CHHS18/112

Canberra Health Services Clinical Guideline Walk in Centre Clinical Treatment Protocols

Contents

Contents ...... 1 Scope ...... 4 Abrasion – Clinical Treatment Protocol ...... 4 Acute Otitis Media – Clinical Treatment Protocol ...... 5 Acute Urticaria – Clinical Treatment Protocol ...... 7 Allergic Conjunctivitis – Clinical Treatment Protocol ...... 10 Allergic Rhinitis – Clinical Treatment Protocol ...... 11 Anaphylactic Reaction – Clinical Treatment Protocol ...... 13 Ankle – Clinical Treatment Protocol ...... 15 Asthma – Clinical Treatment Protocol ...... 19 Atopic Dermatitis – Clinical Treatment Protocol ...... 21 Bites – Clinical Treatment Protocol ...... 24 Blood Glucose Level (BGL) – Clinical Treatment Protocol ...... 27 Boils – Clinical Treatment Protocol ...... 30 Burns – Clinical Treatment Protocol ...... 32 Chemical Splash to Eye – Clinical Treatment Protocol ...... 34 Chlamydia Trachomatis Screening – Clinical Treatment Protocol ...... 36 Common Cold – Clinical Treatment Protocol ...... 37 Contact Dermatitis (Allergen and Irritant) – Clinical Treatment Protocol ...... 39 Contusion – Clinical Treatment Protocol ...... 41 Corneal Abrasion – Clinical Treatment Protocol ...... 43 Coxsackie Virus (Hand Foot and Mouth Disease) and Herpangina – Clinical Treatment Protocol ...... 45 Croup – Clinical Treatment Protocol ...... 48 Dermatophyte (Tinea) Infection – Clinical Treatment Protocol ...... 50 Gastroenteritis - Diarrhoea – Clinical Treatment Protocol ...... 52 Dry Eye Syndrome – Clinical Treatment Protocol ...... 55 Ear Wax – Clinical Treatment Protocol ...... 57

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Elbow – Clinical Treatment Protocol ...... 59 Emergency Contraception – Clinical Treatment Protocol ...... 63 Fever – Clinical Treatment Protocol ...... 65 Finger or Toe Injury – Clinical Treatment Protocol ...... 67 Foot Injury – Clinical Treatment Protocol ...... 71 Fracture Management – Clinical Treatment Protocol ...... 74 Hand Injury – Clinical Treatment Protocol ...... 79 Head Lice – Clinical Treatment Protocol ...... 82 Tension Headache – Clinical Treatment Protocol ...... 83 Impetigo – Clinical Treatment Protocol ...... 86 Infectious Lactational Mastitis – Clinical Treatment Protocol ...... 87 Infective Conjunctivitis – Clinical Treatment Protocol ...... 90 Influenza – Clinical Treatment Protocol ...... 92 Knee Injury – Clinical Treatment Protocol ...... 94 Laceration – Clinical Treatment Protocol ...... 98 Musculoskeletal lower back pain – Clinical Treatment Protocol ...... 102 Lower Urinary Tract Infection – Clinical Treatment Protocol ...... 105 Marine Sting - Clinical Treatment Protocol ...... 107 Measles – Clinical Treatment Protocol ...... 109 Meibomian Cyst – Clinical Treatment Protocol ...... 111 Migraine – Clinical Treatment Protocol ...... 113 Non-Invasive Foreign Body (FB) of the Eye – Clinical Treatment Protocol ...... 116 Non-Specific Viral Rash – Clinical Treatment Protocol ...... 117 Otitis Externa (Swimmer’s Ear) – Clinical Treatment Protocol ...... 120 Paronychia (Acute) – Clinical Treatment Protocol ...... 122 Pregnancy Test – Clinical Treatment Protocol ...... 124 Primary Dysmenorrhoea – Clinical Treatment Protocol ...... 126 Head Injury – Adults (>18yrs) – Clinical Treatment Protocol ...... 128 Head Injury – Children & Adolescents (2-18yrs) – Clinical Treatment Protocol ...... 131 Pulled Elbow – Clinical Treatment Protocol ...... 134 Removal of Cast (ROC) – Clinical Treatment Protocol ...... 136 Rubella – Clinical Treatment Protocol ...... 137 Scabies – Clinical Treatment Protocol ...... 140 Scaphoid Injury – Clinical Treatment Protocol ...... 141

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Self-Harm (Cutting) – Clinical Treatment Protocol ...... 144 Shingles (Herpes Zoster) – Clinical Treatment Protocol ...... 147 Acute Bacterial Rhinosinusitis – Clinical Treatment Protocol ...... 149 Sore Throat (Pharyngitis)/Bacterial Strep Throat/Tonsillitis – Clinical Treatment Protocol.. 151 Spider Bite – Clinical Treatment Protocol ...... 154 Stye (Hordeola) – Clinical Treatment Protocol ...... 156 Subconjunctival Haemorrhage – Clinical Treatment Protocol ...... 158 Subungual Haematoma – Clinical Treatment Protocol ...... 160 Suture/Staple Removal – Clinical Treatment Protocol ...... 162 Uncomplicated Cellulitis – Clinical Treatment Protocol...... 163 Varicella (Chickenpox) – Clinical Treatment Protocol ...... 166 Viral Gastroenteritis - Vomiting - Clinical Treatment Protocol ...... 168 Vulvovaginal Candidiasis – Clinical Treatment Protocol ...... 170 Wound Dressing – Clinical Treatment Protocol ...... 172 Wrist Injury – Clinical Treatment Protocol ...... 174 Implementation ...... 177 Related Policies, Procedures, Guidelines and Legislation ...... 177 Search Terms ...... 177

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Scope

This document applies to all staff working within the Canberra Health Services Walk in Centres.

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Abrasion – Clinical Treatment Protocol

Overview: Condition for treatment – Abrasions are the disruption of the epidermis of the skin, usually through a shearing force. They commonly occur over the bony prominences of the knees, elbows and face. Dirt, gravel or bitumen is often ground into the wound.

Symptoms may include: • Superficial skin loss

Inclusion criteria - • Uncomplicated superficial to partial thickness abrasion, • With or without superficial debris.

Redirect to GP/NP if: • Signs of infection.

Redirect to ED if: • Unable to clean grossly dirty abrasion due to pain, • Suspicion of underlying injury to bone or other structures.

Management/Treatment: Work-up • Determine mechanism of injury to identify high risk wound • Assess for underlying injury to bone or other structures • Assess for need of ADT immunisation • Allergies e.g. local anaesthetic, latex

Treatment • Prior to cleaning an abrasion the wound may be soaked with lignocaine to aid in pain relief. • All abrasions should be cleaned/irrigated with N/Saline. Foreign material may be removed by gentle scrubbing using gauze or a brush. This prevents “tattooing” occurring from retained material. • Antiseptic solutions should not be used to irrigate the wound, even in the presence of infection.

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• The abrasion should be covered with a suitable dressing that will tolerate the expected degree of exudate. Silicone mesh dressings are effective in preventing adherence of dressing to wound.

Advice: • Decreased mobilisation of the wound for 2-3 days post abrasion. • Analgesia. • Client should be made aware of signs of infection. • Discuss appropriate follow up for wound review/dressings. • Client Information Sheet: Care of Wounds.

Medication Standing Order: • Paracetamol • ADT • Lignocaine

References : 1. Armstrong D.G., & Meyr, A. J. (2019). Basic principles of wound management. In H. Sanfey, J. F. Eidt, J. L. Mills & E. Bruera. UpToDate 2. National Institute for Health and Care Excellence: Clinical Knowledge Summary 2012 3. Therapeutic Guidelines 2019: https://tgldcdp.tg.org.au- 4. Young, S. J., Barnett, P. L., & Oakley, E. A. (2005). 10. Bruising, abrasions and lacerations: minor injuries in children I. Med J Aust, 182(11), 588-92.

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Acute Otitis Media – Clinical Treatment Protocol

Overview: Condition for treatment: Acute Otitis Media (AOM) is a common complication of viral respiratory illnesses and is characterised by middle ear inflammation and middle ear effusion. Fever alone is not an indication for antibiotic therapy. Diagnosis is based on the acute onset of either of the following inclusion criteria plus the following diagnostic otoscopic examination criteria.

Symptoms may include: • Distinctly red, yellow or cloudy tympanic membrane (TM) • Moderate to severe bulging tympanic membrane • Loss of normal landmarks and air fluid level behind tympanic membrane • Perforation of TM and/or discharge in auditory canal

Inclusion Criteria: • Recent discharge of pus (otorrhoea) • Fever ≥39 degrees

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• Ear pain (otalgia) • Irritability/pulling at ears • Vomiting (children)

Redirect to GP/NP if: • Chronic Otitis Media – history of recurrent ear infections or inflammation • Perforation of tympanic membrane from trauma • Complex co-morbidities • Systemically unwell with temperature ≥ 39°C with vomiting from onset of symptoms or within the first 48 hours • Hypersensitivity to Penicillin

Redirect to ED if: • Mastoid tenderness - may indicate mastoiditis

Differentials: • Otitis media with effusion • Bullous myringitis • Mastoiditis • Cholesteatoma

Management or Treatment: From the first symptoms of AOM, most people will be pain free within the 24-72 hours without the need of antibiotic treatment. Antibiotics will not relieve the earache.

Recommendations: Less than 48 hours from symptom onset with mild signs/symptoms, no otorrhoea and afebile: • Provision of regular simple over-the-counter analgesia for 24-72hr • Encourage review in 48-72hrs if symptoms worsen or do not improve Greater than 48 hours from symptom onset antibiotics are recommended when: • Systemically unwell with persistent otalgia > 48hrs and • Fever ≥39°C in past 48hrs • Bilateral AOM or otorrhoea.

Advice: • Eustachian tube dysfunction is a common cause of ear pain. Encourage chewing, regular nose blowing and steam inhalation • Recommend for client to have a review of affected ear/ears 5-7 days from onset of symptoms. It is not uncommon for fluid effusion to remain for up to 1 month post AOM. • The client should be encouraged to raise their head while sleeping to reduce the discomfort associated with otitis media. • Client Information Sheet – Ear Infections Better Health Channel

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Medication Standing Order: • Paracetamol • Ibuprofen • Amoxicillin

References : 1. Armengol, C.E. (2018). Otitis media. In R. Schwartz, O.Yigit & P. Bull (Eds.). British Medical Journal Best Practice. Retrieved from http://bestpractice.bmj.com/best- practice/monograph/39/treatment/details.html 2. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 3. Limb, C.J., Lustig, L.R & Durand, M.L. (2019). Acute otitis media in adults. In Deschler, D.G. & Kunin, L (Eds.). UpToDate. Retrieved from: https://www.uptodate.com/contents/acute-otitis-media-in- adults?search=acute%20otitis%20media&source=search_result&selectedTitle=2~150& usage_type=default&display_rank=2 4. Pelton, S. (2019). Acute otitis media in children: treatment. In Edwards, M.S., Isaacson, G.C. & Torchia, M.M (Eds.). UpToDate. Retrieved from: https://www.uptodate.com/contents/acute-otitis-media-in-children- treatment?search=acute%20otitis%20media&source=search_result&selectedTitle=1~1 50&usage_type=default&display_rank=1 5. The Royal Children’s Hospital Melbourne. (2018). Clinical practice guidelines: acute otitis media. Retrieved from http://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/

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Acute Urticaria – Clinical Treatment Protocol

Overview: Conditions for treatment - Urticaria, or hives (sometimes referred to as welts or wheals), is a common disorder. A presumptive trigger, such as a drug, food ingestion, insect sting or infection, may be identifiable in clients with new-onset urticaria, although no specific cause is found in many cases, particularly when the condition persists for weeks or months.

Symptoms may include: • Pale, blanching swellings of the superficial dermis. • Lesions may be small, large, giant, oval, annular or erythematous plaque. • Intensely pruritic • Angioedema

Inclusion criteria: • Urticarial rash; Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 7 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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• Oral mucosal signs or symptoms, • Ongoing gastrointestinal symptoms.

Redirect to GP/NP if: • Ongoing urticaria despite treatment with second generation H1 antihistamine (less sedating) and sedating antihistamine at night.

Redirect to ED if: • Any signs of anaphylaxis – see Anaphylaxis Protocol. • Known exposure, or high likelihood of exposure, to a known allergen with anaphylaxis potential.

Differentials: Non-pruritic conditions: • Viral Exanthems • Auriculotemporal Syndrome • Sweet Syndrome

Pruritic conditions: • Dermatitis – atopic and contact • Drug eruptions • Insect bites • Bullous Pemphigoid • Erythema multiform • Plant induced reactions (for clients who have travelled from overseas or tropical regions of Australia including NT)

Painful conditions: • Urticarial vasculitis

Management or Treatment: Work-up • Thorough history taking regarding potential anaphylactic symptoms. • Examination of any potential triggers such as medications, supplements, foods, products or stings.

Treatment • Oral antihistamines are the main therapy. • Administration of a second generation H1 antihistamine and/or sedating antihistamine at night if itch interfering with sleep. • Avoidance or removal of allergen. • Cool packs and soothing lotions may also reduce the severity of the itch associated with urticaria, although evidence is poor.

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Advice: • Urticaria is often self-limiting and resolves spontaneously. • Acute urticaria lasts for less than 6 weeks. • It is often related to infection, both viral and bacterial, or it can be allergy-related and be preceded by an exposure to an allergen. Identification of this allergen and its avoidance may reduce the incidence of urticaria. • The client may consider discussing allergen testing and long-term allergy management with their GP. • Advice on anaphylaxis or worsening symptoms to be provided. • Client Information Sheet – Urticaria (Hives)

Medication Standing Orders: • 1st line Loratadine • 2nd line Promethazine (at night if itch interfering with sleep) Note as per MSO Promethazine is not to be administered if driving

References: 1. Australian Medicines Handbook. (2019) Loratadine. Rerieved from https://amhonline.amh.net.au/chapters/allergy-anaphylaxis/antihistamines/less- sedating-antihistamines/loratadine?menu=hints 2. Australian Medicines Handbook. (2019) Promethazine Retrieved from https://amhonline.amh.net.au/chapters/allergy-anaphylaxis/antihistamines/sedating- antihistamines/promethazine?menu=hints 3. Clinical Knowledge Summary 2018 ‘Urticaria’ 4. Asero, Riccardo.(2019)). New-onset Urticaria. UpToDate. Retrieved from http://www.uptodate.com/contents/new-onset- urticaria?search=new%20onset%20urticaria&source=search_result&selectedTitle=1~1 50&usage_type=default&display_rank=1 5. Campbell, R L. & Kelso J M. (2019). Anaphylaxis: Acute diagnosis. UpToDate Retrieved from http://www.uptodate.com/contents/anaphylaxis-acute- diagnosis?search=anaphylaxis%20acute%20diagnosis&source=search_result&selected Title=1~150&usage_type=default&display_rank=1 6. Khan, D. (2019). Chronic spontaneous urticaria: Standard management and patient education. UpToDate Retrieved from http://www.uptodate.com/contents/chronic- spontaneous-urticaria-standard-management-and-patient- education?search=chronic%20spontaneous%20urticaria&source=search_result&select edTitle=2~29&usage_type=default&display_rank=2 7. Therapeutic Guidelines. 2019. Acute and Chronic Urticaria. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=urticaria- angioedema&guidelineName=Dermatology#toc_d1e64

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Allergic Conjunctivitis – Clinical Treatment Protocol

Overview: Condition for treatment – Allergic conjunctivitis is the inflammation of the conjunctiva, secondary to allergen exposure, and may be acute, seasonal (e.g. spring pollens) or perennial (e.g. dust mites). It can be associated with allergic rhinitis.

Symptoms may include: • Sudden onset • Ocular pruritis • Occasional mild crusting on waking but mainly watery or mucoid discharge • Eyelid oedema • Often bilateral but one eye can be affected more than the other

Inclusion criteria: Uncomplicated allergic conjunctivitis

Redirect to GP: Condition is resistant to over-the-counter treatment options.

Contact Ophthalmology Registrar or redirected to ED: • Moderate to severe eye pain or pronounced photophobia • Papillae (cobblestone) found on upper eyelid eversion; • Yellow-grey infiltrates across the limbus; • Presence of ciliary injection, • Reduced visual acuity. • Community Optometrist may be an option in some non-urgent cases. Differentials: • Infective conjunctivitis • Irritant conjunctivitis (e.g. non-invasive foreign body; chlorine from swimming pool) • Single red eye – beware acute glaucoma/keratitis/iritis • Vernal or atopic keratoconjunctivitis • Giant papillary conjunctivitis • Dry eye syndrome • Blepharitis

Management or Treatment: Work-up • Obtain accurate history of symptoms • Visual acuity should be assessed on all clients presenting with an eye complaint. • If indicated by eye pain, the cornea should be examined for abrasions using fluorescein.

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• If client is a regular wearer of contact lenses, or if history suggestive of a foreign body, evert the upper eyelid and examine for abnormalities (e.g. papillae, foreign body). • Identify triggers for the allergic conjunctival reaction (e.g. pollens, house dust mites, cosmetics, ophthalmic drugs, contact lenses and solutions). Treatment • Antihistamine tablets, intranasal corticosteroids and/or saline eye drops may be enough to reduce the symptoms of allergic conjunctivitis. Antihistamine eye drops may be required if the other measures do not work. • Client can place a flannel (soaked in cold water) over closed eyes. • Refrigerate lubricating eye drops

Advice: • The client should be advised, where possible, to avoid irritants such as pollens, house dust mites, cosmetics, dust or chemical exposure. • Avoid rubbing eyes as it can make itchiness worse. • Avoid wearing of contact lenses until condition has resolved. • Client information sheet – Allergic Conjunctivitis

Medication Standing Order: • Loratadine • Carmellose 0.5% eye drops

References : 1. Australian Medicines Handbook.(2019) Allergic Inflammatory Eye Conditions. Retrieved from https://amhonline.amh.net.au/chapters/eye-drugs/drugs-allergic- inflammatory-eye-conditions/allergic-conjunctivitis?menu=hints 2. National Institute for Health and Care Excellence: Clinical Knowledge Summary 2012 3. Pedram, Hamrah., Reza,Dara. 2019 Allergic Conjunctivitis,. UpToDate. Retrieved from http://www.uptodate.com/contents/allergic-conjunctivitis- management?search=allergic%20conjunctivitis&source=search_result&selectedTitle=1 ~137&usage_type=default&display_rank=1 4. Therapeutic Guidelines. (2019). Allergic Conjunctivitis. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=conjunctivitis&guidelineName=Antibioti c#toc_d1e356

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Allergic Rhinitis – Clinical Treatment Protocol

Overview: Condition for treatment – Allergic rhinitis (AR) is a common, yet under-appreciated inflammatory condition of the nasal mucosa. AR is mediated by an IgE-associated response to ubiquitous indoor and/or outdoor environmental allergens.

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Symptoms may include: • Nasal pruritus, sneezing, rhinorrhoea and nasal congestion, • Associated palate, throat, ear and eye itching • Eye redness, puffiness and watery discharge.

Inclusion criteria - • Nasal congestion; • Sneezing; • Itchy nose, palate, eyes, • Pattern of allergic trigger.

Redirect to GP/NP if: • Asthma is present.

Redirect to ED if: • Respiratory compromise is present.

Differentials: • Non-Allergic Rhinitis • Chronic Sinusitis • Acute Sinusitis • Viral Rhinosinusitis

Management and Treatment Work-up • Detailed history and identification of allergen if possible

Treatment • Allergen avoidance • Antihistamines • Saline irrigation • Intranasal sprays, including decongestant sprays and intra nasal corticosteroid sprays, • Antibiotic therapy should only be used to manage sinusitis if the symptoms have been present for 7 or more days with purulent nasal discharge, sinus tenderness or maxillary toothache and/or presence of fever longer than 3 days.

Advice: • Adequate comfort/rest. • Increased water intake. • Allergen avoidance and identification. • Allergen testing – requires GP referral.

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Medication Standing Order: • Loratadine • Promethazine

References : 1. Deshazo, R.D., & Kemp, S.F. (2019). Allergic rhinitis: Clinical manifestations, epidemiology and diagnosis. In J. Caren & A.M. Feldwey (Eds.) UpToDate. Retrieved https://www.uptodate.com/contents/allergic-rhinitis-clinical-manifestations- epidemiology-and- diagnosis?source=search_result&search=allergic%20rhinitis&selectedTitle=2~150 2. Therapeutic Guidlines (2019). Rhinitis and Rhinosinusitis.

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Anaphylactic Reaction – Clinical Treatment Protocol

Overview: Condition for treatment: Anaphylaxis is a potentially life threatening severe allergic reaction, that requires immediate treatment with adrenaline. Anaphylaxis should always be treated as a medical emergency. Call an ambulance 000 in Australia.

Symptoms may include: • Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present Or • Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema) Plus • Involvement of respiratory, cardiovascular, or persistent severe gastrointestinal symptoms

Common triggers (allergens) that can lead to anaphylaxis include: • Food – crustaceans (such as lobsters, prawns and crabs), eggs, fish, milk, peanuts, tree nuts (such as almonds, cashews, pecans and walnuts) and sesame or soy products • Insect venom – including bees, jumper ants, ticks, fire ants and wasps • Medicines - prescription drugs (such as penicillin), over-the-counter (such as aspirin) and herbal preparations • Uncommon triggers – include exercise, anaesthesia or latex • Unknown triggers - may never be known

Inclusion Criteria: • Facial swelling, including swelling of the lips and eyelids • Swollen tongue

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• Swollen throat • Reddening of skin across the body • Hives (red welts) appearing across the skin • Abdominal discomfort or pain • Vomiting • Strained or noisy breathing • Inability to talk or hoarseness • Wheezing or coughing • Drop in blood pressure • Unconsciousness • Young children may get floppy and pale

Differentials: • Anaphylactoid reaction should be treated the same as an anaphylactic reaction.

Management / Treatment: Give intramuscular ADRENALINE/EPINEPHRINE as per MSO into mid-lateral thigh without delay • Check vital signs • Call for assistance • Give oxygen and airway support if needed • Lay the patient in a semi-recumbent position – do not allow them to stand or walk • If unconscious place in recovery position and maintain airway • If breathing is difficult allow the patient to sit • Remove allergen (if still present): flick out insect stings, freeze ticks with liquid nitrogen or ether-containing spray (if available) and allow to drop off • ALWAYS give adrenaline FIRST, then asthma reliever puffer, if someone with known asthma and allergy to food, insects or medicine has SUDDEN BREATHING DIFFICULTY (including wheeze, persistent cough or hoarse voice) even if there are no skin symptoms.

Call ambulance to transport patient to hospital • Keep the patient flat and transfer to ambulance via stretcher. Do not allow them to stand or walk even if they appear to have recovered following administration of adrenaline. • Salbutamol is recommended if the client experiences respiratory distress with wheezing • Antihistamines may be given for symptomatic relief of pruritus.

Advice: • Anaphylaxis is an immediate life threatening condition. • Anaphylactic reactions may occur after the consumption of some food types (e.g. nuts or shellfish), the administration of some medications (including alternative

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therapies), being bitten by a venomous creature (e.g. bee sting), or from exposure to another substance (e.g. latex). • The client should seek GP advice as to the creation of an anaphylaxis action plan, including the prescription and dispensing of an ‘EpiPen’, which they then carry with them at all times, and possible referral to a specialist.

Medication Standing Order: • Adrenaline/epinephrine • Oxygen • Salbutamol

References : 1. Australian Prescriber: An Independent Review. (2018). Anaphylaxis: emergency management for health professionals. Retrieved from https://www.nps.org.au/australian-prescriber/articles/anaphylaxis-emergency- management-for-health-professionals 2. Better Health Channel. (2014). Anaphylaxis. Retrieved from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anaphylaxis 3. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/

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Ankle – Clinical Treatment Protocol

Overview: Condition for Treatment: Acute management of an uncomplicated ankle injury, pain or other symptoms. Ankle injuries are common presentations to primary care, ED and sports medicine. The most common type of ankle injuries are inversion and/or plantar flexion injuries that lead to damage to the lateral ligaments. Whenever there is a musculoskeletal injury the joint above and below should be examined.

Symptoms may include: • Ankle pain • Ankle swelling, bruising or redness • Ankle joint stiffness • Ankle instability

Inclusion criteria: Ankle Sprain: • Presenting complaint of ankle pain following acute injury • Able to weight bear on the affected limb and mobilise 4 or more steps during examination

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• Tenderness over the soft tissue aspects of the lateral and/or medial ankle on palpation

Ankle tendinopathy: • Presenting complaint of ankle pain of insidious onset • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation over the soft tissue aspects of the lateral or medial ankle

Ankle fracture (simple, uncomplicated): • Presenting complaint of ankle pain following acute injury • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation to the lateral or medial malleolus or tarsal bones • Pain well controlled with simple analgesia • Refer to Fracture Management protocol

Redirect to NP/PT/GP if: Persistent ankle pain: • Presenting complaint of persistent ankle pain without traumatic mechanism • Able to weight bear on the affected limb and mobilise 4 or more steps during examination

Ankle infection: • Presenting complaint of ankle pain due to an infective cause • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • On examination there is redness (with or without tracking) and localised heat

Referred pain: • Presenting complaint of ankle pain where the origin of the pain/symptoms are elsewhere

Redirect to ED if: Neurovascular compromise: Presenting complaint of ankle pain and – • Neurological deficit noted distal to the site of the complaint • Vascular deficit noted distal to the site of the complaint

Dislocated ankle: Presenting complaint of ankle pain and – • Visible deformity to ankle joint, obvious lateral or medial displacement of the malleolus • Inability to weight bear on the affected limb or mobilise 4 steps during examination

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• High risk of neurovascular compromise with ankle dislocation – immediate medical attention required and redirect to ED via ACTAS

Achilles tendon injury: Presenting complaint of ankle pain following acute injury and – • Localised pain and swelling to the Achilles or distal calf region • Thompson’s Test / calf squeeze test positive

Suspected complicated fracture: Presenting complaint of ankle pain following acute injury and – • Inability to weight bear on the affected limb for 4 or more steps during examination • Significant swelling, bruising, redness • Reduced joint range of movement • Bony tenderness to the ankle or foot • Simple analgesia not able to control pain

Differentials: • Ankle or foot fracture (distal fibula, base of fifth metatarsal, talus, calcaneus, stress fractures) • Proximal fibula (head) fracture • Syndesmosis injury • Lis Franc fracture / injury • Acute Achilles tendon injury (rupture) • Joint pathology – e.g. Gout, osteoarthritis, Osteochondritis Dissecans • Persistent or overuse tendon injury / tendinopathy

Management / Treatment: Acute management of an uncomplicated ankle injury should be guided by the PRICE acronym: • Protection - protect from further injury (e.g. by using a support). • Rest - avoid activity for the first 48-72 hours following injury. Weight bearing as tolerated should be encouraged. • Ice - apply ice wrapped in a towel for 12 minutes at least 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. • Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. • Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. Prolonged periods with the leg not elevated should be avoided.

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Advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: • Heat (e.g. hot baths, saunas, heat packs) • Alcohol (Increases bleeding and swelling and decreases healing) • Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise is encouraged after this time • Massage (May increase bleeding and swelling) • Range of motion exercises should begin within 48-72 hours post the initial injury so long as they do not cause further pain.

Achilles injuries: Thompson’s Test/calf squeeze test (also called Simmond’s Test): • Have the client stand facing a chair with the affected knee resting on the seat and the knee bent to 90 degrees. • Squeeze the calf of the affected leg, looking for pointing of the toes and foot. If this motion is absent this may indicate an Achilles injury (this is a positive Thompson’s test). • Compare to the other side - squeeze the calf of the unaffected leg with the knee flexed to 90 degrees, looking for pointing of the toes and foot (this is a negative Thompson’s test). • Clients with an acute Achilles injury should be placed in an ‘Equinus’ cast and provided crutches to walk NWB on the affected leg. • Clients with an Achilles injury and a positive Thompson’s test should be referred to ED.

Other management: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. If required, the results should be discussed with the Orthopaedic Registrar. • The Canberra Hospital Registrar Review Clinic Process: o Contact, via TCH Switch (02) 512 40000, and present the case to the appropriate registrar.

Note: if, after discussion with the Registrar, the client’s required treatment falls outside of the clinical scope of the WIC they will require redirection to the Emergency Department.

o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client’s notes and fax them with the completed cover sheet to the Registrar Review Clinic (02) 624 44107 o Ensure the client understands that he/she will be contacted by the Registrar Review Clinic with an appointment time and date. • While awaiting review, advise RICE and observe safe use of crutches.

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Advice: • All clients should be encouraged to follow up their soft tissue injury with a physiotherapist for specialist advice regarding diagnosis and management if they have not improved within 5 days. • Client Information Sheet – Ankle Sprain or Strain.

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days following injury. • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References: 1. Bleakley, C.M., Glasgow, P.D., Phillips, N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 2. Duchesne, E., Dufresne, S.S. & Dumont, N.A. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Physical Therapy in Sport. 97, 807-17. 3. Maughan, K. L. (2017). Ankle Sprain. UpToDate. Retrieved from https://www.uptodate.com/contents/ankle- sprain?source=search_result&search=ankle%20sprain%20treatment&selectedTitle=1~ 34 4. UpToDate. (2019). Patient education: Ankle Sprain (the basics). Retrieved from: https://www.uptodate.com/contents/ankle-sprain-the- basics?source=search_result&search=ankle%20sprain&selectedTitle=3~34 5. Vuurberg G, et al. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52:956. doi:10.1136/bjsports-2017-098106

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Asthma – Clinical Treatment Protocol

Overview: Condition for treatment: Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms that vary over time and in intensity, together with variable expiratory airflow limitation. Factors that may trigger or worsen asthma symptoms include viral infections, allergens at home or work (e.g. house dust mite, pollens, and cockroach), tobacco smoke, exercise and stress.

Symptoms may include: • Wheezing

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• Shortness of breath • Chest tightness • Cough

Inclusion criteria: • Cough, wheeze, chest tightness, shortness of breath

Previous diagnosis of asthma not a mandatory requirement to be covered under this protocol ALL patients presenting with asthma-like symptoms need to be followed up by GP or ED

Treat* then Redirect to GP if: • Speaking in full sentences • No signs of respiratory distress • SpO2 ≥95% • Transient asthma-like symptoms

Treat* then Redirect to ED if: • Increased work of breathing e.g. use of accessory muscles, tracheal tug, intercostal recession or abdominal breathing • SpO2 <95% • Unable to speak in full sentences due to dyspnoea • Tachypnoea +/- tachycardia • Markedly decreased air entry/Silent chest • Tripod position/excessive drooling • Physical exhaustion • Inability to lie supine due to breathlessness • Concomitant breathlessness and chest pain * Treatment as per Salbutamol (+/- Oxygen) medication standing order/s

Differentials: • Chest infection, COPD, bronchiectasis, bronchiolitis, vocal cord dysfunction, obesity • FB aspiration, tracheal lesions, GORD, heart failure, pulmonary embolism, mediastinal masses • Chronic sinusitis, cystic fibrosis, aspirin or NSAID hypersensitivity • Lung cancer, asbestosis, pertussis, pulmonary embolism • Peritonsillar, retropharyngeal or lung abscess (especially in children)

Management/Treatment: • Administer salbutamol MDI via spacer as per WIC medication standing order • If clinically indicated administer oxygen as per WIC medication standing order • If clinically indicated, call ambulance for transfer to ED

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Advice: • Follow up with GP should occur within 24 hours of WIC treatment (not applicable to ED redirects) • Encourage people without asthma action plans to develop one with their GP or ACT Health Asthma Education Service. • Use of spacer +/- mask for MDI to be encouraged as it improves drug delivery. Demonstrate correct technique. • All asthmatics should be advised to carry their asthma medication at all times. They should seek medical advice if they find their medication/s to be ineffective. • Asthma-triggering factors should be managed appropriately.

Medication Standing Order: • Salbutamol • Oxygen

References: 1. ‘Asthma’ Clinical Knowledge Summary (2018), National Institute for Health and Care Excellence. 2. eTG (2019). Acute asthma in adults. 3. eTG (2019). Acute asthma in children. 4. National Asthma Council Australia (2019). Australian Asthma Handbook, Version 2.0. National Asthma Council Australia. 5. Fanta, C., Wood, R. & Hollingsworth, H. (2017). An overview of asthma management. UpToDate. 6. Global Initiative for Asthma (GINA). (2019). Asthma Management and Prevention for adults and children older than 5 years. A Pocket Guide for Health Professionals.

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Atopic Dermatitis – Clinical Treatment Protocol

Overview: Condition for treatment: Atopic dermatitis is a chronic, pruritic, inflammatory skin disease primarily affecting children, but it can also affect many adults.

Symptoms may include: • Skin dryness • Erythema • Oozing • Thickening • Crusting of the skin • Pruritus

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Toddlers/Pre-schoolers: • Eczema is more localised and thickened • Typically presents on extensor joints e.g. wrists, elbows, ankles and knees • Can affect genitals • In an older child flexor surfaces of the above joints may become affected • Due to scratching, affected areas may appear raw

School-age children: • Typically affects elbow/knee creases, eyelids, earlobes, neck and scalp • Can develop acute itchy blisters on palms, fingers and feet known as vesicular dermatitis/pompholyx • Coin like areas of dry, red itchy skin can be noted scattered over the body and may be mistaken for ringworm

Adults: • Skin is often drier and lichenified than children • Commonly suffer persistent localised eczema • Recurrent staph infections may be prominent

Inclusion criteria: • Adults and children ≥ 2 years of age

Redirect to GP/NP if: • Atopic Dermatitis that is not being controlled with the use of emollients alone, particularly with paediatric client • Evidence of cutaneous infection or suspected colonisation • Persistent pruritis or symptoms resulting in sleep disturbance

Redirect to ED if: • Client is systemically unwell, severe generalised dermatitis • Severe skin infection, sepsis, eczema herpeticum

Differentials: • Seborrhoeic dermatitis • Irritant contact dermatitis • Allergic contact dermatitis • Scabies • Psoriasis • Mycosis fungoides/ fungal infections

Management /Treatment: Work-up: • Check vital signs and assess for signs of infection

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• For future comparison, draw around the extent of the erythema with a marker pen

Treatment: • Management of atopic dermatitis includes identifying and avoiding aggravating factors when possible, improving skin condition and treating areas of inflammation. Effective treatment restores normal function of the epidermal barrier, which provides protection from the environment. Thus, avoiding triggers, regular emollients and intermittent topical steroids form baseline of management. • First line of management for an acute episode is the application of emollients at least 3 times per day to prevent dry skin. • A low or mid-potency topical corticosteroid can reduce inflammation and pruritus. Using the lowest strength corticosteroid to successfully treat the dermatitis will minimise side effects. However, the goal of topical corticosteroid therapy is to treat all areas of inflammation aggressively until the skin is completely clear. • The use of corticosteroids should be discussed with the Nurse Practitioner, particularly in children.

Advice: • Atopic Dermatitis is a genetic condition that affects the body’s ability to repair damaged skin. • Avoidance of exposure to trigger factors/allergens where possible. • Non-perfumed emollients should be applied at least 3 times per day. • Increasing the skin’s hydration will improve the symptoms of itching and pain, and decreases the skin’s exposure to bacteria. • Soap substitutes such as aqueous cream, soap free body wash. • Application of emollient after bathing may assist is retaining moisture in the skin. • Clients should be encouraged to avoid: o Perfumed lotions, soap, shampoo, bubble bath o Rough clothing, wool, grass, allergens o Avoid hot bath or shower – lukewarm instead o Heavily chlorinated pools or spas • The use of low dose corticosteroids may assist in reducing the inflammation but a discussion with NP/GP is recommended.

Medication Standing Order: • Promethazine (if night time pruritus is a problem)

References : 1. Eczema Association Australasia 2019. Retrieved from: https://www.eczema.org.au/ 2. Hebert, A. & Nguyen, Q. (2019). Atopic dermatitis. BMJ Best Practice. Retrieved from https://newbp.bmj.com/topics/en-us/87 3. Stanway, A. (2004). Atopic dermatitis. DermNet NZ. Retrieved from: https://www.dermnetnz.org/topics/atopic-dermatitis/

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4. Therapeutic Guidelines. (2019). Atopic dermatitis. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=dermatitis&guidelineName=Dermatolog y#toc_d1e129

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Bites – Clinical Treatment Protocol

Overview: Condition for treatment – Human and animal bites including dog and cat bites

Symptoms may include: • Bites are injuries inflicted by teeth of human or animals • Injury forms include lacerations, puncture wounds, and crush or degloving injuries • Bleeding, pain, swelling, bruising, movement restriction, sensation loss

Inclusion criteria: • Client presenting complaining of a bite • Bleeding is controllable • Localised and superficial wounds and client in stable condition

Redirect to GP/NP if: • Signs of infection or allergy to penicillin

Redirect to ED if: • Bites involving deeper structures, e.g. tendons, bones, joints • Bites that are partial and full thickness on any part of the body need to be discussed with the Plastics Registrar on call • Any bites that need debriding of necrotic tissue • Any bites that need consideration for closure • Suspected accompanying crush injury, e.g. large dog bites, needing X-ray • Foreign bodies that cannot be removed in WIC

Differentials: • Consider non-accidental injury and post-exposure prophylaxis for human bites. • Bat bites require ED review for lyssavirus exposure.

Management / Treatment: Work-up • Vital signs • Assess for extent of wound and function of underlying structures

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Treatment For cat or dog bites: Wound Care • All animal bites should be considered contaminated and require wound care • The affected skin surface should be cleaned with soap and water, diluted povidone iodine solution 1:10 or other antiseptic solution. • Then, the wound should be irrigated copiously with water or normal saline under low pressure (with an 18-19 gauge needle or catheter tip and large syringe), debrided if possible. Low-pressure irrigation is adequate to remove grossly visible debris from the surface of the wound, wherein high-pressure irrigation can cause the spread of bacteria into deeper tissue layers. • Any foreign bodies need to be removed if able to do so • Wounds should be left open to heal by secondary intention, simply dressed, and evaluated daily for signs of infection.

Indications for use of antibiotic prophylaxis • Lacerations undergoing primary closure and wounds requiring surgical repair • Wounds on the hand(s), feet, face, or genital area • Wounds in close proximity to a bone or joint (including prosthetic joints) • Wounds in areas of underlying venous and/or lymphatic compromise (including vascular grafts) • Wounds in immunocompromised hosts (including diabetes) • Deep puncture wounds or laceration (especially due to cat bites • Wounds with associated crush injuries • Delayed presentation (≥12 hours after a bite on the extremities and ≥24 hours after a bite on the face • Consider tetanus immunisation status.

For human bites as above, and also • Hep B, Hep C and HIV status should be considered for both victim of bite and possibly the perpetrator. Post-exposure prophylaxis (PEP) is available from Canberra Sexual Health Centre within operating hours or local Emergency Department 24/7. Patient can call NSW PEP Hotline: 1800 737 669 (1800 PEP NOW) to be risk assessed and recommended PEP within 72 hrs.

Advice: • Significant bite or deep puncture wounds that penetrate bone, tendons, joints, or other major structures, wounds on hands or feet; complex facial lacerations; wounds associated with neurovascular compromise should be referred to a Plastic Surgeon through the Registrar Review Clinic. • The Canberra Hospital Registrar Review Clinic referral process: o Contact, via TCH Switch (02) 6244 2222 and present the case to the appropriate Registrar

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Note: If, after discussion with the Registrar, the client’s required interim treatment falls out of the clinical scope of the WIC they will require redirection to the Emergency Department. o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client notes and fax them with the completed cover sheet to the Review Clinic (02) 6244 4107. o Ensure that the client understands that they will be contacted by the Clinic with an appointment time and date. • If foreign bodies are not able to be removed from the wound, then the client should be redirected to the Emergency Department.

Other wounds advice: • Keep wound area clean and dry for 5-7 days. • The dressing may be removed after 2 days. • If the pain associated with the bite becomes worse and/or does not settle down within a day, or if the client notes a rash or swelling away from where the bite is, they should follow up with their GP. • The client should be made aware of the signs of infection and informed to follow up his/her care with GP if he/she notes any infection. • All clients on prophylactic antibiotics should have a review with a GP post-course. • All clients taking prophylactic antibiotics from WIC need to understand that they are prophylactic and not for treatment of actual infection. If this should develop, GP review is required. • Client Information Sheet – Dog or Cat Bites. • Client Information Sheet – Human Bites.

Medication Standing Order: • Paracetamol • Ibuprofen • Amoxicillin with Clavulanate • ADT

References: 1. Armstrong, D. & Meys, A. (2019). Basic principles of wound management. UpToDate. Retrieved from https://www.uptodate.com/contents/basic-principles-of-wound- management?search=bite&topicRef=7671&source=see_link 2. Baddour, L. & Harper, M. (2019). Animal bites (dogs, cats, and other animals); evaluation and management. UpToDate. Retrieved from https://www.uptodate.com/contents/animal-bites-dogs-cats-and-other-animals- evaluation-and- management?search=bite&source=search_result&selectedTitle=1~150&usage_type=d efault&display_rank=1#H3281898041 3. Baddour, L. & Harper, M. (2019). Human bites: evaluation and management. UpToDate. Retrieved from https://www.uptodate.com/contents/human-bites- evaluation-and- Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 26 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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management?search=bite&source=search_result&selectedTitle=2~150&usage_type=d efault&display_rank=2 4. Get PEP.Info. (n.d.). Retrieved from https://www.getpep.info/get-pep-now/nsw/ 5. Therapeutic Guidelines. (2019). Retrieved: https://tgldcdp.tg.org.au 6. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Bites- human and animal.

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Blood Glucose Level (BGL) – Clinical Treatment Protocol

Overview: Condition for treatment - To identify clients who may have blood glucose levels (BGL) that contribute to their presenting problem.

Hypoglycaemia, sometimes called a hypo or low, is a condition that occurs when a person’s blood glucose level (BGL) has dropped too low, below 4 mmol/L. Normal blood glucose levels are between 4.0–7.8 mmol/L.

Hypoglycaemia Symptoms (vary from person to person) may include: Early Symptoms • Shaking, trembling or weakness • Sweating • Paleness • Hunger • Light headedness • Headache • Dizziness • Pins and needles around mouth • Mood change

Severe Symptoms • Lack of concentration/ behaviour change • Confusion • Slurred speech • Not able to treat own hypo • Not able to drink or swallow • Not able to follow instructions • Loss of consciousness • Fitting/seizures

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Hyperglycaemia Patient may be symptom free Hyperglycaemia Symptoms may include: • Feeling excessively thirsty • Frequently passing large volumes of urine • Feeling tired • Blurred vision • Infections (e.g. thrush, cystitis, wound infections) • Weight loss

Inclusion criteria: • Clients with pre-existing diabetes • Wound infections • Clients with exhibiting signs and symptoms of diabetes, e.g. polydipsia, polyuria, blurred vision, infections, adrenergic symptoms (pale skin, sweating, shaking, palpitations and a feeling of anxiety) • Reduced level of consciousness, confusion or disorientation

Redirect to GP/NP if: • Suspected new-onset diabetes and asymptomatic • Delayed wound healing and abnormal BGLs • Client had episodes of hyper/hypo-glycaemia, and now asymptomatic and in normal BGL range • Requiring script for antihyperglycaemic medications

Redirect to ED if: • BGL reading <3mmol/L and symptomatic – redirect to ED post administration of hyperglycaemic agent

Call Ambulance if: • BGL reading >15 mmol/L and have altered level of consciousness. • BGL reading <3 mmol/L and have severely altered level of consciousness (also administer Glucagon).

Differentials: • Alcohol-associated hypoglycaemia • Drug-associated hypoglycaemia (most commonly: Quinolones, beta blockers, ACE inhibitors, etc) • Accidental/deliberate insulin overdose • Sulfonylurea-induced hypoglycaemia • Critical illness (e.g. sepsis)

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Management or Treatment: Administration of Glucagon: • Adult/child >25kgs – 1mg (SC, IMI) • Child <25kgs – 0.5mg (SC, IMI)

Administration of hypoglycaemic kit: • Kits are located in the medication room in the WIC. • Give 15g of quickly absorbed carbohydrate – either 15g glucose (Glutose-15™) tube OR 1 packet of juice AND 15g of slowly absorbed carbohydrate (6 Jatz biscuits). • If the client has not left for ED, re-test after 10 minutes. • If BGL is 3.0mmol/dL, and clinically unwell, repeat the quickly absorbed carbohydrate treatment stat (as above).

Advice: • This treatment provides immediate short-term treatment for a hypoglycaemic episode prior to redirection to the service deemed suitable by the nurse.

Medication Standing Order: • Glucagon

References: 1. ACT Health. (2016). Blood glucose & ketone point-of-care testing. (Document No. CHHS16/083). Canberra, Australia: ACT Government. 2. ACT Health. (2012). Management of hypoglycaemia and hyperglycaemia in Diabetes Mellitus Type 1 (T1DM) and Diabetes Mellitus Type 2 (T2DM) Clients in the Exercise Physiology Department. (Document No. CHHS13/118). Canberra, Australia: ACT Government. 3. Australian Medicines Handbook. (2017). Glucagon (endocrine). Retrieved from https://amhonline.amh.net.au/chapters/chap-10/antidiabetic-drugs/drugs- hypoglycaemia/glucagon 4. BMJ Best Practice Guidelines. (2019). Type 2 diabetes in adults. Retrieved from https://bestpractice.bmj.com/topics/en-gb/24 5. Diabetes Australia. (2015). Hypoglycaemia. Retrieved from. https://www.diabetesaustralia.com.au/hypoglycaemia 6. Service, F.J. & Adrian Vella, M.D. (2018). Hypoglycaemia in adults without diabetes mellitus: Diagnostic approach. UpToDate. Retrieved from https://www.uptodate.com/contents/hypoglycemia-in-adults-without-diabetes- mellitus-diagnostic- approach?search=hypoglycaemia&source=search_result&selectedTitle=1~150&usage_ type=default&display_rank=1 7. Service, F. J., Cryer, P. El., & Vella, M. (2017). Hypoglycaemia in adults: Clinical manifestations, definition, and causes. UpToDate. Retrieved from https://www.uptodate.com/contents/hypoglycemia-in-adults-clinical-manifestations- definition-and-causes

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8. Therapeutic Guidelines. (2019). Principles of management of diabetes. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=principles-of-management-of- diabetes&guidelineName=Diabetes#toc_d1e47 9. Therapeutic Guidelines. (2019). Type 2 diabetes in adults. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=type-2-diabetes-in- adults&guidelineName=Diabetes#toc_d1e2410

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Boils – Clinical Treatment Protocol

Overview: Condition for treatment – A boil is a deep inflammatory nodule with walled-off purulent material, arising from a hair follicle. A carbuncle is an aggregate of infected hair follicles that form broad, swollen, erythematous, deep, and painful masses that usually open and drain through multiple points.

Boils are mostly caused by staphylococcus aureus. They are contagious and may spread to other areas of the body or to other people. Complications include scarring and spread of infection, such as cellulitis.

Symptoms may include • Skin erythema, warmth ,oedema • Pain at the site • Previous skin disruption e.g trauma, eczema • Fever or other systemic manifestations

Inclusion criteria - • Fluctuant boils, < 2cm in diameter; • Non-fluctuant boils.

Redirect to GP/NP if: • Large fluctuant boil >2cm diameter • Boil is on face or spine; • Fever or cellulitis; • Recurrent boils, • Co-morbidities exist – e.g., diabetes, immunocompromised Clients.

Redirect to ED if: • Severe cellulitis, • Client is systemically unwell.

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Differentials: • Carbuncles • Hidradenitis Suppurativa • Infected insect bite • Sebaceous abscess • Pilonidal sinus/perianal abscess

Management /Treatment:

Work-up • Obtained relative history • Examination

Non-fluctuant boils: • Apply a warm, wet compress to the area for 10-15 minutes, every few hours – this is to help open and drain the boil. Wash hands after touching the boil.

Fluctuant boils: • Redirect to NP or GP

Advice: • Client to GP for review in 2 days or earlier if there are any signs of increasing infection (spreading redness, pain and warmth at site, fevers). • Wash the area around the boil thoroughly and frequently with soap and water to help prevent spread of infection. • Client Information sheet – Boils and Carbuncles

Medication Standing Orders: • Paracetamol • Ibuprofen

References: 1. Australian Medicines Handbook. (2019)Antinfectives. Retrieved from https://amhonline.amh.net.au/chapters/anti- infectives/antibacterials/penicillins/dicloxacillin 2. Cks.nice.org Rev July 2017 3. Spelman, Denis,. Baddon, Larry. 2019 Cellulitis and Skin Abscess Clinical Manifestations. UpToDate. Retrieved from http://www.uptodate.com/contents/cellulitis-and-skin- abscess-clinical-manifestations-and- diagnosis?search=recurrent%20boils&source=search_result&selectedTitle=3~150&usage _type=default&display_rank=3

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Burns – Clinical Treatment Protocol

Overview: Condition for treatment - An injury caused by thermal, chemical, electrical or radiation energy. A scald is a burn caused by contact with hot liquid or steam. Friction burn as combination of mechanical and thermal injury.

Symptoms may include: • Discoloration/erythema or pallor/ • Swelling and/or blistering, • Pain or numbness

Inclusion criteria - • Minor burns from epidermal to superficial dermal burns <2% of total body surface area (TBSA). Epidermal burns not to be counted in TBSA.

Redirect to GP/NP if: • Any concerns of secondary infection

Notify Plastics Registrar/Redirect to ED: • Burns to the face, hands, feet, perineum, or genitalia, burns crossing joints, and circumferential burns • Suspected inhalation burns, smoke exposure, airway injury • All deep dermal and full-thickness burns, • Chemical/electrical burns • All burns covering more than 10% of TBSA.

Burn Depth Classification: • Epidermal: intact skin- no blister, erythema (red colour), Brisk CR, Painful. • Superficial dermal: Pink, blister may or may not be present, Brisk CR under the blister, painful. • Mid dermal: Dark pink, sluggish CR • Deep dermal: blotchy cherry red/white, non-blanching, sluggish to no CR, reduced or absent sensation. • Full-thickness: including dermis, possible muscles and bones. White, waxy, cherry red, brown, black. No CR or sensation.

Calculating TBSA affected - in WiC use ‘palm method’: the surface area of the client's palm excluding the fingers- approximately 0.5 percent of TBSA and the entire palmar surface including fingers is 1 percent. Epidermal burns are not to be included in calculation.

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Differentials: • Consider non-accidental injuries in children.

Management/Treatment: Work-up • Check vital signs • Assess for infection, deeper structures function.

Treatment • All burns need to be cooled for 20 minutes under cool running water immediately on arrival to WiC if the client has not already done so. • Remove clothing covering burn site. • Remove any dressings applied prior to arrival from the burn site. • Remove any jewellery from the effected limb or burn site. • Assess burn wound, debriding non-viable superficial tissue using aseptic technique and blisters larger than 5mm may be de-roofed. • Apply appropriate dressing (see flip cart for ANZBA dressing recommendations).

The Canberra Hospital Registrar Review Clinic referral process: • Contact via TCH Switch 025124000 and present the case to the appropriate Registrar.

Note: If, after discussion with the Registrar, the client’s required treatment falls out of the clinical scope of the WIC they will require redirection to the ED.

• Complete the TCH Registrar Review Clinic front sheet and checklist. • Complete the client notes and fax them with the completed cover sheet to the Review Clinic (02) 6244 4107 • Ensure that the client understands that they will be contacted by the Review Clinic with an appointment time and date.

The Canberra Hospital Paediatric BURNS and WOUND Clinics: • Referrals should only be placed when necessary for burns/wounds of concern. • The clinic days of operation are Tuesdays and Fridays. Friday clinics are predominantly for follow-up dressings. • Contact Paediatric Surgical Registrar to discuss case and accept the client for review in the clinic. • Phone Paediatric OPD via TCH switchboard to alert nursing staff to the referral/client. • Fax attached cover sheet with corresponding event summary to the Paediatric OPD.

Advice: • Rest and simple analgesia for pain management. • Elevate limb when possible, especially in first 24-48 hours. • Try to avoid moving or stretching the area, as it may reinjure skin. • Avoid getting your dressings wet.

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• Client to see GP immediately if any unusual symptoms are experienced. • Client Information Sheet – Burns

Medication Standing Order: • Paracetamol • Ibuprofen • ADT

References : 1. National Institute for Health and Care Excellence: Clinical Knowledge Summaries 2017 2. Therapeutic Guidelines, 2019 3. Up to Date, 2019 4. Agency for Clinical Excillence NSW 2019, < https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/250020/Burn- patient-management-guidelines.pdf>. 5. Australia & New Zealand Burns Associations 2019, . 6. Royal Children’s Hospital Melbourne 2019, < https://www.rch.org.au/burns/clinical_information/#Classification_of_burns

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Chemical Splash to Eye – Clinical Treatment Protocol

Overview: Condition for treatment: Patient presents to the WIC with a history of chemical burn/splash to the eye/s.

Symptoms may include: • Eye pain • Periorbital pain/swelling/erythema • Visual disturbance • Corneal opacity

Inclusion criteria: • Isolated injury to eye/s due to chemical exposure

All patients to be redirect to ED unless: • Delayed presentation with no symptoms and neutral pH

Exclusion Criteria: • Penetrating eye injury

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Management or Treatment: • Notify ACTAS • Obtain history while preparing for eye irrigation • Remove contact lenses if present (ideally patient to remove own lenses) • If present, brush off any dry particles/powder from face and around eye/s • Instil tetracaine (amethocaine) 0.5% into affected eye/s as per standing order • Commence irrigation with normal saline or run affected eye/s under tap water • After initial irrigation (unless eye is grossly deranged), evert upper eyelid and clear any debris/FB using cotton tip applicator – irrigate palpebral conjunctiva • Administer tetracaine (amethocaine) 0.5% PRN (to maximum of 3 drops as per standing order) • Continue irrigating eye/s until Ambulance arrives

Late presentations (>1/24 post exposure): • If symptomatic, treat as per acute presentation (see above) • If asymptomatic, assess visual acuity, pupil size/reaction, fluorescein stain, evert upper eyelid and measure eye pH in the conjunctival fornix (lower palpebral conjunctiva) • Consult Ophthalmology Registrar for advice

Advice: • Examples of alkalis: lime; mortar and plaster; drain cleaner; oven cleaner; ammonia; bleach • Examples of acids: toilet cleaner; car battery fluid; pool cleaner

Medication Standing Order: • Tetracaine (amethocaine) 0.5%

References: 1. Australian Medicines Handbook. (2019). Tetracaine. Retrived from https://amhonline.amh.net.au/ 2. College of Emergency Nursing Australasia. (2009). Eye Emergency Manual: An Illustrated Guide (2nd edition). Retrieved from http://www.cena.org.au/wp- content/uploads/2014/10/eye_manual.pdf 3. Emergency Care Institute. (2017). Eye Trauma – Chemical Burns. Retrieved from https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical- tools/ophthalmology/eye_trauma_chemical_burns 4. Gardiner, MF (2019). Overview of eye injuries in the emergency department. UpToDate.

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Chlamydia Trachomatis Screening – Clinical Treatment Protocol

Overview: Conditions for treatment - Opportunistic or potential exposure screening for Chlamydia

Overview • The most commonly reported communicable disease in Australia • Those <30 years are at greatest risk • Frequently asymptomatic • Simple to test and treat • Immunity to new infection is not provided by previous infection

Symptoms may include: • Dysuria, urethral discharge, testicular pain in men • Dysuria, abnormal vaginal discharge, lower abdominal pain, intermenstrual bleed, painful intercourse, postcoital bleed in women

Inclusion criteria: • Those without STI symptoms or known exposure to an STI • Potential exposure > 5 days prior to presentation

Redirect to GP/NP or Canberra Sexual Health Clinic if: • STI symptoms present • Exposure to confirmed Chlamydia or other STI • If suspicion of oral or anal STI (for additional screening)

Differentials: • N/A

Management or Treatment: • A thorough sexual health history should be undertaken to determine the risk of STI, particularly in relation to anal or oral. • A vaginal swab preferred or first catch urine sample for women, and a first catch urine sample for men, is required for Chlamydia screening. The process for sample capture should be explained to the client. • Provide a supply of condoms and lubricant.

Advice: • Explain Canberra Sexual Health Clinic (CSHC) service, including anonymity, contact tracing, and provide a business card with clinic times. • Advise that a WIC nurse will contact him/her within 5-10 days to inform of the results. Ensure correct contact number.

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• If the result is positive, client will need to attend CSHC to receive free treatment and possible further screening. • To refrain from unprotected sex until test results received. • Consider previous sexual partners over last 6 months for possible contact tracing.

Medication Standing Order • N/A

References: 1. Australian STI Management Guidelines for use in primary care. (2018). Chlamydia. Retrieved from www.sti.guidelines.org/sexually-transmissible-infections/chlamydia 2. Marrazzo, J. (2018). Treatment of Chlamydia Trachomatis infection. UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-chlamydia- trachomatis- infection?search=treatment%20of%20chalmydia%20tracomatis&source=search_result &selectedTitle=1~147&usage_type=default&display_rank=1

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Common Cold – Clinical Treatment Protocol

Overview: Condition for treatment - An acute, self-limiting inflammation of the upper respiratory tract mucosa that may involve any or all of the nose, throat, sinuses, and larynx. The condition is rarely characterised by a discrete set of specific symptoms, with the illness varying according to individual and causative pathogen. Occasionally, there is spread to the lower respiratory tract. The condition is associated with more than 200 virus subtypes. The majority of common colds are caused by rhinoviruses (up to 50%), coronavirus (10% to 15%), influenza (5% to 15%), parainfluenza (5%), respiratory syncytial virus (5%), and metapneumovirus. Onset is rapid over the course of 1 to 2 days.

Symptoms may include: • Clear or purulent rhinitis • Sore throat • Sneezing • Post-nasal drainage/drip • Cough (may be non-productive, clear sputum initially, may become purulent) • Fever • Non-specific red pharynx • Nasal mucosal oedema/erythema • Purulent drainage in nares and posterior pharynx

Inclusion criteria: • All clients who present with symptoms of the common cold over the age of 2

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Redirect to GP/NP if: • Fever is over 39°C

Redirect to ED if: • Client’s airway is compromised

Differentials: • Allergic Rhinitis (hay fever) • Acute/Chronic Sinusitis • Streptococcal Tonsillitis • Infectious Mononucleosis • Influenza • Pertussis

Management or Treatment: • As there is no treatment for the common cold, symptom management should be the focus.

Advice: • While the symptoms of the common cold are unpleasant, the illness usually resolves spontaneously in a few days and complications rarely occur. Symptoms usually peak after 3-5 days. Most symptoms resolve after 7-14 days, although a mild cough may persist for longer. • The mechanism for transmission of the common cold is direct contact or by aerosol transmission. People can remain infectious for several weeks. • Primary school/preschool age children have, on average, 3-8 colds per year. Adults experience 2-4 colds per year. • Asthma may exacerbate, and smokers tend to have more severe respiratory symptoms. • An increased fluid intake and the consumption of nutritious food with increased rest may reduce symptom severity. • Gargling with salt water or sucking lozenges and/or ice to suck may help to relieve sore throat or nasal congestion. • Vapour rubs may soothe respiratory symptoms (avoid application to the facial area). • No treatments are available that reliably shorten the duration of the common cold. Antibiotics are ineffective. • Client Information Sheet – Common Cold.

Medication Standing Order: • Paracetamol • Ibuprofen

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References: 1. British Medical Journal Best Practice. (2018). Common cold. Retrieved from https://bestpractice.bmj.com/search?q=common+cold&= 2. Sexton, D. & McClain, M. (2019). The common cold in adults: treatment and prevention. UpToDate. Retrieved from https://www.uptodate.com/contents/the- common-cold-in-adults-treatment-and- prevention?search=common%20cold&source=search_result&selectedTitle=1~150&us age_type=default&display_rank=1 3. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/

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Contact Dermatitis (Allergen and Irritant) – Clinical Treatment Protocol

Overview: Condition for treatment – Contact dermatitis (also called contact eczema) refers to a group of skin disorders in which the skin reaction is due to direct contact with the causative agent. It can be acute or chronic. Contact dermatitis can have an irritant or allergic cause - separating these by clinical or histological features is difficult. In at least 70% of patients it has an irritant cause.

Symptoms may include: • Erythema, blistering or dry and scaly skin (acute) • Thickened (lichenification) and fissured (chronic) • Burning/stinging (commonly with irritant cause) • Blistering and itching +/- oedema (more common with allergic cause)

Inclusion criteria: • Localized skin inflammation caused by exposure to an allergen or irritant

Redirect to GP/NP: • Signs of secondary infection • Not responding to allergen/irritant avoidance +/- OTC topical corticosteroid therapy • Affected surface area >20% • Condition is work-related and likely to result in time off work • Severe episodes

Redirect to CSHC or GP if: • Involvement of genitocrural region

Redirect to ED if: • Client is systemically unwell

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Differentials: • Atopic dermatitis • Seborrhoeic dermatitis • Cellulitis/impetigo • Herpes simplex/varicella zoster • Urticaria • Psoriasis • Hand eczema • Fungal infection • Scabies

Management or Treatment: • Identification and avoidance of the irritant or allergen • Treatment of skin inflammation – consideration of topical corticosteroids • Restoration of the epidermal barrier – emollients or barrier creams • Prevention of further exposure (gloves/barrier creams)

Advice: • Distinguishing between allergic and irritant cause is difficult. • Where possible avoid irritants/allergens. Where exposure is unavoidable, use appropriate personal protective equipment to prevent direct skin contact with irritant/allergen (e.g. detergents, cleaning products, oil, grease). • 8-12 weeks of avoidance may be needed before clinical improvement is seen. Some cases may persist longer than this and require specialist referral. • If condition is affecting the face, avoid or minimise use of cosmetics, skin care products, sunscreen, hair spray/dye. • If condition is affecting hands, consider wearing cotton lined plastic gloves for wet work (for general household work). Remove gloves often, as sweating may aggravate existing dermatitis. • If irritant/allergen not readily identified and condition likely has a work-related cause, suggest discussion with employer to examine Safety Data Sheets as this may help identify the causative agent and recommended protective measures to be employed when handling this agent. • Use soap substitutes. Dry affected areas thoroughly and gently after washing. • Apply moisturisers (avoid aqueous creams) or emollients multiple times per day, particularly after exposure to water.

Medication Standing Orders: • Loratadine (for suspected allergic-type)

References: 1. Brod, B., Fowler, J. & Corona, R. (2019). Management of allergic contact dermatitis. UpToDate. 2. eTG. (2019). Atopic dermatitis.

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3. eTG (2019). Contact dermatitis. 4. Goldner, R. & Fransway, A. (2019). Irritant contact dermatitis in adults. UpToDate. 5. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Dermatitis-contact. 6. Oakley, A. (2012). Contact Dermatitis. DermNet NZ. 7. Weston, W. (2019). Contact dermatitis in children. UpToDate.

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Contusion – Clinical Treatment Protocol

Overview: Condition for treatment: A contusion or a bruise is an injury to tissue, usually through blunt force trauma. Blood from broken vessels accumulates in the surrounding tissues, producing pain, swelling and tenderness.

Symptoms may include: • Pain • Swelling • Bruising

Inclusion criteria: • Uncomplicated contusion

Redirect to ED if: • Neurovascular compromise • Large haematoma and client is on anticoagulant

Redirect to GP if: • Unexplained bruising • Chronic haematoma (> 6 weeks)

Differentials: • Fracture • Sprain • Bleeding disorder

Management or Treatment: • Paediatric consideration: important to consider the pattern of bruising and whether it is consistent with the history of trauma. This may raise the possibility of non- accidental injury. • Consider family violence, especially if the history of the mechanism of injury does not match clinical features.

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• Acute management of an uncomplicated injury should be guided by the PRICE acronym • Apply simple elastic bandage/tubigrip • Client Information Sheet – Bruising or Muscle Strain after an Injury

Advice: • Simple oral analgesia (avoid NSAID’s for the first 5 days following acute soft tissue injury) • To manage the injury use the PRICE measures: o Protection - protect from further injury (e.g. by using a support). o Rest - avoid activity for the first 48-72 hours following injury. o Ice - apply ice wrapped in a towel for 12 minutes, 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. o Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. o Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. If the leg is injured, prolonged periods with the leg not elevated should be avoided. • Advise the person to avoid HARM in the first 72 hours after the injury by applying the following mnemonic: o Heat (e.g. hot baths, saunas, heat packs) o Alcohol (Increases bleeding and swelling and decreases healing) o Range of movement: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise in encouraged after this time o Massage (May increase bleeding and swelling)

Medication Standing Orders: • Paracetamol

References: 1. Australian Medicines Handbook. ((2019). Retrieved from https://amhonline.amh.net.au/ 2. Bleakley CM, Glasgow PD, Phillips N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 3. Duchesne, E., Dufresne, S.S., Dumont, N.A. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Physical Therapy Sport 97: 807-17.

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Corneal Abrasion – Clinical Treatment Protocol

Overview: Condition for treatment: Corneal abrasion refers to a defect in the epithelial surface of the cornea that is caused by mechanical trauma to the surface of the eye. An abrasion may be found in the context of a penetrating injury, contusion, chemical burn, ‘or eyelid injury.

Special types of traumatic abrasions include the following: • Foreign body • Contact lens • Spontaneous (following previous abrasion or corneal defect)

Symptoms may include: • tearing • sensitivity to light • inability to open eye • foreign body sensation

Inclusion criteria: • Age ≥ 6 • Superficial, uncomplicated corneal abrasion found on examination using fluorescein

Redirection: Contact on- call Ophthalmology Registrar if: • Large abrasion > 4mm • Significant eyelid swelling • Reduced visual acuity • Bilateral abrasions • Abrasion that has not healed after 3-4 days of treatment • Abrasion associated with contact lens use • Identified abrasion is dendritic • Presence of embedded foreign body • Protrusion of eyeball (proptosis) • Double vision or impairment of eye movement • Pain not relieved by topical anaesthetic • Hyphema • Corneal opacity; corneal infiltrate, white spot suggesting ulceration • Pus in anterior chamber (Hypopyon) • Purulent discharge accompanying corneal abrasion • Presence of facial/peri-orbital/orbital cellulitis

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Redirect Client to GP/ED as clinically indicated if Registrar not available Community Optometrist may be an option.

Redirect to GP/NP if: • Intolerance/allergy to chloramphenicol

Redirect to ED if: • Chemical/acid/alkali exposure (see relevant protocol) • Penetrating injury/obvious open globe injury • Suspected embedded FB associated with high velocity injuries (e.g. grinding, lawn- mowing) • Pupil irregular, dilated, or fixed • Client is systemically unwell • Central nervous system symptoms, e.g. drowsiness, vomiting, headache, seizure, or cranial nerve lesion

Differentials: • Herpes simplex/zoster (dendritic ulcer/s) • Single red eye – beware acute glaucoma/keratitis/iritis • Foreign body • Infective conjunctivitis • Allergic conjunctivitis • Subconjunctival haemorrhage • Dry eye syndrome

Management or Treatment: Work-up • Take client’s thorough history – mechanism of injury, contact lens history, presence of systemic symptoms or facial/periorbital lesions • Visual acuity should be assessed on all clients presenting with an eye complaint • Examination to be carried out with ophthalmoscope • The cornea should be examined for abrasions • Evert the upper eyelid and examine for foreign body/lesion with magnification • Instil tetracaine into affected eye as required • Confirm the diagnosis of corneal abrasions with fluorescein staining only after completing a complete eye examination • Screen for associated injuries: o Test the extra-ocular eye muscles by assessing eye movements in all directions. o Assess eyelid position and function. o Examine pupil size, shape, and reactivity to light. o Fundoscopic examination to confirm red reflex

Treatment • Chloramphenicol - prevents infection.

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• Paracetamol or ibuprofen if required.

Advice: • Most corneal abrasions will heal in 24-72 hours. • See GP if condition not improving daily. • Do not wear contact lenses until the corneal abrasion has completely healed and for 24 hours after finishing treatment with topical antibiotics. • The eye will feel uncomfortable until the abrasion heals but should improve daily. • Infection resulting from abrasion is rare. • Recurrent abrasion may occur due to improper healing. • Client Information Sheet – Corneal abrasion

Medication Standing Order: • Chloramphenicol • Tetracaine (Amethocaine) • Paracetamol • Ibuprofen

References : 1. Jacobs, D. S. (2019). Corneal abrasions and corneal foreign bodies: Management. In J. Trobe, R. G. Bachur, & J. F. Wiley (Eds.). UpToDate. Retrieved from: http://www.uptodate.com/contents/corneal-abrasions-and-corneal-foreign-bodies- management 2. National Institute for Health and Care Excellence. (2019): Corneal abrasion. Retrieved from https://www.evidence.nhs.uk/search?q=corneal+abrasion 3. Therapeutic Guidelines. (2019). Corneal abrasion and foreign body. Retrieved from: https://tgldcdp.tg.org.au/viewTopic?topicfile=corneal-abrasion-foreign- bodies&guidelineName=Antibiotic#toc_d1e47

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Coxsackie Virus (Hand Foot and Mouth Disease) and Herpangina – Clinical Treatment Protocol

Overview: Condition for Treatment – Hand Foot and Mouth Disease (HFMD) is an acute viral illness characterized by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs which can be caused by either a member of the Coxsackie virus family or by an enterovirus. It most commonly affects children under 5 years of age.

Herpangina is another viral illness characterized by small blisters or ulcers on the back of the throat and roof of the mouth. The causative organism could be any 1 of 22 different enteroviruses, most commonly Coxsackievirus A. As with HFMD, most cases occur in children.

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Both conditions are generally mild and self-limiting.

Symptoms may include: HFMD • May have prodromal period of fever (not always present but usually low grade), malaise and myalgia 1-2 days prior to development of oral enanthem • Reduced appetite and a sore throat; • Stomatitis starting as red spots in the mouth (most commonly on hard palate, tongue and buccal mucosa) and throat and developing into ulcers after 12 hours - ulcers may be painful which may affect swallowing. • The rash (generally not itchy) may be a combination of macular, maculopapular and vesicular.It involves the palms of the hands and soles of the feet. The sores last for about 3-6 days and may be itchy and uncomfortable. The rash may also involve the buttocks and genitals. • Depending upon the infective organism, palmar/plantar skin shedding can occur 1-3 weeks after the illness and nail shedding may occur 1-2 months after the infection.

Herpangina • High fever, malaise, headache and sore throat (from oral enanthem). • Nil associated exanthem (rash).

Inclusion criteria - • Skin and mouth lesions which are characteristic of HFMD or herpangina

Redirect to GP/NP if: • Skin or mouth lesions are uncharacteristic or difficult to identify- and the child is unwell; • Concern regarding secondary infection of lesions, • Any infection during pregnancy.

Redirect to ED if: • Neurological involvement evident; • Signs of dehydration, immunocompromised client.

Differentials: • Oral mucocutaneous herpes simplex virus (HSV) infection • Viral illness/Viral Rash • Aphthous ulcers • Erythema multiforme/Stevens-Johnson syndrome • Pompholyx • Lichen planus • Varicella (chickenpox)

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Management or Treatment: • Analgesics and antipyretics • Adequate fluids and nutrition

Advice: • Ensure fluid intake is adequate. Present to ED if inability to maintain hydration. • Soft diet may be required due to mouth ulcers • Paracetamol/ibuprofen PRN • Cover mouth/nose when coughing/sneezing, then wash hands • Wash hands after moving bowels or handling soiled nappies of infected client • Do not share cups, eating utensils, towels and clothing

Transmission can be from: • Direct contact with nasal/throat secretions through coughing and sneezing • Direct contact with the fluid in the blisters (HFMD only) • Faeco-oral transmission • The virus can be found in the faeces for 4-8 weeks after the initial presentation. Extra care should be taken with hygiene practices during this period. • Clients suffering from HFMD should not attend school or work until all the blisters have dried up, which usually takes 2 – 7 days. • Herpangina lesions generally resolve within 3-10 days.

Medication Standing Order: • Paracetamol • Ibuprofen

References : 1. Buttery, V.W., et al, (2015). Centers for Disease Control and Prevention. Notes from the Field: Atypical Presentations of Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6 — Minnesota, 2014. 2. Gompf, S. G. (2017). Medscape; Herpangina. 3. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2015). Hand foot and mouth disease. 4. Oakley, A. (2016). Dermnetnz; Hand foot and mouth disease. 5. Ogboli, MI & Riordan, A. (2018). Hand-foot-and-mouth disease. BMJ Best Practice. 6. Romero, JR (2018), Hand, foot, and mouth disease and herpangina. In M.S. Edwards & J.E. Drutz (Eds.), UpToDate. 7. The Royal Children’s Hospital Melbourne (2018). Hand, foot and mouth disease fact sheet.

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Croup – Clinical Treatment Protocol

Overview: Condition for treatment - Croup (laryngotracheobronchitis) is a self- limiting viral infection which causes inflammation of the larynx and trachea. It usually commences with a coryzal prodrome, is most common in children under 5 years of age and has a duration of 2 to 5 days.

Symptoms may include: • inspiratory stridor • a hoarse voice • a harsh, barking cough

"There is good evidence to support the routine use of a single dose of corticosteroids in all children with croup, whether mild, moderate or severe. This has been shown to reduce hospital admission rates and prevent re-presentation" (eTG June 2019).

The severity of croup can be categorised as: • mild airway obstruction—normally active, barking (brassy) cough, mild or no chest wall retractions and mild tachycardia, but no stridor at rest • moderate airway obstruction—some or intermittent irritability, some stridor at rest, moderate chest wall retractions, use of accessory respiratory muscles, and tachycardia, • severe airway obstruction— marked persisting stridor at rest, increasing fatigue, markedly decreased air entry and marked tachycardia

Inclusion criteria: • Child > 2years of age with mild croup: barking (brassy) cough, mild or no chest wall retractions, no stridor at rest

Redirect to GP/NP if: • Uncertain of diagnosis • Child currently being treated with prescribed medications for any respiratory illness • Has already been administered a corticosteroid for current illness

Redirect to ED if: • Child has stridor at rest • Immunocompromised • Child requires monitoring of ongoing symptoms • Known structural upper airway abnormalities (e.g. laryngomalacia, tracheomalacia, Down’s syndrome)

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Redirect to ED via ACTAS • Presence of frequent barking cough with audible stridor at rest • Presence of moderate to severe suprasternal and sternal wall retraction • Uncertain of diagnosis with increased work of breathing and reduced pulse oximetry • Clear history of foreign body ingestion/inhalation • Presence of drooling/dysphagia; or tripod positioning • Patient is markedly tachycardic, tachypnoeic, or is confused • Moderate to severe dehydration • Patient is significantly distressed and agitated, or lethargic or restless • Restlessness, decreased level of consciousness, hypotonia, cyanosis and pallor are signs of life-threatening airway obstruction. • Presence of extreme pallor or cyanosis

Differentials: • Lower airway respiratory tract infection • Epiglottis • Inhaled foreign body • Asthma – auscultate for wheeze • Anaphylaxis • Bacterial tracheitis • Peritonsillar/ retropharyngeal abscess

Management or Treatment: • Single stat dose of prednisolone oral liquid • Symptom management – analgesia • Increased fluid intake – small amounts frequently

Advice: • It is most common in children aged 1 to 3 years and has a duration of 2 to 5 days; however, a post-infective cough may persist for many weeks. • Parainfluenza viruses are the most common cause of croup, and antibiotics are not indicated. • Inhalation of humidified air or steam provides no additional benefit. • If the child settles initially after treatment for mild to moderate croup, but later in the day develops stridor at rest, they should go to hospital and be managed as for severe croup. • Try to calm your child as breathing is often more difficult when your child is upset • Client Information Sheet – Croup (Sydney Children’s Health Network)

Medication Standing Order: • Prednisolone • Paracetamol • Ibuprofen

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References: 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. Royal Children’s Hospital Melbourne. (2019). Clinical Guidelines: Croup (Laryngotracheobronchitis). Retrieved from https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchiti s/ 3. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/ 4. Woods, C. (2019). Management of croup. UpToDate. Retrieved from https://www.uptodate.com/contents/management-of- croup?search=croup&source=search_result&selectedTitle=1~73&usage_type=default &display_rank=1

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Dermatophyte (Tinea) Infection – Clinical Treatment Protocol

Overview: Conditions for treatment - Fungal infections of the skin are also known as ‘mycoses’. They are common and generally mild. However, in very sick or otherwise immune-suppressed people, fungi can sometimes cause serious disease.

Symptoms may include: • Itching and stinging • Red scaly rash that is shaped like a ring (annular) • Cracking, splitting and peeling in the toe web spaces • Blisters • Yellow or white discoloration of the nails • Bald spots on the scalp

Inclusion criteria: • Tinea Pedis (foot) • Tinea Corporis (Body other than feet, groin, face, scalp or beard) • Tinea Cruris (groin) • Tinea faciei (face) • Tinea manuum (hand)

Redirect to GP/NP if: • Onychomycosis (nails) • Tinea capitis (scalp) • Tinea barbae (beard) • Immunosuppressed • Diabetes • Multiple co-morbidities

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• Ongoing infection despite appropriate topical therapy • Secondary infection

Redirect ED if: • Client is systemically unwell

Differentials: Tinea Pedis: Interdigita • Erythrasma • Interdigital candida infection

Hyperkeratotic (Moccasin-type) • Atopic dermatitis • Chronic contact dermatitis • Acute palmoplantar eczema • Palmoplantar psoriasis • Pitted keratolysis • Juvenile plantar dermatosis • Keratolysis exfoliativa • Keratodermas

Vesiculobullous • Acute palmoplantar eczema • Acute contact dermatitis • Palmoplantar pustulosis • Scabies

Tinea Corporis • Subacute cutaneous • Lupus erythematosus • Granuloma annulare • Erythema annulare centrifugum • Eczema • Psoriasis • Pityriasis rosea

Tinea Cruris • Inverse psoriasis • Erythrasma • Seborrheic dermatitis • Candidal intertrigo • Onychomycosis – Nails

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Management or Treatment: • Redirection to a pharmacy for appropriate topical antifungal (Terbinafine, allylamines, azoles)

Advice: • Clean and dry skin thoroughly and gently. • Apply topical antifungal for 1-4 weeks. • Wash your hands after touching infected areas. • Do not share towels. • Do not walk around barefoot if you have tinea pedis (tinea of the feet). • Clean the shower, bath and bathroom floor after use. • After washing, dry the skin thoroughly, particularly between the toes and within skin folds. • Expose the skin to the air as much as possible. • Wear cotton socks instead of synthetics. • Use antiperspirants to control excessive perspiration (sweating). • Wear thongs to swimming pools, locker rooms, gyms and other communal areas.

Medication Standing Order N/A

References: 1. Australian Medicines Handbook. 2019. Terbinafine. Retrieved from https://amhonline.amh.net.au/ 2. British Medical Journal Best Practice. (2018). Dermatophyte infections. Retrieved from: https://bestpractice.bmj.com/topics/en-gb/119 3. Goldstein, A. & Goldstein, B. (2015). Dermatophyte (tinea) infections. UpToDate. Retrieved from www.uptodate.com. 4. Oakley, A. (2003). Introduction to fungal infections. DermNet NZ. Retrieved on 2019 from: https://www.dermnetnz.org/topics/introduction-to-fungal-infections/ 5. Therapeutic Guidelines. (2019).Tinea. Retrieved from https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=tinea

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Gastroenteritis - Diarrhoea – Clinical Treatment Protocol

Overview: Condition for treatment: Viral gastroenteritis is a stomach and intestinal infection that affects both adults and children. Clients can suffer either diarrhoea or vomiting, or both. Symptoms may include : • Associated fever, headache, muscle aches, abdominal pain/cramping and a loss of appetite.

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Inclusion criteria: • Age > 2 years with mild or moderate dehydration • Mild dehydration-have no clinical signs but increased thirst. • Moderate dehydration- In consultation with NP o Children: delayed central capillary refill time(CRT) >2 seconds; increased respiratory rate; mild decrease in tissue turgor( tissue rebound <2 seconds) o Adults: Mild lethargy; increased thirst; easily fatigued; reduced urine output; mild dizziness.

Redirect to GP Adults: • Weight loss; • Symptoms persisting longer than 1 week; • ≥ 65 years; • Co-morbidities, e.g. diabetes, immunocompromised; • Fever ≥ 38.3 degrees, • Recent hospitalisation or antibiotic use in the last 3-6 months. • Small blood in stools (unless actively bleeding – ED)

Children: • Fever ≥ 39 degrees; • Diarrhoea has persisted longer than 1 week; • Immunocompromised, • Persistent diarrhoea beyond 72hrs with no signs of severe dehydration

Redirect to ED if: Adults: • Signs of severe dehydration; • Rectal bleeding; • Severe abdominal pain; • Pregnant and unable to tolerate fluids, • ≥ 65yrs with signs of hypovolaemia.

Children: • Has not voided in 6-8hrs during the day or no wet nappies/passing of urine in past 4-6 hours; • Unable to tolerate rehydration fluids; • Number of stools exceeds 6 in 24 hours; • Blood or mucous in the stool, • Moderate to severe dehydration. • Persistent diarrhoea and /or vomiting and signs of severe dehydration • Blood in vomitus, bloody diarrhoea, severe abdominal pain, fever > 38 • Moderately dehydrated, not tolerating fluids and at high risk of developing signs of severe dehydration

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Differentials: • Malaena • Diarrhoea in the presence of pus or mucous • Haematemesis • Hyperemesis • Intussusception • Partial bowel obstruction • Helminthic infection • Protozoal infections • Bacteria gastroenteritis • Clostridium defficile colitis • Food poisoning • Anatomic abnormalities e.g. intestinal obstruction, appendicitis • Bowel disturbances caused by diet • IBS • Malabsorption • Endocrinopathy

Management or Treatment: Primary management of acute diarrhoea is based on oral rehydration and simple analgesia (paracetamol) to manage abdominal discomfort and fevers.

Adults: • First line of management is oral rehydration fluids - 1L/hour to replace losses.

Children: Without dehydration: • Normal age appropriate diet, • Hydrolyte.

With signs of mild dehydration: • Children 2-5 years - oral rehydration 5-15mls/kg of oral hydration fluid (such as hydrolyte) every hour for up to 4 hours . After 4 hours maintenance fluids • Children >5 years - 200ml Hydrolyte after each loose stool plus normal fluid intake.

Advice: Both adults and children should: • Avoid fruit juice, sports drinks and soft drinks; • Avoid alcohol and caffeine based drinks; • Increase starchy type foods with added salt; • Avoid foods high in fat until the gut returns to normal; • Inform the client to seek medical advice if they are unable to tolerate fluids, • See a GP if symptoms persist for longer than 1 week.

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• Client Information Sheet - Gastroenteritis

Exclusion Criteria: Children should be absent from school, childcare and those working in the food industry for at least 48 hours after the last episode of diarrhoea and vomiting.

Medication Standing Order: • Paracetamol

References : 1. Alexandaki,I., Smetana,G. 2019. Acute viral gastroenteritis in adults. UpToDate Retrieved from http://www.uptodate.com/contents/acute-viral-gastroenteritis-in- adults?search=acute%20gastroenteritis%20adult&source=search_result&selectedTitle =1~150&usage_type=default&display_rank=1 2. Australian Medicines Handbook 2019.Diarrhoea. Retrieved from https://amhonline.amh.net.au/chapters/gastrointestinal-drugs/drugs- diarrhoea/diarrhoea?menu=hints 3. Matson,D., O’Ryan,M. 2019. Acute viral gastroenteritis in children in resource-rich countries. UpToDate.Retrieved from http://www.uptodate.com/contents/acute-viral- gastroenteritis-in-children-in-resource-rich-countries-clinical-features-and- diagnosis?search=acute%20viral%20gastroenteritis%20in%20children&source=search_ result&selectedTitle=1~150&usage_type=default&display_rank=1 4. BMJ 2016 Acute viral gastroenteritis in adults and children 2016 5. Clinical knowledge Summary-gastroenteritis 6. Royal Children’s Hospital Clinical Guidelines

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Dry Eye Syndrome – Clinical Treatment Protocol

Overview: Condition for Treatment – Dry eye syndrome (also known as keratoconjunctivitis sicca) is the final common outcome for a number of different conditions which affect the tear film that normally keeps the eye moist and lubricated.

Symptoms may include: • Irritation or discomfort — this may be described as burning, stinging or a ‘gritty’ sensation • Dryness Intermittent blurring of vision • Redness of the eyelids or conjunctiva • Itchiness • Foreign body sensation • Photosensitivity • Mucous discharge • Ocular fatigue

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• Blurred vision

Inclusion criteria: • Age ≥ 10

Redirect to GP/NP if: • All clients are to be referred to GP/NP once treatment has been initiated at the WIC

Redirection to ED: • Moderate to severe eye pain or pronounced photophobia • Papillae (cobblestone) found on upper eyelid eversion • Presence of ciliary injection • Reduced visual acuity

Redirect Client to GP/ED as clinically indicated Community Optometrist may be an option

Differentials: • Allergic/infective conjunctivitis or giant papillary conjunctivitis • Entropion, Ectropion or Nocturnal lagophthalmos (failure to close eyes at night) • Blepharitis • Vernal, atopic keratoconjunctivitis or exposure keratopathy • Ocular pemphigoid • Sjogren’s syndrome

Management/Treatment: Work-up • Visual acuity should be assessed on all clients presenting with an eye complaint. • If indicated by eye pain, the cornea should be examined for abrasions using fluorescein. • If client is a regular wearer of contact lenses, or if history suggestive of a foreign body, evert the upper eyelid and examine for abnormalities (e.g. papillae, foreign body). • Assess for presence of risk factors, e.g. blepharitis, allergic conjunctivitis, rheumatoid arthritis, Sjogren’s syndrome, SLE, dehydration, contact lens use, antihistamines, tricyclic antidepressants, SSRIs.

Treatment • Ocular lubricants should be used to manage the symptoms of dry eye.

Advice: • Dry eye is a chronic condition that may be a symptom of an underlying, more complex condition. • Avoid dry eye irritants such as dry windy conditions, air-conditioned environments, cigarette smoke, dust or chemical exposure.

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• When outdoors the client should be encouraged to wear sunglasses to reduce the impact of wind and sun. • Use a humidifier to moisten the air. • Limiting the use of contact lenses if these cause irritation. • Stopping non-essential medication that worsens the dry eye condition e.g. antihistamines. • Cessation of smoking may help reduce dry eye symptoms. • If using a computer for long periods, ensure that the monitor is at or below eye level. Take frequent breaks from the computer screen. • Client Information Sheet – Dry Eye Syndrome

Medication Standing Order: • Carmellose 0.5% eye drops

References: 1. Australian Medicines Handbook. (2019) Dry Eye Syndrome. Retrieved from https://amhonline.amh.net.au/chapters/eye-drugs/drugs-dry-eyes/dry-eye- syndrome?menu=vertical 2. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2017). Dry eye syndrome. 3. Shtein, R., Trobe, J. & Givens, J. 2019. Dry eye disease. UpToDate. Retrieved from https://www.uptodate.com/contents/dry-eye- disease?search=keratoconjunctivitis%20sicca&source=search_result&selectedTitle=1~ 50&usage_type=default&display_rank=1

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Ear Wax – Clinical Treatment Protocol

Overview: Condition for treatment: Cerumen/ear wax is a mixture of secretions and sloughed epithelial cells. A cerumen impaction is an accumulation of ear wax and/or prevents a required assessment of the ear canal, tympanic membrane or audiovestibular system.

Symptoms may include: • Hearing loss • Pain in the ear • Feeling of fullness, blocked or plugged • Otorrhoea • Tinnitus • Itchiness

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Inclusion criteria: • Client has presented with blocked ear/s and cerumen is found in the ear canal on otoscopic examination. • Ear wax softening drops used for at least 3 days.

Redirect to GP/NP if: • Signs of current infection • History of recurrent otitis externa • History of chronic/recurrent tinnitus • Unilateral deafness or hearing loss not related to the cerumen impaction • Failure to expel wax after multiple irrigation attempts preceded by ear wax drops • Chronic cerumen impaction • Pain or bleeding upon irrigation • History of tympanic membrane perforation, radiation, or surgery • Age under 12 years • Client with cognitive impairment, and cannot express symptoms • Abnormal tissue in the ear • Any other concerns

Differentials: • Keratosis obturans (rare) • Polyp of ear canal • Foreign body in ear canal • Osteoma of ear canal • Extosis of ear canal

Management or Treatment: Ear syringing • Conduct a history and examine ear and document findings. • Explain the procedure and risks to the client. • Obtain verbal consent for procedure. • Follow instructions for ear irrigation device: o Use warm water, test with your finger - cold water can cause nystagmus, dizziness, nausea and vomiting. Hot water can cause considerable damage. • The procedure should be ceased if any pain, nausea, or dizziness is experienced by the client. • Examine the ear again post intervention and document findings. • Advise post-intervention to apply acetic acid drops (available OTC) or “swimmer’s ear” drops, as often some water can become trapped in the canal, especially if it is a narrow canal (which a significant number of people with wax impaction have). This water can lead to Otitis Externa, especially once the wax protection has been removed.

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Advice: Side Effects/Complications: • Temporary symptoms of nerve irritation e.g. cough • Trauma to ear canal and tympanic membrane • Infections

Prevention: • Routine use of oil based or water-based softening once a week to prevent wax build-up • Client Information sheet – Ear Wax

Medication Standing Orders: N/A

References: 1. Aaron, K., Cooper, T., Warner, L. & Burton, M. (2018). Ear drops for the removal of ear wax. Cochrane Library. Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012171.pub2/full?hig hlightAbstract=removal%7Cwithdrawn%7Cear%7Cremov%7Cwax 2. Dinces, E. A. (2019). Cerumen. In D. G. Deschler and H. Libmern (Eds.). UpToDate. Retrieved from https://www.uptodate.com/contents/cerumen?search=ear%20wax&source=search_res ult&selectedTitle=1~57&usage_type=default&display_rank=1 3. Poulton, S., Yau, S., Anderson, D., & Bennett, D. (2015). Ear wax management. Australian Family Physician, 44(10), 731-734. Retrieved from https://www.racgp.org.au/afp/2015/october/ear-wax-management/ 4. UpToDate. (2019). Patient education: ear wax impaction (the basics). Retrieved from https://www.uptodate.com/contents/ear-wax-impaction-the- basics?search=ear%20wax&source=search_result&selectedTitle=2~57&usage_type=defa ult&display_rank=2

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Elbow – Clinical Treatment Protocol

Overview: Condition for Treatment: Acute management of an uncomplicated elbow injury, pain or other symptoms. Injuries to the elbow are common and usually the result of indirect trauma. They are often accompanied by an injury to the wrist or shoulder. Whenever there is a musculoskeletal injury the joint above and below should be examined.

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Inclusion criteria: Elbow Sprain: • Presenting complaint of elbow pain following acute injury • Generalised soft tissue tenderness around the elbow on palpation • Tenderness over the soft tissue lateral epicondyle region (lateral ligaments) on palpation • Tenderness over the soft tissue medial epicondyle region (medial ligaments) on palpation

Elbow tendinopathy: • Presenting complaint of elbow pain of insidious onset • Tenderness on palpation of the soft tissue aspects of the medial or lateral elbow

Fractured elbow (simple, uncomplicated): • Presenting complaint of elbow or forearm pain following acute injury • Bony tenderness on palpation • Pain well controlled with simple analgesia • Refer to Fracture Management Protocol

Pulled elbow: • Presenting complaint of elbow pain and stiffness following a traction injury • History of injury well described • Refer to Pulled Elbow Treatment Protocol

Redirect to NP/PT/GP if: Persistent elbow pain: • Presenting complaint of persistent elbow pain without a traumatic mechanism • Overuse injuries associated with repetitive tasks including tenderness over the lateral epicondyle region (tennis elbow) or medial epicondyle region (golfer’s elbow) on palpation

Elbow infection or inflammatory joint condition: • Presenting complaint of elbow pain of insidious onset • Elbow redness (with or without tracking), swelling and localised heat

Referred pain: • Presenting complaint of elbow pain where the origin of the pain/symptoms are elsewhere

Redirect to ED if: Neurovascular compromise: Presenting complaint of elbow pain and • Neurological deficit noted distal to the site of the complaint

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• Vascular deficit noted distal to the site of the complaint

Tendon rupture: Presenting complaint of elbow pain and • Excessive swelling to the elbow noted, with or without redness/bruising. Retracted bicep muscle noted on examination • Decreased function and reduced active range of movement

Dislocation: • Presenting complaint of bony tenderness of the elbow after a fall or acute injury • Obvious deformity is noted at the elbow joint

Suspected complicated fracture: • Presenting complaint of elbow pain following acute injury • Significant elbow pain, swelling or bruising • Elbow deformity • Pain not well controlled with simple analgesia

Differentials: • Elbow sprain (ligamentous injury) • Elbow strain (muscle / tendon injury) • Elbow fractures – radial head/neck, olecranon, coronoid process, distal humerus, intercondylar fractures, condylar fractures, capitellum • Elbow dislocation • Overuse injuries - Olecranon Bursitis, tendinopathy (tennis elbow, golfer’s elbow)

Management / Treatment: Acute management of an uncomplicated elbow injury should be guided by the PRICE acronym. • Protection - protect from further injury (e.g. by using a support). • Rest - avoid activity for the first 48-72 hours following injury. • Ice - apply ice wrapped in a towel for 12 minutes, 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. • Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. • Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. A sling may be used for comfort in the first 48 hours after injury.

Advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: • Heat (e.g. hot baths, saunas, heat packs)

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• Alcohol (Increases bleeding and swelling and decreases healing) • Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise is encouraged after this time • Massage (May increase bleeding and swelling)

Other management: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. If required, the results should be discussed with the Orthopaedic Registrar. • The Canberra Hospital Registrar Review Clinic Process: • Contact, via TCH Switch (02) 512 40000, and present the case to the appropriate registrar. Note: if, after discussion with the Registrar, the client’s required treatment falls outside of the clinical scope of the WiC they will require redirection to the Emergency Department. • Complete the TCH Registrar Review Clinic front sheet and checklist. • Complete the client notes and fax them with the completed cover sheet to the Registrar Review Clinic (02) 624 44107 • Ensure the client understands that they will be contacted by the Registrar Review Clinic with an appointment time and date.

Advice: • All clients should be encouraged to follow up their soft tissue injury with a physiotherapist for specialist advice regarding diagnosis and management if they have not improved within 5 days. • Client information sheet: Elbow Sprain or Strain.

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days. • Ibuprofen (or any NSIAD’s) are not recommended at all in the management of fractures.

References: 1. Bleakley CM, Glasgow PD, Phillips N, et al. Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM, 2011. 2. Client.co.uk: https://Client.info/health/sprains-and-strains-leaflet https://Client.info/doctor/elbow-injuries-and-fractures 3. Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Phys Ther Sport 2017;97: 807-17.

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4. O’Connor, F.G. (2015). Evaluation of elbow pain in adults. Retrieved from: https://www.uptodate.com/contents/evaluation-of-elbow-pain-in- adults?source=search_result&search=elbow%20sprain&selectedTitle=1

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Emergency Contraception – Clinical Treatment Protocol

Overview: Condition for treatment – Female client has had unprotected sexual intercourse within the last 120 hours and is not using oral or long-acting contraception, or is on oral contraceptive pill and has missed a dose, or is on antibiotics.

Symptoms may include Not applicable

Inclusion criteria • Unprotected sexual intercourse within the last 120 hours and, if under 16 years of age, is deemed Gillick competent.

Redirect to GP/NP if: • Concerned about sexually transmitted disease; • Outside of 120 hour window for emergency contraception, • Positive pregnancy test or client thinks pregnancy is possible from previous sexual intercourse.

Redirect to ED if: • Positive pregnancy test and abdominal pain, • Actively vomiting. • Non-consensual intercourse

Exclusion Criteria: N/A

Management or Treatment: Work-up • Detailed history taking including circumstances of unprotected sex, consensual, menstrual cycle, potential pregnancy from previous unprotected sexual intercourse, STI history, • Pregnancy test following consent

Treatment • Administer Levonorgestrel under clinician supervision in Walk-in Centre. If client vomits within 2 hours after taking emergency contraception they should return to WiC for re-administration If WiC is closed, they should attend GP/ED. Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 63 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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• Advise on side effects. • Following consent screening for STI • Advise clients that if pregnancy occurs after treatment there is possibility of ectopic pregnancy- client should attend ED if develop any abnormal lower abdominal pain. • Mandatory reporting must be complied with where applicable.

Advice: • Advise that Levonorgestrel is only effective for one preceding episode of unprotected sexual intercourse and will not prevent pregnancy from further unprotected sexual intercourse. • Works by disrupting the timing of ovulation or preventing fertilisation of an ovulated egg • Advise to use a barrier contraception method until next menstrual cycle. • If client is already using hormonal contraception advice to take next dose on schedule, even if menstrual period has not occurred. • Encourage client to seek support from GP for ongoing contraception options. • For those clients that are at risk of STI’s, regular condom use should be discussed and an STI screening should be encouraged at least one week after unprotected sex.

The client’s period may be slightly early or late. If more than 1 week late, or unusually light, the client should have a pregnancy test.

Efficacy: Emergency contraception is not 100% effective - the time elapsed since intercourse is critical factor: • <24 hours - 95% • 24-48 hours - 85% • 48-72 hours – 58% • 72-120 hours - <58% • >120 hours considered not effective • If a client is 70kg or more, or has Crohn’s disease, Irritable Bowel or vomiting the efficacy may be reduced.

Medication Standing Order: • Levonorgestrel • Metoclopramide

References : 1. Australian Medicines Handbook.(2019) Emergency Contraception. Retrieved from https://amhonline.amh.net.au/chapters/obstetric-gynaecological-drugs/drugs- contraception/progestogens/levonorgestrel?menu=hints 2. Kaunitz, A.M (2019). Patient Education: Emergency Contraception (morning after pill)(Beyond the Basics). Schreiber, C.A, Eckler, K (Eds.). 3. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/

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4. Turok,D. 2019. Emergency Contraception UpToDate. Retrieved from http://www.uptodate.com/contents/emergency-contraception-morning-after-pill- beyond-the-basics: Last reviewed June 2019

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Fever – Clinical Treatment Protocol

Overview: Condition for treatment: Fever is defined as an elevation of body temperature above 38 and may be due to infection by microorganisms, physiological stresses, central nervous system lesions or non-infectious processes. ℃ Symptoms may include: • N/A - fever is the symptom. The presenting symptoms will help the clinician identify the likely cause of fever.

Inclusion criteria: • Normal colour of skin, lips and tongue; • Alert; • Normal skin turgor, • Moist mucous membranes

Redirect to GP/NP if: • No signs or symptoms of intermediate or high risk fever illness and source of fever is identifiable and may be treated by NP or GP; • No signs or symptoms of intermediate or high risk fever illness and fever of unknown origin lasting > 3 weeks, • Fever > 5 days.

Redirect to ED via ambulance if signs or symptoms of high risk fever illness are present: • Pale/mottled/ashen/blue skin, lips or tongue; • Unresponsive, floppy or only responds to pain; • Respiratory distress; • Tachypnoea* with accessory respiratory muscle use; • Tachycardia*; • Reduced skin turgor; • Non-blanching rash with or without neck stiffness, photophobia; • Seizures or history of convulsions, • Vomiting bile-stained fluid. • Immunocompromised with a temperature > 38

℃

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Redirect to ED if signs or symptoms of intermediate risk fever illness are present. Assess need for ambulance transfer: • Pallor; • Lethargy or decreased activity • Responds to voice; • Tachypnoea* and/or decreased oxygen saturation; • Dry mucus membranes, • Reduced urine output. • Poor feeding

* Refer to CHHS ‘Vital Signs & Early Warning Scores’ policy document for Paediatric Early Warning Scores (PEWS) parameters

Differentials: • N/A as fever is a symptom, not a condition

Management or Treatment: • Fever is a symptom. A cause for the fever should be sought and the client treated or referred on as appropriate. • A thorough history should be obtained, including complete details of the fever pattern and associated symptoms, immunisation status, exposure to animals, recent travel, immunosuppression, recent surgery or invasive procedure, and medications. • Administer paracetamol or ibuprofen if child has pain or is displaying signs of discomfort. Advice: • Consider the use of an antipyretic agent to minimise the symptoms associated with fever. • Antipyretic agents do not prevent childhood febrile convulsions and should not be used specifically for this purpose. • Aspirin should be avoided in children under the age of 16 years due to its rare association with Reye’s syndrome. • Do not administer ibuprofen if patient is dehydrated as it may cause acute renal failure. • Continue antipyretic agents only while symptoms associated with fever persist. • A combination of antipyretic agents should not be given simultaneously. • Consider changing to another antipyretic agent if symptoms associated with fever are not alleviated. • Only consider alternating antipyretic agents if symptoms associated with fever persist or recur before the next dose is due. • Children who are receiving antipyretic medications should not be given combination cough and cold preparations, which often contain antipyretic medications; giving both medications may lead to inadvertent overdose • Tepid sponging is not recommended for the treatment of fever. • Clients with fever should not be underdressed or over-wrapped.

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• Increase fluid intake. • Rest while suffering from an illness causing fever. • Seek medical assessment if any of the following occur: o A rash; o Neck stiffness or photophobia; o Skin/lip pallor; o Any difficulty breathing; o Difficulty swallowing o Headache, tummy or limb pain o Vomiting and not drinking much o Drowsiness or confusion; o Seizure; o Fever >5 days; o Sweating stops, • Client Information Fact Sheet – Fever

Medication Standing Order: • Paracetamol • Ibuprofen

References : 1. Ishimine, P. (2018). Assessment of fever in children. In L. Yee, P. Spandorfer & E. Menson (Eds.) BMJ best Practice. 2. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Feverish children - management. 3. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Feverish children – risk assessment. 4. Sydney Children’s Hospitals Network ‘Factsheet – Fever’ 2019 5. The Royal Children’s Hospital Melbourne, (2018), Clinical Practice Guidelines: Febrile Child. 6. Ward, M. A. (2019). Fever in infants and children: Pathophysiology and management. In M.S. Edwards & M.M. Torchia (Eds.) Up To Date.

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Finger or Toe Injury – Clinical Treatment Protocol

Overview: Condition for treatment: Acute management of an uncomplicated toe or finger injury, pain or other symptoms. Presenting complaint of finger or toe pain resulting from an injury or of insidious onset.

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Symptoms may include: • Finger or toe pain • Finger or toe swelling, bruising or redness • Finger or toe joint stiffness

Inclusion criteria: Finger or toe sprain: • Presenting complaint of finger or toe pain following acute injury • Tenderness over the soft tissue aspects of finger or toe on palpation

Mallet Finger: • Presenting complaint of finger pain following acute injury • Unable to actively extend the distal phalanx

Fractured finger or toe (simple, uncomplicated): • Presenting complaint of finger or toe pain following acute injury • Bony tenderness on palpation • Pain well controlled with simple analgesia • Refer to Fracture Management protocol

Subungual haematoma: • Refer to specific treatment protocol

Redirect to NP/PT/GP if: Persistent finger or toe pain: • Persistent finger or toe pain with or without inflammation, without traumatic mechanism • Reduced function and reduced range of movement • Gout / osteoarthritis suspected

Finger or toe infection: • Persistent finger or toe pain without traumatic mechanism • Redness (with or without tracking), swelling, localised heat

Redirect to ED if: Neurovascular compromise: Presenting complaint of finger or toe pain and - • Neurological deficit noted distal to site of complaint • Vascular deficit noted distal to site of complaint

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Dislocated finger: Presenting complaint of finger pain following injury and - • Obvious dislocation or deformity of the metacarpophalangeal joint (MCPJ), distal interphalangeal joint (DIPJ) or proximal interphalangeal joint (PIPJ), thumb interphalangeal joint (IPJ)

Thumb injury: Presenting complaint of thumb pain following injury and - • Reported abduction injury to thumb with significant pain • Presence of deformity to thumb • Significant swelling, bruising or redness

Dislocated toe: Presenting complaint of toe pain following injury and - • Obvious dislocation or deformity of metatarsophalangeal joint (MTPJ), distal interphalangeal joint (DIPJ), proximal interphalangeal joint (PIPJ) or interphalangeal joint (IPJ) of great toe

Tendon rupture: Presenting complaint of finger or toe pain following injury and -  Excessive swelling or deformity to finger or toe  Decreased mobility or reduced active movements of affected finger or toe

Suspected septic arthritis: Presenting complaint of finger or toe pain and -  Joint redness, swelling, localised heat  Reduced joint range of movement  Systemic signs – fever, sweating, malaise

Differentials: • Overuse injuries – tendinopathy, trigger finger • Gout / cellulitis • Osteoarthritis / Rheumatoid arthritis • Fracture • Cartilage injury / volar plate injury • Central slip tendon injury • Dislocation / subluxation

Management / Treatment: Acute management of an uncomplicated finger or toe injury should be guided by the PRICE acronym: • Protection - protect from further injury (e.g. by using buddy tape or splint). • Rest - avoid activity for the first 48-72 hours following injury.

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• Ice - apply ice wrapped in a towel for 12 minutes, 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. • Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. • Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. If the toe is injured, prolonged periods with the leg not elevated should be avoided.

Also advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: • Heat (e.g. hot baths, saunas, heat packs) • Alcohol (Increases bleeding and swelling and decreases healing) • Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise is encouraged after this time • Massage (May increase bleeding and swelling) • Range of motion exercises should begin within 48-72 hours post the initial injury so long as they do not cause further pain.

Other management: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. If required, the results should be discussed with the Orthopaedic or Plastics Registrar. • If joint instability is noted on examination the affected finger should be buddy strapped to the next uninjured finger or toe. These clients should be referred to the Plastics Registrar at The Canberra Hospital Registrar Review Clinic for follow-up care and advice. • If a mallet finger is noted on examination the finger should be X-Rayed and then placed in a dorsal blocking splint or mallet finger splint (in full DIP joint extension) and the client referred to the Plastics Registrar at The Canberra Hospital Registrar Review Clinic for follow-up care and advice. • The Canberra Hospital Registrar Review Clinic referral process: o Contact via Switch (02) 512 40000 and present the case to the appropriate Registrar.

Note: If, after discussion with the Registrar, the client’s required treatment falls out of the clinical scope of the WIC, he/she will require redirection to the ED

o Complete the TCH Registrar Review Clinic front sheet and checklist o Complete the client’s notes and fax them with the completed cover sheet to the Registrar Review Clinic on (02) 624 44107 o Ensure that the client understands that he/she will be contacted by the Review Clinic with an appointment time and date.

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Advice: • All clients should be encouraged to follow up their soft tissue injury with a GP or physiotherapist for specialist advice regarding diagnosis and management if there is no improvement noted within 5 days. • Client Information Sheet –Finger Strain or Sprain. • Client Information Sheet –Toe Sprain or Strain.

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days. • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References: 1. Bleakley, C.M., Glasgow P.D., Phillips N., et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 2. Brukner, P. and Khan, K. (2012). Brukner & Khan's Clinical sports medicine. (4th ed) (pp. 435-447). Sydney, NSW: McGraw-Hill Education. 3. Duchesne, E., Dufresne, S.S., Dumont, NA. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Phys Ther Sport 97, 807-817. 4. Morris, F., Wardrope, J. and Ramlakhan, S. (2014). Minor injury and minor illness at a glance (pp. 74-78). Wiley & Sons West Sussex. 5. Purcell, D. (2013). Minor injuries. (2nd ed) (pp 23-32;107-130). Edinburgh: Elsevier Churchill Livingstone.

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Foot Injury – Clinical Treatment Protocol

Overview: Condition for treatment: Acute management of an uncomplicated foot injury, pain or other symptoms. Painful feet are a common problem and many risk factors contribute to symptoms including age, obesity, footwear type, high impact exercise and underlying medical conditions.

Whenever there is a musculoskeletal injury the joint above and below should be examined.

Symptoms may include: • Foot pain • Foot swelling, bruising or redness • Foot joint stiffness Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 71 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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Inclusion criteria: Foot sprain: • Presenting complaint of foot pain following acute injury • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation over the soft tissue aspects of the lateral or medial foot

Foot tendinopathy: • Presenting complaint of foot pain of insidious onset • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation over the soft tissue aspects of the lateral or medial foot

Foot fracture (simple, uncomplicated): • Presenting complaint of foot pain following acute injury • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation to the bony aspects of the foot • Pain well controlled with simple analgesia • Refer to Fracture Management protocol

Redirect to NP/PT/GP if: Persistent foot pain: • Presenting complaint of foot pain of insidious onset • Able to weight bear on the affected limb 4 or more steps during examination

Foot infection: • Presenting complaint of foot pain due to an infective cause • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • On examination there is redness (with or without tracking) and localised heat

Referred pain: • Presenting complaint of foot pain where the origin of the pain / symptoms is elsewhere

Redirect to ED if: Neurovascular compromise: Presenting complain of foot pain following acute injury and - • Neurological deficit noted distal to the site of complaint • Vascular deficit noted distal to the site of complaint

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Suspected complicated fracture: Presenting complaint of foot pain following acute injury and - • Inability to weight bear on the affected foot 4 or more steps during examination • Significant swelling, bruising or redness • Bony tenderness to the foot or ankle • Simple analgesia not able to control pain

Differentials: • Fracture – acute or stress • Overuse injuries – Plantar fasciitis, tendinopathy • Tendon rupture (Achilles tendon) • Gout • Cellulitis • Osteoarthritis / Rheumatoid arthritis

Management / Treatment: Acute management of an uncomplicated ankle injury should be guided by the PRICE acronym: • Protection - protect from further injury (e.g. by using a support). • Rest - avoid activity for the first 48-72 hours following injury. Weight bearing as tolerated should be encouraged. • Ice - apply ice wrapped in a towel for 12 minutes at least 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. • Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. • Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. Prolonged periods with the leg not elevated should be avoided.

Advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: • Heat (e.g. hot baths, saunas, heat packs) • Alcohol (Increases bleeding and swelling and decreases healing) • Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise is encouraged after this time • Massage (May increase bleeding and swelling)

Other management: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. If required, the results should be discussed with the Orthopaedic Registrar. • The Canberra Hospital Registrar Review Clinic Process:

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o Contact, via TCH Switch (02) 512 40000, and present the case to the appropriate registrar. Note: if, after discussion with the Registrar, the client’s required treatment falls outside of the clinical scope of the WIC they will require redirection to the Emergency Department. o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client notes and fax them with the completed cover sheet to the Registrar Review Clinic (02) 624 44107 o Ensure the client understands that he/she will be contacted by the Registrar Review Clinic with an appointment time and date. • While awaiting review, advise RICE and observe safe use of crutches.

Advice: • All clients should be encouraged to follow up their soft tissue injury with a physiotherapist for specialist advice regarding diagnosis and management if they have not improved within 5 days. • Client Information Sheet – Foot Sprain or Strain. Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days. • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References: 1. Bleakley, C.M., Glasgow, P.D., Phillips, N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 2. Duchesne, E., Dufresne, S.S. & Dumont, N.A. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Physical Therapy in Sport. 97, 807-17.

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Fracture Management – Clinical Treatment Protocol

Overview: Condition for Treatment: • Assess injury as per related musculoskeletal protocol • Acute management of simple uncomplicated fractures only

Symptoms may include: • Pain, swelling, bruising or redness following an acute injury • Bony tenderness on palpation

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• Joint stiffness

If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Medical Imaging Policy. If a fracture is detected and/or there are other concerns, this should be discussed with the Orthopaedic or Plastics Registrar.

Pregnancy status: • Any female client of child bearing age referred for X-ray must be asked “is there any chance you could be pregnant?” The answer to this question must be recorded on the X- ray request and in the clinical notes. • If the answer is “No” the scan will be performed following normal radiation safety guidelines. • If the patient is unsure then a beta-HCG test must be performed. If this is not possible, a positive answer includes all those who feel they may be pregnant, or are trying to fall pregnant and those who are sure they are pregnant. • Any patient with confirmed pregnancy or unsure status (with negative BHCG urine test) will require Nurse Practitioner review for informed consent to X-ray. This should be documented on the X-ray request and in the patient notes.

Inclusion criteria: Fracture: • All uncomplicated fractures

Tendon rupture: • Acute tendon rupture (e.g. mallet finger)

Redirect to GP following treatment if: • Client has scaphoid specific pain but no fracture is seen on X-Ray. Refer to scaphoid protocol. • Significant pain, swelling, bruising or redness and X-ray reported as normal.

Redirect to ED if: Neurovascular compromise: Presenting complaint of pain following acute injury and - • Neurological deficit noted distal to the site of the complaint • Vascular deficit noted distal to the site of the complaint

Open (compound) fracture Presenting complaint of pain following acute injury and - • Open wound to the injured area with any suspicion of access to the fracture site • Visible bone at wound site.

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Dislocation: Presenting complaint of joint pain following acute injury and – • Visible deformity to joint • Lower limb - Inability to weight bear on the affected limb or mobilise 4 steps during examination. • High risk of neurovascular compromise with dislocation – immediate medical attention required

Complicated fractures: • Suspected fracture of knee, ankle or foot and unable to weight bear 4 or more steps during examination • Suspected fracture of upper leg or hip (above knee) • Suspected fracture of upper arm, shoulder or clavicle (above elbow)

Differentials: • Sprain/strain – refer to related protocol • Ligament or tendon damage / rupture • Referred pain

Management or Treatment: The primary management of pain is through immobilisation via the application of a Plaster of Paris back-slab (full casts are not appropriate in the acute setting) or the use of a brace (e.g. CAM boot or Darco shoe). The type of immobilisation required is determined by the Registrar’s recommendation and is dependent on the area of injury and type of fracture. • Finger, hand or wrist: o Simple volar back-slab – distal radius / ulna fractures require a volar back-slab from the MCPJ crease to 3cms distal to the elbow crease. A thumb cut-out is required. o Resting position ‘posi’ back-slab - Volar slab from fingertips to 3cms from the inner elbow crease with slight wrist extension, 70° angulation at the metacarpal phalangeal joint, with straight fingers. th th o Ulna gutter ‘posi’ variation – For 4 and 5 metacarpal and proximal phalanx fractures the ‘posi’ back-slab wraps around the ulna border of the wrist, hand and lateral 2 fingers. o ‘Sandwich’ slab is a simple volar back-slab with the addition of a dorsal slab from below the MCPJ’s to 3cm distal to the elbow crease. There must be a minimum 2cm gap between the volar and dorsal slabs on each side. o Thumb spica - Scaphoid wrist fractures require a specific scaphoid/thumb spica POP cast or splint. Clients with scaphoid-specific pain without a fracture noted on X-Ray should also have a thumb spica splint or scaphoid POP back-slab applied and be redirected to their GP. Refer to scaphoid protocol. o Buddy tape – Some simple finger fractures may be managed via ‘buddy strapping’ to the neighbouring uninjured finger. Treatment should be discussed with Plastics Registrar for appropriate splinting.

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• Elbow: o Long arm back-slab: For fractures of the proximal radius and ulna or distal humerus a long arm back-slab is required. This should run from the MCPJ crease to 5cm below the underarm crease. o Immobilisation in Collar and cuff sling: Radial head and radial neck fractures require immobilisation in a sling with the elbow at 90 degrees flexion. • Toe/Foot/Ankle: o Short leg POP back-slab from the tip of the toes to 3cms from the dorsal knee crease where the metatarsals are as close to 90° to the tibia/fibula as possible. Re- enforcement may be required via a ‘U’ slab to maintain ankle position. o CAM boot – fitted as per Orthopaedic registrar recommendation. Weight bearing status must be confirmed with Orthopaedic registrar. o Darco shoe (with or without heel wedge) – fitted as per Orthopaedic registrar recommendation. Weight bearing status must be confirmed with the Orthopaedic registrar. o Buddy tape - Simple toe fractures may be managed via ‘buddy strapping’ to the neighbouring uninjured toe. • Lower leg: o Short leg POP back-slab from the MTPJ crease to 3cms from the knee crease where the ankle is as close to 90° as possible. Fractures to the distal tibia and fibula will require immobilisation in this position as recommended by the Orthopaedic registrar. Keep the fibula neck and head free to avoid compression of the perineal nerves. For increased stability and strength, as well as preventing inversion/eversion of the ankle, an extra stirrup piece can also be applied. The stirrup is applied by measuring from 3 finger-breadths below the fibular head to down around the foot, and back up to a position exactly across from the lateral aspect. o Dorsal “Equinus” back-slab: For suspected Achilles tendon partial or complete rupture, a dorsal POP back-slab should be applied and the patient referred to ED. The plaster should be applied to the top of the foot with the ankle in full plantar flexion, with neutral inversion / eversion of the ankle. The plaster should extend from the tibial tuberosity to the distal toes. The patient will require crutches and should be advised to remain non-weight bearing until review in ED. o Long leg or arm casts requested by the Orthopaedic Registrar should be applied in the ED. o It is essential to assess the neurovascular function of the affected limb distal to the injury before and after intervention. o Where immobilisation has been applied to the leg/foot, the client should be provided with fitted crutches and educated on their use.

Advice: • The client should be advised to immobilise and elevate the affected limb, hand or foot as much as possible. • If using Plaster of Paris to create a back-slab, at least 12 layers should be used for a lower limb slab and at least 8 layers for an upper limb slab.

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• Slabs should be kept dry and clean without any object being inserted between the skin and back-slab. • Plastic Surgeons manage fractures of the hand and fingers while Orthopaedic Surgeons manage all other fractures. • The Canberra Hospital Registrar Review Clinic referral process: o Contact via TCH Switch (02) 5124 0000 and present the case to the appropriate Registrar.

Note: If, after discussion with the Registrar, the client’s required treatment falls out of the clinical scope of the WIC they will require redirection to the ED.

o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client’s notes and fax them with the completed cover sheet to the Review Clinic (02) 6244 4107. o Ensure that the client understands that he/she will be contacted by the Review Clinic with an appointment time and date. • Client Information Sheet – Fracture Referral

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References: 1. ACT Health. (2013). ACT Emergency Care Network Scaphoid Fracture Standard Operating Procedure (Document No. DGD-036). Canberra, Australia: ACT Government. 2. Derby, R., & Beutler, A. (2018). General principles of acute fracture management. UpToDate. Retrieved from https://www.uptodate.com/contents/general-principles- of-acute-fracture-management 3. Pountos, I., Georgouli, T., Calori, G., and Giannoudis, P. (2012). Do Nonsteroidal Anti- Inflammatory Drugs Affect Bone Healing? A Critical Analysis. The Scientific World Journal, 2012 (606404). Retrieved from https://doi.org/10.1100/2012/606404 4. Sebastin Muttath, S., Chung, K. C., & Ono, S. (2019). Overview of finger, hand, and wrist fractures. UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-finger-hand-and-wrist-fractures 5. Stracciolini, A. (2019). Basic techniques for splinting of musculoskeletal injuries. UpToDate. Retrieved from https://www.uptodate.com/contents/basic-techniques-for- splinting-of-musculoskeletal-injuries

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Hand Injury – Clinical Treatment Protocol

Overview: Condition for Treatment: Acute management of an uncomplicated hand injury, pain or other symptoms.

Whenever there is a musculoskeletal injury the joint above and below should be examined.

Symptoms may include: • Hand pain • Hand swelling, bruising or redness • Hand joint stiffness

Inclusion criteria: Hand sprain: • Presenting complaint of hand pain following acute injury • Tenderness over the soft tissue aspects of the hand on palpation

Hand tendinopathy: • Presenting complaint of hand pain of insidious onset • Tenderness on palpation over the soft tissue aspects of the hand

Fractured hand (simple, uncomplicated): • Presenting complaint of hand pain following acute injury • Tenderness on palpation to the bony aspects of the hand • Pain well controlled with simple analgesia • Refer to Fracture Management protocol

Redirect to GP/NP/PT if: Persistent hand pain: • Presenting complaint of hand pain without a traumatic mechanism • Reduced range of movement and decreased function

Hand infection: • Presenting complaint of hand pain • On examination redness (with or without tracking), localised heat

Referred pain: • Presenting complaint of hand pain where the origin of the pain/symptoms are elsewhere.

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Redirect to ED if: Neurovascular compromise: Presenting complaint of hand pain and - • Neurological deficit noted distal to the site of complaint • Vascular deficit noted distal to the site of complaint • Signs of CRPS type 1 (RSD) – pain, sweating, skin changes (shiny, mottled, red), hyperalgesia, allodynia (sensitivity to touch)

Tendon rupture: Presenting complaint of hand pain following acute injury and - • Excessive swelling to hand noted • Deformity, decreased active range of movement and reduced function

Differentials: • Fracture of the carpals, metacarpal or phalanx • Osteoarthritis / Rheumatoid arthritis • Trigger finger • Dupuytren’s contracture • Carpal tunnel syndrome • Mallet finger • Trauma – contusion injury

Management or Treatment: Acute management of an uncomplicated ankle injury should be guided by the PRICE acronym: • Protection - protect from further injury (e.g. by using a support). • Rest - avoid activity for the first 48-72 hours following injury. Weight bearing as tolerated should be encouraged. • Ice - apply ice wrapped in a towel for 12 minutes at least 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. • Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. • Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. Prolonged periods with the leg not elevated should be avoided. Advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: • Heat (e.g. hot baths, saunas, heat packs) • Alcohol (Increases bleeding and swelling and decreases healing) • Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise in encouraged after this time • Massage (May increase bleeding and swelling)

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• Gentle range of motion exercises should begin within 48-72 hours post the initial injury so long as they do not cause further pain

Other management: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. If required, the results should be discussed with the Orthopaedic Registrar. • The Canberra Hospital Registrar Review Clinic Process: o Contact, via TCH Switch (02) 512 40000 and present the case to the appropriate registrar. Note: if, after discussion with the Registrar, the client’s required treatment falls outside of the clinical scope of the WIC he/she will require redirection to the Emergency Department. o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client’s notes and fax them with the completed cover sheet to the Registrar Review Clinic (02) 624 44107 o Ensure the client understands that he/she will be contacted by the Registrar Review Clinic with an appointment time and date. • While awaiting review, advise RICE and observe safe use of crutches.

Advice: • All clients should be encouraged to follow up their soft tissue injury with a physiotherapist for specialist advice regarding diagnosis and management if they have not improved within 5 days. • Client Information Sheet – Hand Sprain or Strain.

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days following injury. • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References: 1. Blazar, P. (2019). History and examination of the adult with hand pain. UpToDate. Retrieved from https://www.uptodate.com/contents/history-and-examination-of-the- adult-with-hand- pain?source=search_result&search=hand%20sprain&selectedTitle=1~150 2. Bleakley, C.M., Glasgow, P.D., Phillips, N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 3. Duchesne, E., Dufresne, S.S. & Dumont, N.A. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Physical Therapy in Sport. 97, 807-17.

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Head Lice – Clinical Treatment Protocol

Overview: Condition for treatment – Pediculosis capitis (head lice) is a common condition caused by infestation of the hair and scalp by Pediculus humanus capitis (the head louse), one of three distinct varieties of lice specifically parasitic for humans. The head louse is a tiny, grey-white insect. Female head lice typically live for about one month and lay 7-10 eggs (called nits) per day. The eggs are attached to the base of a hair, near the scalp. The eggs hatch after about 7- 10 days. After the eggs hatch the egg cases become easier to see. Since the eggs are firmly attached to the hair, they move away from the scalp as the hair grows. Commonly affects children 2-12 years and parents of children infected with head lice.

Symptoms may include: • Presence of live lice on scalp or many nits on hair • Eggs may be visible on the hair shaft within 1cm of scalp • Suspected infestation with head lice if there is itching of the scalp and/or eggs are seen attached to hair. Although itching of the scalp is a common presenting symptom of infestation with head lice, itching by itself is not indicative of active head lice infestation.

Inclusion Criteria: • Adults and children ≥ 2 years • Itchy scalp (scalp pruritis)

Redirect to GP/NP if: • Infestation with severe irritation

Redirect to ED if: • Patient is very unwell

Differentials: • Hair casts (Pseudonits) • White or Black Piedra • Seborrhoeic Dermatitis

Treatment: • Manual removal (wet combing): advised for children below 2 years and those avoiding insecticides. o Requires multiple treatment sessions. Wet hair, apply hair conditioner and comb hair with a fine-toothed comb. Repeat combing sessions every 3-4 days until no adult lice are found. • Chemical treatment: redirect to community pharmacist for topical pediculocides.

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Advice: • Most people with head lice do not have any symptoms. Some people feel itching or skin irritation of the scalp, neck and ears. This is caused by a reaction to lice saliva, which the lice inject into the skin during feeding. • Head lice do not jump or fly, but they spread from one person to another, usually head- to-head contact. • Stay home until treatment is complete or no lice can be found. • Head lice spread easily in the community. • Client factsheet – Head Lice ACT Health

Medication Standing Orders: • N/A

References: 1. British Medical Journal Best Practice. (2018). Head lice. Retrieved from: https://bestpractice.bmj.com/topics/en-gb/677 2. Goldstein, A. O. & Goldstein, B. G. (2019). Pediculosis Capitis. In Dellavalle, R. P., Levy, M. L., Rosen, T. & Oforis, A. O. (Eds.), UpToDate. Retrieved from: https://www.uptodate.com/contents/pediculosis- capitis?search=pediculosis%20capitis&source=search_result&selectedTitle=1~42&usage _type=default&display_rank=1

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Tension Headache – Clinical Treatment Protocol

Overview: Condition for treatment: headache is pain localised to any part of the head, behind the eyes or ears, or in the upper neck.

Symptoms may include Tension headache (induced by stress; lasts 30/60 to 7 days): • Dull, non-pulsatile, usually bilateral, constricting pain (not severe); • Pericranial tenderness is common; • Frontal and occipital regions are more commonly affected; • Classically worsens as the day progresses; • Usually short-lived; • Can be either episodic or chronic; • Symptoms such as photophobia, or mild nausea may be experienced, but no more than one of these during each episode. • Unlike migraine, there is no significant nausea, no vomiting and a lack of aggravation by routine physical activity.

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Inclusion criteria - • Headache symptoms consistent with tension-type headache Redirect to GP/NP if: • Headache not responsive to simple analgesia; • Postural headache; • Chronic recurrent headache; • Cluster headache; • Persistent or progressive headache or headache which has changed dramatically; • Headache associated with a substance or its withdrawal, • Pre-existing headache disorder or suspected medication overuse headache; • Current or past history of malignancy

Mild headache that develops within 2-7 days of a lumbar puncture which does not interfere with activities of daily living. Redirect to ED if: • Headache post recent head trauma; • Headache associated with a loss of consciousness and/or neurologic changes/deficits; • Sudden onset of severe headache; • Headache causing severe pain (especially if new onset and age >50); • Headache with associated fever, photophobia, signs of sepsis, rash or neck stiffness; • Brief episodes of headache precipitated by coughing, straining, exertion or bending over (distinguished from pre-existing headache that is momentarily aggravated by exertion); • Headache associated with visual disturbances and/or jaw claudication; • Headache that develops within 2-7 days of a lumbar puncture which interferes with ability to stand or perform activities of daily living. • Headache associated with a painful red eye and misty vision or haloes,

Differentials: • Migraine • Sinusitis • Mild systemic infection e.g. influenza • Otitis media • Medication overuse or withdrawal headache • Intracranial neoplasm • Meningitis • Raised intracranial pressure • Subarachnoid/subdural haemorrhage • Temporal arteritis (AKA giant cell arteritis) • Trigeminal neuralgia • Acute narrow-angle glaucoma • Temporomandibular disorder (TMD) • Idiopathic intracranial hypertension • Cervicogenic • Stroke • Vascular dissection Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 84 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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• Post-concussion headache • Eclampsia/pre-eclampsia

Management or Treatment: • All persons presenting with a complaint of a headache should be thoroughly assessed, both physically and via an extensive history, to minimise the risk of more serious pathologic conditions being overlooked • The primary management of an uncomplicated, gradual onset headache should be based on the identification and minimisation of trigger factors associated with the client’s headache. • Simple analgesia should be administered to aid in the resolution of the uncomplicated headache. • Ensure adequate hydration and rest

Advice: • Take simple analgesia. Aspirin should be avoided in children under the age of 16 years because of its rare association with Reye’s syndrome. • Start taking analgesic medicine at the earliest sign of an attack. • Advise client that any substantial changes in the characteristics of their headache should be review by a GP/medical officer. • Medication overuse headache can result if taking NSAIDs/paracetamol too frequently i.e. on 15 or more days per month. For clients with tension headaches triggered by stress, advise about the importance of regular mealtimes, adequate hydration, and avoidance of caffeine, a regular sleep pattern and exercise. • For tension headaches, acupuncture may be effective but at least 6 sessions are needed. • Physiotherapy and general aerobic exercise can help with tension type headaches. • Client Information Fact Sheet – Headache

Medication Standing Order: • Paracetamol • Ibuprofen

References : 1. Clinical Knowledge Summary ‘Headache – Assessment’ 2017. National Institute for Clinical Excellence 2. eTG (2017). Tension-type headache. 3. Green, M.W., & Colman, R. (2018). Tension Headache. In G. Elrignton, M.S. Husid & P. Davies (Eds.). BMJ Best Practice.Neblett, MT (2018). Assessment of acute headache in adults. BMJ Best Practice 4. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2017). Headache – Medication overuse. 5. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2017). Headache – Tension-type. 6. Oakley, CB (2018). Assessment of acute headache in children. BMJ Best Practice Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 85 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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Impetigo – Clinical Treatment Protocol

Overview: Condition for treatment - Impetigo is a contagious, superficial bacterial infection most frequently seen in children. It is classified as primary impetigo (direct bacterial invasion of previously normal skin) or secondary impetigo (infection at sites of minor skin trauma such as abrasions, minor trauma, and insect bites or underlying conditions such as eczema). It can be further categorised as non-bullous (accounts for 70% of cases) and bullous. The principal pathogen is Staphylococcal aureus, less commonly Streptococcus pyogenes.

Symptoms may include – • Non-bullous: Papules develop which evolve into vesicles and pustules that rapidly break down to form golden adherent crusts which are often located on the face or extremities. • Bullous: Vesicles enlarge to form bullae with clear yellow fluid. Ruptured bullae leave a thin brown crust.

Inclusion criteria - • Uncomplicated Impetigo

Redirect to GP/NP if: • Oral therapy is indicated; • Involves mucosa • Febrile; • Client is immunocompromised, • Failed topical treatment.

Redirect to ED if: • Client is systemically unwell.

Differentials: • Cellulitis/erysipelas • Ecthyma • Scabies • Dermatitis • Fungal skin infection • Varicella zoster • Herpes simplex • Burns

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• Insect bites

Management or Treatment: • Empirical treatment with antibiotic ointment or cream. • Transmission precautions (see below)

Advice: • Transmission of impetigo occurs directly through close contact with an infected person or indirectly via contaminated objects such as toys, clothing, or towels. • Wash hands with soap and water often or use alcohol hand rubs, especially after touching affected areas. • Avoid scratching affected areas • Do not share personal items, such as towels, clothes, or hair combs. • Wash towels and bed linens in hot water and dry them on high heat. • Clean other potentially contaminated objects such as toys or play equipment • Consult GP if condition not responding to treatment. • Remain absent from school/work until 48 hours after commencement of treatment. • Cover all lesions with dressings to prevent spread. • Client Information Sheet – Impetigo

Medication Standing Order: • Mupirocin Ointment 2%

References: 1. Baddour, LM (2019). Impetigo. UpToDate. 2. eTG (2019). Impetigo. 3. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Impetigo.

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Infectious Lactational Mastitis – Clinical Treatment Protocol

Overview: Condition for treatment: Infectious mastitis should be a considered diagnosis for all lactating women. • Infectious mastitis most often occurs following breastfeeding problems which typically result in prolonged engorgement or poor drainage leading to milk stasis. • A thorough clinical history and physical assessment will identify lactational mastitis risk factors such as: previous history of mastitis, damaged and/or infected nipples, inadequate milk drainage, blocked ducts, blocked nipple pore/white spot, abrupt weaning, fatigue, stress, poor health, change in feeding frequency, abundant milk supply, infection in the household, bacterial contamination from the infants

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nose/mouth or mothers hands or nipple cream, trauma to the breast, restrictive clothing. • Symptoms of inflammatory mastitis includes: an absence of systemic symptoms, normal breast appearance with a hard area, or a red, hard, tender area. Inflammatory mastitis should be treated using non-pharmacological measures- increased breastfeeding, expression of milk, etc.

Symptoms may include: • hard, red, tender, swollen area of one or both breasts • other systemic symptoms including one or more of the following: fever, chills, tachycardia, myalgia, headache, flu-like symptoms and/or axillary lymphadenopathy

NB: These symptoms are often rapid in onset.

Inclusion criteria: • Lactating women

Redirect to GP/NP if: • Recurrent mastitis • Suspicion of nipple thrush • No improvement after 48 hours of antibiotic treatment

Redirect to ED if: • Suspicion of abscess

Differentials: • Inflammatory mastitis • Nipple trauma • Engorgement • Candida • Blocked duct • Breast abscess • Breast cancer

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Management / Treatment: For infectious mastitis Work-up: • Check vital signs and assess for signs of infection.

For future comparison, draw around the extent of the erythema with a marker pen.

Treatment: • Administration of antibiotics as per WIC MSO • Provide symptomatic pain relief - ibuprofen or paracetamol as well as cold compresses or ice packs to reduce local pain and swelling. • Improve breast feeding techniques. Continued breastfeeding should be encouraged as treatment does not usually require cessation of breastfeeding. Breast emptying is essential during the course of treatment. There is minimal risk of passing any infection on to the infant. • Refer to GP after 48 hours for follow-up and assessment.

Advice: Non-pharmacological treatment advice: • Effective drainage of breast milk to maintain supply and reduce the risk of abscess formation is essential for all forms of lactational mastitis. o Drain the breast/s often, at least 8-12 times, every 24 hours, either by breastfeeding or expressing. o Apply warmth prior to, and during, feeding to assist milk ejection. o Apply cold compress following the feed to decrease swelling and relieve pain. o Feed from the sore breast first. o Massage the affected breast gently while feeding and while showering/bathing. Massage from the affected area towards the nipple. • Hydration and rest • Refer client to MACH services via CHI (02 6207 9977) at the next available day for ongoing breastfeeding support • Provide and explain the client information pamphlets (Mastitis information brochure), and WIC specific information sheet • Inform the client that if there is no improvement in condition or worsening of condition despite care, advice that they need to seek medical attention • Educate about signs of abscess formation - the presentation of a breast abscess is similar to mastitis, with localised, painful inflammation of the breast associated with fever and malaise, along with a fluctuant, tender, palpable mass.

Medication Standing Order: • Dicloxacillin- first line • Cephalexin-second line if non immediate allergy to penicillin • Paracetamol • Ibuprofen

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References : 1. British Medical Best Practice Guidelines. (2016). Retrieved from https://newbp.bmj.com/search?q=lactational+mastitis 2. Dixon, J. M. (2017). Lactational mastitis. In A. B. Chagpar, E. L. Baron & K. Ecklar (Eds.). UpToDate. Retrieved from: http://www.uptodate.com/contents/lactational- mastitis?source=search_result&search=mastitis&selectedTitle=1%7E55 3. National Health and Medical Research Council. (2012). Infant feeding guidelines: Information for health workers. Australian Government Publication. Retrieved from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_feedin g_guidelines.pdf 4. Riordan, J., & Wambach, K. (2010). Breastfeeding and Human Lactation. Fourth Ed. Sudbury: Jones and Bartlet Publishers. 5. Therapeutic Guidelines. (2019). Lactational mastitis. Retrieved from https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=mastitis

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Infective Conjunctivitis – Clinical Treatment Protocol

Overview: Condition for treatment: Infective conjunctivitis is the inflammation of the conjunctiva, secondary to an infective organism.

Symptoms may include: • Watery or mucoserous discharge (more common in viral conjunctivitis) • Purulent discharge (more common in bacterial conjunctivitis) • Eyelids stuck together in the morning • Tender pre-auricular lymphadenopathy (more common in viral conjunctivitis)

Inclusion criteria: • Uncomplicated infective conjunctivitis

Redirect: Contact on-call Ophthalmology Registrar if: • Moderate to severe eye pain or pronounced photophobia • Conjunctivitis that is resistant to treatment • Conjunctivitis associated with contact lens use • Profuse purulent discharge (suggestive of hyper-acute bacterial conjunctivitis) • Papillae (cobblestone) found on upper eyelid eversion • Yellow-grey infiltrates across the limbus • Presence of ciliary injection • Reduced visual acuity • Known Keratoconus

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• Severe foreign body sensation that prevents the Client from keeping the eye open OR corneal opacity • Fixed pupil with severe headache and nausea • Peri-orbital swelling or erythema suggestive of cellulitis • Corneal opacity Redirect Client to GP/ED as clinically indicated. Community Optometrist may be an option.

Differentials: • Single red eye – beware acute glaucoma/keratitis/iritis • Allergic conjunctivitis • Dacryocystitis • Hyperacute bacterial conjunctivitis • Irritant conjunctivitis • Foreign body • Vernal or atopic keratoconjunctivitis • Giant papillary conjunctivitis

Management / Treatment: Work-up • Visual acuity should be assessed on all clients presenting with an eye complaint. • If indicated by eye pain, or if history is suggestive of HSV infection, the cornea should be examined for abrasions/lesions using fluorescein. • If history suggestive of a foreign body, evert the upper eyelid and examine for abnormalities.

Treatment • Bacterial conjunctivitis is treated with chloramphenicol eye drops. • Viral conjunctivitis can be treated using cold compresses. • Lubricant eye drops can be used for both types of infective conjunctivitis to help reduce discomfort. Topical lubricants can be used as often as hourly for symptom relief.

Advice: • The symptoms associated with conjunctivitis should resolve within 2-5 days; however symptoms may persist for as long as 2 weeks with viral conjunctivitis. • It is important that discharge from the eyes is regularly washed away with warm water, using a new cotton wool ball or tissue to dry each eye. • Conjunctivitis is infectious during the period that discharge is coming from the eyes. Children should remain absent from school and childcare during this period. • Washing hands regularly and not touching the infected eyes will help reduce the risk of infecting others.

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• If applicable, client should not wear contact lenses until all symptoms and signs of infection have completely resolved and any treatment has been completed for 24 hours. • Avoid sharing towels and pillow cases to prevent spreading of infection. • Avoid contact sports and water-based sports until eye is no longer discharging. • Client Information Sheet – Infective Conjunctivitis

Medication Standing Order: • Chloramphenicol 0.5%

References : 1. Australian Medicines Handbook. Retrieved from: https://amhonline.amh.net.au/ 2. Jacobs, D.S. (2018). Conjunctivitis. In J. Trobe, H. Libman (Eds.) UpToDate. Retrieved from: https://www.uptodate.com/contents/conjunctivitis?source=search_result&search=inf ective%20conjunctivitis&selectedTitle=1~150 3. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Conjunctivitis – infective. 4. Therapeutic Guidelines. (April 2019) Retrieved from: https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=conjunctivitis

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Influenza – Clinical Treatment Protocol

Overview: Condition for treatment - An acute respiratory illness due to infection with the influenza virus A, B and rarely C.

Symptoms may include: Uncomplicated influenza presents with fever, coryza, generalised symptoms (headache, malaise, myalgia, and arthralgia) and sometimes gastrointestinal symptoms, but without any features of complicated influenza.

Complicated influenza requires hospital admission with symptoms and signs of lower respiratory tract infection (hypoxaemia, dyspnoea, lung infiltrate), central nervous system involvement and/or a significant exacerbation of an underlying medical condition. At risk groups include clients with chronic respiratory, heart, kidney, liver, or neurological disease, diabetes, or the immunosuppressed, clients over the age 65, pregnant women or women up to 2 weeks post-partum.

Inclusion criteria - • Healthy individuals with uncomplicated influenza.

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Redirect to GP/NP if: • Client is considered in an “at risk” group, and is likely to suffer a worse prognosis from influenza than an otherwise healthy person – anti-viral drugs should be considered.

Redirect to ED if: • Client presents with complicated influenza showing signs of respiratory distress or dehydration.

Differentials: • Common cold/URTI • Pharyngitis – multiple aetiologies • Meningitis • Bacterial or viral lower respiratory tract infection, including pneumonia • Malaria or dengue fever in returning travellers • Infectious mononucleosis

Management or Treatment: • Rest at home, increase fluid intake, use analgesics and antipyretics.

Advice: • Hand washing is essential to minimise transmission. • Reassure the client that the symptoms of uncomplicated influenza (including fever) usually resolve within 1 week. Other symptoms (such as cough, headache, insomnia, weakness and loss of appetite) may take 2 weeks or more to resolve. • Routine follow up is not necessary, but advise the client they should have a lower threshold for seeking help if they are caring for a young child or baby with influenza, as children cannot accurately communicate their symptoms. • The client should be advised to see their GP when they are better about receiving the seasonal flu vaccination. • Aspirin should be avoided in children aged <16 years, due to dangers of Reye ’s syndrome. • Advise the client to: o Drink adequate fluids and take simple analgesia for symptomatic relief; o Rest if they are feeling fatigued, o Stay off work or school during the infectious period - for most people about 1 week will be adequate.

Medication Standing Order: • Paracetamol • Ibuprofen

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References : 1. Kimon, Z,C., (2019). Treatment of Seasonal Influenza in Adults Influenza. UpToDate. Retrieved from http://www.uptodate.com/contents/treatment-of-seasonal-influenza- in- adults?search=influenza&source=search_result&selectedTitle=1~150&usage_type=def ault&display_rank=1 2. National Health Service Institute for Innovation and Improvement: Clinical Knowledge Summaries 2016 3. Therapeutic Guidelines. (2017). Influenza. Retrieved from: https://tgldcdp.tg.org.au/viewTopic?topicfile=influenza&guidelineName=Antibiotic#to c_d1e52 4. Tidy, C. (2015). Influenza. In C. Jackson (Ed.). Client Platform. Retrieved from: http://Client.info/doctor/influenza

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Knee Injury – Clinical Treatment Protocol

Overview: Condition for treatment: Acute management of an uncomplicated knee injury, pain or other symptoms. A thorough history and physical examination are essential in identifying a significant knee injury. This will guide the need for further investigations and / or treatment. If there is little to find despite the history, examination of the hip and lumbar spine may identify referred pain which is often a common cause of knee pain, especially in children.

Whenever there is a musculoskeletal injury the joint above and below should be examined.

Symptoms may include: • Knee pain • Knee swelling, bruising or redness • Knee joint stiffness • Knee instability

Inclusion criteria: Knee sprain: • Presenting complaint of knee pain following an acute injury • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation of the soft tissue aspects of the medial or lateral knee • Minimal swelling noted • Positive knee ligament tests on the affected side

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Knee tendinopathy / muscle injury: • Presenting complaint of knee pain following an acute injury or of insidious onset • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Tenderness on palpation of the soft tissue aspects of the knee • Minimal swelling noted

Redirect to GP/NP/PT if: Persistent knee pain: • Presenting complaint of knee pain of insidious onset • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • Decreased range of movement to affected joint

Atraumatic knee pain: • Knee pain without a traumatic mechanism • Client can weight bear on the affected limb and mobilise 4 or more steps during examination

Knee infection: • Presenting complaint of knee pain due to an infective cause • Able to weight bear on the affected limb and mobilise 4 or more steps during examination • On examination there is redness (with or without tracking) and localised heat

Referred pain: • Presenting complaint of knee pain where the origin of the pain/symptoms are elsewhere

Redirect to ED if: Neurovascular compromise: Presenting complaint of knee pain following acute injury and – • Neurological deficit noted distal to the site of the complaint • Vascular deficit noted distal to the site of the complaint

Knee dislocation: Presenting complaint of knee pain following acute injury and – • Inability to weight bear on the affected limb and mobilise 4 or more steps during examination • Visible deformity to knee joint or patella Knee tendon injury: Presenting complaint of knee pain following acute injury and - • Swelling, bruising or redness evident to tendon site • Reduced active knee range of movement

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• Inability to straight leg raise

Suspected complicated fracture: Presenting complaint of knee pain following acute injury and – • Inability to weight bear on the affected limb and mobilise 4 or more steps during examination • Client unable to bend the knee to 90◦ or greater, or reports knee locking • Significant swelling noted, particularly calf swelling or tightness

Knee joint infection: Presenting complaint of knee pain of insidious onset and – • Joint redness, swelling, localised heat • Reduced joint range of movement • Systemic signs – fever, sweating, malaise (cellulitis or sepsis)

Differentials: • Knee sprain (ligamentous injury) • Knee strain (muscle or tendon injury) • Cartilage or knee joint injury • Knee fracture / lower leg fracture • Patella tendon rupture • Patella subluxation or dislocation • Osteoarthritis / Rheumatoid arthritis • Gout • Referred pain from the hip • Bone tumours

Management or Treatment: Acute management of an uncomplicated knee injury should be guided by the PRICE acronym: • Protection - protect from further injury (e.g. by using a support). • Rest - avoid activity for the first 48-72 hours following injury. • Ice - apply ice wrapped in a towel for 12 minutes, 3 times during the day for the first 48- 72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. • Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. • Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. If the leg is injured, prolonged periods with the leg not elevated should be avoided.

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Advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: • Heat (e.g. hot baths, saunas, heat packs) • Alcohol (Increases bleeding and swelling and decreases healing) • Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise in encouraged after this time • Massage (May increase bleeding and swelling)

• Light mobilisation should begin as soon as possible after the initial injury so long as the motion does not cause further pain, except in the case of significant injuries where the use of crutches is recommended until review by the GP or physiotherapist in 3-5 days.

Other management: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. If required, the results should be discussed with the Orthopaedic Registrar. • The Canberra Hospital Registrar Review Clinic Process: o Contact, via TCH Switch (02) 512 40000, and present the case to the appropriate registrar.

Note: if, after discussion with the Registrar, the client’s required treatment falls outside of the clinical scope of the WIC they will require redirection to the Emergency Department.

o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client’s notes and fax them with the completed cover sheet to the Registrar Review Clinic (02) 624 44107 o Ensure the client understands that he/she will be contacted by the Registrar Review Clinic with an appointment time and date. • While awaiting review, advise RICE and observe safe use of crutches.

Advice: • All clients should be encouraged to follow up their soft tissue injury with a physiotherapist for specialist advice regarding diagnosis and management if they have not improved within 5 days. • Client Information Sheet – Knee Sprain or Strain.

Medication Standing Orders: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days following injury • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures

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References: 1. Bleakley, C.M., Glasgow, P.D., Phillips, N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 2. British Medical Journal Best Practice. (2018). Assessment of knee injury. Retrieved from https://bestpractice.bmj.com/topics/en-gb/575/diagnosis-approach 3. Covey, C.J. & Shmerling, R. H. (2018). Approach to adult with unspecified knee pain. UpToDate. Retrieved from: https://www.uptodate.com/contents/approach-to-the-adult- with-unspecified-knee-pain?source=search_result&search=knee%20sprain&selectedtitle 4. Duchesne, E., Dufresne, S.S. & Dumont, N.A. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Physical Therapy in Sport. 97, 807-17. 5. Harvard Medical School. (2012) Knee sprain. Harvard Health Publications. Retrieved from http://www.health.harvard.edu/pain/knee-sprain

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Laceration – Clinical Treatment Protocol

Overview: Condition for treatment - A laceration is a cut or tear that can involve one or more of the epidermis, dermis, subcutaneous layer and deep fascia.

Symptoms may include Not applicable

Inclusion criteria - • Lacerations that are single layered; • Single laceration < 10cm in length; • Multiple lacerations, total length < 20cm; • Edges easily approximated; • Wound < 12 hours old, • Superficial debris easily removed. • Wound bed visualised and no underlying structures involved

Redirect to GP/NP if: • Signs of infection; • Wound > 12 hours old; • Multiple lacerations, total length > 20cm; • Concerned about ability to close wound with good cosmetic outcome; • > 10cm in length • Human/animal bites (consider Plastics Registrar), • Consider immune status and other co-morbidities. • Concern about laceration to hand, face or neck,

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Redirect to ED or contact Plastics Registrar on call if: • > 10cm in length; • Any neurovascular compromise; • Can visualise or are suspicious of any injury to tendon or ligament; • Concern about laceration to hand, face or neck, • Concerned about ability to close wound with good cosmetic outcome.

To contact Plastics Registrar: • Call TCH Switch, (02) 51240000, and present the case to the appropriate Registrar. • If, after consultation with the Registrar, the client’s required treatment falls out of the clinical scope of WiC, redirect client to ED. • Following discussion with registrar and determined appropriate for review in REGISTRAR Review Clinic: o Complete the Registrar Review Clinic Referral sheet; o Complete the client notes and fax them with the completed referral sheet to the Review Clinic (02) 6244 4107, o Ensure that the Client understands that they will be contacted by the Registrar Review Clinic with an appointment time and date if an appointment time has not been advised by the registrar. o Provide patient with information sheet on referral to Registrar Review Clinic

Differentials: N/A

Management/Treatment: Work-up • Motor, neurological and vascular function should be assessed prior to any intervention. • Clarification of the mechanism of injury to identify high risk wound e.g. bite, puncture wound, power tool • All children aged 2-12 years presenting with a laceration to be assessed for application of Laceraine. • Age of injury • Immunisation status assessed. • Allergies e.g. local anaesthetics, latex

Treatment: • All lacerations are to be cleaned/irrigated with normal saline to ensure they are clean and all foreign material is removed. • Base of wound to be visualised to exclude injury to underlying structures/ presence of foreign body

Laceraine®: Inclusion: children aged between 2-12 with a laceration under 7cm in length:

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• Laceraine® application: o Explain procedure to client/parent/carer; o Clean wound to remove debris and clotted blood; o Wearing gloves, soak gauze with Laceraine® and apply to wound; o Cover cotton wool balls and area around wound with an occlusive dressing; o Leave dressing insitu for 20-30 minutes (max. 60 minutes); test sensation prior to further treatment; o Care should be taken to ensure the product is not inadvertently transferred to the eyes, mouth and other mucous membranes, o Provide the parent/carer with the Laceraine® fact sheet and return the client and their parent/carer to the waiting room to enable Laceraine® to take effect.

Skin Adhesive (Dermabond) Inclusion: if the wound is on a non-functional/low tension, dry area of the body, <4cms, not contaminated or infected, < 12hours since injury then a skin adhesive may be considered

Skin adhesive application: • The procedure should be explained to the client/parent/carer and consent gained to close wound with glue. • Consider getting assistance with wound closure prior to beginning procedure. • The wound should be cleaned and haemostasis achieved prior to closure. • Apply petroleum jelly to surrounding skin if required • The glue vial should be prepared according to the manufacture’s recommendations. • The edges of the wound should be approximated. • A single line of glue should be applied over the full length of the laceration. • Wait 30 seconds prior to applying subsequent layers. • Apply second and third layers over the length of the laceration slightly increasing in width with each application.

Adhesive Strips Inclusion: if the wound is on a non-functional, dry area of the body and is shallow then adhesive strips may be considered: • The procedure should be explained to the client/parent/carer. • Clean wound • Ensure surrounding skin is clean and dry. Apply protective barrier wipe to surrounding skin to increase adhesiveness of strips. • Ensure haemostasis prior to or upon application. • Carefully approximate wound edges. Apply first strip to middle of wound, place half of one strip on one side and then gently bring edges of wound together and pass strip over to adhere to other side. • Place strips alternately to each side to keep skin tension equal. • Consider anchoring rows of strips with two strips across the distal end of rows. • Adhesion of skin closures will be enhanced if you gently but firmly press or stroke the skin closure strip during application.

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Suturing Inclusion: if the laceration is large or may come under tension or be in a moist environment then closure with sutures should be considered • The procedure should be explained to the client/parent/carer and consent gained to suture wound prior to commencement. • The wound should be cleaned and irrigated extensively prior to closure, removal of foreign body including hair • Prepare equipment utilising aseptic technique throughout. • Local anaesthetic (Lidocaine or Lidocaine with adrenaline) should be administered into the wound either via irrigation or subcutaneously through the damaged tissue. Lidocaine with adrenaline/epinephrine should not be used on fingers, toes, genitalia, ears or the nose, but may be of benefit being used in other areas to reduce bleeding during the procedure • Approximate the edges of the wound. • Place the first suture in the middle of the laceration and work out form this point on alternate sides. Use the minimal number of sutures to maintain approximation of the wound. • If the injury is a Y or V shape flap, start by approximating the point of the laceration using a corner stitch. • The suture needle should be held in the needle holding forceps and enter the skin 5mm from the edge, curving 5mm deep and exiting on the opposite side of the laceration 5mm from the edge. • The suture material should then be pulled through leaving a small tail and a knot appropriate for the suture material made. • The tails of the suture should be cut leaving approximately 5mm.

On completion of all wound closure: • Motor, neurological and vascular function should be reassessed to ensure no new deficit has arisen during closure; • Choose appropriate dressing.

Advice: • Elevate to reduce swelling and pain; • If skin adhesive was utilised: it will come off after 5-10 days and should not be removed manually. • If adhesive strips are utilised, o Usually worn until they fall off, approximately 5-7 days - wear time depends of area of the body, friction and skin type; o Edges of strips can be trimmed to extend duration of adherence, o Keep dry for 24 hours after application, then can be pat dry after shower - limit exposure to water to increase duration of adherence. • If sutures were utilised, keep dry, clean and dressed for 2 days. • Inform of when the local anaesthetic is likely to wear off

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• Removal of sutures: please see Removal of suture/ staple CTP • Recommend simple analgesia as required. • Offer ADT if appropriate or consider tetanus immunoglobulin if unknown previous tetanus cover (referral to ED) • Client Information Sheet – Care of Wound

Medication Standing Order: • Paracetamol • Ibuprofen • Lidocaine (Lignocaine) • Lidocaine (Lignocaine) with adrenaline • ADT • Dermabond • Laceraine

References: 1. Australian Medicines Handbook, (2019). Lidocaine (anaesthesia). Retrieved from: https://amhonline.amh.net.au/chapters/chap-02/anaesthesia-local-drugs/anaesthetics- local/lignocaine-01 2. DeLemos, D. (2017). Closure of minor skin wounds with sutures. In A.M. Stack, A. B. Wolfson & J. F. Wiley (Eds.). UpToDate. Retrieved from: https://www.uptodate.com/contents/closure-of-minor-skin-wounds-with- sutures?source=search_result&search=laceration&selectedTitle=1~51 3. Marshall,G., (2013). Skin glues for wound closure.NPS Medicien Wise. http://www.nps.org.au/australian-prescriber/articles/skin-glues-for-wound-closure#b1

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Musculoskeletal lower back pain – Clinical Treatment Protocol

Overview: Condition for treatment – Musculoskeletal lower back pain is pain and / or stiffness of the lumbosacral region (beneath the twelfth rib and above the gluteal folds) persisting for < 12 weeks (for ages >16). Back pain is extremely common, with one in seven Australians suffering from back pain on any given day.

Symptoms may include: • Low back pain • Low back joint stiffness • Referred symptoms to buttocks or legs (pain, pins and needles or numbness)

Inclusion criteria: • Pain over the lumbosacral region (bilateral or unilateral) in the absence of trauma • Acute muscular pain that has been present for less than 10 days

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Redirect to GP/PT/NP if: • Neurological signs: o Radiation of pain down buttock or legs o Pins and needles or numbness • Pain lasting longer than 10 days • Psychosocial risk factors – such as anxiety, work related injury, fear avoidance behaviours • Signs of axial spondyloarthritis: o Persistent back pain (> 3 months duration) o Onset of symptoms before age 45 o Inflammatory back pain (insidious onset, improvement with exercise, worse with rest, pain at night) o Peripheral signs of arthritis o Family history of spondyloarthritis

Redirect to ED if: • Signs of neurological compromise with deteriorating neurological status: o Altered sensation to lower limbs • Signs of cauda equina syndrome: o New bowel or bladder dysfunction o Perineal numbness or saddle anaesthesia o Persistent or progressive lower motor neurone changes • Signs of vertebral fracture: o Older age (> 65 years for men, > 75 years for women) o Prolonged corticosteroid use o Osteoporosis o Severe trauma o Presence of contusion or abrasion • Signs of malignancy: o Unexplained weight loss, age > 50 years o History of cancer o Strong clinical suspicion • Signs of spinal infection: o Fever or chills o Immunosuppression o Pain at rest or at night o Previous IV drug use o Recent injury, dental or spine procedure • Associated collapse or hypotension • Abdominal pain radiating to the lower back

Differentials: • Neurological deficit:

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o Spinal canal stenosis o Radiculopathy o Cauda equina syndrome • Renal: o Nephrolithiasis o Pyelonephritis • Aortic dissection: o Abdominal aortic aneurysm • Serious pathology: o Malignancy (spinal neoplasia) o Fracture (spinal compression) o Infection (abscess, osteomyelitis, septic discitis) • Inflammatory disease: o Ankylosing spondylitis o Reactive arthritis o Psoriatic arthritis • Sacroiliac joint pathology • Psychological distress

Management or Treatment: • Simple analgesia (see Medication Standing Order) • Clients should be recommended to consult their local pharmacist for further analgesic requirements.

Advice:

• Reassure and explain that most episodes of acute low back pain settle quickly. • Encourage client to maintain usual activities, including continuing to work or returning to work as soon as possible, despite pain. • Advise to avoid bed rest. • Avoid activities that increase lower back pain, e.g. heavy lifting, but encourage general activity such as walking. • Heat wrap therapy: apply to the affected area for up to 12 minutes, 2-3 times per day; OR • Ice therapy; apply to the affected area for up to 12 minutes, 2-3 times per day. Wrap ice pack in a towel to avoid direct contact with the skin. • Review psychological risk factors for persistent low back pain, including depression, anxiety, social stress or employment stress. • Certain lifestyle factors, such as smoking, obesity and physical inactivity are associated with persistent lower back pain. • GP or physiotherapy follow-up recommended in 48 hours if no improvement, sooner if pain increases.

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Medication Standing Order: • Ibuprofen • Paracetamol

References: 1. Almeida, M., Saragiotto, B., Richards, B. & Maher, C. (2018). Primary care management of non-specific low back pain: key messages from recent clinical guidelines. The Medical Journal of Australia, 208 (272-275). 2. Bardin, L., King, P. & Maher, C. (2017). Diagnostic triage for low back pain: a practical approach for primary care. The Medical Journal of Australia, 206 (268-273). 3. NSW Agency for Clinical Innovation. (2016). Management of people with acute low back pain: model of care. Chatswood: NSW Health.

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Lower Urinary Tract Infection – Clinical Treatment Protocol

Overview: Condition for treatment: A lower urinary tract infection is one that occurs in a non- pregnant female client (age 16 years or older). A lower UTI can be confirmed by client assessment when there are typical symptoms and signs of UTI, whether or not a urinary pathogen has been detected (urine culture), and an upper UTI and other alternative diagnoses have been excluded.

Symptoms may include: • Urinary frequency, urgency, and/or strangury (the sensation of needing to pass urine despite having just done it) • Dysuria • Urine that is offensive smelling, cloudy or contains blood • Constant lower abdominal ache • Non-specific malaise, such as aching all over, nausea, tiredness and cold sweats, and • Urge incontinence

Inclusion criteria: • Non-pregnant women 16 years and over with UTI symptoms

Redirect to GP/NP: • Pregnant women • Male clients • Children under age of 16 • Clients who have failed recent treatment for a UTI within two weeks • Clients with persistent haematuria • Persons with an indwelling urethral catheter (IDC) or suprapubic catheter (SPC)

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• Clients with mild pyelonephritis – low-grade fever (<38⁰C), flank pain but with no rigors, or vomiting • Patients with risk factors for multidrug-resistant bacteria UTI. Includes such recent infection, recent stay in hospital or aged care facility.

Redirect to ED if: • Suspected sepsis/ urosepsis, shock: tachycardia, tachypnoea, hypotension, vomiting, rigors, fever>38⁰C • Acutely confused clients • Immunocompromised client

Differentials: • Non-infective causes: increased sexual activity (urethral inflammation), foreign body (urethral/vaginal), abnormality or obstruction of the urinary tract. • Peri-urethral and genital infection – Bacterial vaginosis, Herpes Simplex, Chlamydia, and Candida (fungal) infections. • Sexually transmitted infection. In young clients age <30 presenting with symptoms of UTI – STI testing should be encouraged.

Management / Treatment: Work-up: • Check vital signs and assess for systemic signs of infection. • For non-pregnant women with a first episode of acute uncomplicated cystitis, urine culture and susceptibility testing may not be necessary; empirical therapy can be started based on symptoms alone. Urine dipstick analysis has limited diagnostic accuracy but may be helpful if diagnosis is uncertain.

Treatment: • Most women under the age of 65 who are treated symptomatically (without antibiotic therapy) for acute uncomplicated cystitis may become symptom free within 1 week. If antibiotic therapy is not given, the risk of acute pyelonephritis or sepsis following uncomplicated cystitis is low, but may be reduced by antibiotic therapy. o Antibiotics as indicated in WIC MSO o Symptom management – analgesia, fluids o Follow-up is not routinely required for uncomplicated cystitis but should be considered for a potentially complicated infection or failed resolution of symptoms

Urine MCS should be requested for following patients suspected of lower UTI treated under this protocol: • Women over 65 years • Patients who have recently (within three months) taken antibiotics • Patients with recurrent infection: 2 or more in 6 months or 3 or more in a year • Overseas travel in high risk of bacterial resistance area in the last 6 months.

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Pathology request form to be filled and send with specimen to laboratory. Copy of request documented and kept in records book. Patient will receive follow up phone call and advice based on the result. Copy of result can be also forwarded to nominated GP practice.

Advice: • High fluid intake and complete bladder emptying may aid in resolution of UTI. • Symptomatic relief of urinary discomfort with paracetamol and/or ibuprofen. • Recommend post-coital urination. Avoiding spermicide. • Urinary alkalisers may relieve symptoms but efficacy has not been established. • Client to follow up with GP if worsening or prolonged symptoms despite treatment. • Client to follow up with GP if recurring UTI within 3 months of currently diagnosed/treated UTI. • Client Information Sheet – Urinary Tract Infection

Medication Standing Order: • Trimethoprim first line • Cephalexin second line • Paracetamol • Ibuprofen

References: 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. Cochrane Library. (2019). Retrieved from https://www.cochranelibrary.com/ 3. European Association of Urology. (2019). Retrieved from https://uroweb.org/ 4. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2019). Urinary tract infection (lower) - women 5. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/

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Marine Sting - Clinical Treatment Protocol

Overview: Condition for treatment: Marine stings are unlikely in ACT – however, clients may present on return from coastal areas. First aid needs to be provided onsite to prevent further envenomation.

Symptoms may include: • Pain, burning sensation • Redness, swelling, blistering

Inclusion criteria: • Non-tropical marine stings

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Redirect to GP/NP if: • Wound appears infected or foreign body cannot be removed

Redirect to ED if: • Any neurological or cardio-respiratory involvement, client febrile

Differentials: • Irukandji syndrome with delayed pain may require opioid therapy and hospitalisation. • Marine wounds that become infected require different management.

Management / Treatment: • Bluebottle jellyfish first aid: o Remove adhered stings/tentacles. o Immerse in hot water (as hot as can be tolerated without burning the skin), if not available then ice pack. o Avoid vinegar. • Stingray/Stonefish first aid: o Remove any foreign bodies and wash with salt water. o Immerse the limb in hot water (as hot as can be tolerated without burning the skin). • Antibiotics should be considered where the skin has been penetrated and there is a possibility of foreign bodies in the wound. • ADT should be considered for persons that have not had a tetanus immunisation booster in the past 5 years

Advice: • Marine bites and stings may become infected and some injuries will require prophylactic antibiotics. • Symptoms usually spontaneously resolve within 48 hours. • Stings and bites mostly cause pain at the site of the bite or sting, redness and swelling. • Do not use alcohol, ammonia or baking soda on sting area. • Client Information Sheet – Marine Stings

Medication Standing Order: • Paracetamol • Ibuprofen • ADT

References: 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. Agency for Clinical Innovation. (2019). Marine creatures nurse management guidelines. Retrieved from https://www.aci.health.nsw.gov.au/networks/eci/clinical/ndec/marine-stings-nmg

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3. Berling, I. & Isbister, G. (2015). Marine envenomations. Australian Family Physician. 44(1), 28-32. Retrieved from https://www.racgp.org.au/afp/2015/januaryfebruary/marine-envenomations/ 4. Health Direct. (2019). Sea creature bites and stings. Retrieved from https://www.healthdirect.gov.au/sea-creature-stings 5. The University of Adelaide. (2018). CSL Antivenom Handbook: jellyfish and other marine animals. Retrieved from http://toxinology.com/generic_static_files/cslavh_marine.html

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Measles – Clinical Treatment Protocol

Overview: Condition for treatment - Measles is a highly infectious disease caused by the measles virus. Clients are considered infectious from 24 hours before the onset of prodromal symptoms until 4 days after the onset of the rash.

Complications of measles occur more often in immunocompromised and poorly nourished individuals and may include pneumonia/pneumonitis, laryngotracheitis, otitis media, diarrhoea, miscarriage, stillbirth, convulsions, blindness and encephalitis.

Symptoms may include – • Maculopapular rash • Fever • Cough • Malaise • Coryza • Conjunctivitis • Koplik spots (oral enanthem)

Inclusion criteria– • Clinical suspicion of measles • Suspected contact with measles case

Redirect to ED if any of the following (Communicable Disease Control/ED/ACTAS all need notification prior to transfer)

• Presenting with complicated measles infection showing signs of respiratory distress or dehydration. Differentials: • Rubella • Parvovirus B19 (AKA erythema infectiosum or slapped cheek) • Roseola

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• Dengue • EBV infection (Mononucleosis) • Drug eruptions • Scarlet fever • Early meningococcal disease • Zika Virus

Management or Treatment: Measles is highly contagious. If you have a patient who you suspect has measles, it is important to isolate them immediately, apply a face mask to the patient, and immediately notify Communicable Disease Control (CDC) on 02 5124 9213 (business hours) or pager 02 9962 4155 (after hours/weekends/public holidays). Advice from CDC will vary according to the condition of the patient e.g. immunocompromised individuals or pregnant women with uncertain vaccination status may need referral to ED.

• Supportive care. • Appropriate antipyretics can be given to relieve fever. Do not give aspirin to children under 16 years due to the risk of Reye’s syndrome. Advice: • Advise that measles is usually a self-limiting condition which resolves after a week. • Rest and adequate hydration • Antipyretics (avoid aspirin for children <16) • Isolation – especially avoid susceptible people i.e. people not fully immunized (via vaccination/natural exposure), infants, pregnant women, or immunocompromised people. • Client to remain at home until at least 4 days after the onset of the rash. • If condition deteriorates seek urgent medical advice e.g. shortness of breath, uncontrolled fever, convulsions or altered consciousness.

Medication Standing Order: • Paracetamol • Ibuprofen

References: 1. Amrithalingam, G, Brown, K, Polain, OI & Ramsay, M 2017, PHE National Measles Guidelines 2017, Public Health England. 2. Barnett, E (2019). Measles infection. BMJ Best Practice 3. Clinical Knowledge Summary ‘Measles’ (2018). National Institute for Clinical Excellence 4. Communicable Diseases Network of Australia 2015, Measles: National Guidelines for Public Health Units, Australian Government Department of Health. 5. Gans, H & Maldonado, Y.A. (2018), Measles: Clinical manifestations, diagnosis, treatment and prevention, In M.S. Hirsch, S.L. Kaplan & E.L. Baron (Eds.), UpToDate. 6. The Australian Immunisation Handbook 2019, Measles, Australian Government Department of Health.

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Meibomian Cyst – Clinical Treatment Protocol

Overview: Condition for treatment: A meibomian cyst (also known as a chalazion) is a sterile, chronic, inflammatory granuloma in the tarsal plate caused by the obstruction of a meibomian (sebaceous) gland.

Symptoms may include: • It may develop acutely but typically presents as a firm, localised eyelid swelling that develops slowly over several weeks. • Non-tender nodules with the surrounding skin typically lacking any erythema or sign of an acute bacterial infection. • They are more common on the upper eyelid and are usually 2-8mm in diameter. • There may be multiple meibomian cysts.

Inclusion criteria: • Uncomplicated meibomian cyst

Contact on-call ophthalmology registrar if: • Painful eyelid swelling, not responsive to simple analgesia • Protrusion of eyeball (proptosis) • Double vision or impairment of eye movement • Reduced visual acuity • Reduced light reflexes • Presence of peri-orbital (preseptal)/orbital cellulitis • When a full eye examination is not possible If the registrar is not contactable, redirect the client to GP/ED as clinically indicated.

Redirect to GP if: • The diagnosis is uncertain or if the meibomian cyst has an atypical appearance or recurs in the same location (review needed to exclude cancer) • In the presence of uncontrolled blepharitis, seborrhoeic dermatitis or acne rosacea

Redirect to ED if: • Client is systemically unwell • Central nervous system symptoms, e.g. drowsiness, vomiting, headache, seizure, or cranial nerve lesion

Differentials: • Stye (hordeoleum) • Herpes zoster/simplex • Contact/ seborrheic dermatitis • Orbital cellulitis

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• Atopic eczema • Preseptal cellulitis • Blepharitis • BCC/SCC/sebaceous gland • Dacryocystitis carcinoma/melanoma • Acne rosacea

Management or Treatment: Work-up • Visual acuity should be assessed on all clients presenting with an eye complaint. • If indicated by eye pain the cornea should be examined for abrasions using fluorescein. • Evert the upper eyelid to inspect the tarsal conjunctiva if indicated.

Treatment • Apply a warm compress to the affected eye for 5-10 minutes, then gently massage the cyst in the direction of the eyelashes using clean fingers or cotton buds. This should be repeated 3-4 times per day for up to 4 weeks. Avoid excessively hot compresses which may cause burns.

Advice: • Meibomian cysts can occur spontaneously, are generally self-limiting and resolve from between 1-6 months. Although initial discomfort may be experienced, this usually settles. • Seek immediate medical attention if the cyst becomes infected. • If the meibomian cyst is not responsive to 3-4 weeks of conservative treatment, the client may choose to continue monitoring it for another five months or may choose to be referred to ophthalmologist. • Large and persistent cysts (lasting more than 6 months) may require specialist treatment • Advise against attempts to puncture/squeeze the meibomian cyst. • Manage any risk factors (e.g. blepharitis, seborrhoeic dermatitis, rosacea) to reduce the risk of future episodes of meibomian cysts developing. • Paracetamol or ibuprofen may be taken if required. • Client Information Sheet – Meibomian Cyst.

Medication Standing Order: • Paracetamol • Ibuprofen

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References: 1. American Optometric Association. (2019). Chalazion. Retrieved from – http://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye- and-vision-conditions/chalazion?sso=y 2. Ghosh, C. & Ghosh, T. (2019). Eyelid lesions. UpToDate. Retrieved from http://www.uptodate.com/contents/eyelid- lesions?search=meibomian%20cyst&source=search_result&selectedTitle=1~150&usag e_type=default&display_rank=1 3. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2015). Meibomian cyst (chalazion). 4. The College of Optometrists. (2019). Chalazion (Meibomian cyst). Retrieved from https://www.college-optometrists.org/guidance/clinical-management- guidelines/chalazion-meibomian-cyst-.html 5. Therapeutic Guidelines. (2019). Chalazion (meibomian cyst) and hordeolum (stye). Retrieved from: https://tgldcdp.tg.org.au/viewTopic?topicfile=chalazion- hordeolum#toc_d1e47

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Migraine – Clinical Treatment Protocol

Overview: Condition for treatment – Migraine Symptoms may include There is often a sequence of changes including 4 stages which have various symptoms 1. Prodromal: 24 -48 hours prior to headache irritability, food cravings, neck stiffness 2. Aura: usually precedes headache but not always, includes visual, auditory, somatosensory, symptoms 3. Headache: throbbing, pulsatile quality, nausea, vomiting, photophobia, phonophobia 4. Postdromal: After headache resolves, transient pain at location of headache with sudden movement, feeling drained, exhaustion

Risk factors • Emotional stress • Family history of migraine • Female • Menstruation (decline in oestrogen level following high levels prior to menses) • Sleep disturbance • Overuse of headache medications • Dehydration • Dietary changes • Excessive caffeine intake /caffeine withdrawal

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Inclusion criteria - • Known history of migraine, previously managed by GP with a current management strategy • Menstrual Migraine • Non-pregnant client

Redirect to GP/NP if: • First episode of migraine non responsive to simple analgesia • Migraine not responding to normal analgesia regime

Redirect to ED if: • Headache post head trauma (within 3 months) • Abnormal neurological examination or changes in consciousness • Headache with sudden onset, reaching maximum intensity within 5 minutes • Headache with associated fever, signs of sepsis, rash or neck stiffness • Headache associated with a painful red eye and misty vision or halos • Headache associated with visual disturbance and jaw claudication • A substantial change in the characteristics of their migraine • Brief episodes of headache, precipitated by coughing, straining, exertion or bending over (distinguished from postdromal transient pain)

Differentials: • Tension headache • Cluster headache • Medication over use headache • Subarachnoid haemorrhage • Intracranial lesions • Low pressure headache • Idiopathic intracranial hypertension • Systemic or central nervous system infection • Temporal arteritis • Cervical artery dissection • Cerebral venous thrombosis • Ischaemic stroke/TIA • Cervical spine pathology

Management/Treatment: Work-up • All persons presenting with a complaint of migraine should have a detailed history taken and receive a thorough physical assessment • Identify and minimise possible triggers

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Treatment • Simple analgesia and anti-emetics, use soluble products where possible to aid absorption. Sufficient dose early in attack prior to GI absorption impairment • Ensure adequate hydration • Cold packs over forehead/back of skull (supraorbital and greater occipital nerves) • Heat pack over neck and shoulders (innervation of scalp)

Advice: • As migraines are a chronic condition the client should be advised to see their GP for ongoing management of symptoms and attacks. • Start taking analgesic medicine at the earliest sign of a migraine. • Over-the-counter analgesia options should be discussed with a pharmacist. • Advise the Client to rest in a quiet, darkened room and to avoid movement or any activity (including reading or watching television). • Try to maintain a lifestyle that may help avoid migraines: do not skip meals, keep a regular schedule, adequate and regular sleep, avoid dehydration, regular exercise, identify and avoid specific migraine triggers, limit caffeinated beverages, ensure good workplace ergonomics, regular relaxation techniques especially if stress is a trigger. • Consider keeping a food diary noting migraine symptoms in relation to foods. This may help in identifying triggers for causing migraine that can then be avoided. • Medication over-use (rebound) headache may develop insidiously if analgesics are used regularly for more than 2 days in a week.

Medication Standing Order: • Paracetamol • Ibuprofen • Metoclopramide

References : 1. BMJ best practice. (2018). Migraine headaches in adults. Retrieved from: http://bestpractice.bmj.com/best-practice/monograph/10.html 2. National Institute for Health and Care Excellence. (2015). Headaches in over 12s: diagnosis and management. Retrieved from: https://www.nice.org.uk/guidance/cg150/chapter/Recommendations#assessment 3. Therapeutic Guidelines. (2019). Migraine. Retrieved from: https://tgldcdp.tg.org.au/viewTopic?topicfile=migraine&guidelineName=Neurology#to c_d1e47 4. Smith, J,H., 2019. Acute Treatment of Migraine in Adults. UpToDate. Retrieved from. http://www.uptodate.com/contents/acute-treatment-of-migraine-in- adults?search=migraine%20adult%20treatment&source=search_result&selectedTitle= 1~150&usage_type=default&display_rank=1

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Non-Invasive Foreign Body (FB) of the Eye – Clinical Treatment Protocol

Overview: Condition for Treatment: This protocol is for non-invasive foreign bodies of the eye.

Symptoms may include: • A “feeling” of something being in the eye • A sharp pain in the eye, followed by burning and irritation • Eye is watery and red • A scratchy feeling when blinking • Blurred vision or loss of vision in the affected eye • Eye more sensitive to bright lights

Inclusion criteria: • Uncomplicated non-invasive foreign body of the eye

Redirect to ED if: • Presence of embedded foreign body in eye (consider optometrist as another option) • Moderate to severe eye pain or pronounced photophobia; child cannot open eye • Irregular shaped, dilated or non-reactive pupil • Presence of ciliary injection, corneal opacity or large/deep abrasion • Reduced visual acuity • Hyphema or hypopyon present

Redirect Client to GP/ED as clinically indicated. Community Optometrist may be an option.

Differentials: • Corneal abrasion • Embedded foreign body • Dry eye syndrome • Flash burns

Management or Treatment: Work-up: • Visual acuity should be assessed on all clients presenting with an eye complaint. • Instil Tetracaine into affected eye if necessary but after initial irrigation if needed. • Upon completion of examination, if Tetracaine has been used, patient to wear eye patch until anaesthesia has worn off.

Treatment For multiple or loose particles (e.g. sand): • First, attempt irrigation with saline or water.

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• Many foreign bodies will be located in the subtarsal region which means the upper eyelid needs to be everted.

For individual foreign bodies: • Gently roll a moistened cotton tip applicator over the foreign body. • If the foreign body does not readily adhere to the cotton tip applicator, then suspect that the particle is embedded – redirect to optometrist or ED. • Lubricating eye drops may help relieve any residual discomfort post removal of foreign body.

The cornea should be examined for abrasions using fluorescein. If an abrasion is present, refer to corneal abrasion clinical treatment protocol.

If there is a foreign body sensation without the presence of an obvious foreign body, consider referral to optometrist or to ED if there is significant discomfort or it is after hours.

Advice: • If Tetracaine is used, advise the client that the anaesthesia effect will wear off after 15 minutes. • Emphasise the importance of protective eyewear when grinding, sanding etc. • Review needed if symptoms worsening or not resolved in 48 hours

Medication Standing Order: • Tetracaine (Amethocaine) eye drops • Carmellose 0.5% eye drops

References : 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/2019 2. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2017). Corneal superficial injury. 3. UpToDate. (2019). Retrieved from http://www.uptodate.com/contents/search2019

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Non-Specific Viral Rash – Clinical Treatment Protocol

Overview: Condition for Treatment - A viral rash is usually harmless. It is common for the rash to spread to most or all of the body before it goes away. The rash may last from a couple of days to a couple of weeks.

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Symptoms may Include: Rashes have many different appearances: • Red • Red with flat areas • Red with raised areas • Vesicles • Raised bumps • Welts • Blisters • Or any combination of these

Rashes have many different symptoms: • The rash my spread to most or in some cases all of the body before disappearing. • The rash may last from days to weeks. • May or may not be itchy

Some rashes are distinctive such as: • Chickenpox • Hand foot and mouth disease • Henoch-Scholein purpura • Measles • Molluscum • Roseola infantum • Fifth Disease

Identification Assistance • What is the distribution of the lesion? • Is there erythema, hypo- or hyperpigmentation? • Are there secondary characteristics such as scale or erythema? • Is pruritus present? • Is the patient taking any medications, such as prescription, over-the-counter, or herbal? • Is there a photo distribution to the eruption?

Inclusion criteria: • Client presents with mild URTI symptoms and/or mild fever • Rash blanches

Redirect to GP/NP if: • Client is pregnant • Client is immunocompromised • Client is systemically unwell

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Redirect to ED if: • Non blanching rash , purple, petechial in appearance • Fever with stiff neck, photophobia nausea, vomiting, unwell in presentation

Differentials: • Measles • German measles (Rubella) • Chickenpox (Varicella) • Erythema infectiosum • Roseola • Epstein Barr virus • Enterovirus infections

Management or Treatment: • Monitor rash for changes, seek medical review if concerned. • Antihistamine if itch is present. • Cool compress, especially after heat from shower/bath. • Supportive therapy is advised for Clients suffering from a non-specific viral rash • Allergy-based rashes should be reviewed under a treatment protocol such as urticaria.

Advice: • Maintain good hand hygiene. • Avoid scratching which may lead to a skin staphylococcal infection. • Clients suffering from a non-specific viral rash should increase the amount of fluid they are taking and rest. • Most non-specific viral rashes are rarely complicated. • Client information sheet – Viral Rash

Medication Standing Order: • Paracetamol • Ibuprofen

References: 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. British Medical Journal Best Practice. (2018). Assessment of rash in children. Retrieved from: http://bestpractice.bmj.com/best-practice/monograph/857/diagnosis/step-by- step.html 3. Goldstein, B. & Goldstein A. (2019). Approach to the patient with macular skin lesions. UpToDate. Retrieved from: https://www.uptodate.com/contents/approach-to-the- patient-with-macular-skin- lesions?search=viral%20rash&source=search_result&selectedTitle=1~150&usage_type=d efault&display_rank=1 4. The Royal Children’s Hospital of Melbourne. (2017). Rashes caused by viruses. Retrieved from: http://www.rch.org.au/kidsinfo/fact_sheets?Rashes_caused_by_viruses/

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Otitis Externa (Swimmer’s Ear) – Clinical Treatment Protocol

Overview: Condition for treatment –Acute Otitis Externa (AOE) is a diffuse inflammation of the external auditory canal, which may also involve the pinna or tympanic membrane. It is most commonly caused by bacterial and/or fungal infection. Intact canal skin and cerumen production have a protective effect against infections and cerumen produces a slightly acidic pH. Local trauma, insufficient cerumen production, water in the ear canal, humidity and skin conditions can alter the pH and encourage the growth of microorganism predisposing to otitis externa. The diagnosis of AOE requires the presence of a rapid onset (generally within 48 hours) of symptoms coupled with signs of ear canal inflammation.

Symptoms may include: • Acute onset of ear pain (otalgia) • Tragus tenderness • External auditory canal is inflamed with erythema and may be swollen • Recent or present discharge (otorrhoea) • Aural fullness • Itching • Decreased hearing • Tenderness on moving jaw • Tender regional lymphadenitis • Erythematous tympanic membrane

Inclusion criteria: • Adult and children ≥2 years

Redirect to GP/NP if: • Chronic Otitis Externa – history of recurrent ear infections or inflammation • Perforation of tympanic membrane from trauma or infection • Presence of grommet/s in the tympanic membrane • Abscess • If fungal infection is suspected • Complex co-morbidities such as DM and immunocompromised patients • When the auditory canal is occluded from inflammation with inability to instil medication drops effectively – a wick is required to aide in drop application

Redirect to ED if: • Mastoid tenderness may indicate mastoiditis

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• Malignant Otitis Externa – a potentially fatal complication of acute bacterial external otitis when the infection spreads from the skin to the skull base

Differentials: • Acute Otitis Media • Foreign body in the ear • Impacted earwax • Otomycosis fungal infection of external canal • infected hair follicle in canal • skin conditions such as allergic, contact, and atopic dermatitis, and psoriasis, • Viral infections of the external ear • Cholesteatoma • Mastoiditis • Malignant external otitis

Management or Treatment: Recommendation • Dry aural cleaning of the external ear canal - the removal of cerumen, desquamated skin and purulent material from the ear canal greatly facilitates healing and enhances penetration of ear drops into the site of inflammation. Do not syringe - use tissue spears or similar. • Simple over-the-counter analgesia as recommended by pharmacist. • Combination of steroid and antibiotic ear drops. Symptoms usually improve 48-72 hours after initiation of treatment

Advice: • Recommend having a review of affected ear/s 5-7 days post onset of treatment, or earlier if symptoms worsen • Instruction on how to instil ear drops correctly is important to ensure the entire ear canal is coated • Earplugs or a shower cap while bathing or swimming should be used to prevent water entering the ear canal, which can cause a recurrence of the infection. • Avoid water sport for 7-10 days. • Hearing aids and earphones should not be worn until pain and discharge subside • The Client should be advised to avoid using cotton buds or fingertips to clear wax from the ear canal. • Keep the ear/s dry for 2 weeks after treatment (use of a hairdryer at lowest setting can be used to dry the canal). • Primary prevention is aimed at avoidance of risk factors. These include removal of obstructing cerumen ; water precautions; avoidance of trauma to the ear canal and the use of acidifying ear drops after swimming are recommended • Client Information Sheet – Swimmers Ear Infection

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Medication Standing Order: • Paracetamol • Ibuprofen • Dexamethasone + Framycetin + Gramicidin

References: 1. Australian Medicines Handbook. (2019). Retrieved from: https://amhonline.amh.net.au/ 2. Ghossaini, S., Roland, P.S., Wright, A., & Nunez, D.A. (2017). Otitis externa. British Medical Journal Best practice. Retrieved from https://bestpractice.bmj.com/topics/en-gb/40/pdf/40.pdf 3. Goguen, L. (2017). External otitis: treatment. In D.G. Deschler, M.S. Edwards & D.J. Sullivan (Eds.). UpToDate. Retrieved from: http://www.uptodate.com/contents/external-otitis-treatment 4. Morris, P., Leach, A., Shah, P., Nelson, S., Anand, A., Allnutt, R., ... & Patel, H. (2010). Recommendations for Clinical Care Guidelines on the Management of Otitis Media: In Aboriginal and Torres Strait Islander Populations. Retrieved from https://www1.health.gov.au/internet/main/publishing.nsf/Content/B8A6602C7714B4 6FCA257EC300837185/$File/Recommendation-for-clinical-guidelines-Otitis-Media.pdf 5. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Otitis externa 6. Therapeutic Guidelines. (2019). Retrieved from: http://www.tg.org.au/

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Paronychia (Acute) – Clinical Treatment Protocol

Overview: Condition for treatment: Paronychia infections are one of the most common infections of the hand. A paronychia is a localised, superficial infection or abscess of the lateral and proximal skin fold around a nail (paronychium), causing painful swelling. Acute paronychia infections are usually caused by staphylococcus aureus. They can develop either suddenly and last for a few days (acute) or develop gradually and last longer than 6 weeks (chronic). Paronychia occurs in all age groups and is three times more common in women than in men. Paronychia infections develop from trauma to the skin surrounding the nail plate, which allows the entry of infecting organisms. Trauma may be caused by aggressive manicuring, artificial nail placement, contact dermatitis, dyshidrotic eczema, frequent hand immersion in water, finger sucking and nail biting, hang nail, ingrown nail, penetrating nail trauma, and pemphigus vulgaris.

Symptoms may include: • Rapid onset of painful erythema and swelling of the proximal & lateral nail folds, usually 2-5 days post a minor trauma • Superficial abscess may be present

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Inclusion criteria: • Usually affects one finger • Pain and swelling at base of fingernail • Localised pain and tenderness of the nail folds • Red, hot, tender and swollen lateral and/or proximal nail folds often with a visible collection of pus • If the paronychia is fluctuant, incision and drainage may be required

Redirect to GP/NP if: • Cellulitis or fever • Recurrent/persistent paronychia • Immunosuppressed client • Multiple affected fingers- indicates drug induced paronychia

Redirect to ED if: • Client is systemically unwell

Differentials: • Cutaneous candidiasis – this is a common fungal infection that mostly occurs in moist areas of the skin. • Acute contact dermatitis – this is an itchy rash which may become altered by scratching if the condition persists. It varies in appearance from collections of fluid in the skin (vesicles and occasionally bullae) to areas of poorly demarcated redness, and it may include other features such as dryness, scaling and swelling of the skin. • Fingertip injuries • Herpetic whitlow • Cancer (e.g., melanoma, squamous cell carcinoma) • Psoriasis • Felon (staphylococcal finger infection)

Management / Treatment: Work-up • Vital signs • Assess for the extent of infection , nail, DIPJ, pulp involvement

Treatment: Fluctuant Paronychia - incision and drainage may be required: • Local anaesthesia not needed for superficial collection drainage. • Lance paronychium using a sterile needle or blade, after cleaning with saline. Use gentle pressure to express the exudate and apply a sterile NAD dressing. • Client to see GP in 48 hours for review of wound – sooner if any signs of increased pain or redness at site.

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Non Fluctuant Paronychia - • Warm compress soaks for 20 minutes, 3 -4 times per day. • Client to see GP in 48 hours for review of infection if not improving – sooner if any signs of increased pain or redness at site or collection/fluctuation forming.

Advice: Self-care advice: • Avoid using cuticle removers or trimming the cuticle • Avoid trauma to the nails such as picking, sucking or biting • Keep the nails clean and dry • Wear cotton lined gloves to protect fingers if hands are over-exposed to water

Medication Standing Order: • Paracetamol • Ibuprofen

References: 1. Goldstein, B. Goldstein, A. & Tosti, A. (2019). Paronychia. UpToDate. Retrieved from https://www.uptodate.com/contents/paronychia?search=paronychia&source=search_ result&selectedTitle=1~61&usage_type=default&display_rank=1 2. National Health Service Institute for Innovation and Improvement: Clinical Knowledge Summaries. (2017). Paronychia – acute. 3. Therapeutic Guidelines. (2019). Paronychia. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=nail- disorders&guidelineName=Dermatology#toc_d1e379

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Pregnancy Test – Clinical Treatment Protocol

Overview: Condition for treatment – A female client presenting to the WIC with normal symptoms and findings associated with pregnancy or requesting pregnancy testing. The initial diagnosis of pregnancy relies upon laboratory assessment of human Chorionic Gonadotropin (hCG) in urine or blood. History and physical examination are not highly sensitive methods for early diagnosis, but knowledge of the characteristic findings of a normal pregnancy can help alert the clinician to the possibility of an abnormal pregnancy, such as ectopic pregnancy, or the presence of coexistent disorders.

The clinician should determine prior to testing if a pregnancy would be a welcome event for the client, as this may alter the way the results are presented during the consult and subsequent information given.

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Symptoms may include: • Missed period • Nausea and vomiting (often called “morning’ sickness”, but it can occur at any time) • Breast tenderness and enlargement • Fatigue • Passing urine more frequently than usual, particularly at night • Cravings for some foods, distaste for foods you usually like, and a sour or metallic tast e that persists even when you’re not eating (dysgeusia)

Inclusion criteria: • Female client who is sexually active • History of missed or irregular periods • Request by client for pregnancy testing

Redirect to GP/NP if: • If client has confirmed their pregnancy and seeks advice on medication or another medical condition may impact on their pregnancy • Abdominal pain during pregnancy and client is haemodynamically stable • PV discharge during pregnancy and client is haemodynamically stable

Redirect to ED if: • Suspected ectopic pregnancy • Abdominal pain in pregnancy and client is haemodynamically unstable • PV discharge in pregnancy and client is haemodynamically unstable

Differentials: • Amenorrhoea due to comorbidities, medications, low body weight or for investigation • Ovarian pathology symptoms • Genitourinary infections • Phantom pregnancy symptoms

Management or Treatment: • Collection of urine specimen to test for human Chorionic Gonadotropin (hCG). • Results given to client along with counselling regarding false positives/negatives and need for a follow up blood test.

Advice: • The pregnant client should be advised to book an appointment with their GP or primary care provider for confirmation of their pregnancy and initial antenatal care. • Health care relationships may be formed with midwives, GPs and obstetricians, either in the private or public sectors. • The following websites can provide information for women continuing their pregnancy in the ACT:

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o http://www.health.act.gov.au/our-services/women-youth-and- children/maternity-services/care-during-pregnancy o http://www.pregnancybirthbaby.org.au/having-a-baby-in-the-act o Client Information Sheets o Counselling services available for unplanned pregnancy: https://www.shfpact.org.au/

Medication Standing Order: • Paracetamol

References : 1. Better Health Channel. (2019). Pregnancy-signs and symptoms: Retrieved from: https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-signs-and- symptoms?viewAsPdf=true

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Primary Dysmenorrhoea – Clinical Treatment Protocol

Overview: Condition for treatment: Dysmenorrhea is a painful cramping, usually in the lower abdomen, occurring shortly before and/or during menstruation. It is caused by a natural chemical called prostaglandin that are made in the lining of the uterus. For treatment and advice in the WIC, dysmenorrhoea should be isolated to the primary cause, eliminating other possible aetiology such as endometriosis, pelvic inflammatory disease (PID), pregnancy related PV bleeding or STIs. • Pregnancy and infection should be ruled out prior to management of primary dysmenorrhea

Symptoms may include: • Presence of recurrent crampy lower abdominal pain that occurs shortly before and/or during menses in the absence of other pelvic pathology

Inclusion criteria • Female clients with a presenting problem of low abdominal cramping immediately before or during menses with no history or symptoms of genitourinary infection or suspected underlying pathological condition.

Redirect to GP/NP if: • Client is wanting prevention such as hormonal contraception. • Client has persistent intermenstrual or post coital bleeding. • Clients with secondary dysmenorrhoea (same clinical features as primary dysmenorrhea, but may be associated with underlying pelvic pathology such as Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 126 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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endometriosis, uterine fibroids, endometrial polyps, or PID) will need to be referred to their GP and may require referral to a gynaecologist for further investigation. • Clients with complicated gynaecological histories or multiple comorbidities.

Redirect to ED if: • Suspected systemic infection – fevers, tachycardia, hypotension • Severe abdominal pain • Heavy PV loss and haemodynamically unstable

Differentials: • Recent history of, or currently being treated for, genitourinary infections • Ovarian pathology

Management or Treatment: • A non-steroidal anti-inflammatory drug (such as ibuprofen) or paracetamol will usually provide pain relief in primary dysmenorrhoea. • Hormonal contraception is an alternative first-line treatment and has the additional advantage of providing contraception – refer client to GP/NP. • Tocolytic management (calcium antagonist) - Refer to GP • Transcutaneous electric nerve stimulation (TENS)- Refer to GP or physiotherapist

Advice: • Clients with contraindications of gastrointestinal complications secondary to the use of NSAIDs should be started on paracetamol and referred to a GP/NP for further pain management and PR non-steroidal anti-inflammatory options. • Heat therapy (e.g. hot water bottle, heat bag) to the lower abdomen and/or back may help to reduce uterine muscle cramping/pain, gentle exercise, and relaxation techniques. • If period pain is a common condition, NSAID therapy should be initiated 1-2 days prior to menses. • If period pain is a chronic condition (greater than 3 months), the client should be referred to their primary care provider for further investigation and management • Hydration and menses-specific diet considerations should be discussed, e.g. higher iron, magnesium, B1 and 6, Vitamin E and calcium intake. • Client Information Sheet – Menstrual pain: dysmenorrhoea

Medication Standing Order: • Paracetamol • Ibuprofen

References: 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/

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2. Sermin Timur Taşhan, Yeşim Aksoy Derya, & Gülçin Nacar. (2018). An analysis of dysmenorrhoea and depressive symptoms in university students: A case‐control study Retrieved from https://onlinelibrary.wiley.com/doi/10.1111/ijn.12678 4. Smith, R. & Kaunitz, A. (2007). Treatment of primary dysmenorrhea in adult women. UpToDate. Retrieved from https://www.uptodate.com/.../treatment-of-primary- dysmenorrhea-in-adult-women 5. Therapeutic Guidelines. (2019). Primary dysmenorrhea. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=menstrual- disorders&guidelineName=Sexual and Reproductive Health#toc_d1e588 6. Wong, C., Farquhar, C., Roberts, H. & Proctor, M. (2009). Oral contraceptive pill for primary dysmenorrhoea. Cochrane Database System Review, 7(4). doi: 10.1002/14651858.CD002120.pub3

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Head Injury – Adults (>18yrs) – Clinical Treatment Protocol

Overview: Condition for Treatment: Head injury includes any trauma to the scalp, skull or brain Symptoms may include: Less severe symptoms: mild headache, small haematoma, single episode of vomiting.

Severe symptoms: diminished loss of consciousness, CSF leakage from ear/nose

Symptoms can be markedly variable depending upon severity of trauma. The above examples are far from an exhaustive list of possible symptoms.

Inclusion criteria • Minor Head Injury: o No LOC (the exception being a brief LOC [<5 minutes] with no symptoms at 4/24 post-injury) o GCS 15 o May have mild scalp bruising or superficial laceration o Isolated head injury o Mild, acute lethargy, nausea, dizziness, mild headache, <2hrs post injury

If the individual presents to the WiC immediately post head injury and they are symptomatic, an ED redirection is indicated. Head injured individuals should be monitored until at least 4/24 has elapsed from the time of their injury. The WiC is not an appropriate facility for ongoing monitoring.

Redirect to GP if: • Post-Head Injury – Requiring clearance to return to work/sports

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Redirect to ED if: • Moderate Head Injury: o Any LOC (the exception being a brief LOC [<5 minutes] with no symptoms at 4/24 post-injury) o GCS <15 on initial assessment o Amnesia for event pre & post head injury* o Persistent abnormal alertness / behaviour / cognition* o Persistent headache since injury o Anticoagulant/Antiplatelet therapy (incl. aspirin) o Age >65yrs o Known coagulopathy (e.g. liver disease, factor deficiency) o Dangerous/high energy injury** (e.g. Pedestrian hit by MV/MB, ejection from MV/MB, fall from >1meter or >5 stairs, diving accident, bicycle accident, any other potentially high-energy mechanism). o Post-traumatic seizure o Unwitnessed head injury where uncertainty about LOC o Previous neurosurgery o Neurological impairment disorder (e.g. dementia, learning disability) o Intoxicated (EtOH &/or other drugs) o Focal neurological deficit** (Difficulties with understanding, speaking, reading, writing, problems with balance/walking, general weakness, visual changes, abnormal reflexes) o Any vomiting o Multi-system trauma** o Multiple co-morbidities or combination of worrying factors o Large scalp bruise, haematoma or laceration** o Delayed presentation or representation** o Possible non-accidental injury or a vulnerable person

If staff are unsure or have further concerns, the Admitting Officer (AO) at Canberra Hospital ED can be contacted.

Call Ambulance if: • Severe Head Injury: o Decreased conscious state (GCS <14) o Localising neurological signs (unequal pupils, lateralising motor weakness) o Signs of increased intracranial pressure (bradycardia, resp. depression & HTN) o Penetrating head injury o CSF/blood leak from nose or ears (signs of base of skull #). o Associated with cervical spine tenderness

* particularly if persists beyond 4hrs post time of injury **clinical judgement required – may require ACTAS transport

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Differentials: • CVA • Acute Subdural Haematoma • Seizure/post-ictal

Management or Treatment: Minor Head Injury: • The patient may be discharged from the Walk-in Centre to the care of a responsible adult who can stay with the patient for 24/24 after injury. • If there is any doubt as to whether there has been loss of consciousness or not, assume there has been and treat as for moderate head injury (unless LOC of <5 minutes with no symptoms at 4/24 post-injury). • Adequate analgesia (paracetamol only, no NSAIDs) • Minor head injury handout, incl. signs & symptoms of deterioration.

Advice: • Rest o Adequate sleep & mental rest for 24-48 hours. o Have a responsible person stay with them for the first 24/24 after injury. • Pain o Paracetamol (e.g. Panadol®) may be given for a headache. Do not use aspirin or other NSAIDS, including ibuprofen. • Wound Care o Refer to wound care protocol and provide wound care handout. • Driving o Do not drive or operate for at least 24 hours, until feeling much better. • Drinking/Drugs o Do not drink alcohol, take sedating medication or use drugs as this could mask deterioration. • Work o Upon symptom resolution and a rest period of at least 24 hours, a graduated return to work can be undertaken • Sport o Generally a return to full contact sport should not occur any earlier than 6 days post-concussion. A more rapid return would be decided by the GP. o A graduated approach to resumption of activity is recommended. o A GP review is required prior to returning to sport. • Attend GP o If symptoms persist >3/7 (e.g. mild headache/dizziness/nausea) • Attend ED/Call ambulance o Feeling faint or drowsy, cannot be woken up, acting strangely or saying things that don’t make sense, have a constant severe or a worsening headache, cannot remember new event or recognise people or places, LOC or seizure, limb

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weakness/numbness or LOC, blurred/double vision, slurred speech, fluid/bleeding from ear/nose, loss of hearing, vomiting.

Medication Standing Order: • Paracetamol

References: 1. UpToDate, 2019 (https://www.uptodate.com/contents/acute-mild-traumatic-brain- injury-concussion-in-adults) 2. Queensland Health, Closed Head Injury (Adult) Clinical Pathway, 2014 3. NSW Health, Closed Head Injuries in Adults – Initial Management, Feb 2012 4. NSW Institute of Trauma and Injury Management, Initial Management of Closed Head Injury in Adults, 2nd Ed, 2011 (https://www.aci.health.nsw.gov.au/networks/itim/resources) 5. NICE 2019 – Head Injury (https://www.nice.org.uk/guidance/cg176)

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Head Injury – Children & Adolescents (2-18yrs) – Clinical Treatment Protocol

Overview: Condition for Treatment: Head injury includes any trauma to the scalp, skull or brain Symptoms may include: Less severe symptoms: mild headache, small haematoma, single episode of vomiting.

Severe symptoms: diminished loss of consciousness, CSF leakage from ear/nose

Symptoms can be markedly variable depending upon severity of trauma. The above examples are far from an exhaustive list of possible symptoms.

Inclusion criteria • Minor/Low-risk head Injury: o No LOC (the exception being a brief, witnessed LOC [<60 seconds] presenting >4/24 post injury with no symptoms) o Up to one episode of vomiting o Stable, alert conscious state (GCS 15 (if can scale), AVPU=A) o May have minor scalp bruising or laceration

If the individual presents to the WiC immediately post head injury and they are symptomatic, an ED redirection is indicated. Head injured individuals should be monitored until at least 4/24 has elapsed from the time of their injury. The WiC is not an appropriate facility for ongoing monitoring.

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Redirect to GP if: • Post-Head Injury – Requiring clearance to return to work/sports

Redirect to ED if: • Moderate/Intermediate-risk head Injury: o Any LOC (the exception being a brief, witnessed LOC [<60 seconds] presenting >4/24 post injury with no symptoms). o GCS <15; AVPU 1 vomit o Persistent/severe headache o Up to one single brief (<2min) convulsion occurring immediately after the impact o May have a large scalp bruise, haematoma or laceration. o Bleeding disorder, e.g. haemophilia

If staff are unsure or have further concerns, the Admitting Officer (AO) at Canberra Hospital ED can be contacted.

Call Ambulance if: • Severe/High-risk head Injury: o GCS <14; AVPU

Differentials: • Non-accidental injury (NAI) • Multi-trauma patients • Non-mechanical fall (e.g. syncopal episode with possible cardiovascular/neurological cause. • Cervical spine injury • Alternate diagnosis, i.e. seizure, metabolic, poisoning, infectious diseases.

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Management or Treatment: Minor/Low-risk Head Injury: • The patient may be discharged from the Walk-in Centre to the care of their parents/responsible adult who can monitor child/adolescent for at least 24 hours post head injury. • If there is any doubt as to whether there has been loss of consciousness or not, assume there has been and treat as for moderate head injury (unless LOC <60 seconds and asymptomatic). • Adequate analgesia (paracetamol) • Minor head injury handout, incl. signs & symptoms of deterioration.

If non-accidental injury suspected, mandatory reporting to Child and Youth Protection Services is required

Advice: • Rest o Encourage the child to lie down or choose a quiet activity. Allow the child to sleep if desired. It is not dangerous to sleep after a minor head injury (especially if it is nap time), although the parent should monitor the child. A mild headache, nausea, and dizziness are common, especially during the first few hours after the injury. If the child is nauseous or has vomited, try offering clear liquids (eg, Hydralyte/Gastrolyte, clear juice). o Physical and cognitive rest for 48/24. • Wound care o Refer to WiC wound care policy and provide wound care handout • Swelling o Swelling (a large lump or "goose egg") is also common after a head injury. To reduce swelling, an ice or a cold pack can be applied to the area for 20 minutes. Swelling usually begins to improve within a few hours, but may take one week to completely resolve. • Pain o Paracetamol (eg, Panadol®) may be given for a headache. If the child's headache is severe or worsens, the child should be evaluated by a healthcare provider. • Work o Upon symptom resolution and a rest period of at least 24 hours, a graduated return to work can be undertaken • Return to sport o Return to full contact sport should not occur any earlier than 14 days post- concussion. o A graduated approach to resumption of activity is recommended. o A GP review should be undertaken prior to return to full contact sport. • Attend GP o If symptoms persist >3/7 (e.g. mild headache/dizziness/nausea) • Attend ED if child develops: o Severe headache, especially if getting worse Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 133 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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o New onset dizziness o Unsteady walking o Vomiting >1 episode o Unexpected drowsiness or weakness o Disorientation or confusion o Continued crying or unusual agitation o Slurred speech or blurred/double vision o Seizure

Medication Standing Order: • Paracetamol

References: 1. Royal Children’s Hospital, 2018 (https://www.rch.org.au/clinicalguide/guideline_index/Head_injury/) 2. NSW Health 2011; Children & infants – Acute Management of Head injury. (https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2011_024.pdf) 3. Children’s Health Queensland Hospital & Health Service 2019; Head injury – Emergency management in Children (https://www.childrens.health.qld.gov.au/guideline-head-injury-emergency- management-in-children/) 4. UpToDate 2019, Concussion in Children and Adolescents

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Pulled Elbow – Clinical Treatment Protocol

Overview: Condition for treatment: A pulled elbow refers to subluxation of the radial head. Typical history involves adult or taller person pulling on fully extended arm of child followed by child refusing to use affected arm. Injury also commonly occurs from young child being swung by the arms. Whenever there is a musculoskeletal injury the joint above and below should be examined.

Symptoms may include: • Elbow pain with movement • Elbow stiffness • Affected arm held still by side

Inclusion criteria: • Uncomplicated pulled elbow • Mild tenderness to radial head • No visible distress unless movement attempted • Mechanism of injury well understood and witnessed by an adult Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 134 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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Redirect to ED if: Suspected fracture or dislocation: • Significant swelling, bruising or deformity to elbow • Significant distress with bony palpation or assessment • Pain not well controlled with simple analgesia • Mechanism of injury not well understood • Refer to Fracture Management protocol

Failed reduction attempt: • Attempted reduction not successful if continued disuse of affected arm persists after 10-minute observation period.

If non-accidental injury is suspected, mandatory reporting to Care and Protection Services is required.

Differentials: • Congenital dislocation of the radial head • Elbow fracture/dislocation • Fractures affecting the upper limb (clavicle, humerus, wrist)

Management or Treatment: Reduction manoeuvres (may have two attempts at each manoeuvre unless child is overly distressed): Primary manoeuvre: hyperpronation • Gently grasp affected elbow at 90 degrees of passive elbow flexion, with finger or thumb over radial head. • Grasp the hand/wrist of the affected arm and hyper pronate the forearm while directing pressure towards the torso and feeling/listening for radial head reduction. • Flexion of the elbow can then be performed if radial head was not felt to have relocated.

Secondary manoeuvre (if primary fails): supination/flexion • Gently grasp affected elbow with finger or thumb over radial head. • Hold arm in extended position with forearm pronated. • Passively supinate the forearm and flex the elbow while feeling/listening for radial head reduction. Post procedure: • Child should begin using the affected arm within 5-10 minutes after treatment.

Advice: • Avoid lifting the child up by the hands or wrists. • Avoid swinging the child around by their hands or wrists

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• If the elbow was out for an extended time, then tenderness may last up to 24 hours. Give simple analgesia if needed. • Client Information Sheet – Pulled Elbow

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days.

References: 1. ACT Government Community Services. (n.d.). Keeping Children and Young People Safe. Retrieved from https://www.communityservices.act.gov.au/ocyfs/keeping-children- and-young-people-safe 2. Bexkens, R., Washburn, F. J., Eygendaal, D., van den Bekerom, M. P., & Oh, L. S. (2017). Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. The American Journal of Emergency Medicine, 35(1), 159-163. Retrieved from http://dx.doi.org/10.1016/j.ajem.2016.10.059 3. Krul, M., van der Wouden, J. C., van Suijlekom‐Smit, L. W., & Koes, B. W. (2012). Manipulative interventions for reducing pulled elbow in young children. The Cochrane Library. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007759.pub3/epdf 4. Moore, B.R. & Bothner, J. (2019). Radial head subluxation (nursemaids’s elbow). In A.M. Stack, J.F. Wiley (Eds.). UpToDate. Retrieved from https://www.uptodate.com/contents/radial-head-subluxation-nursemaids- elbow?source=search_result&search=pulled%20elbow&selectedTitle=1~6 5. Simon, R. R., Sherman, S. C., & Koenigsknecht, S. J. (2007). Emergency Orthopedics: The Extremities. New York: McGraw-Hill, Medical Pub. Division. 6. The Royal Children’s Hospital Melbourne. (n.d.). Clinical Practice Guidelines – Pulled Elbow. Retrieved from http://www.rch.org.au/clinicalguide/guideline_index/Pulled_elbow/

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Removal of Cast (ROC) – Clinical Treatment Protocol

Overview:

Condition for treatment: Removal of a fibreglass cast, following fracture.

Symptoms may include: • N/A

Inclusion criteria: • Clients referred to the Walk-in Centre from TCH Fracture Clinic for the removal of their cast.

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Redirect to GP or emergency if: • Client is complaining of increase in pain or has symptoms of neurovascular compromise. • Client suffers from diabetes mellitus or neurovascular conditions. • Client has an ongoing wound sustained from initial injury that has not healed.

Management or Treatment: • Check the Fracture Clinic cast removal order on CPF and consult with the referring clinician if there are any concerns. • Client will be informed of the process of cast removal and consent obtained. • Position the client comfortably with the affected limb resting on the bed or tray table. • Check the plaster saw to ensure the oscillating blade is properly fixed, is not worn and functions as required. • Ensure the blade guard and suction hose are properly attached. • Inform the client that the plaster saw will be noisy and offer ear protection. • Offer eye protection if appropriate. • Assess skin integrity, limb symmetry and neurovascular status. • Wash the limb with water and apply moisturiser – Sorbolene / Epaderm. • If asymmetry or concerns for neurovascular status are present, contact the Orthopaedic Registrar on-call.

Advice: • Provide cast removal information sheet.

References: 1. ACT Health. Canberra Hospital and Health Services Clinical Procedure: Plaster and Polyester Cast Management (2018). Retrieved from http://inhealth/PPR/Policy%20and%20Plans%20Register/Plaster%20and%20Polyester%2 0Cast%20Management.doc 2. Better Health Channel. (2018). Plaster care. Retrieved fromhttps://www.betterhealth.vic.gov.au/health/conditionsandtreatments/plaster-care 3. Kids Health for Nemours. (2019). What to expect when your cast comes off. https://www.kidshealth.org/en/teens/cast-care.html

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Rubella – Clinical Treatment Protocol

Overview: Condition for treatment: Rubella is a viral disease characterised by rashes, swollen glands and fever. The disease is usually mild and of little significance unless you are pregnant. Infection of a pregnant woman (congenital rubella syndrome) commonly results in miscarriage, stillbirth, or birth of an infant with major birth abnormalities.

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Symptoms can include: • Maculopapular rash • Fever (approx. 50% of infections) • Arthralgias (joint pain) • Mild lymphadenopathy involving the post-auricular, posterior cervical, and occipital lymph node groups • Malaise • Coryza • Pharyngitis • Non-purulent conjunctivitis

Inclusion criteria: • Uncomplicated rubella with clinical and epidemiological supportive evidence

Redirect to GP/NP if: • Pregnant women • Immunocompromised clients • Rubella suspected but not supported by clinical and epidemiological evidence

Redirect to ED if: • Client is systemically unwell

Risk Factors: • Incomplete immunisations • Confirmed contact • International travel

Differentials: • Measles • Roseola infantum (HHV-6 HHV-7 Sixth disease) • Scarlet fever (Group A Strep pyogenes) • Erythema infectiosum • Parvovirus B19 (5TH Disease) • Entoviral infections • Dengue virus • Zika virus • Secondary syphilis • Infectious mononucleosis (Epstein Barr virus) • Kawasaki’s syndrome • Cutaneous drug reactions • Juvenile rheumatoid arthritis

Management or Treatment: • Treatment of symptomatic infection is largely supportive, as the illness is self-limiting.

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• Maternal infection during pregnancy may cause spontaneous abortion, foetal death, or multiple congenital anomalies (congenital rubella syndrome). Specialty consultation is strongly recommended for pregnant women with exposure to rubella. • Airborne precautions as per TCH Infection Prevention and Control Manual. • Client Information Sheet – Rubella • Notify Infection Control on 6244 2512. After-hours, call Health Protection Service Emergency Pager (02) 9962 4155 (24 hours). • Complete the Notifiable Disease Form and fax/phone details through. • Clinical evidence: • A generalised maculopapular rash and fever and arthralgia/arthritis OR lymphadenopathy OR conjunctivitis. • Epidemiological evidence: • An epidemiological link is established when there is: contact between two people involving a plausible mode of transmission at a time when: one of them is likely to be infectious (about one week before to at least four days after appearance of rash) and the other has an illness which starts within 14 and 23 days after this contact; and at least one case in the chain of epidemiologically linked cases (which may involve many cases) is laboratory confirmed.

Advice: • Rubella is infectious and affected persons should remain absent from school/work for 4 days post-presentation of the rash.

Medication Standing Order: • Paracetamol • Ibuprofen

References: 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. British Medical Journal Best Practice. (2019). Rubella. Retrieved from https://bestpractice.bmj.com/topics/en-gb/1167/history-exam 3. Edwards, M., Hirsch, M. & Sullivan, M. (2019). Rubella. UpToDate. Retrieved from https://www.uptodate.com/contents/rubella?search=rubelaa&source=search_result&se lectedTitle=1~150&usage_type=default&display_rank=1 4. NSW Government Health Guidelines. (2019). Rubella (German Measles) control guidelines. Retrieved From https://www.health.nsw.gov.au/Infectious/controlguideline/Pages/rubella.aspx

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Scabies – Clinical Treatment Protocol

Overview: Condition for treatment – Scabies is a highly infectious skin infestation caused by the Sarcoptes Scabiei mite. It is usually transmitted by close person-to-person contact, though it can occasionally be transmitted by clothing and linens. The distribution of scabies usually involves the sides and webs of the fingers, the flexor aspects of the wrists, the extensor aspects of the elbows, the skin adjacent to the nipples (especially in women), the periumbilical areas, waist, male genitalia, the extensor surface of the knees, the lower half of the buttocks and adjacent thighs, and the lateral and posterior aspects of the feet. The back is relatively free of involvement, and the head is spared except in very young children. Rarely, scabies may be localised to a single area.

Symptoms may include: • generalised and intense itching, often worse at night • burrows • small, erythematous, nondescript papule papules especially on face, neck, palms and soles in children • vesicles, excoriations

Risk Factors: • Overcrowded living conditions/poverty • Living in close quarters with others who are infected • Under 15 or over 65 years • Sexual contact with new or multiple partners • Immunosuppression

Inclusion criteria: • Uncomplicated scabies, treat in conjunction with a pharmacist.

Redirect to GP/NP if: • Immunocompromised client • Failed topical treatment • Client is over 70 years of age

Redirect to ED if: • Client is systemically unwell.

Differentials: • Eczema • Seborrheic dermatitis • Tinea • Atopic dermatitis

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• Impetigo • Flea Bites

Management or Treatment: • Permethrin 5% Cream from pharmacy as per directions.

Advice: • Treat household contacts and close friends at the same time, even if others are asymptomatic. • Do not treat infants under 2 years old with Permethrin. • Apply cream to entire body from neck to soles of feet – follow product directions. • Wash bed linen, clothing, soft toys, etc. in hot water and line dry in the sun or in hot dryer. • Repeat treatment with Permethrin 5% in 1 week for moderate to severe infections. • Client information sheet – Scabies.

Medication Standing Order: • N/A

References : 1. Australian Medicines Handbook. (2019). Permethrin 5%. Retrieved from https://amhonline.amh.net.au/ 2. British Medical Journal Best Practice. (2019). Scabies. Retrieved from: https://bestpractice.bmj.com/topics/en-gb/124/history-exam 3. MIMS Online. (2019). Permethrin. Retrieved from: https://www.mimsonline.com.au/Search/FullPI.aspx?ModuleName=ProductInfo&sear chKeyword=Permethrin&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID= 29330001_2 4. UpToDate. (2019). Scabies epidemiology, clinical features, and diagnosis. Retrieved from: https://www.uptodate.com/contents/scabies-epidemiology-clinical-features- and- diagnosis?search=scabies&source=search_result&selectedTitle=1~90&usage_type=def ault&display_rank=

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Scaphoid Injury – Clinical Treatment Protocol

Overview: Condition for treatment: Presenting complaint of wrist pain after a fall onto out-stretched hand (FOOSH), with scaphoid specific symptoms. Whenever there is a musculoskeletal injury the joint above and below should be examined.

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Symptoms may include: • Wrist pain • Wrist swelling, bruising or redness • Wrist joint stiffness

Inclusion criteria: Positive scaphoid specific tests including any of the following: • Tenderness in the anatomical snuff box (ASB) • Tenderness on axial compression and distraction of the thumb (telescoping) • Tenderness of the proximal pole of the scaphoid (palmar aspect)

Redirect to ED if: Suspected complicated fracture or carpal dislocation: Presenting complaint of wrist pain following acute injury and - • Excessive swelling to wrist or scaphoid • Deformity to wrist or hand • Simple analgesia not able to control pain

Neurovascular compromise: Presenting complaint of wrist pain following acute injury and - • Neurological deficit noted distal to the site of the complaint • Vascular deficit noted distal to the site of the complaint

Differentials: • Distal radius fracture • Dislocation of carpal bones • Scapho-lunate ligament injury • Fractured base of thumb –Bennett’s Fracture • Carpal Tunnel Syndrome - compression of median nerve • Tendinopathy - associated with over-use /new activity (such as De Quervain’s tenosynovitis) • Wrist sprain (ligamentous injury)

Management or Treatment: • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Fracture Management protocol. All suspected scaphoid injuries should be referred for X-ray by requesting “Wrist with scaphoid views”.

Positive X-ray result: • If required, the results should be discussed with the Orthopaedic Registrar. • The Canberra Hospital Registrar Review Clinic Process: o Contact, via TCH Switch (02) 512 40000 and present the case to the appropriate registrar.

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Note: if, after discussion with the Registrar, the client’s required treatment falls outside of the clinical scope of the WIC he/she will require redirection to the Emergency Department. o Complete the TCH Registrar Review Clinic front sheet and checklist. o Complete the client’s notes and fax them with the completed cover sheet to the Registrar Review Clinic (02) 624 44107 o Ensure the client understands that he/she will be contacted by the Registrar Review Clinic with an appointment time and date.

Negative X-ray result: Referral to GP in 7 days: • Positive scaphoid specific tests with normal X-Ray. • Treatment includes application of a scaphoid thumb spica wrist splint or POP back- slab if they have positive scaphoid specific tests, even if the X-Ray is reported as normal. • Application of a scaphoid thumb spica back-slab should be fitted with a high arm sling. • Advice given to seek GP review in one week. • Early referral for further imaging should be considered for those clients with positive scaphoid specific tests, where immobilization in a splint or back-slab may cause significant social and economic disruption.

Advice: • Plaster care or advice should be given to client to ensure that he/she understands the importance of the back-slab being kept clean and dry and he/she should not insert any item between the back-slab and skin that will cause further injury and potential infection. • Keep arm elevated in sling provided. • If a thumb spica wrist splint is applied, advice should be given that the splint must be treated like a plaster and remains in place at all times until review by the Orthopaedic registrar. • Avoid contact sports, driving or any activity which could result in further injury. • Client information sheet – Plaster care • Neurovascular observations should be performed – colour, warmth, sensation, uncontrolled pain and movement of thumb and digits. • Referral to Registrar Review Clinic Clients – ensure the client understands that the clinic will contact him/her with an appointment time on the contact number they have provided. If the client has not received a call within 2 days of referral he/she can contact the clinic through the TCH Switch as per the Fracture Referral Information. • All clients should be encouraged to follow up their soft tissue injury with a physiotherapist for specialist advice regarding diagnosis and management.

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Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days following injury. • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References: 1. Bleakley, C.M., Glasgow, P.D., Phillips, N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 2. Brukner, P. and Khan, K. (2012). Brukner & Khan's Clinical sports medicine. (4th ed) (pp. 427-447). Sydney, NSW: McGraw-Hill Education. 3. deWeber, K. (2019). Scaphoid fractures. UpToDate. Retrieved from: https://www.uptodate.com/contents/scaphoid- fractures?source=search_result&search=scaphoid%20fracture&selectedTitle=1~25 4. Morris, F., Wardrope, J. and Ramlakhan, S. (2012). Minor injury and minor illness at a glance. Wiley & Sons West, Chichester, West Sussex. 5. Pountos, I., Georgouli, T., Calori, G., and Giannoudis, P. (2012). Do Nonsteroidal Anti- Inflammatory Drugs Affect Bone Healing? A Critical Analysis. The Scientific World Journal, 2012(606404). Retrieved from https://doi.org/10.1100/2012/606404

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Self-Harm (Cutting) – Clinical Treatment Protocol

Overview: Condition for treatment: Self-harm behaviours are the deliberate destruction of a person’s body. Clients aged 16 or over who have self-harmed via cutting and have presented for wound management.

Symptoms may include: Self-harm is a complex issue, often the end result of an individual being overwhelmed and failing to utilise other less destructive coping mechanisms.

Physical Symptoms: • Laceration • Scratches • Scarring

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Psychosocial Symptoms: • Emotion numbing / instability • Mood swings • Depression / Anxiety • Guilt • Shame • Disgust

Behavioural Symptoms: • Wearing conservative clothing • Spending long period alone • Keep sharp objects • Difficulty with interpersonal relationships • Impulsive behaviours

Inclusion criteria: • Single laceration (length <10cm) or multiple lacerations (combined total length <20cm) with no evidence of underlying structural damage or neurovascular changes • Age of wound <18 hours old • No signs of infection in the wound • No further plan or intent to self-harm • No thoughts, plans or intent of suicide • No thoughts, plans or intent to harm others • Able to establish mental health history • Client has history of self-harming and support network available e.g. social worker, psychologist, mental health plan, psychiatrist, under MH team, family

Redirect to GP/NP if: • Signs of wound infection • Single laceration >10cm (if GP/NP unavailable, then ED) • Multiple lacerations >20cm (if GP/NP unavailable, then ED) • First time to self-harm and no further plan or intent • Under the age of 16 • Client concerns for aesthetic outcome

Redirect to ED if: • Suicide plan or intent • Systemically unwell - signs of infection • Further self-harm plan or intent • Plan or intent to harm others • First time to self-harm • Under the age of 16 (out of hours) • Client concerns for aesthetic outcome

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• Multiple presentations over the past 24 hours • Showing signs of escalation if mental health status

Advice: • Comprehensive history will be taken to understand why the choice has been made to self-harm. • APN/NP will call the treating team within normal business hours, ACCESS afterhours. This will ensure continuity of care. Offer the client to speak with the ACCESS or treating team member during the consultation. • Give support and reassurance to the client. • Offer phone numbers for supportive contact. • Fax copy of clinical notes to mental health treating team or ACCESS. When there is a variance in the presentation or more relevant information may be useful for the MH team to know. ACCESS TEAM - open 24 hours Phone: 1800 629 354 Phone:02 6205 1065 FAX: 6174 7175 Child and Adolescent Mental Health Services (CAMHS) - under 18’s - Open 08:30 to 16:51 Intake Line, Phone: 6205 1971 Mental Health Treatment Teams – Open hours 08:30 - 16:51 City Mental Health Team 1 Moore Street, level 2, Canberra City Ph: 5124 1795 Fax: 6205 5224 Tuggeranong Mental Health Tuggeranong Community Health Centre Ph: 5214 1300 Fax: 6205 2900 Woden Mental Health Team Phillip Health Centre Ph: 5124 1269 Fax: 6205 2650 Belconnen Mental Health Team Belconnen Community Health Centre Ph: 5124 4294 Fax: 6205 0988 Gungahlin Mental Health Team Gungahlin Community Health Centre Ph: 5124 4294 (calls will go through Belconnen MH # until further notice) Fax: 6207 6785

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Management or Treatment: • Assess severity of injury and respond accordingly. • Obtain a comprehensive history from the client. • Contact ACCESS team or if in hours an appropriate treating team where applicable. • Once suitability for WIC ascertained, treat according to laceration protocol. • Re-direct safely in conjunction with ACCESS or treating team. • In the event of suicide plan or intent, transfer to ED via ACTAS. • In the event of plan or intent to harm others, transfer to ED via ACTAS. • Redirect to GP if not being actively managed. • Send discharge summary to GP, consider providing private psychologist information.

References: 1. Allan, C. L., Behrman, S., & Ebmeier, K. P. (2012). Primary care management of clients who self-harm. The Practitioner, 256(1751), 19-23. 2. Beyond Blue. (2019). Self-harm and self-injury. Retrieved from https://www.youthbeyondblue.com/understand-what's-going-on/self-harm-and-self- injury 3. National Institute for Health Care and Clinical Excellence. (2013). Self-Harm. Retrieved from https://www.nice.org.uk/guidance/qs34/resources/selfharm-pdf- 2098606243525 4. The British Medical Journal. (2017). Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care. Retrieved from https://www.bmj.com/content/359/bmj.j4351 5. The Department of Health. (2013). Mental Health Triage Tool. Retrieved from http://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~tri ageqrg-mh 6. Warden, S., Spiwak, R., Sareen, J., & Bolton, J. M. (2014). The SAD PERSONS scale for suicide risk assessment: a systematic review. Archives of suicide research, 18(4), 313- 326.

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Shingles (Herpes Zoster) – Clinical Treatment Protocol

Overview: Condition for treatment - Shingles (herpes zoster) is a viral infection of nerve cells that occurs when a latent infection with varicella-zoster virus reactivates because of a decrease in virus-specific cell-mediated immunity. It is uncommon in childhood; incidence and severity increases with age.

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• Rash with a dermatomal distribution (usually unilateral). Rash starts out as macules and papules then develop into vesicular lesions. • Pain – The associated neuritis can cause intense neuralgic pain over the affected area, especially with trigeminal nerve involvement. Often described as burning, aching or stabbing.

Inclusion criteria - • Shingles type vesicular rash, pain is tolerable, >72 hours since onset of rash.

Redirect to GP/NP if: • Rash < 72 hours old • Rash > 72 hours old with new lesions continuing to appear • Fever • Signs of super imposed infection • Pregnant women • Immunocompromised individuals • Organ transplant recipients • Recurrent herpes zoster

Redirect to ED if: • Pain unbearable • Acute retinal necrosis • Eye involvement (can discuss case with on-call ophthalmology consultant/registrar at TCH. If unavailable, patient to be referred to ED) • Ipsilateral facial paralysis • Ear pain and vesicles in the auditory canal

Shingles is a reportable infection. Staff need to complete and fax the Report of Notifiable Condition or Related Death Form to ACT Health Protection Service.

Differentials: • Herpes Simplex • Contact Dermatitis Management or Treatment: • Provide simple analgesia if required • Dress weeping lesions

Advice: • Hydration • Rest • Paracetamol. Consult GP if pain poorly controlled by paracetamol. • Avoid NSAID use in children because of increased risk of severe skin infection • Wash hands after touching lesions.

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• Explain that only people who have not had chickenpox or the varicella vaccine can catch chickenpox from a person with shingles. • Avoid contact with people who have not had chickenpox, particularly pregnant women, immunocompromised people, and babies younger than 1 month of age. • Avoid sharing towels and clothes • Wear loose fitting clothes to reduce irritation. • Cover lesions that are not under clothes while the rash is still weeping. • Avoid use of topical creams and adhesive dressings as they can cause irritation and delay rash healing • Keep the rash clean and dry to prevent secondary bacterial skin infection. • Avoid work, school, day care if the rash is weeping and cannot be covered • The person will remain infectious until all the vesicles have crusted over (usually 5-7 days after onset of rash). • Seek medical attention if suspicion of secondary skin infection (e.g. cellulitis)

Medication Standing Order: • Paracetamol • Ibuprofen (adults only)

References : 1. Albrecht, MA (2018). Treatment of herpes zoster in the immunocompetent host. UpToDate. 2. Albrecht, MA & Levin, MJ (2019). Epidemiology, clinical manifestations, and diagnosis of herpes zoster. UpToDate. 3. Clinical Knowledge Summary ‘Shingles’ (2018). National Institute for Clinical Excellence. 4. eTG (2019). Shingles. 5. Le, P & Rothberg, M (2018). Herpes zoster infection. BMJ Best Practice.

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Acute Bacterial Rhinosinusitis – Clinical Treatment Protocol

Overview: Condition for treatment – Rhinosinusitis refers to inflammation of the nasal mucosa and the paranasal sinuses. Acute bacterial rhinosinusitis is usually a self-limiting condition and antibiotics make little difference to the course of the illness. Secondary bacterial infection occurs in less than 2% of patients. The nasal cavity and paranasal sinuses reach near-adult proportions by age 12 years, though development may not be complete until age 20 - sinus infections are less common in children.

Symptoms may include - • Sinus pain; • Muco-purulent nasal discharge; • Headache;

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• Tenderness over sinuses especially unilateral maxillary tenderness; • Pressure sensation when bending forward / trunk flexion, • Pyrexia • Tooth ache • Loss of smell

Inclusion criteria – • Acute rhinosinusitis which has been present for less than 4 weeks.

Redirect to GP/NP if: • Poly pharmacy, multiple co morbidities, • Allergy to penicillin • Already on antibiotics and not improving.

Redirect to ED if: • Any respiratory compromise • Systemically unwell with symptoms of spreading bacterial infection/ sepsis.

Differentials: • Allergic Rhinitis • Chronic Sinusitis • Migraine • Orbital Cellulitis • Pre septal /periorbital Cellulitis • Intracranial Abscess • Meningitis • Nasal foreign body • Dental pain

Management /Treatment Work-up • Check vital signs • Eye examination may be required additionally depending on symptoms

Treatment • Supportive therapy for the first 7-10 days: • Analgesia and antipyretics • Saline irrigation • Intranasal sprays, including decongestant or steroid nasal sprays

Antibiotic therapy should only be used to manage suspected bacterial sinusitis which should be suspected with the following: • severe symptoms (fever 39°C or higher plus purulent nasal discharge or facial pain) at the onset of illness that persist for 3 to 4 consecutive days, OR

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• worsening symptoms after initial improvement (‘double sickening’) or persistent symptoms without improvement for at least 7 to 10 days.

Advice: • Adequate comfort/rest. • Increased water intake. • Salt water nasal sprays or sucking menthol sweets may help to relieve the blocked nose. • Steam inhalation, such as in the shower, may help to relieve congestion - care should be taken to avoid burns. • Heat packs applied over forehead may help to relieve nasal pressure and congestion. • Review and reassessment of the diagnosis is required by GP if symptoms do not improve in 5 days, or earlier if symptoms worsen.

Medication Standing Order: • Paracetamol • Ibuprofen • Amoxicillin

References : 1. Australian Medicine Handbook. (2019). Anti-infectives: Amoxycillin. Retrieved from: https://amhonline.amh.net.au/chapters/chap-05/antibacterials- 01/penicillins/amoxycillin 2. British Medical Journal. (2017). Acute sinusitis. Best Practice. Retrieved from: http://bestpractice.bmj.com/best-practice/monograph/14.html 3. Patel, Z.M. & Hwang, P.H. (2017). Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment. In D.G. Deschler, S.B. Calderwood & S. Bondi (Eds). UpToDate. Retrieved from: https://www.uptodate.com/contents/uncomplicated-acute-sinusitis- and-rhinosinusitis-in-adults- treatment?source=search_result&search=sinusitis&selectedTitle=1~150 4. Therapeutic Guidelines. (2019). Ear, nose and throat infections. Retrieved from: https://tgldcdp.tg.org.au/viewTopic?topicfile=ear-nose-throat-infections#toc_d1e888

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Sore Throat (Pharyngitis)/Bacterial Strep Throat/Tonsillitis – Clinical Treatment Protocol

Overview: Condition for treatment: Acute pharyngitis is characterised by the rapid onset of a sore throat and pharyngeal inflammation (with or without exudate). Absence of cough, nasal congestion and nasal discharge distinguishes bacterial from viral aetiologies. It can be caused by a variety of viral and bacterial pathogens, including Group A Streptococcus (GAS), as well as fungal pathogens (Candida). Bacterial pharyngitis is more common in

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winter (or early spring), while enteroviral infection is more common in the summer and autumn. This is generally a self-limiting condition with resolution within 2 weeks.

Symptoms may include: • Sore throat, dryness, itching • Pain on swallowing • Tonsils swelling • Fever • Neck pain

Inclusion criteria: • Pharyngitis or tonsillitis

Redirect to GP/NP if: • Liver or splenic tenderness • Rash • Candida infection • Recurrent infection • Multiple co-morbidities • Suspected gonorrhoea or chlamydia infection

Redirect to ED if: • Unable to swallow water, drooling, vomiting, rigors, tachycardia, dehydration • Airway compromised due to swelling • Suspected retropharyngeal, peritonsillar or lateral abscess • Suspected epiglottitis

Differentials: • Epiglottitis • Peritonsillar abscess • Infectious mononucleosis • Kawasaki disease • Hand-foot-and-mouth disease

Management or Treatment: Work-up: • Take temperature and assess for lymphadenopathy • Examine the throat for exudate and tonsillar swelling • An abdominal examination should be conducted to examine for splenic tenderness in conjunction with pharyngitis

Treatment: • As there is no treatment for a viral sore throat (pharyngitis), symptom management should be the focus.

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• Where bacterial strep throat/tonsillitis is suspected, antibiotic therapy may be indicated. Traditional clinical features including fever (above 38°C), tender cervical lymphadenopathy, tonsillar exudate, and absence of cough, rhinorrhoea or nasal congestion have poor predictive value for streptococcal infection.

Antibiotic treatment is indicated for high risk groups to prevent non suppurative complications: • patients aged 2 to 25 years from populations with a high incidence of acute rheumatic fever (e.g. Aboriginal and Torres Strait Islander Australians, Maori and Pacific Islander people) • patients of any age with existing rheumatic heart disease • patients with scarlet fever • they may also be indicated for patients with severe symptoms (see Redirect to ED section)

Advice: • While the symptoms of a sore throat are unpleasant, the illness usually resolves spontaneously in a few days and complications rarely occur. • An increased fluid intake and the consumption of nutritious soft food with increased rest, may reduce symptom severity. • Gargling with salt water or sucking lozenges and/or ice to suck may help to relieve sore throat. • Persons that have had tonsillitis diagnosed 3 or more times in one year should be referred to their GP. • Client with a sore throat and a rash or splenic tenderness should be redirected to GP/NP. • Client Information Sheet – Sore Throat.

Medication Standing Order: • Paracetamol • Ibuprofen • Phenoxymethylpenicillin- first line • Cephalexin - second line if non-immediate penicillin allergy

References : 1. British Medical Journal Best Practice. (2018). Retrieved from https://newbp.bmj.com/search?q=sore+throat 2. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Sore throat – acute. 3. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/ 4. UpToDate. (2019). Retrieved from: https://www.uptodate.com

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Spider Bite – Clinical Treatment Protocol

Overview: Condition for treatment - In Australia, there are only 3 insects with venom that is capable of systemic envenomation that may cause death – the Funnel-Web spider, the Red Back spider and the Paralysis Tick. The greatest concern from any bite or sting is the risk of allergic reaction leading to anaphylaxis and post-bite infection. Many skin lesions and effects are blamed on spider bites which are unverified.

Symptoms May Include: • Redback: pain (can radiate to draining lymph nodes, proximal limb, abdomen, chest or back); sweating (can be local to bite or regional); nausea, vomiting, headache; malaise, lethargy; local piloerection and erythema; hypertension; irritability and agitation; fever, paraesthesia or patchy paralysis, muscle spasms, priapism • Funnel-web: diaphoresis, hypersalivation, lacrimation, piloerection, hypertension, bradycardia or tachycardia, and miosis or mydriasis; paraesthesia (local, distal and oral), fasciculations (local or generalised, commonly tongue fasciculations) and muscle spasms; abdominal pain, nausea, vomiting and headache; pulmonary oedema and, less commonly, myocardial injury; agitation, anxiety and, less commonly, drowsiness or coma. • All other Australian spiders: minor, self-limiting effects e.g. local pain, swelling, erythema, itch

Inclusion criteria - • Client with suspected or confirmed spider bite • If possible, identify type of spider via an online chart and document • No local or systemic signs of envenoming as listed above

Redirect to GP/NP if: • Signs of infection but no signs of envenomation

Redirect to ED if: • Offending spider confirmed or strongly suspected to be funnel-web or redback and bite is <6/24 old • Symptoms suggestive of either funnel-web or redback envenomation (see symptoms above)

Differentials: • Consider other causes of local skin lesions and reactions, such as infections, bites and stings of other arthropods, and several other more common skin conditions.

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Management / Treatment: Work-up • Vital signs • Check for signs of infection

Treatment • For suspected or confirmed funnel-web spider bite presenting <6/24 post bite, apply pressure bandage, immobilise the affected area and keep the affected limb down • For suspected or confirmed redback spider bites, apply cold pack to bite area and elevate affected part of the body (if appropriate). DO NOT apply pressure bandage. • ACTAS to be called for systemically unwell patients and those who have been bitten within the last 6/24 by a suspected/confirmed funnel-web spider. • For all asymptomatic patients with confirmed or suspected spider bites presenting >6/24 post bite, they can be provided with reassurance that serious envenomation is highly improbable. They are able to return home with advice to present to ED if they develop any symptoms. • If Anaphylaxis – see Anaphylaxis Treatment Protocol. • If localised allergic reaction, continue with urticaria protocol. • Clean skin and apply dressing • ADT if not up to date (do not delay transfer to hospital to administer ADT).

Advice: • Most local reactions to spider bites resolve spontaneously in approximately 7 to 10 days • Do not scratch the area as it may become infected. • Necrotising wounds secondary to spider bites in Australia are rare. • Simple analgesia • Antihistamine

Medication Standing Order: • Paracetamol • Ibuprofen • ADT • Antihistamine e.g. Loratadine, if not effective consider promethazine

References : 1. Braitberg, G & Segal, L (2009). Spider bites: Assessment and management. Australian Family Physician, 38 (11), pp 862-67. 2. http://www.toxinology.com/index.cfm 3. https://www.healthdirect.gov.au/spider-bites 4. https://www.uptodate.com/contents/approach-to-the-Client-with-a-suspected- spider-bite-an-overview

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Stye (Hordeola) – Clinical Treatment Protocol

Overview: Condition for treatment: A stye is an acute, localised abscess situated on the eyelid. An external stye is situated on the eyelid margin and is caused by infection of an eyelash follicle. An internal stye occurs on the conjunctival surface of the eyelid and represents an infection of a meibomian gland.

Symptoms may include: • Eyelid redness and swelling • Eyelid pain • Pustule on eyelid margin or tarsal conjunctiva

Inclusion criteria: • Uncomplicated stye

Contact Ophthalmology Registrar if: • Moderate to severely painful external stye – for consideration of epilating the eyelash from the infected follicle or incising and draining • Stye is persistent and not responsive to conservative treatment • Stye has an atypical appearance or recurs in the same location • Protrusion of eyeball (proptosis) • Double vision or impairment of eye movement • Reduced visual acuity • Reduced light reflexes • Presence of peri-orbital (preseptal)/orbital (postseptal) cellulitis • When a full eye examination is not possible

Redirect to GP for: • Treatment of any underlying condition such as blepharitis, trichiasis, ectropion or rosacea which may predispose individual to developing stye

Redirect to ED if: • Client is systemically unwell • Central nervous system symptoms such as drowsiness, vomiting, headache, seizure, or cranial nerve lesion

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Differentials: • Meibomian cyst • Herpes zoster/simplex • Contact dermatitis • Orbital (postseptal) cellulitis • Atopic eczema • Peri-orbital (preseptal) cellulitis • Blepharitis • BCC/SCC • Dacryocystitis • Rosacea • Sebaceous cell carcinoma • Melanoma Management / Treatment: Work-up • Visual acuity should be assessed on all clients presenting with an eye complaint (a stye should not affect visual acuity). • If indicated by eye pain, the cornea should be examined for abrasions using fluorescein. • Evert the upper eyelid if history suggests a foreign body or stye appears to be internal.

Treatment • Apply a warm compress to the affected eye for 5-10 minutes. Repeat 3-4 times daily until the stye drains or resolves. Clean flannel rinsed in hot water can be used. Avoid excessively hot compresses which may cause scalding. • Assuming the eye is normal and the abscess pointing, gentle expression with cotton buds may be attempted after instilling tetracaine (amethocaine).

Advice: • Reassure client that stye is self-limiting and rarely cause serious complications. Drainage and resolution tends to occur within 5-7 days. • Do not attempt to puncture the stye (can precipitate peri-orbital [preseptal] cellulitis). • Client to see GP about managing stye risk factors (as listed above under ‘Redirect to GP’) • Suggest paracetamol or ibuprofen to relieve pain if required. • If symptoms become worse or stye does not resolve within the expected timeframe, client to see a GP. • Explain that infection can spread from eyelid margin causing conjunctivitis. • Occasionally an internal stye can develop into a meibomian cyst. • Avoid using contact lenses and eye make-up until the stye has healed. • Topical antibiotics are not recommended. • Client Information Sheet – Stye

Medication Standing Order: • Paracetamol • Ibuprofen • Tetracaine (amethocaine)

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References: 1. Gosh, C. & Ghosh, T. (2019). Eyelid lesions. UpToDate. 2. eTG (2019). Chalazion (meibomian cyst) and hordeolum (stye). 3. National Institute for Health and Care Excellence: Clinical Knowledge Summaries (2015). Styes (hordeola).

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Subconjunctival Haemorrhage – Clinical Treatment Protocol

Overview: Condition for treatment: Bleeding beneath the conjunctiva which may have no known cause, or may be caused by minor trauma (e.g. coughing).

Symptoms may include: • Flat, bright red patch anywhere in the conjunctiva with sharply defined edges and relatively normal conjunctiva surrounding it • Usually no pain or vision loss but mild irritation may be present

Inclusion criteria: • Age ≥ 6

Redirect to GP/NP if: • Hypertensive (systolic >140mmHg or diastolic >90mmHg), • Client taking anti-coagulants • Age < 6 • Eye discharge present • Eyelid swelling

Redirect to ED if: • Pupils are not equal • Presence of severe eye pain • Foreign body/trauma penetrating eye • Haemorrhage present bilaterally • Hyphema • Presence of severe photophobia in affected eye • Protrusion of eyeball/ proptosis • Double vision or impairment of eye movement • Reduced visual acuity by 2 lines • Reduced light reflexes • Presence of orbital (postseptal)/orbital cellulitis • When a full eye examination is not possible • Client is systemically unwell

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• Central nervous system symptoms, e.g. drowsiness, vomiting, headache, seizure, or cranial nerve lesion

Redirect Client to GP/ED as clinically indicated. Community Optometrist may be an option.

Differentials: • Hyphema • Infective/allergic conjunctivitis • Scleral laceration • Single red eye – beware acute glaucoma/keratitis/iritis/uveitis

Management / Treatment: Work-up • Visual acuity should be assessed on all clients presenting with an eye complaint. • If indicated by eye pain the cornea should be examined for abrasions using fluorescein. • If history of foreign body, evert the upper eyelid and examine for abnormalities. • Measure and record blood pressure. • Ascertain whether the client is on anti-coagulant medication. • The haemorrhaged region should be unilateral, localized, and sharply circumscribed. It should not cross the limbus. Underlying sclera should not be visible.

Treatment • The diagnosis is confirmed by normal acuity and the absence of discharge, photophobia, pain or foreign body sensation. • Generally, no treatment is required. Lubricating eye drops may improve comfort, although pain is generally absent. • Discourage elective use of aspirin products or NSAIDs.

Advice: • Reassure the client that subconjunctival haemorrhages are self-limiting and not associated with bleeding within the eyeball. • Non-traumatic haemorrhages resolve over a period of 2-3 weeks. • They may occur spontaneously or may follow minor eye trauma even rubbing or Valsalva effect such as coughing, sneezing, vomiting or straining/lifting. Rarely, they may be associated with high blood pressure or from being over-anticoagulated. • If complication of contact lens use is likely, avoid using contacts until condition has resolved and consider cutting long nails, disposing of current set of lenses and reviewing insertion/removal technique. • Client Information Sheet – Subconjunctival Haemorrhage

Medication Standing Order: • Carmellose 0.5%

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References : 1. Cronau, H., Kankanala, R. R., & Mauger, T. (2010). Diagnosis and management of red eye in primary care. American Family Physician, 81(2), 137-44. 2. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2016). Red eye. 3. Tarlan, B., & Kiratli, H. (2013). Subconjunctival haemorrhage: risk factors and potential indicators. Clinical ophthalmology, 2013(7), 1163-1170. doi: https://doi.org/10.2147/OPTH.S35062 4. UpToDate. (2019). Retrieved from https://www.uptodate.com/

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Subungual Haematoma – Clinical Treatment Protocol

Overview: Condition for treatment: Subungual haematoma refers to blood that is trapped under the nail after trauma. Subungual haematomas may be simple (i.e. the nail and nail fold are intact) or accompanied by significant injuries to the nail fold and digit (e.g. fingertip avulsion or fracture). Subungual haematoma drainage, also known as nail bed trephination, can be performed to relieve this discomfort. Trephination of subungual hematomas are performed when acute (less than 24 to 48 hours old), are not spontaneously draining and are associated with intact nail folds, and pain. After 48 hours, most subungual hematomas have clotted and trephination is typically not effective.

Symptoms may include: • Blood between nail bed and nail plate • There may be associated distal phalanx pain/redness/bruising/swelling

Inclusion criteria: • Presence of a painful haematoma presenting as a deep blue/black discolouration underneath the nail bed • Causative traumatic injury <48 hours prior to presentation • Motor, neurological and vascular function assessed and found to be intact • No deformity or signs of tendon injury • Concern re fracture/dislocation of distal interphalangeal joint (DIP) – redirect for nurse-initiated x-ray prior to trephination

Redirect to GP/NP if: • Signs of infection are present • Increased risk of infection due to co-morbidities e.g. diabetes mellitus

Redirect to ED if: • Positive signs of neurovascular impairment

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• Positive signs of extensor tendon avulsion • Significant secondary deformity to finger or nail structure

Differentials • Onychomycosis • Melanonychia Striata • Subungual exostosis • Splinter haemorrhages • Benign and malignant tumours

Treatment • Evaluate for possible extensor tendon avulsion (mallet finger) by having client fully extend the DIP joint. • X-ray suggested for all patients with large subungual hematomas that occupy >50 percent of the nail plate because associated fractures are common with these injuries. If fracture present, do not perform trephination - contact CHHS Plastics Registrar for direction. • If there are no redirection triggers and fracture has been excluded, trephination can be performed using a bevelled needle. Care is required as this procedure carries the risk of injuring the nail bed with the point of the needle.

Procedure of boring a hole through the nail plate using a bevelled needle • Clean the nail with antiseptic. • Apply gentle downward pressure on the nail plate with an 18gauge (or smaller gauge in children) needle. Rotate the needle back and forth over the central part of the haematoma until blood seeps from the hole. Avoid drilling down directly over the lunula as it may cause damage to the nail matrix. • When resistance from the nail gives way, stop further downward pressure to avoid damaging underlying nail bed. The client will experience immediate relief. • Clean away blood with sterile gauze. Apply band aid.

Advice • Keep the trephined area covered with a band aid for at least 48 hours as oozing of blood from the trephined nail may continue for between 24-48 hours • Instruct the patient and family to keep the affected digit clean and dry. There is no need to soak the affected digit because this treatment may lead to fibrin clot breakdown and allow the introduction of bacteria into a previously sterile space • Return to WIC for review if suspected reaccumulation of haematoma as evidenced by return of pain within 48 hrs of initial treatment. • Present to GP if signs of infection i.e. increasing pain, warmth, redness, excessive swelling, fever • The nail does not need to be removed. Inform the client that he/she may eventually lose the fingernail and a new nail will grow out in 3-6 months.

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Medication Standing Order • Paracetamol • Ibuprofen

References 1. Bonisteel, P.S. (2008). Practice tips. Trephining subungual hematomas. Canadian Family Physician; 54: 693. 2. Cohen, P. R., Schulze, K. E., & Nelson, B. R. (2007). Subungual hematoma. Dermatology Nursing, 19(1), 83. 3. Daoud, A. and Zaiac, M. (2019), Common nail procedures, Nail Disorders, 139-146. Elsevier. 4. Fastle, R. K. & Bothner, J. (2018). Subungual Hematoma. In A. M. Stack, A. B. Wolfson, J.F. Wiley (Eds.). UpToDate. 5. Mayorga, O., & Wall, S. P. (2017). Subungual Hematoma Drainage. In E. D. Schraga & M. L. Windle (Eds.) Medscape. 6. Patel, L (2014), Management of simple nail bed lacerations and subungual haematomas in the emergency department. Pediatric Emergency Care, 30(10), 742- 745.

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Suture/Staple Removal – Clinical Treatment Protocol

Overview: Condition for Treatment: Removal of sutures or staples Symptoms may include: • Occasional mild redness +/- crusting around staple/suture insertion sites

Inclusion criteria: • Removal of sutures on uncomplicated wounds

Redirect to GP/NP if: • Signs of infection • Complex post-surgical wounds • Eyelid sutures • Sutures not ready for removal • Soluble sutures

Redirect to ED if: • Systemically unwell

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Differentials: • N/A

Management or Treatment: • The timing of suture removal varies depending on the part of the anatomy that has been sutured. o Eyelids: 3 days o Face: 2 - 3 days (child); 4 - 5 days (adult) o Neck: 3 - 4 days o Scalp: 7 -14 days o Trunk and upper extremities: 7 days o Lower extremities: 8 - 10 days

Advice: • After the stitches or staples are removed, the client should be advised to protect the scar from the sun. • Advise the client to use sunscreen on the area or wear clothes or a hat that covers the scar for up to a year.

Medication Standing Order: • N/A

References: 1. deLemons, D. (2019). Closure of minor skin wounds with sutures. UpToDate. Retrieved from https://www.uptodate.com/contents/closure-of-minor-skin-wounds-with- sutures#H39 2. Selbst, S.M. & Attia, M.W. (2006). Minor trauma - lacerations. Textbook of Pediatric Emergency Medicine (5th edition), Lippincott Williams and Wilkins: Philadelphia.

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Uncomplicated Cellulitis – Clinical Treatment Protocol

Overview: Condition for treatment: Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue. Oral antibiotic therapy is adequate when the person with cellulitis has no systemic signs or symptoms of infection and has no uncontrolled co-morbidity that may complicate treatment. Dental cellulitis is covered under Dental Abscess CTP. S. pyogenes, or another Streptococcus species (e.g. group B, C or G), is the most common cause of nonpurulent, recurrent cellulitis (e.g. associated with lymphoedema) or spontaneous, rapidly spreading cellulitis. Routine skin swabs are not necessary for non-purulent cellulitis.

Symptoms may include: • Acute onset of red, painful, hot, swollen, and tender skin • Fever, malaise, nausea, and rigors may accompany or precede the skin changes Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 163 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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• Unilateral presentation- cellulitis of both limbs is less common

Inclusion criteria: • Age ≥ 12 • Weight ≥ 40kg

Redirect to GP/NP if: • Client has an immediate hypersensitivity to penicillins • Presence of lymphoedema, leg oedema, venous insufficiency • Blistered skin/exudating wound, venous ulceration • Infected traumatic wounds, existing fungal infection • Client is pregnant • Age <12 years, weight < 40 kg • Multimorbidity i.e. presence of two or more chronic conditions • Polypharmacy i.e. the use of 4 or more regular medications • Cellulitis is recurrent i.e. more than two episodes at the same site within 1 year • Cellulitis simultaneously in two or more separate locations • Cellulitis is associated with fresh or saltwater exposure • Presence of peri-orbital cellulitis with no eyeball pain, pain with eye movement or visual disturbance • Presence of mild facial cellulitis, perichondritis of pinna • Cellulitis which is persistent i.e. not responsive to first course of oral antibiotics or client is systemically well but has one or more co-morbidities that may complicate or delay the resolution of cellulitis, e.g. chronic venous insufficiency, peripheral vascular disease, morbid obesity, diabetes mellitus – GP/NP can contact the TCH/ Calvary HITH Registrar who can arrange for admission and intravenous antibiotic administration in the community (referral process covered on GP Healthnet).

Redirect to ED if: • Client is systemically unwell: tachycardic, tachypnoeic, hypotensive, vomiting, ≥ 38⁰C temperature, or is confused • Circumferential cellulitis or threat to limb due to vascular compromise • Presence of severe (extensive) cellulitis; myositis, fasciitis or osteomyelitis • Risk factors for rapid progression of infection (such as poorly controlled diabetes or significant immune compromise) • Suspected collection or abscess requiring surgical drainage • Presence of orbital cellulitis with eye pain, pain with eye movement and visual disturbance.

Differentials: • Large local reaction • Acute gout • Thrombophlebitis • Deep vein thrombosis

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• Stasis dermatitis/eczema/vasculitis • Acute contact dermatitis • Septic arthritis/bursitis • Lipodermatosclerosis • Erythema nodosum • Pyoderma gangrenosum

Management or Treatment: Workup • Take vital signs and assess for tracking and lymphadenopathy. • Examine for tinea/intertrigo/maceration and advise on treatment if necessary. • For future comparison, draw around the extent of the erythema with a marker pen. • Do not perform routine swabs from intact skin.

Treatment • Antibiotic therapy is indicated for the treatment of cellulitis. • Dressing maybe required so refer to wound dressing WIC CTP. • Paracetamol/ibuprofen as necessary for pain. • Consider ADT status and vaccinate if appropriate.

Advice: • If systemic signs develop or the condition deteriorates despite treatment (i.e. fever, vomiting, rigors) client should present to ED. • There may be an increase in redness in the first 24-48 hours of treatment. • Paracetamol and/or ibuprofen for pain management. • Follow up with GP after completing after 48 hrs of antibiotic treatment, or earlier if deterioration in condition. • Elevate the limb for comfort (if applicable). • Drink adequate fluids to prevent dehydration. • Avoid compression garments during acute phase. • Client Information Sheet – Uncomplicated Cellulitis

Medication Standing Order: • Paracetamol • Ibuprofen • Phenoxymethylpenicillin first line • Cephalexin second line for non-immediate penicillin allergy • ADT

References : 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2016). Cellulitis – acute. 3. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/

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4. UpToDate. (2019). Retrieved from: www.uptodate.com.au

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Varicella (Chickenpox) – Clinical Treatment Protocol

Overview: Condition for treatment: Varicella (chickenpox) is a highly contagious childhood exanthem caused by the varicella zoster virus. It is usually self-limiting however complications can be life threatening.

Symptoms may include: • Prodromal period of fever, malaise, sore throat, loss of appetite. • Diffuse, itchy rash which starts as macules, then evolves into papules and eventually vesicles and possibly pustules. Some lesions may be crusted over. • In vaccinated children, the symptoms are generally milder (i.e. less fever and fewer lesions) and the rash is more likely to be atypical (e.g. maculopapular)

Inclusion criteria: • Children ≥ 2 years with uncomplicated varicella.

Redirect to GP/NP if: • Pregnant women • Immunocompetent nonpregnant adults – GP/NP may consider treatment if it can be started within 36 hours of the onset of rash • Immunocompromised clients • Children with significant pre-existing skin disease (e.g. eczema) • Unvaccinated adolescents and adults • Persons with severe disease

Redirect to ED if: • Client presents with a complicated varicella infection and is showing signs of respiratory distress or dehydration.

Varicella is a reportable infection. Staff need to complete a REPORT OF NOTIFIABLE CONDITION OR RELATED DEATH FORM and send to Communicable Disease Control via fax, email or internal mail.

Differentials: • Herpes Zoster infection (shingles) • Herpes simplex virus infection • Hand, foot and mouth disease • Impetigo • Scabies

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• Stevens-Johnson syndrome/toxic epidermal necrolysis • Monkeypox (Recent travel to Africa or recent exposure to exotic pets)

Management or Treatment: • Antiviral treatment is recommended for pregnant women and children with severe eczema. It can be started within 72 hours of the onset of rash – refer to GP. • Hydration is important, particularly in toddlers and children with fever. • Calamine lotion and antihistamines may provide some relief from itching, however supporting evidence is limited and some experts suggest that calamine lotion can dry the skin and therefore increase the intensity of itch.

Advice: • Varicella is infectious from 1–2 days before the rash appears until the vesicles are dry or have crusted over. Affected persons should remain absent from school/work until all the lesions have crusted over (usually about 5 days after the onset of the rash). • Transmission is by personal contact or droplet spread, with an incubation period of 1–3 weeks • Close contacts from 48 hours prior to the onset of rash should be notified as they may have been exposed to the virus. This is especially important with contacts who are pregnant, neonates or immunocompromised as they are at higher risk of severe disease and complications. • Itch may be exacerbated by dry skin so use emollients and soap-free cleansers • Itch may be exacerbated by heat exposure so wear light clothing and avoid hot baths and showers. • Don’t scratch - fingernails should be cut short to help avoid excoriation from scratching and secondary bacterial infection - use mittens/gloves in young children. • Paracetamol may be used to treat fever. • Salicylates should be avoided. Aspirin has been associated with the onset of Reye’s syndrome in the presence of viral infection. • NSAIDs should be avoided in children due to possible increased risk of group A streptococcal (GAS) superinfection • Once the infection has subsided, the virus persists in sensory nerve root ganglia. Years or decades later, it can reactivate and cause herpes zoster (shingles) • It is possible to develop chickenpox after exposure to a person with shingles, but it is not possible to develop shingles from exposure to a person with chickenpox

Medication Standing Order: • Paracetamol • Loratadine • Promethazine

References: 1. Albrecht, MA (2019). Clinical features of varicella-zoster virus infection: Chickenpox. UpToDate.

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2. Albrecht, M. (2019). Treatment of varicella (chickenpox) infection. UpToDate. 3. British Medical Journal Best Practice. (2019). Acute varicella Zoster. 4. eTG (2019). Chickenpox. 5. Fazio, S. & Yosipovitch, G. (2019). Pruritus: Overview of management. UpToDate. 6. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2018). Chickenpox.

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Viral Gastroenteritis - Vomiting - Clinical Treatment Protocol

Overview: Condition for treatment - Viral gastroenteritis is a stomach and intestinal infection that affects both adults and children. Clients can suffer either diarrhoea or vomiting, or both. Other symptoms may include fever, headache, muscle aches, abdominal pain/cramping and a loss of appetite.

Symptoms may include: • There may be associated diarrhoea, cramping abdominal pain and fever • Signs of dehydration are covered below

Inclusion criteria: • Age ≥ 2 years with mild to moderate dehydration • Mild dehydration – have no clinical signs but increased thirst • Moderate dehydration – o Children: delayed central capillary refill time (CRT) >2 seconds; increased respiratory rate; mild decrease in tissue turgor (tissue rebound <2 seconds) o Adults: mild lethargy; increased thirst; easily fatigued; reduced urine output; mild dizziness; decreased skin turgor; dry mucous membranes; headache

Redirect to GP if: • If persistent vomiting beyond 1-2/7 with no signs of severe dehydration • If recent antibiotic use (rule out Clostridioides difficile)

Redirect to ED if: • Persistent diarrhoea and/or vomiting and signs of severe dehydration o Severe dehydration . Children: central CRT >3 seconds/mottled skin; signs of shock (e.g. tachycardia; irritability; reduced LOC; hypotension); deep acidotic breathing; decreased tissue turgor; tears absent when crying . Adults: tachycardia/postural tachycardia (increase of >15bpm moving from supine to standing); orthostatic hypotension (a drop of >20mmHg in systolic B/P moving from supine to standing); postural dizziness; lethargy/confusion; may develop abdominal pain and/or chest pain Doc Number Version Issued Review Date Area Responsible Page CHHS18/112 1 16/03/2018 01/04/2020 CAS 168 of 177 Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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• Blood in vomitus, bloody diarrhoea, or severe abdominal pain • Moderately dehydrated, not tolerating fluids and at high risk of developing signs of severe dehydration • Has not needed to void in the past 6-8 hours (during the day, or a young child has not had a wet nappy for 4-6 hours) with dehydration status trending towards severe

Differentials: • Bacterial gastroenteritis • Protozoal infections • Food poisoning • Volvulus • Appendicitis • Non-gastrointestinal infection e.g. UTI, pneumonia, otitis media • Endocrine disorder e.g. diabetes mellitus, Addison’s

Management or Treatment: • Primary management of acute vomiting is based on oral rehydration. • Anti-emetic medications (Metoclopramide) are recommended only with intractable vomiting in client’s ≥20 years of age. • Analgesia may be of benefit to reduce the symptoms of abdominal pain associated with vomiting.

Advice: • Oral rehydration therapy (with Hydralyte/Gastrolyte) is the first line treatment • Increase fluid intake • For children, aim for 5-15ml/kg of oral rehydration solution every hour for up to 4 hours.Give small amounts of fluid often • Avoid diuretic-type drinks e.g. coffee • In young children with concomitant diarrhoea, soft drinks, fruit juices and other sugary drinks including sports drinks are not recommended due to their high osmolarity which can worsen diarrhoea • Age appropriate bland diet if appetite has returned • Inform the client to present to ED if they continue vomiting and their general condition deteriorates e.g. increased lethargy; not voiding for several hours etc • Avoid foods high in fat and sugar • Regular and thorough hand washing is encouraged to reduce the risk of spreading the infection

Children should be excluded from attending childcare/school and adults working with vulnerable population groups or within the food industry should be excluded from work until they have been symptom free for at least 48 hours.

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Medication Standing Order: • Metoclopramide • Paracetamol

References: 1. Brown, KE (2017). Viral Gastroenteritis. BMJ Best Practice 2. eTG (2018). Supportive management of acute gastroenteritis. 3. Haque, SK & Batlle, D (2018). Volume Depletion in Adults. BMJ Best Practice 4. Mason, K & Carter, MR (2018). Volume depletion in children. BMJ Best Practice. 5. National Institute for Health and Care Excellence: Clinical Knowledge Summaries. (2019). Gastroenteritis. 6. Sterns, R. (2019). Etiology, clinical manifestations, and diagnosis of volume depletion in adults. UpToDate. 7. The Royal Children’s Hospital Melbourne: Clinical Practice Guidelines (n.d.). Dehydration. 8. The Royal Children’s Hospital Melbourne: Clinical Practice Guidelines (2015). Gastroenteritis. 9. The Sydney Children’s Hospitals Network (2017). Gastroenteritis fact sheet.

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Vulvovaginal Candidiasis – Clinical Treatment Protocol

Overview: Condition for treatment – Vulvovaginal Candidiasis (also known as thrush) is very common (80% of women will experience an episode of thrush), and is due to an overgrowth of the normal yeast found in the GI tract and vagina known as Candida Albicans.

Symptoms may include: • vaginal discomfort i.e. itching/burning • white vaginal discharge, • redness and/or swelling of the vagina or vulva • stinging and/or burning when urinating or during sex • splits in the genital skin

Inclusion criteria: • Clients presenting with candidiasis-like symptoms (vaginal discomfort i.e. itching/burning, white vaginal discharge, redness and/or swelling of the vagina or vulva, stinging and/or burning when urinating or during sex, splits in the genital skin) • Pregnancy should be ruled out prior to the management of vulvovaginal candidiasis • The possibility of coexisting sexually transmitted infections should be ruled out prior to the management of vulvovaginal candidiasis. Thrush is not an STI.

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• A thorough history should be obtained from the Client to identify recurrent or complicated thrush, constant symptoms or more than 4 episodes per year.

Redirect to GP/NP or CSHC if: • Recurrent (four or more acute episodes per year) or complicated episodes of thrush • Malodorous vaginal discharge • Presence of genital warts/lesions or sores or suspected STI • Clients with complicated vulvovaginal candidiasis i.e. those who are immunosuppressed or have diabetes should be managed by a GP/NP • Client is pregnant • Post-menopausal women who are on Hormone Replacement Therapy (HRT) • Severe genital discomfort

Redirect to ED if: • Client is hemodynamically unstable • Urinary retention with or without abdominal pain

Differentials: • STI – Herpes Simplex Virus (HSV), Trichomoniasis • Bacterial Vaginosis • Cystitis • Vulvovaginal dermatitis or psoriasis • Vaginal foreign body

Management or Treatment: • Discuss treatment with Imidazoles. These are available over the counter at Pharmacies. • Refer to GP or CSHC • It is recommended in Therapeutic Guidelines that: Before starting treatment, take a swab to confirm the diagnosis and determine the species of Candida. A swab taken after antifungal treatment may be falsely negative for some time, even though the patient still has symptoms. When a patient has already used an over-the-counter treatment, this complicates assessment in primary care.

Advice: • Some intravaginal preparations for the management of vulvovaginal candidiasis may cause irritation. • The client should minimise their exposure to non pH-balanced soap products, both personal and laundry types. • Perfumes should not be used in the perineal area. • Females should be advised to wipe from front to back to prevent faecal contamination of the vagina. • Antibiotic therapy is a common cause of thrush and women undergoing a course of antibiotics should be encouraged to take a pro-biotic supplement.

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• Client Information Sheet – Vaginal Thrush

Medication Standing Order: • Paracetamol • Ibuprofen

References : 1. Australian Medicines Handbook. (2019). Retrieved from https://amhonline.amh.net.au/ 2. National Health Service Institute for Innovation and Improvement: Clinical Knowledge Summaries. (2017). Candida – female genital. 3. Therapeutic Guidelines. (2019). Candida Vulvovaginitis in women. Retrieved from https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Dermatology&to picfile=anogenital-skin- conditions&guidelineName=Dermatology§ionId=toc_d1e247#toc_d1e247

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Wound Dressing – Clinical Treatment Protocol

Overview: Condition for treatment - A breakdown in the connective function of the skin, caused by either surgery, a blow, a cut, chemicals, heat/cold, pressure, shear injuries, a result of disease, leg ulcers or carcinomas. They can be classified as either chronic or acute. The aim of wound care is to achieve healing without infection, scaring or deformity.

Symptoms may include: • Pain • Bleeding • Skin or tissue loss • Exudate • Change to function and/or sensation

Inclusion criteria: • Wounds that are new, have been dressed elsewhere and have no arranged follow up • Wounds that are due for a dressing change in the absence of complications or infection

Redirect to GP/NP if: • Wound is infected and/or symptomatic of infection, e.g. febrile, redness, swelling, exudate • Sutures in post-operative wounds with complications • Heavily soiled wounds

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Redirect to ED if: • Any neurovascular compromise/uncontrolled bleeding • Can visualise or are suspicious of any injury to tendon, ligament or deeper structure • Concern about wound to hand or face • Concerned about ability to close wound with good cosmetic outcome • Immunocompromised client, systemically unwell with wound and/or infection • Open fractures, exposed tendons, bones, muscles

Differentials: • Acute or chronic • Laceration • Burn • Bite – human/animal • Surgical • Cellulitis • Inflammatory conditions

Management or Treatment: • Take client’s history and confirm appropriateness of WIC dressing change. • Explain procedure to client. • Obtain verbal consent, make documentation of consent. • Assemble equipment, using universal precautions. • Remove old dressing, assess wound, cleanse with N/Saline. If there is a lot of dirt, grass or contamination, running tap water is very effective. Apply appropriate clean dressing. Superficial grazes & cuts to clean dry areas of the body may be left open to the air. • Document condition of wound and procedure in client’s notes. • Consider documenting wound status by client, keeping photo record on own smart phone. • Discuss management strategies for wound prevention/minimisation where appropriate, for example application of emollient to skin twice daily reduces risk of skin tears by 50%.

Advice: • Give appropriate wound care advice/ wound information sheet. • Arrange follow up with Community Nursing (CHI – 6207 9977), My Aged Care, GP Nurse. • Client Information Sheet – Wound Dressing

Medication Standing Order: • Consider ADT immunisation if appropriate. • Consider oral paracetamol if appropriate.

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Reference: 1. Armstrong, D. & Meyr, A. (2019). Basic principles of wound management. UpToDate. Retrieved from https://www.uptodate.com/contents/basic-principles-of-wound- management?search=wound%20management&source=search_result&selectedTitle=1 ~150&usage_type=default&display_rank=1 2. CliniMed. (n.d.). What is a wound? Retrieved from https://www.clinimed.co.uk/wound-care/wound-essentials/what-is-a-wound 3. Primary Clinical Care Manual (10th edition). (2019). Acute wound. RFDS/QLD Government. 4. Therapeutic Guidelines. (2019). Retrieved from https://tgldcdp.tg.org.au/ 5. Wound Care Australia. (2019).

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Wrist Injury – Clinical Treatment Protocol

Overview: Condition for treatment: Acute management of an uncomplicated wrist injury, pain or other symptoms. Three quarters of wrist injuries are fractures of the distal radius and ulna. The eight carpal bones are injured less frequently. Accurate diagnosis and correct treatment help to prevent long-term loss of function.

Symptoms may include: • Wrist pain • Wrist swelling, bruising or redness • Wrist joint stiffness

Inclusion criteria: Wrist sprain: • Presenting complaint of wrist pain • Tenderness over the soft tissue aspects of the wrist on palpation

Scaphoid injury: • See scaphoid treatment protocol

Fractured wrist: • See fracture treatment protocol

Redirect to GP/NP/PT if: Persistent wrist pain: • Presenting complaint of persistent wrist pain without a traumatic mechanism • Reduced range of movement and decreased function may be present

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• Excessive swelling to wrist noted • On examination redness, with or without tracking, localised heat

Referred pain: • Presenting complaint of wrist pain where the origin of the pain is elsewhere

Redirect to ED if: Neurovascular compromise: Presenting complaint of wrist pain and - • Neurological deficit noted distal to the site of complaint • Vascular deficit noted distal to the site of complaint

Suspected fracture with visible deformity: Presenting complaint of wrist pain following injury and - • Obvious deformity to wrist (eg – dinner fork deformity)

Dislocated wrist: Presenting complaint of wrist pain and - • Obvious displacement of the carpal junctions.

Tendon rupture: Presenting complaint of wrist pain and - • Excessive swelling to wrist noted • Decreased active range of movement and reduced function

Differentials: • Wrist sprain (ligamentous injury) • Triangular fibrocartilage (TFCC) injury • Tendinopathy (wrist flexor and extensor compartments) • Colles’ fracture (distal radius with dorsal angulation of fragments) • Smith’s fracture (distal radius with volar angulation of fragments) • Scaphoid fracture • Barton’s fracture (distal radius intra-articular fracture with dislocation of the radiocarpal joint). • Chauffeur's fracture (fracture of the radial styloid process) • Greenstick fracture (confined to children) • Fracture of the ulnar styloid

Management / Treatment: • Acute management of an uncomplicated wrist injury should be guided by the PRICE acronym: o Protection - protect from further injury (e.g. by using a tubigrip support). o Rest - avoid activity for the first 48-72 hours following injury.

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o Ice - apply ice wrapped in a towel for 12 minutes, 3 times during the day for the first 48-72 hours following the injury. This should not be left on whilst the person is asleep. Ice should not be applied directly to the skin. o Compression - with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep. o Elevation - keep the injured area elevated and supported on a pillow until the swelling is controlled. • Advise the person to avoid HARM in the first 72 hours after the injury by applying the following acronym: o Heat (e.g. hot baths, saunas, heat packs) o Alcohol (Increases bleeding and swelling and decreases healing) o Re-injury / Resistance exercise: exercise may increase bleeding in the first 48-72 hours. Gentle mobilisation/exercise in encouraged after this time o Massage (May increase bleeding and swelling) • Range of motion exercises should begin within 48-72 hours post the initial injury so long as they do not cause further pain. • Whenever there is a musculoskeletal injury the joint above and below should be examined. • If bony tenderness is identified on examination, an X-Ray should be ordered and reported as per the Walk-in Centre Medical Imaging Policy. If required, the results should be discussed with the Orthopaedics or Plastics Registrar.

Advice: • Client information sheet – Wrist sprain or strain • All clients should be encouraged to follow up their soft tissue injury with a GP or physiotherapist for specialist advice regarding diagnosis and management if they have not improved within 5 days.

Medication Standing Order: • Paracetamol • Ibuprofen (or any NSAID’s) are not recommended for acute soft tissue injuries in the first 5 days. • Ibuprofen (or any NSAID’s) are not recommended at all in the management of fractures.

References : 1. Bleakley, C.M., Glasgow, P.D., Phillips, N, et al. (2011). Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM. 2. Boggess, B. R. (2016). Evaluation of the adult with acute wrist pain. In K.B. Fields & J. Grayzel (Eds.). UpToDate. Retrieved from https://www.uptodate.com/contents/evaluation-of-the-adult-with-acute-wrist- pain?source=search_result&search=wrist%20sprain&select

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3. Duchesne, E., Dufresne, S.S. & Dumont, N.A. (2017). Impact of inflammation and anti- inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Physical Therapy in Sport. 97, 807-17. 4. Payne, J. (2016). Wrist fractures. In J. Cox (Ed.). Client. Retrieved from https://Client.info/doctor/wrist-fractures

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Implementation

This will be implemented through Staff Orientation and team meeting within each of the Walk in Centres.

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Related Policies, Procedures, Guidelines and Legislation

Legislation • Health Records (Privacy and Access) Act 1997 • Human Rights Act 2004 • Work Health and Safety Act 2011

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Search Terms

Walk in Centre, WIC, Walk-In, Clinical Treatment Protocols Back to Table of Contents

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following: Date Amended Section Amended Divisional Approval Final Approval 18/12/2019 Minor amendment to Cathie O’Neill, ED CAS Cathie O’Neill, ED CAS put onto new template and update information inline with recently updated MSOs

This document supersedes the following: Document Number Document Name

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