistoryincluding: Cons –
Acute rheumaticfever(ARF)mustbeconsideredaspossiblesepticarthritisuntilexcluded urgent orthopaedicconsultation be lifethreateningandcancauselife-longdisability.Botharesurgicalemergenciesrequire Acute haematogenousosteomyelitis(OM)andsepticarthritis(SA)areseriousconditions,may Septic arthritiscanaffectanyjointorbone,butmostcommonlyinvolvethelowerlimbs Consider boneorjointinfectioninchildrenifarepeatpresentationofanapparentinjury sprained ankle Infections ofbones/jointscanoftenpresentwithareportedhistoryinjuryinchildrene.g. or occursoverajoint Bone andjointinfectionsshouldbeconsideredifaskininfectionistakinglongtimetoresolve management Suspected boneandjointinfectionsshouldalwaysbereferredtohospitalforinvestigation – – – Bone andjointinfections – – ask about: can thechildweight bearorusethelimb history ofthepain,whendiditstart, whatmakesitworse – – ult MO/NP skin infections recently fever orpoorappetite 1 1 401 Osteomyelitis Signs andsymptomsofosteomyelitissepticarthritis 2,3 septicarthritis
705 4
-child • • • • • Impetigo, page Fever, systemicallyunwell May beswelling,heatandrednessoverjoint Pain andtendernesslocalisedtojoint Refusal tomovejointorpainonmoving Pain, limp,refusaltoweightbear 392 Septic arthritis Bone and joint 759 Bone and joint problems problems joint Bone and 35 333 Section 8: Paediatrics | Section 8: Paediatrics Tuberculosis, page Acute pain management, page 1
rash sore throat recently throat sore or joints of pain in bones episodes previous of ARF history any injury pain significant recent diarrhoea tonsillitis recent viral illness, – – – – – – – – referral to Orthopaedic Specialist or Paediatrician or both referral to Orthopaedic Specialist or Paediatrician may order x-ray and IV antibiotics bloods including blood cultures may be required evacuation/hospitalisation ask them to point to the place where the pain is ask them to point to the swelling, tenderness and warmth palpate bone and joint for in joint, as tolerated check range of movement observe how child holds and uses limb involved observe how child holds any foreign travel tuberculosis. See signs and symptoms of exposure to varicella – – – taken current medicines – – – – – – – – – – – – – – – – –
Consult MO/NP on all occasions of suspected osteomyelitis and septic arthritis Consult MO/NP on all occasions of suspected osteomyelitis or both if osteomyelitis or septic arthritis is Refer to Orthopaedic Specialist or Paediatrician suspected or confirmed All children with suspected osteomyelitis or septic arthritis should be managed in hospital All children with suspected osteomyelitis or septic ARF should be considered in all cases – – Rest and immobilise limb Treat pain and fever with paracetamol. See – Consult MO/NP who will arrange: – Insert IV or Intraosseus cannula: – – – Perform standard clinical observations (full CEWT score or other local Early Warning and Response observations (full CEWT score or other local Early Perform standard clinical Tools) including: Perform physical examination – – – – –
• • • • • • • • • •
6. Referral/consultation
5. Follow up 4. Management 760 Child protection Child protection Child protection | Primary Clinical Care Manual 10th edition | Definitions Recommend • • • • Related topics Rape andsexualassault,page • • • • • • • • • • Mandatory of thechild(S11 under AboriginaltraditionandTorres StraitIslandercustom,apersonwhoisregardedasparent Executive) havingorexercisingparental responsibilityforthechild/youngperson.Thisincludes Parent Child Mandatory reporting Protection Act1999 education andcare professionalsandchildadvocates aremandatoryreporters(S13E(1)of the Queensland shouldrefertolocalpolicyandprocedures Child Protectionlawsarestate-based.Healthprofessionalsinjurisdictions outsideof CRANAplus BushSupportServices Child safetyissuescanbeextremelydistressing.Considerseekingsupport. Agenciesinclude child/young person'sclinicalrecord Document anyconcerns,symptoms,injuriesordisclosures,exactquotesanddiagramsinthe – – report butthefamilyhasmultipleorcomplexneeds: If concernsofsuspectedchild/youngperson'sabuseorneglectdonotreachthethresholdfora Print acopyofthereport,placeitintoclinicalrecordandsendtolocalCPLO department-contacts/child-family-contacts/child-safety-service-centres/regional-intake-services Child SafetyAfterHoursService(CSAHS).See: has beensubmitted,alsophoneChildSafetyServices-RegionalIntakeService(CSS-RIS)or In Queenslandwhenawrittenoronline'Reportofsuspectedchildinneedprotection'form child-protection-guide/online-child-protection-guide https://www.csyw.qld.gov.au/about-us/partners/child-family/our-government-partners/queensland- where toreportorreferconcernsaboutachild/youngperson'ssafetywellbeing.Availableat: The ChildProtectionGuide contacts Maintain mandatoryreportingtraining,andbefamiliarwithlocalpolicies,protocols, advice andassistance Each QueenslandHealthHospitalandServicehasaCPLOCPAavailabletoprovide Advisor (CPA)(S13H line managerorseniorcolleague,aChildProtectionLiaisonOfficer(CPLO) If areasonablesuspicionofharmtochild/youngpersonisformedconsiderconsultingwith – – Family Support make areferraltolocalfamilysupportservicese.g.FamilyandChildConnectorIntensive obtain consent -anindividualunder18yearsofage asperthe - isthechild/youngperson’smother, fatherorsomeoneelse(otherthantheChief 1 reporter ) - doctors,registerednurses,teachers, policeofficers,earlychildhood -mandatoryreporters mustreportareasonablesuspicion, formedinthe Child ProtectionAct1999 Child ProtectionAct1999 659 isanonlinedecision-supporttooltoassistwithdecisionsregarding 1800 805391ortheEmploymentAssistanceProgram(EAP) ) ) https://www.csyw.qld.gov.au/contact-us/ Child ProtectionAct1999 Child Child protection 761 - - ) Child Child protection Child Protection Act 1999 Act Child Protection Section 8: Paediatrics | Section 8: Paediatrics e.g. rejection, hostility, teasing/bullying, yelling, ignoring or e.g. rejection, hostility, teasing/bullying, yelling, 2 - developmental or emotional delay, disruptiveness, aggressive - it is policy that all Queensland Health staff have a duty of care to report duty of care have a Health staff Queensland policy that all - it is e.g. hitting, shaking, throwing, burning, biting, poisoning, drowning, using a e.g. hitting, shaking, throwing, burning, biting, - considerations when forming a ‘reasonable suspicion’ include: - considerations when forming occurs when a male or female adult, or an older child or adolescent including a occurs when a male or female adult, or an older - an injury, a disclosure - physical symptoms such as genital or anal pain, bleeding, discharge or pain on - physical symptoms such as genital or anal pain, e.g. providing unhygienic/unsafe housing, failing to seek medical treatment when e.g. providing unhygienic/unsafe housing, failing - lack of adequate food, clothing, warmth and shelter, emotional and physical security and
- is any detrimental effect of a significant nature on the child/young person’s physical, of a significant nature on the child/young - is any detrimental effect a disclosure by the child/young person or someone else a disclosure by the child/young person or someone emotional or anxiety symptoms, but none are specific for sexual abuse emotional or anxiety symptoms, but none are specific violence prostitution emotional/psychological abuse and exposure to domestic and family excessive criticism, threats of violence/abandonment sexual abuse in sexual activity. It can be physical, verbal sibling, uses power to involve a child/young person penetration, sexual suggestion, sexual or emotional and includes any form of sexual touching, or sexual explicit material and child exposure, and exhibitionism, exposure to pornography neglect food, clothing or bedding. It can also required, insufficient supervision, providing insufficient another person’s actions e.g. allowing a include failing to act protectively in response to contact with the child/young person convicted child sex offender to have unsupervised physical abuse weapon to inflict punishment the nature and severity of the detrimental effects the nature and severity of effects will continue the likelihood that the detrimental age the child/young person’s whether there are detrimental effects on the child/young person’s body, psychological or effects on the child/young person’s body, whether there are detrimental evident or likely to become evident in the future emotional state that are physical, psychological or emotional abuse or neglect physical, psychological sexual abuse or exploitation – – – – – – – – – – – –
Emotional/psychological abuse ness, bullying, withdrawn, extreme attention seeking behaviour, non-organic physical complaints – Neglect protection, medical and dental care, cleanliness, education and supervision Sexual abuse complaints passing urine, STI or pregnancy, non-organic physical – Physical abuse – – – examples: – – – – concerns can include the following A suspected child/young person in need of protection Significant harm – or as a series or combination of acts, omissions, or circumstances. It is immaterial how the harm is of acts, omissions, or circumstances. It is or as a series or combination may include: caused, however, causes – – to protect them from harm to protect them Harm omission or circumstance; well-being. It can be caused by a single act, psychological or emotional be in need of protection, including an unborn child that may be in need of protection after they are be in need of protection unborn child that may protection, including an be in need of suspicion that reporting a reasonable should consider who are not mandatory reporters born. Staff significant risk of suffering is suffering, or is at unacceptable person has suffered, a child/young able and willing have a parent/carer neglect; and may not by emotional abuse and/or harm caused able risk of suffering, significant harm caused by physical or sexual abuse; and may not have a and may not abuse; or sexual by physical harm caused significant of suffering, able risk of the harm (S13E(2) them from to protect able and willing parent reporting Non-mandatory person may that a child/young course of their employment, suspicion, formed in the a reasonable course of their employment, that a child/young person has suffered, is suffering, or is at unaccept or is is suffering, suffered, has person a child/young that employment, their of course • • • • • • • • 1. May present with (general) 762 Child protection 3. Clinicalassessment Physical abuse 2. Immediatemanagement(general) | Primary Clinical Care Manual 10th edition | 4. Management • • • • • • • • • • • • • • • department-contacts/child-family-contacts/child-safety-service-centres/regional-intake-services of Communities,ChildSafetyandDisability Services.See If suspicionofnon-accidentalinjuryisformednotifyChildSafetyServices, QueenslandDepartment Discuss withMO/NP.Mayneedtotransferhospitalforfurtherinvestigation CPA toconsiderdiscussionwithareferralcentreabouttransferforfurther investigation Discuss withseniorcolleaguee.g.NurseManager,SeniorHealthWorker, DirectorofNursing,CPLO, If anydisclosuresaremadedocumentusingexactwordsandphrases available at: Document thehistoryandinjury.Childabusediagramstoassistwith recordingabuseare Treat thephysicalinjury Ensure child/youngpersonissafe – – – – – – Think ofnon-accidentalinjuryif: clinicalguide/guideline_index/Child_Abuse_Diagrams/ body. Childabusediagramstoassistwithrecordingavailableat: Examine thechild/youngperson:recordinjuryandalsoanyotherinjuries.Checkwhole Past history:previousinjuries,medicalproblems child/young person’scarer/guardian history abouthowtheinjuryoccurred.Whathappened,where,when,whowasthere,is History ofinjury:wheneverachild/youngpersonpresentswithaninjury,takeandrecorddetailed consult MO/NP,orcallforpoliceassistanceasappropriate If thechild/youngpersonhasjustcausedorisabouttocauseseriousharmselfothers and contactpolicebycalling‘tripleO’forassistance committed orisabouttobecommitted,immediatelyconsultwithlinemanagement/seniorstaff If anobviouscriminaloffence(sexualassault,significantphysical,domesticviolence)hasbeen Attend toanyseriousillnessorinjuryrequiringimmediatemedicalattention gov.au/csu/factsheets For clinicalriskfactorsandindicatorsofthetypesharmtochildrensee – – – – – – bruises orfractureswheretheexplanationchangesdoesnotmakesense there isdelayinseekingmedicalattention a baby<2yearsofagewithanyfracture a non-mobilebabywhohasbruises,headinjury,neurologicalsymptoms the child/youngpersonorsomeoneelsetellsyouthatitwascausedbyaparent/carer the injuryisinapattern/shapeyourecognisesuchashand,beltorbuckle https://www.rch.org.au/clinicalguide/guideline_index/Child_Abuse_Diagrams/ https://www.rch.org.au/clinicalguide/guideline_index/Child_Abuse_Diagrams/ for moredetailedinformation https://www.csyw.qld.gov.au/contact-us/ https://www.rch.org.au/ https://qheps.health.qld.
Child protection 763 - -
Child Child protection Section 8: Paediatrics | Section 8: Paediatrics
notify Child Safety Services professionals can consider advising the family to report concerns or disclosures of sexual professionals can consider advising the family to abuse to the police support child/young person and their protective parent/carer consider the safety of the child/young person of sexual abuse there is often no physical or medical evidence be safe with their parent or carer, health If the child is medically stable and assessed to the child/young person, suggestive of an inappropriate power differential, constituting an age the child/young person, suggestive of an inappropriate to or use of pornographic material, gap of 5 years or more, involving coercion, exposure Safety Services involving other family member, notify the Child If recent assault will need to transfer to regional centre for urgent forensic examination. Child If recent assault will need to transfer to regional Unit would also be involved in this Safety Services and/or Child Protection and Investigation process non-consensual, not fully comprehended by report sexual activity that has been assessed as discuss with senior colleague e.g. Nurse Manager, Senior Health Worker, Director of Nursing, discuss with senior colleague e.g. Nurse Manager, CPLO, CPA, MO/NP speech and language development/abilities differences in ages age of young person, age of sexual partner and for adolescent, consider general examination not genital examination general examination not being mindful of person, intellectual and emotional development consider age of child/young if required to physically touch the child/young person during the assessment, always ask for touch the child/young person during the assessment, if required to physically why to further explain what you are doing and permission. It is best practice young person’s exact words and the question that was asked before disclosure question that was asked exact words and the young person’s of serious injuries/ person’s genitals, unless needed because don’t examine the child/young bleeding evidence) person or change their clothes (may be forensic don’t wash the child/young document history provided document history the child/ made, document person. For any disclosures the child/young don’t try to question – – – – – – – – – – – – – – – –
– – If episode(s) of abuse are NOT recent: – – – – – If episode(s) are recent: – appropriate paediatric skills including child protection and/or sexual medical examination training appropriate paediatric skills including child protection to approach the case or skills. Consult with a CPA to advise how best person as the initial response to a child Do not request STI tests in an asymptomatic child/young suspicion of sexual abuse Child Sexual Assault (CSA) examinations should usually be performed at the request of Queens Child Sexual Assault (CSA) examinations should after there has been some further corrobora land Police Service (QPS) and/or Child Safety Services needs to be performed by an MO/NP with tion of possible sexual abuse. CSA examination – – Sexual activity in adolescent – – not recent If episode(s) of abuse are – – information provided, the child/young person’s behaviour, signs of genital injury, indications on signs of genital injury, indications person’s behaviour, provided, the child/young information clothing: – – If the history suggests recent sexual abuse e.g. within the last 72-96 hours because of the 72-96 hours because abuse e.g. within the last suggests recent sexual If the history
• • • • • • •
4. Management
3. Clinical assessment 3. Clinical Sexual abuse abuse Sexual 764 Child protection 3. Clinicalassessment Neglect | Primary Clinical Care Manual 10th edition | 4. Management 3. Clinicalassessment Emotional abuse 4. Management • • • • • • • • • • • • • • • • • • See Reportingand referringchildprotectionconcerns Safety Services mandatory reportofchildabuseand neglectisrequiredandadviceofharmprovidedtoChild If symptomsaresignificantandare/could betheresultofparentalactionsorbehaviours,a Consider referraltosupport,counselling agenciesifavailable Consider referraltoPaediatricianand/or ChildandYouthMentalHealthServices disturbances e.g.depression,anxiety,fearfulness,runningaway excessive angeroraggression,eatingdisorders,poorgrowth,developmental delayandemotional Child/young personmayrequireassessmentofresultantsymptomsincluding withdrawal, Determine theseverityofproblem Ensure thecarersunderstandimpactofbehavioursandactiononchild/young person’sneeds – Ask carer/youngpersonaboutbehaviourswhichmayindicateemotional abuse: attempting toprovidesupport Notify ChildSafetyServicesifnoprogressinchild/youngperson’sconditiondespiteprovidingor If medicalissuesrefertoPaediatrician Involve appropriatehealthteammembers,ChildHealthNurse,MO/NP,Worker Work withcarer/guardiantodevelopaplanmeetthechild/youngperson’sneeds Ensure thecarer/guardianunderstandneedsofchild/youngperson Record concerns,supportofferedandactiontaken Arrange forMO/NPreviewtoconsidermedicalproblemse.g.poorgrowth Ask aboutdifficultiessuchassubstanceuseandfamilyviolence Take historyaboutchild/youngperson’scareandcarers – – – – – person: Check thefollowingissueswhichmightsuggest/impactoncarer/guardianneglectingchild/young – – – – – – ridiculing orothernon-physicalformsofhostilebehaviourrejectingtreatment disruptiveness, aggressiveness,bullying,threatening,scaring,exposure todomesticviolence, young person knowledge ofparent/carermentalillnessandwhenunwellarenotabletocareforthechild/ concern raisedaboutfinancialresourcesavailabletocareforchild/youngperson forms inappropriaterelationshipse.g.clingywithclinicalstaff person medical neglect-latepresentationorlackofadherencetotreatmentachild/young child/young personisunkempt,unwashed,hungry
3 Child protection 765 - Child Child protection ). Relevant Section 8: Paediatrics | Section 8: Paediatrics Child Protection Act 1999 Child Protection
Advisor and/or Child Protection Liaison Officer who are available to offer support, clinical advice Advisor and/or Child Protection Liaison Officer and reporting information Consult MO/NP. Child may need evacuation medico-legal services and/or Child Protection Seek advice from the local Hospital Health Services tal and up to date accounts of concerns, consultations, contacts, actions and plans related to of concerns, consultations, contacts, actions tal and up to date accounts be requested presentation as these may Additionally, update progress notes in the clinical record to reflect requests for correspondence notes in the clinical record to reflect requests Additionally, update progress to an external agency or written reports of relevant information provided File all written summaries of the child/young person’s clinical record in the correspondence section objective non-judgemen person clinical record accurate, considered, Document in the child/young Health Services Child Protection Liaison Officer and/or medico-legal services is recommended Liaison Officer and/or medico-legal Health Services Child Protection correspondence and record with Child Safety Services, keep copies of all When sharing information record section of the child/young person’s clinical requests in the correspondence Requests for information should be responded to as per local Hospital and Health Services Hospital and Health Services responded to as per local information should be Requests for processes with the local Hospital sharing information, for any reason, discussion If there are concerns about Services (Child Safety Services) upon request (S159N(1) Safety Services) upon Services (Child the child/ in need of protection, about a child/young person may include information information comprised of person. It may be relevant to the child/young family or someone else young person’s facts or opinion All delegated staff must provide relevant information in their possession regarding a child/young a child/young regarding in their possession information relevant must provide staff All delegated Disability Child Safety and the Department of Communities authorised officer of person to an
• • • • • • • • • Information sharing and documentation sharing Information
6. Referral/consultation (general) 5. Follow up (general) up Follow 5. 4
Section 4 Page left intentionally blank General
766 | Primary Clinical Care Manual 10th edition | 9
Immunisations
767 768 Immunisations Immunisations | Primary Clinical Care Manual 10th edition | 3. Clinicalassessment 2. Immediatemanagement 1. Maypresentwith HMP Background Recommend • • • • • • • Sexual healthimmunisation,page Anaphylaxis, page Related topics • • • • • • – – – – presentation. Check: Obtain documentedevidenceofvaccines alreadygivenandassesswhichvaccinesaredueat Handbook Standard current Follow up/receivinga'lateforvaccinationdate'notification.Referto the 'catch-upchapter'in Targeted communityimmunisationprogramse.g.annualinfluenzaand pneumococcalprograms vaccination statusandarrangeroutineorcatch-upifrequired For hospitalised patients e.g. all paediatric or emergency admissions, review documented Integrate immunisationaspartofroutinechildhealthcheck/chronicdiseasecheck indicated, vaccinatethepatient Vaccination providers should utilise all clinical encounters to assess vaccination status and, when
The For furtheradviceonimmunisationcontactyourlocalPublicHealthUnit must beappropriatelyendorsed Targeted approvedimmunisationprogramsmayvaryfromstatetostate,orregionregion,and region The NIPsisantigenbasedandvaccinecombinationsmayvaryfromstatetostate,orregion schedule (NIPs)acatch-upshouldbeplanned If thepatienthasnorecordofvaccinationforageappropriateNationalImmunisationProgram and adults Utilise allclinicalencounterstoassessvaccinationstatusandwhenindicated,vaccinatechildren – – – – Immunisation program other clinics/GPpractice wheremayhavebeenvaccinated clinical notes My HealthRecord Australian ImmunisationRegister(AIR) AustralianImmunisationHandbook AustralianImmunisationHandbook vaccination proceduresshould be followedasthecurrent 102 771 Notapplicable -adult/child isavailableat: immunisationhandbook.health.gov.au Tetanus immunisation,page Australian Immunisation 773
Immunisations 769
Australian . Record minimum/ Section 9: Immunisations Section 9: Immunisations National Vaccine Storage Guidelines 'Strive for 5' Storage Guidelines National Vaccine for contact details 1,2 Australian Immunisation Handbook
in clinical record in the AIR encounter form or equivalent patient information recall system on the clinic recall database as appropriate i.e. on a personal health record book or personal record to be retained by patient on a personal health record book or personal record – – – –
– – – date of the next scheduled vaccination Document details of vaccination: – Advise patient or guardian of the patient how to report a significant adverse event following Advise patient or guardian of the patient how immunisation should be informed, preferably in writing, of the Prior to departure, the patient's parent or guardian should be offered in appropriate settings guidelines infection control standard per as of disposed be must vials vaccine and syringes Needles, who has just been vaccinated, must be advised The patient, or the parent or guardian of the patient that may occur after vaccination on the management of the common adverse events Check each dose of vaccine to ensure the expiry date has not lapsed and there is no particulate Check each dose of vaccine to ensure the expiry matter or colour change in the vaccine should be checked and opportunistic vaccination The vaccination status of other family members The patient to be vaccinated or that patient's parent or guardian must be advised that the patient or that patient's parent or guardian must The patient to be vaccinated the vaccination in a designated place for 15 minutes after should remain under observation be in accordance with the of administration of the vaccine(s) must The dose, route and technique current assessment, valid consent must be obtained from the patient to be vaccinated or from their parent must be obtained from the patient to be vaccinated assessment, valid consent prior to subsequent be documented. Explicit verbal consent is required or guardian. This should vaccination encounters written consent has been recorded at previous vaccinations even when specialist immunisation clinic, a MO/NP with expertise in vaccination, local Public Health Unit, or clinic, a MO/NP with expertise in vaccination, specialist immunisation See the within your state or territory health authority. the immunisation section Immunisation Handbook and the pre-vaccination of appropriate information (as per above) Following the provision that patient's parent or guardian. This must be documented parent or guardian. This that patient's for vaccination must be to determine the vaccinee's medical fitness A pre-vaccination assessment must be discussed with a about the patient's eligibility for vaccination undertaken. Any concern the current edition of the the current twice daily maximum temperatures risk of vaccine of vaccination and the risks and benefits information about the Appropriate or with the patient to be vaccinated to, and discussed with, diseases must be provided preventable Resuscitation equipment, medicines and protocol necessary for the management of anaphylaxis of anaphylaxis the management for protocol necessary and medicines equipment, Resuscitation session immunisation prior to each and checked available must be according to cold chain components, and other vaccine monitor vaccine refrigerator Maintain and • • • • • • • • • • • • • • 4. Management 4. 770 Immun isations | Primary Clinical Care Manual 10th edition | *See theNIPs forfunded(free)vaccines Conditions/situations Management ofassociated emergency:SeeAnaphylaxis,page 102 current editionofthe Note: Inactivated poliomyelitis(IPV) Human papillomavirus(HPV) For babiesofHBsAGpositivemothers only Hepatitis BImmunoglobulin#(Midwivesonly) Hepatitis AandBcombination Hepatitis B# Hepatitis A conjugated (Hib-MenCCV) Haemophilus influenzaetypeB-meningococcalC Haemophilus influenzaetypeB(Hib) type B(DTPa-hepB-IPV-Hib) B-inactivated poliovirus-Haemophilusinfluenzae Diphtheria-tetanus-acellular pertussis-hepatitis poliovirus (dTpa-IPV) Diphtheria-tetanus-acellular pertussis-inactivated poliovirus (DTPa-IPV) Diphtheria-tetanus-acellular pertussis-inactivated (DTPa) Diphtheria-tetanus-acellular pertussischild adolescent (dTpa)#Ω Diphtheria-tetanus-acellular pertussisadult/ Diphtheria-tetanus (dT) and onlyintheantenatalsetting MID mayproceedwith#only.Ωifcompletedanimmunisationtrainingcourse, IPN andRIPRNmayproceed ATSIHP, IHWandRNmustconsultMO/NP Schedule Dose, routeandtimingintervalofadministration ofthesevaccinestobeinaccordancewiththe 4 AustralianImmunisationHandbook • • • • • •
Queensland Healthordelegate An immunisationprogramcertifiedbytheChiefExecutiveof directed byaPublicHealthMedicalOfficerOR For useinacase/outbreaksituation,orotherspecificsituations,as the ChiefHealthOfficerOR For useinotherimmunisationprogramsthathavebeenapprovedby (NHMRC) forfutureinclusioninNIPsOR As approvedbytheNationalHealthandMedicalResearchCouncil schedule (NIPs)OR In accordancewiththecurrentNationalImmunisationProgram PLUS Immunisation Handbook In accordancewiththecurrenteditionofTheAustralian Antigens (vaccine) Vaccines Meningococcal B 23-valent pneumococcalpolysaccharide (23vPPV) 13-valent pneumococcalconjugate(13vPCV) Varicella (VV) Varicella (herpeszoster) Rotavirus Meningococcal Cconjugated(MenCCV) Meningococcal ACWY Measles, mumps,rubella,varicella(MMRV) Measles, mumps,rubella(MMR)# Japanese encephalitis-liveattenuated Japanese encephalitis-inactivated Influenza #Ω *
ATSIHP/IHW/IPN/MID/RIPRN Extended authority
1 Immunisations 771 to Section 9: Immunisations Section 9: Immunisations https://www.health.qld.gov.au/ to guide practice in relation to 1 Anaphylaxis, page 102 Immunisation program, page 768 Not applicable Australian Immunisation Handbook 1 1 men who have sex with men, persons who inject drugs, inmates of correctional facilities, sex persons who inject drugs, inmates of correctional men who have sex with men, industry workers – if practising outside of Queensland use the local reporting systems if practising outside of Queensland in Queensland report any significant adverse event following immunisation (AEFI) directly following significant adverse event in Queensland report any at: available form AEFI an completing by Health Queensland clinical-practice/guidelines-procedures/diseases-infection/immunisation/service-providers/ adverse-event
Sexual health immunisation – – – immunisationhandbook.health.gov.au The Australian Immunisation Handbook is available at: identifies groups with special vaccination requirements, The Australian Immunisation Handbook identifies groups with including but not limited to: Always refer to The Communicable Diseases Control Centre Opportunistically assess for risk factors requiring additional immunisations Opportunistically assess for risk factors requiring immunisations. For further advice contact your local sexual health nurse, Public Health Unit or immunisations. For further advice contact your
Opportunistic assessment for immunisations as part of routine sexual and reproductive health/ Opportunistic assessment for immunisations as other clinical practice Risk factor(s) identified as per the current Australian Immunisation Handbook – – Confirm date next vaccinations are due Confirm date next vaccinations be promptly reported :: adverse events following immunisation must All serious or unexpected a Queensland tuberculosis control unit and conversant with recommended procedures as per procedures recommended conversant with unit and control tuberculosis a Queensland Handbook the current Australian Immunisation Australian Immunisation Handbook current Australian Immunisation are authorised by nursing staff who trained medical and be administered by specially Should only Should only be administered under vaccination programs approved by the Chief Health Officer by the Chief approved programs vaccination under only be administered Should as per the testing and interpretation be experienced in skin nursing personnel must Medical and
• • • • Acute hepatitis A, page 433 Acute hepatitis B, page 435 Related topics • • • • • • •
Recommend Background Tuberculosis (BCG) Tuberculosis Q Fever HMP
2. Immediate management 1. with May present
5. Follow up Additional vaccines with special conditions special with vaccines Additional 772 Immun issatatioonsns .Followup 5. *Vaccines onNIPsarefunded(free)foreligiblepatients .Management 4. Clinicalassessment 3. | Primary Clinical Care Manual 10th edition | Management ofassociatedemergency:SeeAnaphylaxis,page102 current editionoftheAustralianImmunisationHandbook Note: IPN, RIPRNandSRHmayproceed ATSIHP, IHWandRNmustconsultanMO/NP • • • • • • Hepatitis A Allseriousorunexpectedadverseevents followingimmunisationmustbepromptlyreported: Confirm date(s)fornextvaccinations dueasappropriate – Ensure allstandardvaccinationproceduresarefollowed.SeeImmunisationprogram,page768 For assessmentpriortoimmunisation,seeImmunisationprogram,page768 needed, andtocheckifrecommendedvaccinesarefunded Check withyourlocalPublicHealthUnit,orstateterritoryimmunisationprogramforadviceas Immunisation Handbook Assess person for recommendedvaccinationin their individual contextas per the current – Schedule Conditions/ situations – – Dose, route and timing interval of administration of these vaccines to be in accordance with the if practisingoutside ofQueenslandusethelocalreporting systems providers/adverse-event gov.au/clinical-practice/guidelines-procedures/diseases-infection/immunisation/service- Queensland Healthbycompletingan in Queenslandreportanysignificant adverseevent following immunisation(AEFI)directly 1 1 • • • • • • 4
Hepatitis B Queensland Healthordelegate An immunisationprogramcertifiedbytheChiefExecutive directed byaPublicHealthMedicalOfficerOR For useinacase/outbreaksituation,orotherspecificsituations,as by theChiefHealthOfficerOR For useinotherimmunisationprogramsthathavebeenapproved (NHMRC) forfutureinclusioninNIPsOR As approvedbytheNationalHealthandMedicalResearchCouncil schedule (NIPs)OR In accordancewiththecurrentNationalImmunisationProgram PLUS Immunisation Handbook In accordancewiththecurrenteditionofAustralian 1 Antigens (vaccine)* Vaccines AEFI ReportingForm Human papillomavirus (HPV) availableat:
ATSIHP/IHW/IPN/RIPRN/SRH Extended authority Measles, mumps,rubella https://www.health.qld. (MMR)
Australian to 1 Immunisations 773
Australian Immunisation Section 9: Immunisations Section 9: Immunisations 768 immunisationhandbook.health.gov.au Immunisation program, page Immunisation program, page is available at: - adult/child for contact details for contact Not applicable 1 102 : 1 ss tetanus immunisation status before giving vaccination status before ss tetanus immunisation < 5 years 5-10 years > 10 years Australian Immunisation Handbook Australian Immunisation – – –
– – is there any uncertainty around previous doses have ≥ 3 doses of a tetanus containing vaccine been given previously have ≥ 3 doses of a tetanus containing vaccine been when was the last tetanus containing vaccine given: – is delayed more than 4 hours re-implantation of an avulsed tooth wounds complicated by pyogenic infections or burns wounds with extensive tissue damage e.g. contusions or horse manure, especially if topical disinfection superficial wounds contaminated with soil, dust compound fractures bite wounds bodies, especially sharp objects deep penetrating wounds, wounds containing foreign routine scheduled vaccine tetanus prone wound Tetanus immunisation Tetanus – – – – – – – – – – – – Asse apparently trivial injury, such as from a rose thorn, or with no history of injury. It is for this reason such as from a rose thorn, or with no history of apparently trivial injury, clean, minor cuts are considered tetanus prone that all wounds other than The The definition of a tetanus prone injury is not straight forward as tetanus may occur after prone injury is not straight forward as The definition of a tetanus
– Obtain history of previous tetanus vaccinations: – – – skin 'popping' i.e. injecting under the skin Does the patient inject drugs. In particular practise – – – Generally, all wounds other than clean minor cuts are considered tetanus prone. In particular: Generally, all wounds other than clean minor cuts – – – Handbook – – Assess for appropriateness of tetanus immunisation as per the current Assess for appropriateness of tetanus immunisation Tetanus prone wound As part of immunisation schedule Consult with a specialist immunisation clinic, an MO/NP/IPN with expertise in vaccination, local in vaccination, expertise with an MO/NP/IPN clinic, immunisation with a specialist Consult See the authority. territory health your state or within section or the immunisation Health Unit, Public Handbook Immunisation Australian
• • • Related topics Anaphylaxis, page • • • • • • •
Recommend Background HMP
3. Clinical assessment 2. Immediate management
1. May present with 6. Referral/consultation 6. 774 Immun issatatioonsns 4. Management | Primary Clinical Care Manual 10th edition | ‡ dTpaprovidesaddedprotectionagainstpertussisandshouldbeconsidered -notfundedonNIPs Management ofassociatedemergency: current editionof Note: Diphtheria, tetanusdT(ADT) pertussis (dTpa) Diphtheria, tetanusacellular pertussis (DTPa) Diphtheria, tetanusacellular IPN andRIPRNmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP Management ofassociated emergency: edition of Note: IPN andRIPRNmayproceed ATSIHP, IHW,IPAPandRNmustconsultMO/NP • • • • • • Injection Schedule Schedule Form Administer tetanuscontainingvaccine±TIGasappropriate – If atetanuspronewound: Pre andpostvaccinationproceduresmustbefollowed.See Immunisation program,page If avaccineisrecommendedtoday,ensurestandardpre-vaccinationproceduresareadheredtosee tetanus immunoglobulinisrequired Australian ImmunisationHandbook Using informationyouhaveobtainedfromthehistoryofprevioustetanusvaccinations,referto If patienthasahumoralimmunedeficiencytheymayrequiretetanusimmunoglobulin(TIG) – Dose, routeandtimingintervalofadministration ofTIGtobeinaccordancewiththecurrent Dose, routeandtimingintervalofadministrationthesevaccinestobeinaccordancewiththe local disinfectionand,whereappropriate,surgicaltreatmentofwoundmustneverbeomitted The Vaccine
Australian ImmunisationHandbook 250 units Strength The AustralianImmunisationHandbook 1 4 4 administration administration 768 Tetanus immunoglobulin(TIG) Route of Route of Tetanus vaccines IM IM See See sectionontetanustodetermineifaboosterand/or
Anaphylaxis, page Anaphylaxis, page Adult formulation years ‡ Adolescent/adult formulationif>10 Paediatric formulationif<10years hours haveelapsedsince 500 unitsifmorethan24 Recommended dosage Recommended age 250 units wound 102 102 OR Immunisation program,page
ATS ATS IHP/IHW/IPAP Extended authority IHP/IHW/IPAP Extended authority / IPN/RIPRN Duration / IPN/RIPRN stat Duration
768 stat
1 1 Immunisations 775
: https://www.health.qld. Section 9: Immunisations Section 9: Immunisations be promptly reported be promptly must available at: AEFI Reporting Form AEFI Reporting for contact details
gov.au/clinical-practice/guidelines-procedures/diseases-infection/immunisation/service- providers/adverse-event use the local reporting systems if practising outside of Queensland in Queensland report any significant adverse event following immunisation (AEFI) directly to (AEFI) directly following immunisation adverse event report any significant in Queensland Health by completing an Queensland – –
Australian Immunisation Handbook Australian Immunisation Consult with a specialist immunisation clinic, an MO/NP/IPN with expertise in vaccination, local immunisation clinic, an MO/NP/IPN with expertise Consult with a specialist health authority. See the immunisation section within your state or territory Public Health Unit, or the – visit(s) to complete course visit(s) to complete following immunisation unexpected adverse events All serious or – If TIG or vaccine given provide patient with record of vaccination for them to notify their primary to notify their for them vaccination record of patient with provide or vaccine given If TIG care provider health next - arrange/confirm be required may schedule catch-up course not completed, tetanus If primary • • • •
6. Referral/consultation 5. Follow up Follow 5. Section 4 Page left intentionally blank General
776 | Primary Clinical Care Manual 10th edition | 10
Appendices
777 778 Medication history and reconciliation Medication reconciliation Medication historyandreconciliation | Primary Clinical Care Manual 10th edition | General approaches • • • • • • Background • • events where resourcesarelimitede.g.time. Target patientsatgreaterriskofadversemedicationeventsandthose usinghighriskmedications ordered, administeredorsupplied Ideally medicationreconciliationshouldbecompletedonallpatientsbefore anymedicinesare – – – – following page: Medication reconciliationisa4stepprocess. Where possible,useapharmacist,includingviatelehealthservicesforremotesupport uploads/2010/01/Medication-Management-Plan.pdf assets/pdf_file/0030/335478/sw016.pdf The QueenslandMedicationActionPlanisavailableat such asaNationalMedicationManagementPlan. Medication reconciliationmustbedocumentedandwherepossiblerecordedonaclinicalform – – – – Medication historyerrors: – – – – Medication reconciliation: – – – – supply accuratemedicinesinformationwhencareistransferred reconcile thehistorywithprescribedmedicinesandfollowupdiscrepancies confirm theaccuracyofmedicationhistory history (BPMH),page780 obtain anddocumentthebestpossiblemedicationhistory(BPMH).See – – – – – – – – have beenshowntooccurin26-87%ofmedicationrecords can causeharminupto30%ofcases often occurwhenpatientsarebeingtransferrede.g.evacuatedtohospital,returninghome are common errors. is astrategythathasbeenshowntoimprovemedicationsafetyandsignificantlydecrease is arequirementtomeetthenationalMedicationSafetyStandards prescribed. AnydiscrepanciesarediscussedwiththeMO/NP matches themedicinespatientshouldbeprescribedagainstthosetheyareactually current medicines is aformalprocessofobtainingandverifyingcompleteaccuratelisteachpatient's onthefollowingpage 1 1,2
4 See or Targetpatientsatgreaterriskofadversemedication https://www.safetyandquality.gov.au/wp-content/ 3 See Four stepsofmedicationreconciliation https://qheps.health.qld.gov.au/__data/ 3
1 Best possiblemedication 3 table on Medication history and reconciliation 779779 5 6 Medication history and reconciliation and history Medication and include: 2. Confirm the accuracy of the history RFDS, RSQ a carer when patient is being discharged the patient the incoming clinician when care is being being is care when clinician incoming the transferred the retrieval team when transported i.e. 4. Supply accurate medicines information – – – – – – Inspect patient’s medication containers including blister packs Contact MO/NP and other prescribers and pharmacists Interview carers and family members Review health records Provide a list of medicines and reasons for any changes to: – – Review medication list 1 • • • • • • APINCH Section 10: Appendices | Section 10: Appendices medicines Target patients at greater risk of adverse medication events medication risk of adverse at greater patients Target > 65 years for non-indigenous people > 65 years for Islander people Aboriginal and Torres Strait > 45 years for
– – Best possible medication arcotics and other sedatives eparin, enoxaparin, warfarin and other anticoagulants nti-infectives otassium and other electrolytes hemotherapeutic agents Those diagnosed with a mental health condition Those diagnosed with a Those with impaired kidney, liver or heart function Those with impaired kidney, obese Those who are morbidly Those diagnosed with cancer Those taking > 4 medicines or medicines with complex regimens > 4 medicines or medicines Those taking intolerances allergy, adverse drug reaction or medication Those with a history of medication adherence to medication regimens Those with a poor level of – Children clinically deteriorating Those who are The elderly – nsulin prescriptions referrals, discharge summary medication charts N C H A P I 3. Reconcile the history with prescribed
– – – – – – – – –
• • • • • • • • • • Where there are discrepancies, discuss these with the MO/NP or other prescriber Document reasons for change to medicines Compare the patient's medication history with the prescribed medicines Check that these MATCH Document reasons for change to medicines – interview and other sources such as: – – See history (BPMH), page 780 Compile list of medicines from patient – – – – – – High-risk medicines are known by the acronym High-risk medicines are 1. Obtain best possible medication history • • • • • • • • Four steps of medication reconciliation 780 Medication history and reconciliation Best possiblemedicationhistory(BPMH) | Primary Clinical Care Manual 10th edition | • • • Background • • • • The followingchecklistcanassisttocompleteathoroughBPMH – – – – – – Types ofmedicationtobenotedinclude: – – – – – ABPMHconsistsof: A BPMHistheresponsibilityofeachclinicianinvolvedinmedicationreconciliationprocess. history Use thechecklistbelowtopromptspecificquestionsobtainbestpossiblemedication improve patientsafety Obtaining a BPMH is one of the the timeofpresentation. A medicationhistoryisarecordofallprescribedandnon-prescribedmedicinesthataretakenat It isacollaborativeprocess – – – – – – – – – – – prn medicines recreational drugs traditional medicatione.g.bushmedicine complementary orherbalmedicines non-prescribed andnon-prescriptionmedicines prescribed andprescriptionmedicines document thehistory recording adversereactions verification withmorethanonesourcee.g.previousmedicationcharts,carer,MO/NP,GP patient details,dateofhistory,namestaffmember,sourcesinformation an interviewwiththepatientsand/orfamily/carerwhereverpossible 8 1 4 stepsinthemedicationreconciliationprocess 7 , which aims to Medication history and reconciliation 781781
Medication history and reconciliation and history Medication , include allergies, reactions and intolerances including: Section 10: Appendices | Section 10: Appendices e.g. tobacco, alcohol, marijuana, illicit drugs e.g. weekly or twice weekly e.g. contraceptive rods, hormonal implants for cancer e.g. contraceptive rods, e.g. nose/ear/eye drops, pessaries, suppositories, vaginal rings, e.g. nose/ear/eye drops, including insulin pumps, analgaesia pumps including insulin pumps, by asking: e.g. creams, ointments, lotions, patches e.g. creams, ointments, 'People often have difficulty taking their pills for one reason or another. 'People often have difficulty taking their pills Have you had difficulty taking your pills?' your medicines?' 'About how often would you say you miss taking Completed courses of medicine Ceased medicines Altered medicines Vitamins Natural therapies Traditional medicines Herbal medicines Bush medicines Analgesics diarrhoea heartburn, constipation, medication for reflux, Gastrointestinal spray patches, gum, Nicotine replacement Sleeping tablets Sleeping tablets sprays, sublingual spacer, with or without puffers Inhalers, therapy hormone replacement Oral contraceptives, • • Any previous adverse medication reactions Wearing any medical alert jewellery Assess adherence • • • Intermittent medicines Recently changed medicines or regimens • Other people's medicine Social and recreational drugs • • • Implantable medicines Complementary medicines • Topical medicines Inserted medicines medicated IUCD • Injected medicines • medicines Over-the-counter • • Prescription medicines Prescription • • 782 Notification of a patient death 1. Obviousdeath Notification ofapatient | Primary Clinical Care Manual 10th edition | 2. Reportabledeath • • • • • • • Information • • • police investigationshaveconcluded, unlessotherwisedirectedbythepolice Medical equipment,tubesandmedical devicesattachedorinsertedshouldremaininsituuntil pdf qld.gov.au/__data/assets/pdf_file/0006/92868/m-osc-fs-information-for-health-professionals. Information forhealthprofessionals aboutCoronialprocessesisavailableat: to dosobythecoroner An MOisnottocompletea coroner from mechanicalfalls)thedeathmustbereportedtopolicewhowill thenreportthedeathto When thedeathisconsideredreportableasaviolentorotherwiseunnatural death(otherthanthose file/0008/87803/cor-f-1a.pdf scan/email tothecoroneravailablefrom: advice, theMOwillcompletea Where thedeathisconsideredareportableorifunsureandthere isaneedtoseekcoroner's – – – – – – – – (Qld). The A decisionmustbemadeifthedeathisareportableinaccordancewith – – Complete a – – – – – – – – – – Some resourcesforotherStatesarelistedintheResourcessectionbelow Other jurisdictionsareadvisedtofollowlocalpolicyandprocedures The followingreferstothemanagementofapatientdeathinstateQueensland death where health procedurerelateddeathwherewasnotreasonablyexpected tobetheoutcome death asaresultofpoliceoperations death incustodyofpolice,courts,correctiveservicesorjuvenilejustice violent orotherwiseunnaturaldeath guardianship orchildprotectionlegislation) death incare(appliestopeoplecaredforunderdisability,mentalhealth,justice,child death insuspiciouscircumstances death ofanunknownperson file/0035/577673/life_extinct.pdf Queensland Healthintranetat: 'Obvious death'isdefinedonthe being issuedforthedeceased to facilitatethemanagementofdeceasedincommunitypriordeathcertificate death casesonly)forthepurposeofmanagementandtransportationdeceasedbody can becompletedbyanMO/NP,RegisteredNurse,ParamedicorPoliceOfficer(incertainobvious criteria forareportabledeath
Life ExtinctForm Form 9:CauseofDeathCertificate Form 9:CauseofDeathCertificate Form 1a:Medicalpractitionerreportofdeathtoacoroner death Life Extinct Form 1 are: https://www.courts.qld.gov.au/__data/assets/pdf_ https://qheps.health.qld.gov.au/__data/assets/pdf_ notissuedandunlikelytobe , availableinallQueenslandfacilitiesoronthe for areportabledeath,unlessauthorised https://www.courts. Coroners Act2003 andfax/
Notification of a patient death 783783
https:// Certificate must Certificate Child protection, can be completed by completed can be Perinatal death Form 9 and Form 9a . See . Issuing cause of death cause of death Issuing Notification of a patient death patient a of Notification form, available from: Not reportable https://www.courts.qld.gov. . Unexpected stillbirths should be reported . Unexpected stillbirths perinatal Form 9 Death other than available at: available > 24 weeks gestation are a reportable event in the > 24 weeks gestation are Form 9: Cause of Death Certificate Cause of Death Form 9: , funeral directors may require an Authority to Transport; , funeral directors may require Section 10: Appendices | Section 10: Appendices a Life extinct form (baby at least 20 weeks gestation or 400 grams weight and died 400 grams weight and died 20 weeks gestation or (baby at least Deceased person stillbirths - Queensland Audit of Surgical Mortality contact the Hospital and - Queensland Audit of Surgical Mortality contact Form 9a Perinatal Supplement to Form 9: Cause of Death Supplement to Form Form 9a Perinatal Consider HHS Death Review Process - contact Hospital and Health Service Director of Obstetrics - contact Hospital and Health Service Director of - contact Hospital and Health Service Director of Mental Health - contact Hospital and Health Service Director of perinatal death http://qheps.health.qld.gov.au/psu/clinicalincident/docs/fs-stillbirth-report. in Queensland Health facilities and non-inpatient deaths where the patient in Queensland Health facilities and non-inpatient not a reportable death not a reportable Report Of Suspected Child In Need Of Protection Report Of Suspected Child - or unsure notify coroner deceased person requires transport requires person deceased Complete Form 1a and 1a and Form Complete Reportable death to coroner
inpatient deaths
perioperative patient death Health Service Director of Medical Services page 760 mental health patient maternal patient death child death secure.communities.qld.gov.au/cbir/PrescribedEntityChildSafetyReport – – – –
review process. Contact the Hospital and Health Service Director of Medical Services for more review process. Contact the Hospital and Health information and applicable forms – All the last 30 days are subject to a local death was treated by a Queensland Health facility within – – check Hospital and Health Service forms check Hospital and Health specific types of deaths: Other Forms may apply to – Where a stillbirth in RiskMan pdf triplicate forms available in all facilities Form 9 and Form 9a are also be completed expected Since November 2016, all Regulation 2012 – s29(1) Hospital and Health Boards Guide to reporting a reporting tool. Refer to the Queensland Health using the RiskMan incident au/__data/assets/pdf_file/0014/210218/osc-fs-issuing-cause-of-death-certificates-apparent- natural-causes-deaths.pdf is a Where the death after birth) a within 28 days Where the death is the death is Where Coroner the State Office of issued by the to guidance only. Refer an MO causes deaths natural for apparent certificates • • • • • • •
4. Specific instances 3. Non-reportable death Non-reportable 3. 784 Notification of a patient death 5. Resources | Primary Clinical Care Manual 10th edition | Victoria Queensland • • • • Coroner ClinicalLiaisonServiceavailableat: Coroners courtavailableat: about-coroners-court/resources-and-legislation#state Coronial managementresources: The QueenslandCoronerisavailableforadviceandassistanceMondaytoFriday0830-1630hours 0732396193,orOnCallafterhours www.coronerscourt.vic.gov.au https://www.courts.qld.gov.au/courts/coroners-court/ 0732473372 www.health.vic.gov.au/cls/index.htm Glasgow coma scale / AVPU 785785 Child 1,2 2-5 years Glasgow coma scale/AVPU coma Glasgow Confused, cries but is consolable Inappropriate words/moaning/ Grunts, moans, inconsolable, No sounds objects/smiles/alert/coos/babbles objects/smiles/alert/coos/babbles words to usual ability persistent cries and/or screams irritable, restless 5. Orientated/interacts/follows 5. Orientated/interacts/follows 4. 3. 2. 1. Section 10: Appendices | Section 10: Appendices No response Obeys commands Localises to pain Withdraws to pain Flexor response to pain (bends arm or leg) Extensor response to pain (straightens arm or leg) 1. 1. No eye opening/no response 6. 5. 4. 3. 2. 4. Opens eyes spontaneously or to speech 3. Opens eyes on command (pinching) 2. Opens eyes with pain
Adult AVPU Child > 5 years No response (unresponsive) No response Alert verbal statement Responds to painful stimuli Responds to Glasgow coma scale (GCS) - adult/child/infant Glasgow coma scale Inappropriate meaningless words Incomprehensible No sounds Fully orientated not sure of Confused, disorientated: happened noises - grunts, moans their name or where they are or what their name or where they 3. 2. 1. 5. 4. V A P U
immobilised limbs or spinal cord injuries dysphasia a language or cultural barrier dementia or some psychiatric disorders cranial nerve injuries a hearing impairment been intubated or has a tracheostomy had medicines including anaesthetics, sedatives, neuromuscular had medicines including anaesthetics, sedatives, or drugs blockades and similar, intoxication with alcohol a direct eye injury or periorbital swelling Scale < 15 8 prepare to intubate Drop of 2 or more from last assessment. If GCS ≤
(GCS) − − − − − − − − − Always act on: − − Maximum scale: 15 (fully alert, conscious) Minimum scale: 3 (unconscious) Maximum scale: 15 (fully alert, conscious) Minimum In these situations, it is appropriate to record the individual scales for each measurable response In these situations, it is appropriate to record the individual scales for each measurable response (motor, verbal or eyes) GCS not testable if any of the following apply: • • Best motor response response Best verbal Eyes open Glasgow Coma Scale/ Coma Glasgow 786 Safe use of paracetamol Safe useof | Primary Clinical Care Manual 10th edition | • • • • • • • Background • • • • • Risk Factor(seenextTable) and actualweight<50kg Severe hepaticimpairment and actualweight≥50kg Severe hepaticimpairment actual weight<50kg 1 ormoreriskfactorsand actual weight≥50kg 1 ormoreriskfactorsand No riskfactors 1 ormoreriskfactors factors onnextpage) No riskfactors(see For neonatesandinfants<3monthsseekspecialistadvice available from be basedonidealbodyweight Dose should be titrated accordingtoweight and riskfactors. In obese children the dosage should In acuteoverdose,paracetamolcanleadtosevereandsometimesfatalhepatotoxicity Paracetamol hasawellestablishedsafetyprofilewhenusedappropriately Paracetamol (alsoknownasacetaminophen)isacommonandwidelyusednon-opioidanalgesic 1 paracetamol Recommended doseparacetamol(oral)-Prescribingguide https://www.rch.org.au/childgrowth/Growth_Charts/# • • • • • • • • • • • 2 doses in24hours hours uptoamaximumof3 15 mg/kg/doseevery4-6 hours maximum of2gin24 0.5-1 gevery4-6hours,upto a of 4dosesin24hours hours uptoamaximum 15 mg/kg/doseevery4-6 a maximumof3gin24hours 0.5-1 gevery4-6hours,upto 0.5-1 gevery4-6hours,upto Do notexceed3gin24hours Do notexceed1gperdose in 24hours up toamaximumof45mg/kg 15 mg/kg/doseevery4-6hours Do notexceed4gin24hours Do notexceed1gperdose in24hours uptoamaximumof60mg/kg 15 mg/kg/doseevery4-6hours a maximumof4gin24hours i.e.50 Children 3monthsto1year Adult andchild≥12years th centileonanappropriateweight-for-agepercentilechart Dose
1 1,2
• • • • • • • monitoring LFTandINR beyond 48hours,consider If treatmenttocontinue Review at48hours Review at48hours monitoring LFTandINR beyond 48hours,consider If treatmenttocontinue Review at48hours consider reducingdose beyond 48hours, If treatmenttocontinue Review at48hours Duration 3 benzathine and procaine benzylpenicillin Administration 787787 Bicillin 1 4 1,2,3 Child procaine penicillin) Acute pain management, page 35 Febrile illness Febrile Younger age vomiting or dehydration Prolonged fasting, Chronic under-nutrition Hepatic impairment intake e.g. in over-the- Prior paracetamol preparations counter cough/cold paediatric formulations Use of adult rather than designed for an Use of paediatric formulations or availability of older age group e.g. siblings formulations multiple strengths of paediatric • • • • • • • • Benzathine and procaine benzylpenicillin administration benzylpenicillin procaine and Benzathine ' device, and distraction techniques for children ® Adult Section 10: Appendices | Section 10: Appendices Factors that may increase the risk of paracetamol toxicity paracetamol the risk of increase that may Factors cream to the injection site 30-60 minutes prior to giving needle cream to the injection site 30-60 minutes prior ® ventrogluteal (gluteus medius muscle) injection ventrogluteal (gluteus medius muscle) The addition of 0.5-1.0 mL of 1% lidocaine (lignocaine) is used elsewhere but is not is but elsewhere used is (lignocaine) lidocaine 1% of mL 0.5-1.0 of addition The
level with the knuckles of your index and middle fingers Remember to remove your fingers before you inject, to prevent a needle stick injury Locate and place your index finger on the anterior superior iliac crest. Your thumb should be pointed thumb Your superior iliac crest. on the anterior finger and place your index Locate towards the front of the leg be Spread your middle finger to form a ‘V’ - the injection site is in the middle of the ‘V’, which should If lying prone, ask them to ‘toe in’ to internally rotate the femur. If lying supine, ask them to flex their If lying prone, ask them to ‘toe in’ to internally rotate injection from a standing position knee. It is not recommended to give a ventrogluteal trochanter, that is, your left hand on their right leg Place the heel of your opposite hand on the grater and vice versa Approach the patient with the drawn-up medicine in a syringe and explain the procedure Approach the patient with the drawn-up medicine and bend their knee on the leg chosen for the Position the patient on their side (position of choice) injection. This helps to locate the greater trochanter Note: in Australia recommended with preloaded syringes available Avoid major nerves and blood vessels. Do not give into the deltoid Avoid major nerves and blood vessels. Do not give site for 30 seconds prior to the injection Apply firm pressure with thumb to the exact injection i.e. over 2 minutes Use 21 G needle and deliver injection very slowly Administer analgesia as clinically indicated. See Administer analgesia as clinically indicated. See quadrant of the buttock, mid lateral aspect of the Give by deep IM injection only into the upper, outer thigh or into the ventrogluteal area Allow medicine to warm up to room temperature by rolling the syringe between hands for 1-2 minutes Allow medicine to warm up to room temperature as applying ice to injection site 10 minutes prior to Consider other pain management measures such injection, use of a 'Buzzy Apply EMLA
Elderly, frail patients Elderly, frail Chronic, excessive alcohol use Chronic, excessive of anticonvulsants Chronic use impairment Severe hepatic Prolonged fasting or dehydration fasting Prolonged Chronic under-nutrition • • • • • • • • • • • • • • • •
• • • • • • 2. Giving a 1. Administration tips 1. Administration LA®) and procaine benzylpenicillin ( LA®) and procaine Administration tips for benzathine benzylpenicillin ( tips for benzathine benzylpenicillin Administration 788 benzathine and procaine benzylpenicillin Administration Finding theventroglutealsite | Primary Clinical Care Manual 10th edition | • finger doesnotreachtheiliaccrest,thenslideyourhandupleguntilit If youhavesmallhandsandfindthatwiththeballofyourhandongreatertrochanterindex (middle finger) Posterior iliaccrest Anterior superioriliacspine(ASIS)-(indexfinger) Ventrogluteal (gluteusmedius)injectionsite 5,6 Greater trochanter(palm)
(middle finger) Posterior iliaccrest
De-escalation techniques 789789
De-escalation techniques De-escalation , including activating a Code Black , including activating a Code Section 10: Appendices | Section 10: Appendices 3
1,2 Emergency Preparedness Plan Emergency Preparedness
In smaller health facilities and in remote areas, referral should occur at a much earlier stage and in remote areas, referral should occur at In smaller health facilities Follow your facility’s emergency if appropriate resources be managed by to public safety or their own safety which cannot If a patient presents a risk call Police resources within the facility, aimed at short-term defusing of anger, avoiding aggression and reducing the use of restrictive and reducing the use avoiding aggression defusing of anger, aimed at short-term in a difficult situation the patient choices offer to is to avoid confrontation, The aim interventions. in reaching a calmer state and to assist and adequate support or agitated patient without to manage a distressed Never attempt De-escalation is the use of techniques, including verbal and non-verbal communication skills, communication non-verbal and verbal including techniques, of is the use De-escalation
only one staff member verbally engage the patient Be empathic, non-judgemental and respectful. Emphasise your desire to help Introduce yourself, your role and the purpose of the discussion Introduce yourself, your role and the purpose of Do not routinely administer sedating medicines upon presentation that Lead the discussion and engage the patient. Even though other staff are nearby, it is imperative available this may help in de-escalation at the staff member, change to another staff If patient persists in directing anger or suspicion member to continue de-escalation in communicating with an agitated or angry patient One staff member should take the primary role Make sure more than one staff member is present. If there is a trusted staff member of the patient the of member staff trusted there is a If present. is member staff than one more sure Make Be aware of or suspect abuse as a contributory factor in violence and aggression in children. See Be aware of or suspect abuse as a contributory Child protection, page 760 in the past for this patient Consider de-escalation techniques that have worked Consent to administration of sedating medication can be used as part of the de-escalation process Consent to administration of sedating medication one) to discuss their wishes if they become agitated Use patients’ behaviour care plans (if they have Continually show respect and empathy for patient Monitor changes in mood or composure that may lead to aggression Monitor changes in mood or composure that may angry, aggressive or uncooperative in areas away Manage patients who may become, or who are, are not alone from other patients or visitors, but ensure staff and interactions to avoid or manage 'flashpoints' Use a wide range of verbal and non-verbal skills with the clinician care, including young patients and children Empower patients to actively participate in their or carers Work in partnership with patients and their families Use 'active listening' techniques, and a verbal 'loop' seeking to find a way to respond that agrees and a verbal 'loop' seeking to find a Use 'active listening' techniques, with the patient patient to do e.g. accept medication, sit down Explain to the patient what the clinician wants the Establish a working relationship with patients who may be angry or uncooperative Establish a working relationship
• • • • • • • • • • • • • • • • • • • • • • • • •
2. Techniques
1. General principles De-escalation techniques De-escalation 790 De-escalation techniques | Primary Clinical Care Manual 10th edition | 3. Additionaltechniqueswithchildrenandadolescents • • • • • • • • • • • • • • • • stay ifitissafetodoso them withinthefacilitymaybeuseful.Individualswhoappeartocalm patientcanbeaskedto If thepresenceofparents/guardians/friendsisincreasinglevelagitation thenseparating Reassure andhelpparents/guardianswiththeirownanxiety children/adolescents canbesupportedtotakethisoption) Where relevant,thechildoradolescentshouldbegivenoptionoftakingoralmedication(most engagement Using anonjudgementalattitudetowardsthebehaviourofchildoradolescentiscriticalto aggression isoccurringi.e.toaquietroomorarea Offer opportunityforachildoryoungpersontomoveawayfromsituationswhereviolence de-escalation techniquestheyuse Use calmingtechniquesanddistractionwithchildren-ifappropriateaskparents/guardianswhich plans For patientswithadisability,ensurethatthecommunicationalignspatient's or nicotineinhaler room/area. Ifpatientwantsacigaretteconsidernicotinereplacemente.g.gum/lozenges,patches Avoid enteringdiscussionaboutleavingthefacility,focusconversationonstayingwithin Where relevant,thepatientshouldbegivenoptionoftakingoralmedication making aphonecallontheirbehalf)andattendingtophysicalneedscanbeveryhelpful Courtesies suchasacupof(lukewarm)tea,sandwiches,accesstotelephone(0rstaffmember and waitforanopeningtoallowthepatientventsomeoftheirfrustrations Use aslow,clearandsteadyvoicedonotraiseyourvoice.Ifthepatientraisestheirvoice,pause information Use short,clearstatements,avoidmedicaljargon.Thepatientmaynothavethecapacitytoprocess concessions canbuildtrustandrapport Focus onthehereandnow,identifywhatisachievable,ratherthandecliningallrequests,small Try toidentifypatient’sneedsthathavenotbeenmetandhelpthemexploretheirfears Listen tothepatient’sconcerns,askwhattheywantandareworriedabout patient andaggressivebehaviourmayescalate happen', 'you’dbetterstopthatrightnow…orelse'asthisislikelytobeperceivedathreatbythe Avoid potentiallyprovocativestatementssuchas'calmdown'or'ifyoudon’tsettledownxwill abbreviations and acronyms 791791 Abbreviations and acronyms and Abbreviations Activated partial thromboplastin partial thromboplastin Activated time distress Acute respiratory syndrome fever Acute rheumatic therapy Antiretroviral bacteriuria Asymptomatic Acute severe behavioural disturbance Australian Society of Clinical Immunology and Allergy Anterior superior iliac spine Antistreptolysin O titre Acute post streptococcal glomerulonephritis Aspartate aminotransferase Drugs Alcohol, Tobacco and Other Service Aboriginal and Torres Strait Islander Health Practitioner scale Unresponsive Voice Pain Alert Naked Blood borne virus Bacille Calmette Guerin Breastfeeding Barmah Forest Virus Blood glucose level Basic life support Body mass index Blood pressure Borderline personality disorder Beats per minute Best possible medication history Behavioural and psychological symptoms of dementia Bacterial vaginosis Complement component 3 Complement component 4 Culturally and linguistically diverse Clinical Care Guideline Chronic Conditions Manual Controlled cord traction Children’s Early Warning Tool Comprehensive metabolic panel 20 APSGN aPTT ARDS ARF ART ASB ASBD ASCIA ASIS ASO ASOT AST ATODS ATSIHP AVPU Bare BBV BCG BF BFV BGL BLS BMI BP BPD bpm BPMH BPSD BV C3 C4 CALD CCG CCM CCT CEWT chem20 acronyms Increasing/increased Decreasing/decreased Greater than Less than equal to Less than or or equal to Greater than Plus or minus Registered trade mark Phone number OR notifiable conjugate 13-valent pneumococcal 23-valent pneumococcal polysaccharide Airway Breathing CPR Defibrillation index Ankle-brachial pressure Actual body weight Aged Care Assessment Team enzyme Angiotensin converting enzyme Angiotensin converting inhibitors Acute coronary syndrome Four meningococcal groups - A,C,W,Y Adult Deterioration Detection System Attention-deficit hyperactivity disorder Adjusted body weight Adult diphtheria and tetanus Automated external defibrillator Adverse event following immunisation Acid-fast bacilli Australian Immunisation Register Advanced life support Alanine aminotransferase Anti-hepatitis B core total antibodies Anti-hepatitis B surface antibody Australia and New Zealand Committee on Resuscitation Acute otitis media Australian Medicines Handbook Antepartum haemorrhage Application Angiotensin-receptor blocker
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≤ ≥ ± ® 13vPCV 23vPPV ABCD ABPI ABW ACAT ACE ACEI ACS ACWY ADDS ADHD AdjBW ADT AED AEFI AFB AIR ALS ALT anti-HBc anti-HBs ANZCOR AOM AMH APH App ARB Abbreviations and and Abbreviations 792 abbreviations and acronyms | Primary Clinical Care Manual 10th edition | EEG ECP ECG ECC EBV EAR EAP EAC DVT DTPa dTpa DTP dT DT DMPA DM DKA DCI dBP dB CVA CTG CT CSWD CST CSS-RIS CSOM CSF CSAHS CRP CrCl CPR CPLO CPA COPD COAGs CO CNS CMV CK CIW-Ar 2 Electroencephalogram Emergency contraception pill Electrocardiogram Endocervical curettage Epstein-Barr virus Expired airresuscitation Employment AssistanceProgram Exercise associatedcollapse Deep veinthrombosis pertussis Diphtheria-tetanus-acellular pertussis Diphtheria-tetanus-acellular Drug TherapyProtocol Diphtheria-tetanus Delirium tremens acetate Depot medroxyprogesterone Diabetes mellitus Diabetic ketoacidosis Decompressive illness Diastolic bloodpressure Decibel(s) Cerebrovascular accident Cardiotocography Computed tomography debridement Conservative sharpwound Cervical screeningtest Intake Service Child SafetyServices-Regional Chronic suppurativeotitismedia Cerebrospinal fluid Child SafetyAfterHoursService C-reactive protein Creatinine clearance Cardiopulmonary resuscitation Child ProtectionLiaisonOfficer Child ProtectionAdvisor disease Chronic obstructivepulmonary Coagulation tests Carbon dioxide Central nervoussystem Cytomegalovirus Creatine kinase Assessment forAlcohol-revised Clinical InstituteWithdrawal G FTA FPS-R FNE FMO FMH FLACC FiO FHR fFN FEV FBP FBC FAST EWARS eTG ETCO ESR EPDS ENT eLFT EIA eGFR eFAST HbA1C Hb GUD GTT GTN GP GORD GIT GI GHB GFR GDM GCS GBS GAS G6PD 2 2 Erythrocyte sedimentationrate Scale Edinburgh PostnatalDepression Ear, noseandthroat Electrolytes andliverfunctiontest assay Enzyme-linked immunosorbent Estimated glomerularfiltrationrate sonography intrauma Extended focusedassessmentwith Glycated haemoglobin Haemoglobin Genital ulcerdisease Glucose tolerancetest Glyceryl trinitrate General Practitioner Gastro-oesophageal refluxdisease Gastrointestinal tract Gastrointestinal Gamma hydroxybutyrate Glomerular filtrationrate Gestational diabetesmellitus Glasgow ComaScale Group B Group A dehydrogenase deficiency Glucose-6-phosphate Gauge e.g.14gauge Fluorescent treponemalantibody Faces painscalerevised Forensic NurseExaminer Forensic MedicalOfficer Fetomaternal haemorrhage Consolability scale Face, Legs,Activity,Cry, concentration Fraction ofinspiredoxygen Fetal heartrate Fetal fibronectin Forced expiratoryvolume Full bloodpicture Full bloodcount sonography intrauma Focused assessmentwith System Early WarningandResponse Online TherapeuticGuidelines End-tidal carbondioxide Streptococcus Streptococcus © abbreviations and acronyms 793793
C conjugated Abbreviations and acronyms and Abbreviations Medical termination of pregnancy Nucleic acid testing National Emergency X-Radiography Utilisation Study Nasogastric Nasogastric tube National Health and Medical Research Council National Immunisation Program schedule Last normal menstrual period Loss of consciousness Lysergic acid diethylamide Lower vaginal swab Mucosal atomisation device Monoamine oxidase inhibitor Maximum Microscopy, culture, sensitivity Metered dose inhaler Multi-drug therapy Meningococcal vaccine Maternity Early Warning Tool Mental Health Review Tribunal Midwife Minutes millimetres of mercury Measles, mumps, rubella Measles, mumps, rubella, varicella Medical Officer Medical Officer/Nurse Practitioner Methicillin-resistant staphylococcus aureus Medical State Examination Men who have sex with men Midstream urine sample List of Approved Medicines (Qld Medicines of Approved List institutions) hospitals and pubic block branch Left bundle dehydrogenase Lactate test Liver function bisexual transgender Lesbian gay and others intersex queer fossa Left inguinal airway Laryngeal mask Last menstrual period NIPs MO/NP MRSA MSE MSM MSU MTOP NAT NEXUS NG NGT NHMRC max. MCS MDI MDT MenCCV MEWT MHRT MID Min mmHg MMR MMRV MO LDH LFT LGBTIQ+ LIF LMA LMP LNMP LOC LSD LVS MAD MAOI LAM LBBB type B Inactivated poliomyelitis vaccine Brand of hand held blood analyser Intrauterine contraceptive device Intrauterine device Intrauterine growth restriction Intravenous Intravenous cannula Authorised Indigenous Health Worker Intramuscular Intermenstrual bleeding International Normalised Ratio Isolated Practice Area Paramedic Immunisation Program Nurse Intracranial pressure Intensive care unit Indwelling catheter Injecting drug use Immunoglobulin A Immunoglobulin M Hormone replacement therapy Herpes simplex virus Herpes simplex virus type 2 High vaginal swab Intrapartum antibiotic prophylaxis Inflammatory bowel disease Ideal body weight Hospital and Health Service Haemophilus influenzae virus Human immunodeficiency Health Management Protocol Human papillomavirus Heart rate Hepatitis B virus Hepatitis C virus of the fetus Haemolytic disease and the newborn Hepatitis B High flow nasal cannula state Hyperosmolar hyperglycaemic Hepatitis B core antibody B core Hepatitis B antigen to hepatitis IgM antibody B e-antigen Hepatitis B immunoglobulin Hepatitis antibody Hepatitis B surface antigen Hepatitis B surface 2 IVC IUGR IV IUD iSTAT IUCD IPN IPV IPAP IMB INR IM IgM IHW IgA IDC IDU ICU IBW ICP IAP IBD HVS HSV HSV HR HRT HPV HIV HMP Hib HHS HHS hepB HFNC HDFN HCV HBsAG HBV HBIG HBsAb HBeAg HBcAb HBcIgM 794 abbreviations and acronyms | Primary Clinical Care Manual 10th edition | POC PoCT PNG PID PICU PIC PHU PEP PEGs PEFR PEA PE PCR PCR PCP PCCM PCB PBS PAAP-A P2/N95 ORS OME OM OGTT OGT ODT OCP PCR OCP OCP O NT NSTEMI NSTEACS NSSI NSAID NPWT nmMRSA NIPT POP 2 Poisons InformationCentre Public healthunit Post-exposure prophylaxis Polyethylene glycols Peak expiratoryflowrate Pulseless electricalactivity Pulmonary embolism Protein/creatinine ratio Prot Polymerase chainreactionOR Phencyclidine Primary ClinicalCareManual Post coitalbleeding Pharmaceutical BenefitsScheme protein-A Pregnancy associatedplacental filtering personalmasks Standards applyingtoparticulate Oral rehydrationsolutions Otitis mediawitheffusion Otitis media Oral glucosetolerancetest Orogastric tube Oral disintegratingtablet reaction Faecal multiplexpolymerasechain Oral contraceptivepill Ova, cystsandparasites Oxygen Northern Territory Non STEMI syndrome Non-ST elevationacutecoronary Non-suicidal self-injury drug Non-steroidal anti-inflammatory Negative-pressure woundtherapy Non multi-resistantMRSA test Non-invasive pre-natalscreening Progestogen only pill Product ofconception Point ofcaretesting Papua NewGuinea Pelvic inflammatorydisease Paediatric intensivecareunit RPR ROM RNA RN RLS RIPRN RIF RhD RHD RFDS RBC rAOM QPS Q-MEWT Qld QAS QADDS Q-ADDS or PTSD PTB PROM PrEP PPV PPI PPH PPE pPCI SpO SOB SNRI SM SLE SIDS SC sBP SaO SAH SA RV RSQ RRV RR 2 2 Preterm birth Premature ruptureofmembranes Pre-exposure prophylaxis Positive pressureventilation Proton pumpinhibitor Post-partum haemorrhage Personal protectiveequipment intervention Primary percutaneouscoronary saturation Peripheral capillary oxygen Shortness ofbreath reuptake inhibitors Serotonin andnorepinephrine Scheduled medicines Systemic lupuserythematosus Sudden infantdeathsyndrome Subcutaneous Systolic bloodpressure Oxygen saturation Subarachnoid haemorrhage Septic arthritis Review Retrieval ServicesQueensland Ross RiverVirus Respiratory rate Rapid plasmareagintest Rupture ofmembrane Ribonucleic acid Registered Nurse Restless legssyndrome Registered Nurse Rural andIsolatedPractice Right inguinalfossa Rhesus factor Rheumatic heartdisease Royal FlyingDoctorService Red bloodcells Recurrent acuteotitismedia Queensland PoliceService Warning Tool Queensland MaternityEarly Queensland Queensland AmbulanceService Detection System Queensland AdultDeterioration Post-traumatic stressdisorder abbreviations and acronyms 795795
3 Abbreviations and acronyms and Abbreviations World Health Organization Beta human chorionic gonadotropin Degrees celsius twice a day at night four times a day immediately and once only three times a day gram kilogram milligram(s) microgram(s) litre(s) millilitre(s) centimetre(s) minute(s) millimole(s) seconds Ultraviolet acuity Visual examination Vaginal fibrillation Ventricular bleeding Vitamin K deficiency Ventricular tachycardia Venous thromboembolism Varicella virus White cell count -hCG qid stat tds g kg mg microgram L mL cm min mmol secs VF VKDB VT VTE VV WCC WHO ⠰C abbreviations and terms medicine Acceptable bd nocte UV VA VE Urinary tract infection Ulipristal acetate Unprotected sexual intercourse Unique record, unique record number Upper respiratory tract infection Universal Serial Bus Ultrasound scan Transvaginal ultrasound of cervical length Transvaginal Scan Urea and electrolytes Urea, electrolytes and creatinine United Kingdom Medical Eligibility Criteria Termination of pregnancy Treponema pallidum haemagglutination assay Treponema pallidum particle agglutination assay Thyroid stimulating hormone Toxic shock syndrome Support Unit Thyroid function test Therapeutic Goods Administration Transient ischaemic attack Tetanus immunoglobulin Tympanic membrane infants kit Snake venom detection Temperature Tuberculosis Total body surface area Tricyclic antidepressant Telehealth Emergency Management Selective serotonin reuptake Selective serotonin inhibitors myocardial infarction ST-elevation Sexually transmitted infection Surgical termination of pregnancy Sublingual under the tongue in Sudden unexplained death Several species Several postpartum Secondary haemorrhage Nurse Health Program Sexual rupture of Spontaneous membranes USS UTI URTI USB URN UPSI UR UPA UKMEC UE UEC TVS TVCL TSH TSS TPPA TPHA TOM TIG TM TGA TIA TFT TEMSU TBSA TCA TB SVDK T SUDI Subling STI STOP STEMI SSRI SROM SRH spp SPPH 796 index Abdominal pain Abdominal injuries Abbreviations A Index | Primary Clinical Care Manual 10th edition | Acute coronary syndrome Acute Activated charcoal Acronyms Abuse and child neglect, Abscess Causes of of Assessment Acute Clinical pathways link Wounds Rheumatic fever Retention ofurine Pulmonary oedema Post streptococcalglomerulonephritis Pain management Otitis media Mastoiditis Lower leg ischemia Hypertensive crisis Headache Gonococcal andchlamydial conjunctivitis Glaucoma Gastroenteritis/dehydration -child Gastroenteritis/dehydration -adult Behavioural disturbance Bacterial sinusitis Asthma Abdominal pain Tooth Incision anddrainage Breast carbunclesBoils, In female Child ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ���������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� ������������������������������������������������� ����������������������������������������������� �������������������������������������������� �������������������������������������������� �������������������������������������������� ����������������������������������������� ����������������������������������������� Index ���������������������������������������� ��������������������������������������� ��������������������������������������� ���������������������������������������� �������������������������������������� ������������������������������������� ������������������������������������ ���������������������������������� ���������������������������������� ��������������������������������� �������������������������������� ���������������������������� ������������ ������������ �������� �� 398 262 399 588 700 348 760 238 238 678 239 383 256 730 336 387 243 467 724 635 198 705 327 140 144 183 241 791 791 712 154 135 119 151 35 Allergic reaction, severe Allergic reaction, mild Alcohol Airway and cervical spine protection Aerosol sniffing Advanced life support Adult presentation Adrenaline (epinephrine), for anaphylaxis Administer medicines, authority Acute rheumatic fever (ARF) Acute post streptococcal glomerulonephritis Acute otitis media Analgesia Anaemia -child Amputation, acute minor Amphetamines, overdose Altered level of consciousness Allergic rhinitis Angina, unstable Anaphylaxis Anaphylaxis Withdrawal Related epigastric pain Intoxication Algorithms History andphysical examination Secondary prophylaxis for Bicillin LA Thrombolysis, at rural or remote facility Options for reperfusion Indications for reperfusion Acute painmanagement Differential diagnoses Diagnosis Management flowchart Autoinjector Adrenaline (epinephrine) doses Step wiseapproach Non-pharmacological ������������������������������������������������������ ��������������������������������������������������� ��������������������������������������������������� ������������������������������������������������� ��������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ����������������������������������������������� ����������������������������������������������� ����������������������������������������������� ��������������������������������������������� ��������������������������������������������� ��������������������������������������� ����������������������������������������� �������������������������������������� ��������������������������������� ��������������������������������� ���������������������������������� ���������������������������������� ������������������������������� ������������������������������ ������������������������������ ������������������������������ ������������������������������ �������������������������� ���������������������������� ������������������������� �������������������������� ����������������� ����������������� ����������������� �������� ������ ��� 289 490 320 320 700 442 205 287 487 247 443 108 705 703 749 102 102 164 104 104 104 138 139 139 712 135 20 20 62 38 39 76 56 73 35 9 index 797797 55 511 771 215 215 471 575 701 212 212 212 301 301 474 552 579 787 758 252 467 467 443 227 234 562 478 439 582 302 292 469 309 398 226 296 308 208 Index
��� ������������� ������������������������ �������������������������� ��������������������������� Vaginal bleeding in bleeding Vaginal �������������������������������� ��������������������������������� ����������������������������������� ������������������������������������� ������������������������������������� ��������������������������������������� �������������������������������������� ���������������������������������������� ����������������������������������������� ������������������������������������������ see also ��������������������������������������������� ������������������������������������������������ ����������������������������������������������� ����������������������������������������������� ������������������������������������������������ ������������������������������������������������ ������������������������������������������������� ������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� Haemorrhage ���������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� ��������������������������������������������������������� see ������������������������������������������������������������ ������������������������������������������������������������ ������������������������������������������������������������� ����������������������������������������������������������������� ������������������������������������������������������������������� Ectopic pregnancy Ectopic Acute severe patients in non-consenting Interventions considerations Safety Spider Tick Breech of perineum and repair Episiotomy dystocia Shoulder Animal Bat Centipede Dog Human Scorpion Snake Sedation pregnancy Bat bite/scratch Bat BCG of symptoms psychological and Behavioural (BPSD) dementia disturbance Behavioural Barmah Forest Virus Forest Barmah support life Basic Blue-ringed octopus Blue-ringed Boils - child infections joint Bone and obstruction Bowel Bitumen burns Bitumen Bleeding, Bleeding nose Bleeding, vaginal, child pressure, Blood fingernail under Blood Bluebottle sting Bimanual compression Bimanual Birth, imminent Bite Bends, decompression illness decompression Bends, tips LA, administration Bicillin fever LA, rheumatic Bicillin 9 35 58 24 20 119 133 154 147 617 575 516 187 130 535 212 164 453 559 327 705 785 732 445 443 358 450 670 238 442 464 708 508 500 484 664 628 , ������ ���� ����� 670 ��������������� ����������������������� �������������������������� ��������������������������� ���������������������������������� ����������������������������������� ������������������������������� ���������������������������������������� ����������������������������������������� ������������������������������������������� ������������������������������������������� ��������������������������������������������� ����������������������������������������������� ������������������������������������������������ ���������������������������������������������������� �������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ��������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������� ������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������� �������������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������� �������������������������������������������������������������� ��������������������������������������������������������������� ����������������������������������������������������������������� Supply of medicines by ATSIHP and IHW ATSIHP by of medicines Supply Trauma Skin, child Skin, STI risk Suicide Mental health Mental examination state Mental Pain adult Skin, History and physical examination - adult and physical History examination - child and physical History in child Hydration Chest pain Chest Ear Eye Abdominal pain Abdominal Bicillin LA Bicillin for prophylaxis Secondary �������������������������������������������������������������������� Bacterial vaginosis Bacterial Bacterial sinusitis, acute sinusitis, Bacterial Back slabBack Authority to give medicines give to Authority AVPU B Asystole Asymptomatic bacteriuria, pregnancy bacteriuria, Asymptomatic Asthma, chronic Asthma, Asthma, acute Asthma, Assessment Arrhythmias leg occlusion, Arterial ARF Apgar score Apgar Aortic dissection Anxiety Aortic compression Anti-D Antepartum haemorrhage (APH) haemorrhage Antepartum Animal bites Animal care Antenatal 798 index Bronchitis, adult Bronchiolitis Broken teeth Broken rib Broken bone, Breech birth abscess Breast Bradyarrhythmia Brackish orsalt water cut BP, child Box jellyfish | Primary Clinical Care Manual 10th edition | Catastrophic haemorrhage Cardiac arrhythmias Carbuncles Carbon monoxide inhalation Cannabis, overdose Candidiasis C Button battery ingestion/insertion Burns Brudzinski's sign Tourniquet Vaginal Skin Oral Superficial -middermal Rules ofnines Referral criteria Minor Mid -deep dermal Major Hydrofluoric acid General Full thickness Epidermal Electrocution Dressings Chemical Bitumen Assessment of% total body surface area Assessment ������������������������������������������������������������ ������������������������������������������������������������ ���������������������������������������������������� ��������������������������������������������������������� ��������������������������������������������������������� ��������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� see �������������������������������������������������� �������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ����������������������������������������������� ���������������������������������������������� ������������������������������������������������� ��������������������������������������������� ��������������������������������������������� Fracture ������������������������������������������ ����������������������������������������� ������������������������������������������ ���������������������������������������� �������������������������������������� ��������������������������������� �������������������������������� ����������������������������� ����������������������������� ������������������� 665 ���� , 680 288 209 409 220 226 226 398 630 588 222 224 695 304 582 324 338 225 272 218 164 164 149 219 219 219 219 219 219 219 355 701 147 147 217 174 91 Child protection Chest wound/injury Chest pain Chemical burns to theeyes Chemical burns Charcoal, activated Chancre,see Syphillis Cervical spine injury Cervical spine immobilisation Cellulitis Choking Chloramphenicol Chlamydial conjunctivitis Chlamydia Child with: Sexual abuse Sexual Reporting Physical abuse Neglect Emotional abuse Abuse andneglect Penetrating (open)causes Non-penetrating causes Possible cardiac Myocardial infarction Differential diagnosis Assessment Angina coronaryAcute syndromes Skin Periorbital Orbital Flowchart Vomiting anddiarrhoea, acute Vomiting Stridor Sore throat Fever Elevated BP Ear pain/symptom Diarrhoea, chronic Cough Arthritis Abdominal pain �������������������������������������������������������������� ������������������������������������������������������������ ���������������������������������������������������������� �������������������������������������������������������� ��������������������������������������������������������� ��������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ����������������������������������������������� ���������������������������������������������� ������������������������������������������� ������������������������������������������ �������������������������������������������� ����������������������������������������� ������������������������������������������ ������������������������������������������ ���������������������������������������� �������������������������������������� �������������������������������������� �������������������������������������� ������������������������������������� ���������������������������������� ���������������������������������� ��������������������������������� ������������������������������� ������������������������������ ��������������������������� ��������������������������� �������������������������� ������������������� 646 262 700 708 685 760 706 760 678 676 679 623 762 383 730 764 764 365 225 100 367 763 677 401 674 675 164 375 375 130 130 132 172 172 181 135 135 135 135 171 99 index 799799 161 611 155 415 516 555 274 675 210 691 556 273 109 601 601 445 243 227 227 385 363 730 569 569 478 782 599 599 789 603 605 440 389 608 Index
����� ����� Front Front see �������������� �������������� ���������������� ������������������ �������������������� �������������������������������� ��������������������������������� ���������������������������������� ������������������������������������� ��������������������������������������� ���������������������������������������� �������������������������������������������� ��������������������������������������������� ��������������������������������������������� ���������������������������������������������� ���������������������������������������������� ����������������������������������������������� ������������������������������������������������� �������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������ ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������ ���������������������������������������������������������������� In pregnancy Adult Child Intrauterine contraceptive device (IUCD) device contraceptive Intrauterine hormonal Long-acting acetate Medroxyprogesterone pill only Progestogen implant progestogen Sub-dermal and IHW ATSIHP by of medicines Supply Combined oral contraceptive pill contraceptive oral Combined Emergency Implanon �������������������������������������������������������������������� Delirium Dementia Dengue fever Cystitis, adult Cystitis, D DCI of notification Death, (DCI/bends) illness Decompression Deep vein thrombosis techniques De-escalation Dehydration Cord prolapse Cord abrasion Corneal ulceration Corneal ingestion substance Corrosive/caustic with - child Cough trauma, of notification early for Criteria insert cover Croup Crusted scabies poisoning Cyanide Controlled cord traction cord Controlled Convulsions COPD cuts Coral clamping Cord presentation Cord 10 73 73 27 54 29 28 431 197 743 316 381 621 614 723 597 785 785 785 189 379 383 324 720 287 430 384 429 382 309 428 428 380 620 289 682 ����������������� ���������������������� ����������������������� ����������������������� ����������������������������� ��������������������������������� ��������������������������������� ���������������������������������� ���������������������������������� ������������������������������������ �������������������������������������� ��������������������������������������� ������������������������������������������ ������������������������������������������� ������������������������������������������ ����������������������������������������� ������������������������������������������ ������������������������������������������ ������������������������������������������� ��������������������������������������������� ������������������������������������������������ ������������������������������������������������ �������������������������������������������������� �������������������������������������������������� ������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������� ����������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ����������������������������������������������������������� Barrier methods Barrier For doctor consultation doctor For retrieval For Glasgow Coma Scale Coma Glasgow Unconscious Alterered level of level Alterered of level Assessing AVPU Trachoma Viral Bacterial and chlamydial Gonococcal Overview Allergic Adult Child Management of Management Assessment of lower limb ulcers lower of Assessment Dressings swab wound a to collect How Sniffing petrol/glue/aerosol Sniffing Contraception Contact tracing Contact Contacts, Queensland Contacts, Constipation - child Constipation Conscious state Conscious Cone shell envenomation shell Cone Conjunctivitis Condoms Compound fractures Compound Compartment syndrome Compartment Collapsed patient Collapsed swab a wound Collecting Cold (common) Cold Cocaine, overdose Cocaine, Clinical consultation Clinical Cleaning techniques for ears for techniques Cleaning Guidelines Care Clinical Ciguatera poisoning Ciguatera Chronic wounds Chronic Cholesteatoma Chroming 800 index Diabetes, inpregnancy Diabetes Depression Depo-Provera Dental caries Dental abscess | Primary Clinical Care Manual 10th edition | E DVT socketDry Drugs/substances, use of Drug induced psychosis Drug box examples DRS CABCD, trauma DRS ABCD resuscitation Drowning/submersion Dressings Donovanosis Dog bite Dislocations Dislocated shoulder Digital block nerve Diarrhoea Diabetic foot ������������������������������������������������������������������� General Antenatal schedule Supply ofmedicines by ATSIHP andIHW Hypoglycaemia Hyperosmolar Hyperglycaemic State Hyperglycaemia Diabetic ketoacidosis Chronic wound Burns Child, chronic Child, acute Adult Osteomyelitis diabetes infoot, diabetesInfection infoot, Pre-existing OGTT Hypoglycaemia Gestational ������������������������������������������������������������ ���������������������������������������������������������� ���������������������������������������������������������� ��������������������������������������������������������� ��������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ��������������������������������������������� �������������������������������������������� ������������������������������������������� ���������������������������������������������� ������������������������������������������ ������������������������������������������� ������������������������������������������ ������������������������������������������ ������������������������������������������ �������������������������������������� ������������������������������������ �������������������������������������� ������������������������������������ ���������������������������������� �������������������������������� ��������������������������� ������������������� ����������� ����� 206 220 484 650 494 348 430 599 679 344 730 243 522 425 445 524 352 128 481 523 164 194 194 525 212 421 521 521 155 113 113 113 115 54 11 Emergency contraception Electrocution Electric shock Ectopic pregnancy Eclampsia ECG Flash Ear wick, how to Ears, cleaning techniques Ears Early Warning and Response System tools Ear infections, general Eardrum rupture, traumatic Epiglottitis Epigastric pain, alcohol related Epididymo-orchitis Envenomation Entonox Endone Tissue spear Suction Rupture of the eardrum Otitis media witheffusion Otitis media, chronic suppurative Otitis externa Foreign body/insect in Dry perforation Discharging for ≥2weeks Discharge, grommets Cholesteatoma Assessment Acute otitis media Acute mastoiditis Differential diagnosis Tick Spider Snake Sea snake Irukandji Cone shell jellyfish Box Blue-ringed octopus Labour Acute pain ��������������������������������������������������������������� ������������������������������������������������������������ ���������������������������������������������������������� ��������������������������������������������������������� ��������������������������������������������������������� �������������������������������������������������������� ��������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� ���������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ������������������������������������������������ ����������������������������������������������� ���������������������������������������������� ���������������������������������������������� ������������������������������������������� ������������������������������������������� ������������������������������������������� ��������������������������������������� ��������������������������������������� ��������������������������������������� ����������������������������������� ���������������������������������� ��������������������������������� ���������������������������������� ��������������������������������� �������������������������������� ������������������������������� ������������������������������ ��������������������������� ���������������������������� ������������������������� ��������������� ����������� 296 306 309 309 708 292 292 302 632 304 720 720 720 728 728 726 729 722 247 530 724 691 723 149 149 725 719 719 712 712 721 135 611 551 717 711 511 46 43 8 index 801801 37 99 99 174 191 110 134 187 185 185 185 421 641 310 310 310 310 345 190 109 189 425 188 359 653 243 729 297 363 730 643 324 249 366 398 640 289 Index
������� ���������� ������� ���������������������� ���������������������������� ������������������������������������� �������������������������������������� ��������������������������������������� ����������������������������������������� ����������������������������������������� ����������������������������������������� ������������������������������������������ ������������������������������������������ ���������������������������������������������� ��������������������������������������������� ���������������������������������������������� ������������������������������������������������ ������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������� ��������������������������������������������������������� ��������������������������������������������������������� ���������������������������������������������������������� ��������������������������������������������������������� ����������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������� ���������������������������������������������������������������� Pelvis Plaster cast care of limbs Simple, Adult Child Osteomyelitis obstruction Airway Choking Ear Eye slab Back Compound Limbs Mandible/jaw Other spiny fish spiny Other Stonefish Bullrout fish Cat Possible causes Possible Genital herpes Genital Funnel-web spider bite spider Funnel-web G (GHB), overdose Gamma-hydroxybutyrate Gastroenteritis upper bleeding, Gastrointestinal (GORD) disease reflux Gastro-oesophageal Foot infection, diabetes infection, Foot body Foreign Fracture Fitting scale assessment pain behavioural FLACC Flail chest eye to burn Flash Flu, adult examination eye Fluorescein, Fluoride varnish seizures Focal Folliculitis Fish stings Fish Genital sores/ulcers Genital warts Genital 37 45 30 29 29 371 375 375 361 361 374 275 545 674 619 372 109 367 359 359 379 387 385 234 358 358 363 562 207 362 362 362 384 384 369 366 360 360 386 ������������� ���������������� ������������������� �������������������� ����������������������� ���������������������������� ������������������������������ ����������������������������������� ����������������������������������� ������������������������������������ �������������������������������������� ���������������������������������������� ���������������������������������������� ������������������������������������������� ������������������������������������������ ��������������������������������������������� �������������������������������������������� ��������������������������������������������� ��������������������������������������������� ���������������������������������������������� ��������������������������������������������� ���������������������������������������������� ���������������������������������������������� ������������������������������������������������� �������������������������������������������������� ������������������������������������������������ �������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ������������������������������������������������� �������������������������������������������������� ��������������������������������������������������� Tips acuity Visual Eversion of the eyelid of Eversion examination Fluorescein movements and eye Pupils ������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������ �������������������������������������������������������������� ������������������������������������������������������������
Periorbital cellulitis Periorbital Red Trachoma Loss of vision Loss cellulitis Orbital of Padding Painful Corneal ulceration Corneal acute Glaucoma, Iritis, acute Chlamydia trachomatis Chlamydia Conjunctivitis abrasion Corneal Assessment Flash burn Flash body Foreign Penetrating Blunt burn Chemical Preparation Who to contact
Fish hook removal hook Fish First catch urine catch First Fetal fibronectin (fFN) testing (fFN) fibronectin Fetal child - diagnosis differential Fever, Fentanyl Febrile convulsion Febrile FACES pain scale pain FACES F Eye shield Eye Eyes Eye injury Eye Eversion of eyelid of Eversion Evacuation/retrieval Eucalyptus oil, overdose oil, Eucalyptus Episiotomy and repair of perineum of repair and Episiotomy Epistaxis 802 index Gonorrhoea Glue sniffing Glue, skin Glue ear Glaucoma, acute GlasgowComa Scale Gingivitis GI bleed, upper Giardiasis Gestational diabetes, | Primary Clinical Care Manual 10th edition | Headache Hb ranges, child Hay fever Hansen's Disease (Leprosy) Haemothorax Haemorrhage Haemoglobin ranges, child Haematemesis H Gum disease Group B Streptococcus prophylaxis siezure mal Grand Screening anddiagnosis OGTT Subarachnoid haemorrhage Acute andchronic Upper gastrointestinal bleeding Shock Secondary postpartum Rectal Primary postpartum Postextraction tooth In trauma Epistaxis Catastrophic, trauma Antepartum After birth Risk factors In antenatal care How to take culture for GBS ������������������������������������������������������������ ���������������������������������������������������������� ���������������������������������������������������������� ����������������������������������������������������������� ���������������������������������������������������������� ��������������������������������������������������������� ����������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ������������������������������������������������ ����������������������������������������������� ��������������������������������������������� ���������������������������������������� ����������������������������������������� �������������������������������������� see also ����������������������������������� ������������������������������������ ���������������������������������� ������������������������������� ������������������������������� ������������������������������ ���������������������������� �������������������������� Antenatal care ����������������������� ������������������� ����������������� 206 289 500 320 249 249 586 540 623 250 738 336 234 387 522 522 785 750 750 164 353 353 572 572 535 165 413 541 541 251 351 110 157 717 174 77 Heart disease, chronic Health Management Protocols Head to toe assessment, trauma Head lice/nits Head inury advice Head injuries HPV Hookworm Hives, seeUrticaria HIV History and physical examination Herpes, genital Hepatitis C Hepatitis B Hepatitis A HELPERR stroke Heat Heat exhaustion Heart murmur Heart failure, acute Hyperthermia Hypertension inpregnancy Hypertension Hydrofluoric acid burns Hydration child, assessment of Hydration adult, assessment of Human papilloma virus (HPV) Human immunodeficiency virus (HIV) ������������������������������������������������������������������� Supply ofmedicines by ATSIHP andIHW Thunderclap Child Adult Severity Preeclampsia/eclampsia Hydralazine Supply ofmedicines by ATSIHP andIHW In pregnancy In child,BP values Hypertensive crisis -acute ������������������������������������������������������������������� ����������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������ �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ������������������������������������������������ ���������������������������������������������� ���������������������������������������������� �������������������������������������������� ������������������������������������������ �������������������������������������� ������������������������������������ ������������������������������� ���������������������������� ���������������������������� ��������������������������� ���������������������������� ����������������� ������������������� ����������������������� �������������� 670 ����� ����� 23 , , 664 226 246 320 706 656 656 528 526 526 643 702 530 653 653 445 445 166 732 740 579 433 437 435 418 527 144 231 231 231 179 157 175 151 20 10 index 803803 91 67 67 28 113 191 413 154 745 555 537 144 149 552 277 182 198 166 367 544 736 407 278 548 540 304 462 306 386 306 308 308 Index ��
��������� ������������������������� ��������������������������������� ���������������������������������� ���������������������������������������� ���������������������������������������� ������������������������������������������ ������������������������������������������ ������������������������������������������� �������������������������������������������� �������������������������������������������� ��������������������������������������������� ���������������������������������������������� ������������������������������������������������ ������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������� ������������������������������������������������������� ����������������������������������������������������������� ������������������������������������������������������������� �������������������������������������������������������������� ��������������������������������������������������������������������� Preterm prelabour rupture of membranes rupture prelabour Preterm 1st stage 2nd stage/birth stage 3rd in prophylaxis B Streptococcus Group Preterm Bluebottle Box jellyfish Irukandji jellyfish Other Lithium overdose Lithium LMA LMNOP mnemonic to how roll, Log Lacerations, see Acute wounds see Acute Lacerations, intolerance Lactose airway mask Laryngeal children Laxatives, failure ventricular Left acute ischemia, Leg Leprosy counselling means Lethal strike Lightning K sign Kernig's Ketoacidosis L Labour Irrigation, eye Irrigation, Irukandji ISOBAR J fracture Jaw stings Jellyfish cruris Tinea see itch, Jock Iritis, acute Iritis, overdose Iron 42 84 69 171 115 175 116 771 771 771 561 747 163 183 773 525 552 559 565 372 503 558 601 180 729 324 205 205 392 392 560 560 768 768 768 768 603 229 399 ���������������� ��������������������� ����������������������� ������������������������� ������������������������� ��������������������������������� ������������������������������������� ����������������������������������������� ������������������������������������������ ������������������������������������������� ���������������������������������������������� ��������������������������������������������� ���������������������������������������������� ���������������������������������������������� ���������������������������������������������� ����������������������������������������������� ������������������������������������������������ ������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������ �������������������������������������������������������� �������������������������������������������������������� ����������������������������������������������������������� ���������������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� �������������������������������������������������������������
Head Spinal Traumatic Amputation, minor Amputation, Chest minor Crush, Vaccine in pregnancy Vaccine Abdominal Q Fever health Sexual Tetanus Vaccinations BCG Childhood Influenza Vitamin K Vitamin Apgar Score Apgar factors risk Hypoglycaemia, Resuscitation Alcohol induced Alcohol In newborn In pregnancy
Intussusception Intrauterine contraceptive device contraceptive Intrauterine Intraocular air Intraocular infusion Intraosseous Insect in ear Insect Injuries Influenza, adult Influenza, Infected scabies, see Impetigo scabies, Infected Incision of abscess of Incision Impetigo Implanon Immunisation Imminent birth Imminent Immediate care of the newborn of care Immediate IM injection, child - maximal amounts - maximal child IM injection, Ibuprofen I Hypothermia Hypoglycaemia 804 index Mania Mandible/jaw fracture Mandatory reporter, child abuse Major burns M Lyssavirus Lung cancer Lower legischemia, acute Low abdominal pain, female Løvsett’s manoeuver Loss of vision, sudden | Primary Clinical Care Manual 10th edition | Mental health Meningitis Melioidosis, pneumonia Medroxyprogesterone acetate Medicines, authority to use Medication reconciliation Medication history, best McRoberts Mauriceau-Smellie-Veit manoeuvre Mastoiditis, acute Mastitis Marine lacerations, see Water related wounds Manual removal, placenta Suicidal behaviour Schizophrenia Safety considerations Puerperal psychosis Psychosis Physical restraint (avoiding) Non-consenting patients Mental stateexamination Mania Drug-induced psychosis Depression Behaviouraldisturbance, severe Assessment Anxiety Signs of ��������������������������������������������������������������� ������������������������������������������������������������ ��������������������������������������������������������� �������������������������������������������������������� ����������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������ Lethal means counselling ��������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ��������������������������������������������� �������������������������������������������� ����������������������������������������� ��������������������������������������� ��������������������������������������� ������������������������������������� ����������������������������������� ����������������������������������� ���������������������������������� ��������������������������������� ���������������������������������� ��������������������������������� ��������������������������������� ���������������������������������� ����������������������������� ����������������������������� ���������������������������� �������������������� �������������������������� ����������������������� ���������������������� ������������������� ���������������� �������������� 453 � , 209 484 484 484 484 469 580 588 780 222 462 760 329 599 584 450 456 467 454 724 635 778 585 578 481 481 481 481 477 474 374 134 154 215 191 91 91 9 Near drowning, seeDrowning Nauseaand vomiting Nasal tampon Nasal packing rash Nappy Naloxone N Myocardial infarction Mycoplasma genitalium MSU, how to Mouth ulcers Morphine Morning after pill pill Missed Miscarriage Minor burns Methoxyflurane Mental state examination Mental health assessment NSAID, overdose Nose bleed Norwegian scabies Non-shockable rhythm Nits NEXUS Low-Risk Criteria Newborn life support flowchart Newborn, immediate care of Neuropathic ulcer block,Nerve digital Neonatal resuscitation Needle thoracentesis ������������������������������������������������������������������� Posterior Anterior Resuscitation Apgar Score ����������������������������������������������������� ����������������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� Safety Plan Risk assessment ����������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������� ���������������������������������������������������� �������������������������������������������������� ����������������������������������������������� ����������������������������������������������� ����������������������������������������������� ��������������������������������������������� ��������������������������������������������� �������������������������������������������� ������������������������������������������ ���������������������������������������� ���������������������������������������� ����������������������������������������� �������������������������������������� ���������������������������������������� ��������������������������������������� ������������������������������������ ������������������������������������ ���������������������������������� �������������������������������� ����������������������������� ����������������������������� ��������������������������� ������������������������� 47 , 608 206 390 420 429 464 224 236 623 450 279 234 558 347 565 565 559 128 281 235 235 182 453 567 418 461 415 173 135 611 513 48 46 44 58 index 805805 19 91 23 22 26 411 133 617 134 134 375 353 353 554 477 190 740 740 505 635 635 673 562 276 324 623 667 768 685 622 282 289 286 689 668 Index
����������������� ���������������� ��������������������� ������������������������ ����������������������������� ������������������������������ ������������������������������ �������������������������������������� ��������������������������������������� ��������������������������������������� ����������������������������������������� ������������������������������������������ ������������������������������������������� ������������������������������������������� ��������������������������������������������� ����������������������������������������������� ����������������������������������������������� �������������������������������������������������� �������������������������������������������������� ����������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������ ������������������������������������������������������������ ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� Delivery of Delivery Adult Child Adult Child Immunisation in pregnancy Immunisation Child Child Ordering Chlamydia/gonorrhoea check STI Adult �������������������������������������������������������������������� Pinworms versicolor Pityriasis Placenta Petechial rash ingestion other oils, and fuels Petrol, sniffing Petrol Pharyngitis examination Physical (avoiding) restraint Physical PID Perianal/perineal itch Perianal/perineal tamponade Pericardial Pericarditis repair Perineum, disease Periodontal Periodontitis cellulitis Periorbital cough) (whooping Pertussis poisoning Pesticides, Pathology child and adult - presentation Patient (PID) disease inflammatory Pelvic Pelvis, fracture discharge Penile ulcer Peptic Paraquat, poisoning Paraquat, obtaining history, Past 41 35 35 35 65 36 36 64 64 711 717 135 135 134 719 130 375 257 725 758 673 425 522 726 283 238 362 302 665 786 282 664 664 664 280 ���� ��������������� ��������������������� �������������������������� ��������������������������� ������������������������������ ��������������������������������� ��������������������������������� ����������������������������������� ������������������������������������ ������������������������������������� ��������������������������������������� ������������������������������������� �������������������������������������� ��������������������������������������� ������������������������������������������� ������������������������������������������ ��������������������������������������������� ����������������������������������������������� ��������������������������������������������� �������������������������������������������������� ������������������������������������������������� ������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ���������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������������ ���������������������������������������������������������� ����������������������������������������������������������� ������������������������������������������������������������� ��������������������������������������������������������������� ������������������������������������������������������������� ��������������������������������������������������������������
����������������������������������������������������������������� Testicular/scrotal Ear Eye Management Assessment Assessment scales Chest Abdominal Acute Analgesia Differential diagnosis Differential examination and physical History illness signs, serious Risk Could this this be sepsis Could Delivery systems Delivery scenarios Use in specific Ear wick technique wick Ear
Paralysis tick Paracetamol, safe use safe Paracetamol, Paracetamol overdose Paracetamol, Pain
Paediatric presentation Paediatric P Oxygen Overdose, see Poisoning and overdose and see Poisoning Overdose, Otitis media with effusion with media Otitis Otitis media, chronic suppurative chronic media, Otitis Otitis externa Otitis Osteomyelitis in foot, diabetes Osteomyelitis Organophosphates/carbamates, poisoning Organophosphates/carbamates, child Osteomyelitis, Orbital cellulitis Orbital Opioid, overdose Opioid, OGTT Oesophageal pain Oesophageal O NSTEACS NSTEMI 806 index Pneumothorax Pneumonia castcare Plaster backPlaster slab | Primary Clinical Care Manual 10th edition | check Postnatal Post extraction haemorrhage, tooth Poisons Information Centre (PIC ) Poisoning and overdose Tension Sucking chest wound Spontaneous Simple Open Child Adult Manual removal of Sedatives/hypnotics Risk assessment Poisons Information Centre (PIC ) Petrol, fuels andother oils Paraquat Paracetamol Organophosphates/carbamates (pesticides) Opioids NSAID Lithium Iron ingestion General approach Gamma-hydroxybutyrate (GHB) Eucalyptus oil ECG changes Cyanide Corrosive/caustic substanceingestion Ciguatera Carbon monoxide Cannabis Aspirin/salicylates Antipsychotics Antihistamines Antidepressants Anticonvulsants Anticholinergics Amphetamines andcocaine Activated charcoal ���������������������������������������������������������� ���������������������������������������������������������� ����������������������������������������������������������� ��������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������ Severity ���������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ����������������������������������������������� ����������������������������������������������� ����������������������������������������������� ���������������������������������������������� ����������������������������������������������� ��������������������������������������������� ��������������������������������������������� �������������������������������������������� ������������������������������������������� ������������������������������������������ ����������������������������������������� �������������������������������������������� ����������������������������������������� ����������������������������������������� ��������������������������������������� �������������������������������������� �������������������������������������� ������������������������������������� ������������������������������������� ������������������������������������ ����������������������������������� ���������������������������������� �������������������������� ����������������������� ���������������������� ������������������ ������������������ ��������������� ������� 288 280 698 286 289 269 282 262 262 264 283 329 265 287 697 278 270 267 276 279 259 592 259 259 259 188 272 273 578 277 261 274 291 275 316 187 271 351 133 173 173 173 173 Pregnancy, bleeding Pregnancy Preeclampsia/eclampsia Post streptococcal diseases Post partum haemorrhage Preterm prelabour rupture of membranes Preterm labour Preterm baby Pressure bandage, snake bite Urinary tract infection in Unintended Termination of Rh(D) immunoglobulin Preeclampsia Lifestyle considerations during Leaving community Hypertension in Group BStreptococcus risk factors Ectopic Diabetes in Counselling andeducation Asymptomatic bacteriuriain Antenatal care Magnesium sulfate Imminenteclampsia, signs If fitting Features of APSGN Acute rheumatic fever Secondary Primary Fetal lung maturation Fetal fibronectin (fFN) testing Temperature control Special considerations for Resuscitation inplastic bag Neonatal resuscitation Handling and skin protection Vaginal bleeding, to 20 weeks Vaginal bleeding after 20 weeks Ectopic pregnancy At birth Antepartum haemorrhage ������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ Secondary prophylaxis for Bicillin LA �������������������������������������������������� �������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ������������������������������������������������ ��������������������������������������������� �������������������������������������������� �������������������������������������������� ������������������������������������������ ����������������������������������������� ��������������������������������������� ������������������������������������ ������������������������������������ ����������������������������������� ���������������������������������� ��������������������������������� ��������������������������������� ������������������������������� ������������������������������� ����������������������������� ����������������������������� ��������������������������� �������������������������� �������������������������� ������������������������� ������������������������� ������������������������ ���������������������� ���������������������� ��������������������� ��������������������� ������������������� ����������������� �������������� ������������� ��������� 498 498 508 500 586 700 700 568 568 568 442 526 546 293 443 530 530 544 705 532 565 565 507 507 545 572 572 537 535 535 501 516 516 541 521 531 531 531 513 511 511 index 807807 54 56 30 29 29 29 29 139 537 219 565 705 166 445 254 443 370 303 256 207 324 439 203 442 509 509 320 508 406 682 682 208 208 208 Index ���
����� ������������������������� ��������������������������� �������������������������� ������������������������������� ����������������������������������� ���������������������������������� ����������������������������������� ������������������������������������� �������������������������������������� ���������������������������������������� ����������������������������������������� ������������������������������������������ ����������������������������������������� ������������������������������������������� ��������������������������������������������� ����������������������������������������������� ����������������������������������������������� �������������������������������������������������� ������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������ ��������������������������������������������������������� ��������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ������������������������������������������������������������ �������������������������������������������������������������������� Sutures Tick ring Tight and IHW ATSIHP by of medicines Supply Adult Blood under finger/toenail under Blood hook Fish Bicillin LA Bicillin for prophylaxis Secondary Advanced life support Advanced Neonatal Preparation Who to contact Routine administration events Sensitising Acute Child Adult/child/infant S mnemonic SAMPLE Renal colic Renal Renal disease ACS options, Reperfusion Removal of Removal Rhinitis, allergic Rhinitis, child Rhinosinusitis, Ring removal Ringworm Ross River Virus RSQ burns nines, of Rules Ruptured eyeball labour & pre preterm membranes, of Rupture Retention of urine, acute urine, of Retention Retrieval/evacuation Queensland Services Retrieval Rh(D) immunoglobulin fever Rheumatic Respiratory tract infection, upper infection, tract Respiratory Resuscitation 19 27 54 58 155 771 251 215 516 163 144 164 481 481 481 481 481 481 756 746 787 359 324 287 287 659 685 299 389 289 288 , 133 ����������� ������������� �������������� ������������������ ����������������������������� ���������������������������������� �������������������������������� ���������������������������������� ��������������������������������������� ����������������������������������������� ������������������������������������������ ������������������������������������������ ������������������������������������������ ����������������������������������� ����������������������������������������� ������������������������������������������� ������������������������������������������� �������������������������������������������� ���������������������������������������������� ������������������������������������������������� ������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������� ��������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������� ���������������������������������������������������������������
Cocaine (GHB) Gamma-hydroxybutyrate Trauma Amphetamines (marijuana) Cannabis All presentations All patient Collapsed Child Adult In pregnancy Adult Schizophrenia Drug-induced psychosis Drug-induced Psychosis Puerperal
Recreational drugs, overdose drugs, Recreational Rapid assessment Rapid Rabies assault sexual and Rape R Quick wee Quick Quinsy Queensland contacts Queensland Q Fever immunisation Q Fever Pyloric stenosis Q Pyelonephritis Pupils and eye movements, assessment movements, eye and Pupils Pulmonary oedema Pulmonary activity electrical Pulseless Pulmonary embolus Pulmonary Puerperal psychosis Puerperal Psychotic disorders Psychotic Psychosis Primary and secondary survey, trauma survey, secondary and Primary tips administration penicillin, Procaine Redback spider bite spider Redback Rectal bleeding Rectal 808 index Sedatives/hypnotics, overdose Sedation score Second skin, Secondary postpartum haemorrhage Sea urchin injuries Sea snake bite Scrotal pain School sores, Schizophrenia Scabies | Primary Clinical Care Manual 10th edition | Sexually transmitted infections, general Sexually transmitted infections, check Sexual health immunisation Sexual assault Sexual abuse, child Septic child arthritis, Sepsis/septic shock Sensitising events, Rh(D)immunoglobulin Seizure Norwegian Crusted Partner notification Medication management Follow up Education andprevention Decision making flowchart Contact tracing Condom education Who totest Which tests When totest Specimen collection How to Screening Risk factors Risk criteriafor illness/sepsis Couldchild thisbesepsis, Tonic-clonic Partial Grand mal Focal Febrile convulsions ��������������������������������������������������������������� �������������������������������������������������������������� ������������������������������������������������������������ ���������������������������������������������������������� ���������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� see ����������������������������������������������������� see ������������������������������������������������������ ���������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ����������������������������������������������������� �������������������������������������������������� ���������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ������������������������������������������������ Tinea versicolor Impetigo ��������������������������������������������� �������������������������������������������� �������������������������������������������� �������������������������������������������� ������������������������������������������ �������������������������������������� �������������������������������������� ������������������������������������� ������������������������������������ ������������������������������ ���������������������������� ��������������������������� ��������������������������� �������������������������� �������������������������� ������������������������ ����������������� ��������������� ������������ �������� 620 620 620 622 586 665 292 509 659 618 763 109 758 616 616 616 619 619 481 621 621 291 257 314 615 617 415 415 415 110 110 110 110 110 771 80 80 82 40 81 Skin parasites Skin glue Skin assessment Sinusitis Simple fracture of limbs Shoulder dystocia Shockable rhythm Shock Sexually transmitted infections - STI's Sniffing petrol/glue/aerosol Snakebite Skin problems Child Adult Septic Obstructive Hypovolaemic Cardiogenic Syphilis PID Mycoplasma genitalium Low abdominal paininfemale HIV Herpes Gonorrhoea Genital warts Genital sores/ulcers Epididymo-orchitis Donovanosis Chlamydia Bacterial vaginosis Tinea versicolor Tinea/ringworm Scabies Nappy rash Impetigo Foot infection, diabetes Folliculitis Cellulitis Carbuncles Candidiasis Boils Scabies Head lice/nits ������������������������������������������������������������������� �������������������������������������������������������������� �������������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������ ����������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������ ������������������������������������������������������������ ����������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� �������������������������������������������������� �������������������������������������������������� ��������������������������������������������������� ������������������������������������������������� ������������������������������������������������� �������������������������������������������������� ����������������������������������������������� ����������������������������������������������� ���������������������������������������������� ���������������������������������������������� ����������������������������������������������� ������������������������������������������ �������������������������������������������� ������������������������������������������ �������������������������������������� �������������������������������������� ������������������������������������� ������������������������������������ �������������������������������� ����������������������������� ������������������������������ ��������������������� 57 289 406 628 640 409 398 398 398 646 420 650 292 656 392 632 205 670 623 623 623 643 , 653 635 635 327 579 401 418 421 185 415 415 411 80 24 58 77 77 77 77 index 809809 9 27 27 141 173 774 355 773 333 257 257 725 140 345 352 740 740 445 338 338 338 338 344 324 258 342 203 203 203 706 348 685 500 646 646 498 , Index
139 ������� ������� ����������������� ����������������� ����������������������������������� ��������������������������������� ���������������������������������� �������������������������������������� �������������������������������������� ���������������������������������������� ������������������������������������������ ������������������������������������������� �������������������������������������������� ������������������������������������������������ ������������������������������������������������ ������������������������������������������������ ����������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� ��������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������������ ����������������������������������������������������������� ������������������������������������������������������������ ������������������������������������������������������������� ������������������������������������������������������������� �������������������������������������������������������������� ����������������������������������������������������������������� Tenecteplase Oral Differential diagnoses Differential Adult child Avulsed Broken Dental abscess caries Dental Displaced socket Dry Fluoride varnish Toothache Trauma Removal of sutures Removal Staples care Antenatal see In pregnancy, Qld Centre, Surveillance Syphilis ����������������������������������������������������������������������� Supply chronic medicines, ATSIHP and IHW and ATSIHP medicines, chronic Supply Thrombolysis, at rural or remote facility or remote rural at Thrombolysis, Thrush Tension pneumothorax Tension pregnancy of Termination pain Testicular torsion Testicular immunisation Tetanus vaccines Tetanus Threadworm sore Throat, Teeth Telehealth TEMSU Suturing ear Swimmer's chorea Sydenham’s Syphilis T Tapeworms TB Supply medicines, authority medicines, Supply 157 135 173 181 315 315 195 195 314 187 312 312 158 301 310 301 128 616 740 180 297 456 324 676 203 304 464 302 685 309 309 299 306 296 296 308 308 208 , 164 �������� ������������������������������������ ������������������������������������� �������������������������������������� ����������������������������������������� ����������������������������������������� ������������������������������������������ ������������������������������������������� ���������������������������������������������� ��������������������������������������������� ������������������������������������������������ ������������������������������������������������� ������������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ��������������������������������������������������� ��������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ����������������������������������������������������� ������������������������������������������������������ ����������������������������������������������������� ����������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������� ��������������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������� �������������������������������������������������������������� ��������������������������������������������������������������� ���������������������������������������������������������������� ����������������������������������������������������������������� Risk assessment Risk behaviour Suicidal ������������������������������������������������������������������� Stingray Tick Sea urchin Sea Spider Sponges Irukandji other Jellyfish, spider Redback Scorpion Cone shell Cone Fish Funnel-web Blue-ringed octopus Blue-ringed Box jellyfish Centipede Bluebottle Child Adult Suicide Subungual haematoma Subungual wound chest Sucking Submersion Subarachnoid haemorrhage, spontaneous haemorrhage, Subarachnoid Stroke Strongyloides Stridor - child with - child Stridor STIs, see Sexually transmitted infections transmitted Sexually see STIs, Stings STEMI sting Stingray Staples Sprains Splint, of limb of Splint, Sponge sting Spinal injuries Spinal Spider bites, general bites, Spider Sore throat Sore Softcollar injury tissue Soft 810 index Tissue spear, cleaning ear Tinea versicolor(pityriasis versicolor) Tinea Tight ringremoval Tick bites TIA | Primary Clinical Care Manual 10th edition | Trichomonas Traumatic injuries cover insert Trauma, criteria for early notification, Trauma Transient ischaemic attack ear Tragal pressure, Trachoma Toxicology (poisoning and overdose) Tourniquet, catastrophic haemorrhage Total body surface area, burns Torsion of testes Tooth-knuckle injury Tooth, socket dry Tooth, bleeding post extraction Toothache Tooth abscess Tooth, Tonsillitis ���������������������������������������������������������������������� Pedis Cruris Corporis Capitis Tickparalysis/tick typhus Removalof tick Vaginal in pregnancy Spinal Secondary survey Primary survey Head Chest Abdominal Child Adult ����������������������������������������������������������������� see also ��������������������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� ������������������������������������������������������������ ����������������������������������������������������������� ������������������������������������������������������������ ����������������������������������������������������������� ���������������������������������������������������������� ��������������������������������������������������������� ���������������������������������������������������������� ��������������������������������������������������������� ������������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������ ���������������������������������������������������� ��������������������������������������������������� Teeth ������������������������������������������������� ������������������������������������������������ ����������������������������������������������� ����������������������������������������������� ���������������������������������������������� �������������������������������������������� �������������������������������������������� �������������������������������������������� ������������������������������������������� ����������������������������������������� ���������������������������������� ��������������������������������� ���������������������������� ���������������������������� �������������������������� ����������������� see ������������������ �������������� Front 208 406 630 506 685 348 384 302 720 720 623 342 324 407 407 407 407 259 303 180 352 164 164 219 257 212 183 163 163 158 158 165 351 175 411 171 Urine Urinary tract infection Upper respiratory tract infection (URTI) Unconscious Umbilical cord prolapse orpresentation Ulcer U Tuberculosis Tropical ear Vaccines Vaccination procedures VA V UTI, Uterine inversion Urticaria ���������������������������������������������������������������������� Pyelonephritis In pregnancy Cystitis Child Adult child Adult Venous Neuropathic Mouth Lower limb Genital Corneal Chronic wounds Arterial BCG Suprapubic aspirate -child Retention of Quick wee -child to how MSU, Midstream sample -child First catch -STIs Clean catch - younger child Bladder stimulation -child see Urinary tract infection �������������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������� ������������������������������������������������������������ ����������������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� ��������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������������� ������������������������������������������������������� Asymptomatic bacteriuriain ������������������������������������������������������� �������������������������������������������������������� �������������������������������������������������� ������������������������������������������������� ������������������������������������������������ ������������������������������������������������ ������������������������������������������������ ������������������������������������������������ ��������������������������������������������� ������������������������������������������� ������������������������������������������ ����������������������������������������� �������������������������������������� ����������������������������� �������������������������� �������������������������� ������������������������� ������������� ������������ 682 640 390 389 389 389 320 429 429 429 429 768 569 324 256 358 385 427 770 347 578 756 756 619 756 754 725 333 516 516 755 755 771 73 index 811811 421 212 427 202 428 209 209 209 209 Index
�������������������������������� ���������������������������������������� ������������������������������������������ ����������������������������������������������� ���������������������������������������������� ���������������������������������������������������� ���������������������������������������������������� ������������������������������������������������������� �������������������������������������������������������� Foot infection, diabetes infection, Foot laceration Marine water Salt Tooth-knuckle related Water Chronic Closure cuts Coral Wound swab, how to how swab, Wound X Y Z 13 58 58 36 36 49 48 48 20 511 513 617 561 535 374 212 677 787 198 740 653 243 358 730 623 623 623 623 205 429 665 630 628 ��������������������������� ����������������������������� ������������������������������ ���������������������������������� ������������������������������������ ���������������������������������������� �������������������������������������� ����������������������������������������� ��������������������������������������� Pertussis ���������������������������������������� ���������������������������������������� ������������������������������������������� ��������������������������������������������� ���������������������������������������������� ����������������������������������������������� see ����������������������������������������������� ����������������������������������������������� ������������������������������������������������� ��������������������������������������������������� ����������������������������������������������������� ���������������������������������������������������� ����������������������������������������������������� ������������������������������������������������������ ������������������������������������������������������ ������������������������������������������������������� ���������������������������������������������������������� �������������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� ������������������������������������������������������������� ����������������������������������������������������������� ����������������������������������������������������������� �������������������������������������������������������������
Child Warning signs in children signs Warning Adult Antiemetic Assessment of with Child Child Adult Trichomonas Mycoplasma genitalium Mycoplasma check STI Thrush Bacterial vaginosis Bacterial Chlamydia Gonorrhoea After 20 weeks After pregnancy Ectopic weeks to 20 Up Acute minor Amputations, Bites
Whooping cough, Whooping What's new What's Warts, genital Warts, W Vomiting and diarrhoea, gastro diarrhoea, and Vomiting Vomiting Vitamin K, for newborn K, for Vitamin Vital signs, normal signs, Vital Vision, sudden loss of loss sudden Vision, acuity Visual Verbal rating pain scale pain rating Verbal Verbal analogue pain scale pain analogue Verbal Ventricular tachycardia Ventricular to how injection, Ventrogluteal Ventricular fibrillation Ventricular Venous ulcer Venous Vaginal discharge Vaginal Vaginal bleeding in pregnancy in bleeding Vaginal Worms, intestinal Worms, Wounds