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Centre for Remote Health A joint centre of Flinders University and Charles Darwin University CARPA Standard Treatment Manual 5 th edition Main Changes.

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Presentation on theme: "Centre for Remote Health A joint centre of Flinders University and Charles Darwin University CARPA Standard Treatment Manual 5 th edition Main Changes."— Presentation transcript:

1 Centre for Remote Health A joint centre of Flinders University and Charles Darwin University CARPA Standard Treatment Manual 5 th edition Main Changes

2 Protocol Format Ask - getting the person’s story Check - observations, assessments, tests, to help with diagnosis (includes look, feel, listen, do) Do – treatments or interventions Follow Up - ongoing care or actions S O D A F

3 New protocols Low blood glucose – Emergency and assessment Breathing problems in children – Child health Rashes – Child health – includes Measles Amphetamines and other stimulants – Mental health and drug problems Interpreting results – Chronic diseases Assessing and reducing cardiovascular risk – Chronic diseases Combined checks for chronic diseases – Chronic diseases Leprosy – General topics

4 New protocols 2 Child growth and development – Child health – replaces Child growth and malnutrition, includes developmental issues Sick babies under 2 months – Child health – replaces Babies less than 3 months old who are sick Messages for healthy food choices, physical activity, size and weight – Chronic diseases – replaces Healthy choices for food and activity and Healthy weight for adults Joint problems – General topics – replaces Joint infection (septic arthritis), includes other swollen, painful joint presentations Joint sprains and strains – General topics – replaces Sports injuries Pain management – General topics – includes Paracetamol doses and Pain relief

5 Changed protocols Moved Breathing problems in adults – from Emergency and assessment to General topics Asthma in Adults – from Chronic diseases to General topics Chronic lung disease in adults – from Chronic diseases to General topics Adult health check – from General topics to Chronic diseases Brief interventions –from General topics to Chronic disease Nose bleed – from General topics to Emergency and assessment Name change Psychiatric emergencies – now Mental health emergency Kidney (renal) disease in adults – now Chronic kidney disease High fats in the blood (lipids) – now Abnormal blood fats (lipids)

6 Removed protocols Mental health introduction Overview of chronic diseases Immunisation/vaccination Babies less than 3 months old who are sick – replaced by Sick babies under 2 months Child growth and malnutrition – replaced by Child growth and development Joint infection (septic arthritis) – replaced by Joint problems Sports injuries – replaced by Joint sprains and strains

7 Removed protocols Procaine penicillin reactions – combined with Anaphylaxis Healthy choices for food and activity – included in Messages for healthy food choices, physical activity, size and weight Healthy weight for adults – included in Messages for healthy food choices, physical activity, size and weight Syphilis – included in Sexually transmitted infections (STIs) in men Chest pain assessment – included in Chest pain Pain relief – included in Pain management Paracetamol doses – included in Pain management Measles – included in Rashes

8 Emergency and assessment General changes O 2 by non rebreathable mask 10L/min child, 15L/min adult (was 8L/min with reservoir bag) O 2 6L/min children (was 4) Put in IV cannula (was a drip) Normal saline (was Hartmanns, normal saline or Haemaccel) O 2 stats added to observations

9 Emergency and assessment DR ABC D Aligned with Australian Resuscitation Council guidelines Abdominal pain Buscopan removed as treatment for gallstones and diarrhoea Anaphylaxis Use of hydrocortisone and antihistamines removed Bites – animal and human Use clindamycin (was roxithromycin) if allergic to penicillin Fits Glucose (was dextrose) doses changed Manage BGL less than 4mmol/L (was less than 2mmol/L)

10 Emergency and assessment 2 Burns Additional criteria to send to hospital – major and minor burns Working out children’s fluids  Need maintenance and replacement fluids  Fluid replacement at 4ml (was 3ml) x weight in kgs x % body surface burnt Infected - cephazolin (was roxithromycin) if allergic to penicillin Chest pain Treatment  Initial – all  STEMI  AMI without ST elevation More details on thrombolysis

11 Emergency and assessment 3 Injuries Bleeding – manage shock Severe head injury – give flucloxacillin (was ceftriaxone) Spinal injury - check for erection (priapism) Abdominal injury – do not spring pelvis Infected wounds  dicloxacillin OR flucloxacillin AND probenecid (was procaine penicillin)  Trimethoprim-sulfamethoxazole (was roxithromycin) if allergic to penicillin Old wounds  Amoxicillin-clavulanate (was procaine penicillin) and  Clindamycin if allergic to penicillin (was roxithromycin)

12 Emergency and assessment 4 Low blood glucose – new protocol Meningitis Added - give dexamethasone IV OR if not available, give hydrocortisone IV Near hanging Give fluids if low BP (was unless) Nose bleed Details on Merocel pack and balloon catheter now in CPM Unconscious person Section on immediate management added

13 Child health Anaemia Diagnosis of anaemia – Hb by age Prevention of iron deficiency in preterm and small babies Information on screening Hb measurements in g/L (was g/dL) Do FBE if Hb less than 90g/L (was 11g/dL) Follow-up – check Hb at 4 then 12 weeks (was 4 then 4) Chest infection – 2 months to 5 years (was 3 months) Fast breathing in children table Reliever – 3 doses 20min apart (was 2 doses 15min apart) Mild pneumonia - Procaine penicillin or amoxycillin oral for 3 days (was 5 days)

14 Child health 2 Breathing problems in children – new protocol CSLD  3 rd line treatment azithromycin (was rozithromycin) Asthma  How bad is the asthma – O 2 saturation: mild 95-100%, moderate 91-94% (was 94-100% and 90-94%)  Severe asthma – hydrocortisone IM/IV 5mg/kg/dose up to 100mg – can repeat after 6 hours (was hydrocortisone IM/IV 0.25mg/kg)  Very severe asthma – Put 5mg salbutamol in nebuliser, mix with normal saline to make 5ml (was put 5ml of undiluted salbutamol in nebuliser)  Very severe asthma – hydrocortisone IM/IV 5mg/kg/dose up to 100mg (was hydrocortisone IM/IV 0.25mg/kg)

15 Child health 3 Child growth and development Child heath assessments Developmental issues Fetal alcohol syndrome Dental and oral problems – 6 months to 5 years – new protocol Infant and child growth and nutrition Growth faltering  Oral zinc doses by age  Metronidazole oral or tinidazole to treat Giardia, give if there is diarrhoea  Give vitamin A removed

16 Child health 4 Diarrhoea Persistent diarrhoea  Age categories for zinc doses  Diarrhoea lasting more than 7 days (was 14)  Give vitamin A removed Ear problems Prevention strategies Assessing/diagnosing ear problems Drowning insects – Use lignocaine 1% or amethocaine 1% Hearing tests and results Otitis media with effusion – Amoxyicillin for 14 days (was 10- 14 days)

17 Child health 5 Ear problems AOM with bulge or perforation - Amoxyicillin for 7 days (was 14 days. If still bulge – double amoxyicillin to 50mg/kg/dose (was think about using45mg/kg) Ciprofloxacin 5 drops 2 times a day (was dexamethasone- framycetin-gramicidin 2-4 drops 2-4 times a day) CSOM - Ciprofloxacin 5 drops 2 times a day (was dexamethasone-framycetin-gramicidin 2-4 drops, 2-4 times a day) Softening wax  Sodium bicarbonate solution 4 drops twice a day for 3–4 days  Docusate sodium eardrops (was Waxsol/Coloxyl eardrops) Rashes – new protocol

18 Child health 6 Sexual abuse & sexual assault – children & young people Requirement to know legislation and protocols around mandatory reporting Presentations of child sexual abuse Guideline for suspected sexual assault/abuse/maltreatment of person under 18yrs STIs (includes screening and reporting) Sick babies under 2 months (was under 3 months) Signs of serious sickness can be non specific - be aware of warning signs – table of warning signs Give gentamicin (was think about gentamicin) Do U/A removed

19 Child health 7 Urine problems – 2 months (was 3 months) to 12 years Urinary tract infection  Reasons to suspect UTI – and think about balanitis, phimosis or paraphimosis  Table - collecting urine samples  Amoxycillin-clavulanate for 5 days (was 7 days)  If allergic to penicillin, give trimethoprim-sulfamethoxazole oral for 5 days (was 7 days)  MCUG for all children under 1 year with confirmed UTI (was child under 5 years with abnormal renal US)  References to ‘preventer antibiotic’ removed

20 Child health 8 Vesico-ureteric reflux  Explanation of VUR – involves urine flowing back up to kidneys  Child with VUR may be on long-term antibiotics  No age for MCUG (was under 5years) Blood or protein in urine  Subclinical cases added  Other cause of blood in urine (haematuria) added  Protein in urine added Problems in boys  New heading

21 Mental health Mental health assessment Prompts for mental health examination: A-Appearance, B-Behaviour, C-Conversation, A-Affect, P-Perception, C-Cognition, I-Insight, R-Rapport Mental health emergency Olanzapine - anti-psychotic of choice Do not give benzodiazepines, eg diazepam to child, or person who is drunk – wait 6–8 hours after last drink Give diazepam 5-10 every 2-6 hours max 40mg daily (was 10- 20mg every 2-6hours max 60mg daily) Give risperidone oral 0.5–2mg (was 2mg) Anxiety Panic attacks

22 Mental health 2 Confusion – delirium and dementia Cognitive assessment Depression Depression assessment – Kessler K -10 Medical review at 6 and 12 months (was 12 months) Stopping treatment – reduce by ½ tablet (was ¼-½) Family and domestic violence Signs that child may be exposed or involved Checklist for intervention (ABCDEF)

23 Mental health 3 Grief and loss Clinical treatment section Sleeping tablets 1–3 nights (was temazepam 10mg 3–4 nights) Psychosis Neuroleptic Malignant Syndrome Medicine – see AMH or Medicines Book (was risperidone 2-4mg oral daily) Suicide risk Suicide risk assessment Stay Strong Plan

24 Drug and alcohol Alcohol information Safe drinking levels (per day) – safe: 0-2, risky:3-4, dangerous: more than 4. None if pregnant Alcohol problems – acute Mild withdrawal – taper diazepam dose to nothing over 3-5 days (was 5 days) Diazepam oral doses – medical consult before giving more than 80mg in first 24 hours – 90kg or under, 100mg in first 24 hours – over 90kg (was if you need to give more than 100mg in a day) Amphetamines and other stimulants – new protocol

25 Drug and alcohol 2 Cannabis Medicines for cannabis withdrawal Follow up Petrol and solvent sniffing Immediate and long term effects Olanzapine oral 5-10mg – up to 20mg daily (was diazepam 10-20mg every 2-6 hours)

26 Sexual health STIs in men Full STI check up table If oral or anal gonorrhoea – give ceftriaxone IM 500mg Confirmed/secondary syphilis give benzathine penicillin 1.8g If pain on passing urine or discharge from penis and outside local area – Ceftriaxone IM 500mg (was 250mg) Herpes - first episode – Valaciclovir 5-10days (was 5 days), recurrent – Valaciclovir oral 500mg twice a day for 3 days (was 5 days) OR Famciclovir oral 500mg once then 250mg 12 hourly for 3 doses (was 250gm 3 times a day for 5 days) Viral warts – Use podophyllotoxin 0.15% cream (was podophyllotoxin 0.25% cream or podophyllin) Putting on a condom pictures (see CPM)

27 Chronic diseases Adult health check Age ranges added – older person 55 years (was 50 years) Have every 2 years (was every year) Older person – check vision, ask about hearing and dental problems, osteoporosis risks Follow up – medical review, dental review, treatment if cardiovascular risk over 15% Brief intervention Sticking to it FRAMES Messages for healthy food choices, physical activity, size and weight BMI table and information (see CPM)

28 Chronic diseases 2 Tobacco information Fagerstom test for nicotine dependence Details on medicines ‘5As’ approach to help people stop smoking Assessing and reducing cardiovascular risk – new protocol Combined checks for chronic diseases – new protocol

29 Chronic diseases 3 Interpreting results ACR results  Male 0-2.4, Female 0-3.4 – normal (was 0-3.4)  Male 2.5-34, Female 3.5-34 – Micro-albuminuria (was 3.4-35) Waist circumference Target levels for blood fats HbA1c and non-fasting OGTT for diagnosing diabetes Cardiovascular risk levels in relation to BGL results Normal BP results - 130/80 or more but less than 140/90 (was less than 140/90)

30 Chronic diseases 4 Abnormal blood fats 2 yearly checks, annual checks for high risk Target level for blood fats  TC – less than 4 (was 4 or less)  HDL-C more than 1 (was 1 or more)  LDL-C less than 2.5 or less than 2 if known vascular disease (was 2.5 or less)  TG – less than 1.5 (was 2 or less) Try life style changes for 6-12 weeks before starting medicines (was 3-6 months) Lipid controlling medicines include statins and fibrates Check LFTs, CK after 4 weeks on medicine (was check LFTs after 6 weeks on medicine) Combined checks

31 Chronic diseases 5 Chronic kidney disease Glomerular filtration rate replaces calculated kidney function Need 2 abnormal ARC at least 3 months apart, or 2 reduced eGFR to diagnose chronic kidney disease (was If ACR more than 3.4 repeat within 1 month to confirm kidney disease) Action by stage  Stage 1 – ACEi (was not specified)  Stage 2 – ACEi (was ACEi or ARB)  Stage 3 – ACEi and ARB (was not specified) Target Hb is 110-130g/L (was 120g/L) Do not give metformin Coronary artery disease Medicines for chest pains (angina)

32 Chronic diseases 6 Diabetes Impaired glucose tolerance – think about starting metformin Gestational diabetes Adjusting insulin dose for low blood glucose readings Metformin maximum dose 3g (was 1g) Think about starting insulin if 2 or more HbA1c results of more than 7% (was 9%) or BGLs always more than 8-10mmol/L (was 10 mmol/L) Foot examination details (see CPM) Heart failure Chronic heart failure treatment significantly revised

33 Chronic diseases 7 High BP Routine check every 2 years (was 1 year) Management by absolute cardiovascular risk May take 4 weeks to see full response to medicine change (was 3-4 weeks)

34 General topics Bone infection If delay in sending to hospital – give cephazolin (was flucloxacillin ) Chest infection – over 5 years and adults Looking for signs of chronic problem Mild/moderate pneumonia – doxycycline Severe pneumonia – ceftriaxone (was benzyl penicillin or procaine penicillin) Sinusitis and bronchitis separated  Bronchitis – antibiotics no longer recommended  Sinusitis – doxycycline

35 General topics 2 Chronic lung disease Questions flagging obstructive sleep apnoea Comparison of chronic lung diseases Progression of medicines for COPD Separation of management of COPD and bronchiectasis Asthma in adults Doses of inhaled corticosteroids Puffer and spacer use (see CPM) Chickenpox and shingles Doses for antivirals removed

36 General topics 3 Coral and sea cuts Cellulitis  Treatment time frame – 5-7 days  If penicillin allergy – Clindamycin Pustule  Treatment time frame – 10 days  If penicillin allergy – Roxithromycin Moderate/severe  Send swab for MC&S  Follow up – repeat cephtriaxone and send to hospital if not getting better Doxycycline – over 8 years (was over 10 years)

37 General topics 4 Dental and oral problems Oral health messages Severe infection – clindamycin if penicillin allergy Broken tooth Pain and significant swelling  Amoxycillin (was phonoxymethyl penicillin and probenecid)  If penicillin allergy clindamycin (was roxithomycin) Broken jaw – Amoxycillin (was procaine penicillin) Heat illness Heat cramps Features of heat exhaustion and heat stroke

38 General topics 5 Eye problems Antibiotic eye ointment 4 times a day (was 2 times a day) Penetrating eye injury – give cephtriaxone (was give cephtriaxone and gentamicin). If ceftriaxone not available give cephazolin Conjungtivitis  Treatment for bacterial and viral separated Gonococcal conjunctivitis  Think of in babies under 6 weeks (was under 4 weeks)  Ceftriaxone (was procaine penicillin or amoxycillin with probenecid)  Babies under 2 weeks send to hospital urgently (was under 1 month)

39 General topics 6 Cellulitis  Orbital cellulitis – Check for relative afferent pupil defect  Periorbital cellulitis – Severe infection give ceftriaxone or flucloxacillin and send to hospital  Orbital cellulitis – Give flucloxacillin (was only if signs of infection)  If stye, blocked tear duct or wound (was procaine penicillin until better AND docloxacillin or flucloxacillin if abscess/sty, impetigo, infected cut) Trachoma  Azithromycin for young children (was erythromycin)  Anti-glaucoma drops as advised by eye doctor (was timolol and pilocarpine)

40 General topics 7 Hepatitis When to refer to a specialist – non-viral hepatitis infection Management of chronic hepatitis B and C Cirrhosis Tests for viral hepatitis infection Classification of hepatitis B status Joint problems – new protocol Joint sprains and strains – new protocol Leprosy – new protocol Meliodosis Give ceftriaxone and gentamicin (was ceftriaxone only)

41 General topics 8 Pain management Combines Pain relief, Chronic pain and Paracetamol doses Acute pain  Visual pain scale  Paracetamol-codiene – do not use for children under 7 years  Do not use NXAIDs – Kidney function/eGFR less than 60 or unknown or high cardiovascular risk  Dosing regimen for opioid injections changed  Naloxone given every 2 minutes (was 3 minutes)  Ibuprofen not used for moderate pain  IM Naloxone not used  Metoclopramide not used for children Chronic pain  Managing chronic pain

42 General topics 9 Painful scrotum Infected testes can be due to mumps virus Table Assessing a painful scrotum combines Ask and Check tables Suspected UTI – Give cephalexin or amoxicillin- clavulanate (was ceftriaxone or ciprofloxacin) Review at day 3 (was review next day, if getting better review again at day 3)

43 General topics 10 Palliative care Expanded description including advanced care plan Working out pain medicine doses Other treatments Managing care (was Treating symptoms) Pain management (was giving medicines) Rectal bleeding Ask about family history of bowel cancer Do abdominal examination

44 General topics 11 Skin conditions School sores  If injection not possible give amoxycillin oral  Follow-up  Clean sores with soap and water (was providone-iodine)  If there are clearly infected sores (was If more than 6 infected sores or sores look severe)  If allergic to penicillin give trimethoprim-sulphamethoxazole (was roxithromycin) Scabies  Leave crotamiton cream on babies under 2 months for 24 hours  Follow-up  For children 2 months and over and adults repeat treatment in 1 week ( was (was repeat after 2 weeks if moderate to severe, or still itchy)

45 General topics 12 Crusted scabies  Descriptions of mild moderate and severs crusted scabies  Give ivermectin if over 5 years. Best with full cream milk or food ( was Give ivermectin on empty stomach) Boils, carbuncles, abscesses  Keep boils covered with a dressing, was and change every day until healed to prevent cross-infection to other parts of body. Most important preventive measure  If allergic to penicillin give clindamycin  Ask family to wash all clothes and bedding in hot soapy water while on antibiotics, encourage regular hand washing  Follow-up  BGL (was if person keeps getting boils)  Swab for MC&S if severe or several boils (was if person keeps getting boils)  Give dicloxacillin or flucloxacillin for 5 days (was 5-7 days)

46 General topics 13 Head lice  Treat with permethrin 1% shampoo if causing problems (was treat with permethrin 1% shampoo)  Advice for avoiding head lice removed Cellulitis  If not improving after 2 days – medical review, treat as severe cellulitis  If allergic to penicillin give clindamycin (was cephalexin)  Severe cellulitis – give cephazolin 3-5days (was give dicloxacillin or flucloxacillin IV every 6 hours) Cold sores  Make sure they get enough fluids – may need IV fluids if severe  Medical consult if severe or recurrent – may need antiviral treatment  Dab with povidone-iodine, if first day removed

47 General topics 14 Molluscum contagiosum  May need antibiotics if it gets infected removed Tinea  Tinea of the scalp  Collecting samples for tinea diagnosis  Nails – Give terbafine continuously for 4 weeks OR 1 cycle (14 days) = 7days with treatment, 7 days without treatment : For fingernails 4 treatment cycles, for toenails 8 treatment cycles (was daily for 6 weeks for fingernails and 12-16 weeks for toenails)  Tinea versicolor – Put ketaconazole 2% shampoo on affected skin, leave on overnight (was selenium sulphide 2.5% shampoo on affected skin. Leave for 60 minutes)  For small areas on skin – Terbinafine cream  For large areas of skin – Griseofulvin tablets

48 General topics 15 Sore throat Warning about difficulty of using oral antibiotics for full 10 days If allergic to penicillin give roxithromycin Tetanus immunisation Giving tetanus immunisation Giving tetanus immunoglobin Follow-up Think about when treating a wound – injury, bite, lost tooth, burn (was wound or burn) Indications for tetanus immunisation

49 General topics 16 Tuberculosis Think of tuberculosis if CSLD or bronchiectasis Treatment is usually given 3 times a week (was daily or 2-3 times a week) Urine problems UTIs  Treatment – Give trimethoprim or nitrofurantoin or amoxycillin-clavulanate (was cephalexin or amoxycillin- clavulanate)  Female resistant – Treat as advised on pathology result for 7 days (was 5-7 days, might need norfloxacin)  Female recurrent – Medical review (was treat as advised on pathology result for 5-7 days, may need longer course)  Complicated UTIs – medical review (was give cephalexin or amoxycillin-clavulanate or nitrofurantoin)

50 General topics 17 Kidney infection  Follow-up mild kidney infection – review at 3 days, if not getting better medical consult, EUC and refer for renal US  Mild kidney infection – Give cephalexin or amoxycillin-clavulanate for 10 days (was single dose gentamycin and cephalexin for 14 days) Blood in urine  Can be caused by cancer  Feel (palpate) abdomen and flanks/loins

51 General topics 18 Worms More information on individual worms Dwarf tapeworm Strongyloides – can cause growth faltering, low potassium especially in young child Faeces testing – include strongyloides culture Test for strongyloides if on corticosteroids for at least 2 weeks (was course of less than 1 week not likely to lead to strongyloides) Community deworming – 6 months – 16 years give albendazole single dose twice a year (was 6months – 5 years albendazole single dose 3 times a year, 5- 16 years twice a year)

52 Reference Section Reference Table  Normal values, fluid and oxygen rates Antibiotics doses table Abbreviations Contact Numbers Index detailed


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