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EMERGENCY PROTOCOLS AND PROCEDURES

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

TABLE OF CONTENTS EMERGENCY PROTOCOLS AND PROCEDURES Guidelines for Emergency Kits/Carts Vasovagal Syncope (Fainting) Allergic Reactions including Acute Anaphylaxis, in Adults, Infants and Children Allergic Reaction/Anaphylaxis Record Policy for Reviewing Emergency Protocols/Procedures Emergency Checklist Evaluation Tool for Practice Drill 14 14.1 14.4 14.6 14.12 14.14 14.15 14.16

Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

GUIDELINES FOR EMERGENCY KITS/CARTS IN PUBLIC HEALTH CLINIC SITES A. GENERAL POLICY

Local factors such as anticipated EMS response time, the availability of a physician and the ability of trained personnel to initiate an emergency procedure in the event of vasovagal syncope, and/or an acute anaphylaxis/allergic reaction will determine the need for supplies beyond the minimum and expanded protocol/procedure for some clinics. Emergency plans and procedures should be coordinated with the local Emergency Medical System (EMS). All emergency drugs and supplies should be kept together in a secured kit or cart that is easily moveable and readily accessible/visible during clinic service hours. Inventory should be checked monthly with careful attention to medication expiration dates and the working condition of equipment. B. DEFINITION OF EMERGENCY KIT/CART

Emergency kits/carts are those drugs and supplies which may be required to meet the immediate therapeutic needs of clients and which are not available from other authorized sources in sufficient time to prevent risk or harm to clients. Medications may be provided for use by authorized health care personnel in emergency kits/carts, provided such kits/carts meet the following requirements: 1. Storage Emergency kits/carts shall be stored in limited-access areas and sealed with a disposable plastic lock to prevent unauthorized access and to insure a proper environment for preservation of the medications in them. 2. Labeling - Exterior The exterior of emergency kits/carts shall be labeled so as to clearly and unmistakably indicate that it is an emergency drug kit/cart and is for use in emergencies only. 3. Labeling ­ Interior All medications contained in emergency kits/carts shall be labeled in accordance with the name of the medication, strength, quantity, lot # and expiration date.

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4.

Removal of Medications Medications shall be removed from emergency kits/carts only pursuant to nurse protocol/procedure, by authorized clinic personnel or by a pharmacist.

5.

Inspections Each emergency kit/cart shall be opened and its contents inspected by the authorized personnel monthly with the exception of oxygen (every 6 months). The monthly inspection shall be documented on an Emergency Check-Off Log sheet which includes: a. the listing of all emergency supplies and equipment, b. the name of the medication(s), its strength, quantity, lot # and expiration date, c. the staff member's name who performed the inspection and d. the inspection date. Upon completion of the inspection, the emergency kit/cart shall be resealed with the appropriate disposable plastic key.

6.

Minimum Medication(s) a. b. c. d. e. f. Epinephrine 1:1000, 1 mL (2 ampules) Diphenhydramine 50 mg/mL (2 ampules) Diphenhydramine elixir/solution 12.5 mg/5 mL (1 bottle) (Optional) Diphenhydramine HCl 25,50 mg caps (1 bottle of each) Methylprednisolone 125 mg (4 vials) Portable oxygen (generally administered by nasal cannula in situations of chest pain or difficulty breathing at 5 L/min, at 2 L/min if patient has history of emphysema or chronic lung disease)

7.

Minimum Supplies a. b. c. d. e. f. g. h. i. j. Blood pressure cuffs (adult and child) Stethoscope Flashlight/extra batteries Copy of emergency protocols/procedures Allergic Reaction/Acute Anaphylaxis Record Bag-valve-mask (AMBU) for resuscitation (adult and child) Copy of initialed current Monthly Checklist of Drugs and Supplies Nasal cannula for oxygen administration Needles and syringes Filter needles, 5 micron, for use when aspirating a medication from a glass ampule, to reduce contamination

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

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Recommended Additional Supplies (For use where additional protocol/procedures and trained personnel are available) a. IV needles/infusion sets b. IV fluids (normal saline is recommended) c. Gauze pads, tape d. Epinephrine 1:10,000 for IV use e. Oral airways (Adult/Child) f. Pulse-oximeter g. Automated external defibrillator (AED)

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

NURSE PROTOCOL/PROCEDURE FOR VASOVAGAL SYNCOPE (FAINTING) DEFINITION Syncope (fainting) is a transient vascular/neurogenic reaction marked by pallor, nausea, sweating, bradycardia, and rapid fall in arterial blood pressure which, when below a critical level, results in loss of consciousness. Vasovagal syncope usually occurs in the upright position and is often preceded by warning symptoms (e.g., nausea, dizziness, weakness, yawning, apprehension, visual blurring, sweating). Vasovagal syncope is usually due to emotional stress related to fear or pain (e.g., having blood drawn or an injection). 1. 2. 3. 4. Fall in blood pressure. Slow pulse. Pallor, perspiration. May progress to loss of consciousness.

ETIOLOGY OBJECTIVE

ASSESSMENT PLAN

Vasovagal Syncope (fainting) THERAPEUTIC 1. 2. 3. 4. Place client in recumbent position with head lower than the rest of the body, or, if sitting, place head between knees. Monitor blood pressure and pulse; observe the client until completely recovered. Do not allow the client to resume an upright position too quickly. Suggest that the client be accompanied when leaving the clinic.

REFERRAL To EMS or closest medical facility, if client does not stabilize.

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REFERENCES 1. 2. 3. Richard Sadovsky, "Evaluation and Management of Vasovagal Syncope," American Family Physician, The American Academy of Family Physicians, May 15, 2001. (Current) The Merck Manual of Diagnosis and Therapy, Eighteenth Edition, Section 7, Cardiovascular Disorders, Approach to the Cardiac Patient, Syncope, revised November 2006, <http://merck.com/mmpe/sec7/ch069> (August 29, 2007). Constance R. Uphold and Mary Virginia Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003, pp. 515-516. (Current)

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

NURSE PROTOCOL AND PROCEDURES FOR ALLERGIC REACTIONS, INCLUDING ACUTE ANAPHYLAXIS IN ADULTS, INFANTS AND CHILDREN DEFINITIONS Allergic reactions are sudden and possibly life-threatening (anaphylactic) reactions, after exposure to an antigen which has been injected, ingested or inhaled. When a client is given an agent (e.g., antibiotic or vaccine) capable of inducing anaphylaxis, he/she should be required to remain in the clinic for at least 30 minutes (provide documentation in chart if client leaves before 30 minutes). Reactions range from mild, self-limited symptoms to rapid death: 1. Mild to moderate allergic reactions involve signs and symptoms of the gastrointestinal tract and skin. Observing the client for rapid increase in severity of signs and symptoms is important, as the sequence of itching, cough, dyspnea and cardiopulmonary arrest can lead quickly to death. 2. Severe/anaphylactic reactions involve signs and symptoms of the respiratory and/or cardiovascular systems. These may initially appear minor (i.e., coughing) but any involvement of the respiratory tract or circulatory system has the potential to rapidly become severe. Death can occur within minutes. Therefore, prompt and effective treatment is mandatory if the client's life is to be saved. ETIOLOGY Agents commonly associated with allergic reactions/anaphylaxis, include: 1. Antibiotics (especially penicillin). 2. Biologicals (non-human sera, gamma globulin, vaccines, blood and blood products). 3. Local anesthetics. 4. Aspirin and other nonsteroidal anti-inflammatory drugs. 5. Hymenoptera stings (bee, yellow jacket, wasp, hornet, fire ants). 6. Allergy extracts (skin-testing and treatment solutions). 7. Foods (especially eggs, nuts and shellfish). 8. Intravenous narcotics (heroin). 9. Alternative medicines (e.g., herbal or home remedies). 10. Environmental agents (e.g., pollens, grasses, molds, smoke, animal dander). 1. In 1-15 minutes clients may develop: a. Apprehension. b. Flushing and/or skin edema. c. Palpitations. d. Numbness and tingling. e. Itching.

Emergency Protocols and Procedures 14.6

SUBJECTIVE & OBJECTIVE

Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

f. g. h. i. j. k. 2. ASSESSMENT PLAN

Localized or generalized urticaria (rash, welts). Choking sensation. (Indicates laryngeal edema which may precipitate closure of the airway.) Coughing and wheezing. Difficulty breathing. Nausea and vomiting. Dizziness and fainting.

In another 1-2 minutes, shock may develop with severe hypotension and vasomotor collapse.

Allergic reaction, severe (any respiratory or circulatory signs/symptoms; anaphylaxis) to mild or moderate THERAPEUTIC Step 1 Call for HELP · Have someone call the physician and/or EMS/911. · Assign one person to keep the anaphylaxis record and be the timekeeper. · Do not leave the client unattended! If the client received an immunization, apply a tourniquet above the injection site, if possible, to reduce systemic absorption of the antigen. NOTE: This practice does appear to be standard of care but the evidence basis for this is unclear. Step 3 Procedures · Place patient in supine POSITION, legs elevated. · Assure OPEN AIRWAY and begin CPR if indicated. · Begin monitoring VITAL SIGNS with BP every 5 minutes. · Help to maintain position of comfort (sitting if wheezing; supine with legs elevated if light-headed or in shock). · Oxygen at 4-6L/minute by nasal cannula, face mask OR blow-by, if indicated and available. · Monitor with pulse-oximeter, if available.

Step 2

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Step 4

For shock or cardiovascular collapse:

NOTE: In case of shock or cardiovascular collapse, it is preferred that this be administered IV or endotracheally by physician or EMS if rapidly available; if not, administer IM epinephrine as follows. Epinephrine IM Dosing for shock or cardiovascular collapse

(Dosing by body weight is preferred; the standard dose is 0.01 mg/kg body weight [including for low birth weight babies], up to 0.5 mg.) Age Group Weight* Epinephrine IM Dose lbs. (kg) (1mg/ml=1:1,000 wt/volume)

1-6 months 7-18 months 19-36 months 37-48 months 49-59 months 5-7 years 8-10 years 11-12 years > 12 years <9 (<4) 9-15 (4-7) 15-24 (7-11) 24-31 (11-14) 31-37 (14-17) 37-42 (17-19) 42-51 (19-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

Weigh baby and calculate appropriate dose

0.05 mg/0.05 mL 0.10 mg/0.10 mL 0.13 mg/0.13 mL 0.16 mg/0.16 mL 0.18 mg/0.18 mL 0.20 mg/0.20 mL 0.30 mg/0.30 mL 0.40 mg/0.40 mL 0.50 mg/0.50 mL

*Weights reflect 50th percentile for corresponding ages. May repeat every 15-20 minutes PRN for a total of 3 doses (<1.5 mL [1.5 mg] total)

For wheezing, laryngeal edema (stridor), hypotension: Epinephrine IM Dosing for allergic reaction

(The standard dose is 0.01 mg/kg body weight [including for low birth weight babies], up to 0.5 mg) Age Group Weight* Lbs. (kg) Epinephrine IM Dose (1mg/ml=1:2,000 wt/volume) EpiPen Jr. Epinephrine IM Dose (1mg/ml=1:1,000 wt/volume) EpiPen Epinephrine IM Dose (1mg/ml=1:1,000 wt/volume)

Weigh baby and calculate appropriate dose

1-6 months 7-18 months 19-36 months 37-48 months 49-59 months 5-7 years 8-10 years 11-12 years > 12 years

<9 (<4) 9-15 (4-7) 15-24 (7-11) 24-31 (11-14) 31-37 (14-17) 37-42 (17-19) 42-51 (19-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

0.15mg/0.3mL 0.15mg/0.3mL 0.15mg/0.3mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL

0.05 mg/0.05 mL 0.10 mg/0.10 mL 0.13 mg/0.13 mL 0.16 mg/0.16 mL 0.18 mg/0.18 mL 0.20 mg/0.20 mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL

*Weights reflect 50th percentile for corresponding ages. May repeat every 15-20 minutes PRN for a total of 3 doses.

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

Step 5

For itching, redness, welts/hives without respiratory or circulatory signs, diphenhydramine PO or IM (see dosing below): Diphenhydramine Oral Dosing 12.5 mg/5 mL elixir/solution, OR 25 mg or 50 mg capsules

Infant: 1.25 mg/kg/dose PO STAT Child: 1.25 mg/kg/dose (max 50mg) PO STAT Adult: 50 mg to 100 mg PO STAT Diphenhydramine IM Dosing 1.0 mg/kg body weight, up to 100 mg

Diphenhydramine Oral Dosing Chart, Elixir/Solution (12.5 mg/5mL)

Weight (kg) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Diphenhydramine Oral Elixir/Solution Dose (mL) 0.5 mL 1 mL 1.5 mL 2 mL 2.5 mL 3 mL 3.5 mL 4 mL 4.5 mL 5 mL 5.5 mL 6 mL 6.5 mL 7 mL 7.5 mL 8 mL 8.5 mL 9 mL 9.5 mL 10 mL Weight (kg) 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Diphenhydramine Oral Elixir/Solution Dose (mL) 10.5 mL 11 mL 11.5 mL 12 mL 12.5 mL 13 mL 13.5 mL 14 mL 14.5 mL 15 mL 15.5 mL 16 mL 16.5 mL 17 mL 17.5 mL 18 mL 18.5 mL 19 mL 19.5 mL 20 mL

OR

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

Diphenhydramine IM Dosing

(Dosing by body weight is preferred.) (The standard dose is 1.0 mg/kg body weight, up to 100 mg) Age Group

1-6 months 7-18 months 19-48 months 4-7 years 8-10 years 11-12 years >12 years

Weight* lbs. (kg)

<9 (<4) 9-15 (4-7) 15-24 (7-11) 24-37 (11-17) 37-51 (17-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

Diphenhydramine Dose (Injection: 50 mg/mL)

Weigh baby and calculate appropriate dose 5 mg / 0.1 mL 10 mg / 0.2mL 15 mg / 0.3 mL 20 mg / 0.4 mL 30 mg / 0.6 mL 40 mg / 0.8 mL 50 to 100 mg / 1.0 ­ 2.0 mL

*Weights reflect 50th percentile for corresponding ages.

Step 6

Give corticosteroid (methylprednisolone) to decrease the incidence and severity of delayed reactions. Corticosteroids may not influence the acute course of the reaction; therefore, they have a lower priority than epinephrine and antihistamines.

Methylprednisolone Sodium Succinate IM Dosing

(Dosing by body weight is preferred.) (The loading dose is 2 mg/kg/dose, then 1.0 mg/kg body weight every 6 hours for up to 5 days) Age Group

1-6 months 7-18 months 19-48 months 4-7 years 8-10 years 11-12 years >12 years

Weight* lbs. (kg)

<9 (<4) 9-15 (4-7) 15-24 (7-11) 24-37 (11-17) 37-51 (17-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

Methylprednisolone Sodium Succinate Loading Dose (Injection: 125mg/2mL)

Weigh baby and calculate appropriate dose 14 mg / 0.22 mL* 22 mg / 0.35mL* 34 mg / 0..54 mL* 46mg / 0.74 mL* 70 mg / 1.12 mL* 90 mg / 1.44 mL* >90 mg / 1.44 mL

* based on maximum weight in category

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

Step 7

Assure that the Allergic Reaction/Anaphylaxis Record (see pp. 14.12-14.13) has been completed and a copy given to EMS personnel before they transport the client.

REFERRAL 1. 2. 3. Immediately refer clients with wheezing, laryngeal edema, hypotension, shock or cardiovascular collapse. Immediately refer if symptoms progress despite treatment. Refer to primary care provider for further evaluation those clients with itching, redness welts/hives.

FOLLOW-UP 1. 2. 3. REFERENCES 1. 2. 3. 4. 5. 6. 7. Axalla J.Hoole, Patient Care Guidelines for Nurse Practitioners. 5th ed., Lippincott, Philadelphia,1999, pp 55-58. (Current) Drug Information Handbook, 12th ed., Lexi-Comp. Inc., Hudson, OH, 2004-2005, pp 443-445, 505-506. American Pharmaceutical Association, American Hospital Formulary Service, 2005, pp. 16-18, 1281-1286. Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 5th ed., Mosby Inc., St. Louis, June 1, 2003, p. 226. (Current) Michael S. Blaiss, M.D.,"Anaphylaxis and Anaphylactoid Reactions," Best Practice of Medicine, modified August 2, 2002, <http://merick.praxis.md/index> (April 12, 2004). (Current) Constance R. Uphold and Mary Virginia Graham, Clinical Guidelines in Family Practice, 4th ed., Barmarrae Books, Inc., Gainesville, FL, 2003, p. 952. (Current) Richard S. Krause, M.D., "Anaphylaxis," Department of Emergency Medicine, State University of New York at Buffalo School of Medicine, <http://www.emedicine.com/emerg/topic25.htm#target1> (April 18,2007). Place an allergy label on the front cover of the client's medical record. Educate the client/caretaker about medical alert bracelets. If the allergic reaction is immunization-induced, complete a vaccine adverse event record (VAERS).

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ALLERGIC REACTION / ANAPHYLAXIS RECORD ­ page 1 District/Clinic Site __________________________________________ Date _________________ Client Demographic Information: Name: ______________________________________ DOB _____/_____/_____ AGE ________ months / years Estimated/Actual Weight

(please circle one)

Infant / Child / Adult _____lbs/kg

Event which preceded reaction: _____ Immunization _____ Medication administered _____ Biologicals administered _____ Other: (please explain) ________________________________________________ TIME OF REACTION: ______ AM / PM Signs and Symptoms: (please check) _____ Apprehension _____ Flushing and/or skin edema _____ Palpitations _____ Numbness and tingling _____ Itching _____ Localized or generalized urticaria (rash, welts) TIME EMS CALLED: ______ AM / PM _____ _____ _____ _____ _____ _____ _____ Choking sensation Coughing and wheezing Difficulty breathing Nausea and vomiting Severe hypotension Vasomotor collapse Loss of consciousness

Other: _________________________________________________________________________ OTHER OBSERVATIONS / COMMENTS: _____________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ SIGNATURE OF RN/NP: __________________________________________________________ DISPOSITION: __________________________________________________________________ REVIEWER: ____________________________________________________________________ NOTE: Send copies of both pages of this record with clients referred to a physician's office or hospital

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

ALLERGIC REACTION / ANAPHYLAXIS RECORD ­ page 2

1. Call for HELP. Have EMS called. Assign timekeeper/recorder. Assure AIRWAY. Check VITAL SIGNS q 5 minutes. CPR if necessary. FOR SHOCK AND CARDIOVASCULAR COLLAPSE (NOTE: In case of shock or cardiovascular collapse, it is preferred that this be administered IV or endotracheally by physician or EMS if rapidly available): Epinephrine 1 mg/mL = 1:1,000 wt/volume (w/v) AGE WEIGHT IM DOSE

1-6 mos 7-18 mos 19-36 mos 37-48 mos 49-59 mos 5-7 yrs 8-10 yrs 11-12 yrs 12 yrs < 9 (< 4) 9-15 lbs (4-7 kg) 15-24 lbs (7-11 kg) 24-31 lbs (11-14 kg) 31-37 lbs (14-17 kg) 37-42 lbs (17-19 kg) 42-51 lbs (19-23 kg) 51-77 lbs (23-35 kg) 77-99 lbs (35-45 kg) >99 lbs (>45 kg) Weigh/calculate dose 0.05 mg / 0.05 mL 0.10 mg / 0.10 mL 0.13 mg / 0.13 mL 0.16 mg / 0.16 mL 0.18 mg / 0.18 mL 0.20 mg / 0.20 mL 0.30 mg / 0.30 mL 0.40 mg / 0.40 mL 0.50 mg / 0.50 mL

OR Diphenhydramine 50 mg/mL (vial) IM

WEIGHT IM DOSE <9 (<4) Weigh/calculate dose 9-15 lbs (4-7 kg) 5 mg / 0.1 mL 7-18 mos 15-24 lbs (7-11 kg) 10 mg / 0.2mL 19-48 mos 24-37 lbs (11-17 kg) 15 mg / 0.3 mL 4-7 yrs 37-51 lbs (17-23 kg) 20 mg / 0.4 mL 8-10 yrs 51-77 lbs (23-35 kg) 30 mg / 0.6 mL 11-12 yrs 77-99 lbs (35-45 kg) 40 mg / 0.8 mL >12 yrs >99 lbs (>45 kg) 50 mg to 100 mg / 1.0-2.0 mL 5. TO DECREASE INTENSITY AND SEVERITY OF DELAYED REACTIONS Methylprednisolone Sodium Succinate IM _____ mL (according to dosing table on p. 14.10) Client Name:___________________________ DOB:_________________ VITAL SIGNS Time B/P _____ _ __/_ __ _____ _ __/_ __ _____ _ __/_ __ _____ _ __/_ __ _____ __ _/_ __ _____ __ _/_ __ _____ __ _/_ __ Pulse ____ ____ ____ ____ ____ ____ ____ Resp __ __ __ __ __ __ __ AGE 1-6 mos

2.

3.

May repeat every 15-20 minutes as needed, for a total of 3 doses (<1.5 mL [1.5 mg] total).

FOR WHEEZING, LARYNGEAL EDEMA (STRIDOR), HYPOTENSION

Epinephrine IM Dosing for allergic reaction (The standard dose is 0.01 mg/kg body weight, up to 0.5 mg)

Epinephrine IM Dose (1mg/ml=1: 2,000 w/v) EpiPen Jr. Epinephrine IM Dose (1mg/ml=1:1,000 w/v) EpiPen Epinephrine IM Dose (1mg/ml=1:1,000 w/v) Weigh/calculate dose 0.05 mg/0.05 mL 0.10 mg/0.10 mL 0.13 mg/0.13 mL 0.16 mg/0.16 mL 0.18 mg/0.18 mL 0.20 mg/0.20 mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL

Age Group 1-6 months 7-18 months 19-36 months 37-48 months 49-59 months 5-7 years 8-10 years 11-12 years > 12 years

Weight* lbs. (kg) < 9 (< 4) 9-15 (4-7) 15-24 (7-11) 24-31 (11-14) 31-37 (14-17) 37-42 (17-19) 42-51 (19-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

CPR Indicated: ________YES ______NO TIME CPR started:__________AM / PM TIME CPR ended: __________AM / PM Epinephrine 1:1000 1 w/v ampule TIME _______ _______ _______ DOSE ________ ________ ________ ROUTE IM IM IM

0.15mg/0.3mL 0.15mg/0.3mL 0.15mg/0.3mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL 0.30 mg/0.30 mL

*Weights reflect 50 percentile for corresponding ages. May repeat every 15-20 minutes PRN for a total of 3 doses.

th

Diphenhydramine 12.5 mg/5 mL (Elixir/Solution) OR 25 mg, 50 mg (Capsules) TIME ORAL DOSE ________ ________ _______ _______

4.

FOR ITCHING, REDNESS, WELTS/HIVES: Diphenhydramine 12. 5 mg/5 mL Elixir OR Diphenhydramine 25 mg or 50 mg Capsules INFANT CHILD ADULT 1.25 mg/kg/dose PO, once STAT 1.25 mg/kg/dose (up to 50 mg) PO, once 50-100 mg PO, STAT

Diphenhydramine 50 mg/mL vial TIME _______ IM DOSE ________

TIME EMS ARRIVED:___________AM/PM Emergency Protocols and Procedures 14.13

Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

POLICY FOR REVIEWING EMERGENCY PROTOCOLS/ PROCEDURES IN PUBLIC HEALTH CLINIC SITES A review of emergency protocol/procedures shall be completed at least once annually at each clinic site. The Nursing Supervisor shall arrange for the annual review and completion of the attached checklist. Staff member(s) listed below participated in training updates for all age ranges and performed in a mock emergency drill on . (Date)

District Health Director: Printed Name______________________________ Signature__________________________________ Date District Public Health Nursing and Clinical Director: Printed Name_______________________________ Signature__________________________________ Date Name(s) of Staff Member(s)

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EMERGENCY CHECKLIST FOR PUBLIC HEALTH CLINIC SITES PURPOSE To assure that each site is equipped and prepared to handle emergencies that may occur. The Nursing Supervisor and District Public Health Nursing & Clinical Director will assure that this checklist is completed annually for each site and that follow-up occurs for any inadequacies/incomplete areas.

# 1. 2. 3. 4. 5. 6. 7. 8. 9. EMERGENCY ITEM Emergency numbers posted on each phone Exits clear Hallways clear Staff able to describe action to take in case of emergency Staff demonstrates use of anaphylaxis equipment Emergency tray stored in secured area except during clinic hours Emergency tray stocked according to district protocol for anaphylaxis All staff trained in emergency procedures and certified in CPR (every 2 years) Practice emergency drill(s) conducted and documented at least annually. NOTE: Drills should include agegroup variations (i.e., adults, infants and children.) Complete/ Adequate Incomplete/ Inadequate Comments

County______________________ Nursing Supervisor: Printed Name ____________________________________ Signature _____________________________________ Date of Review: _______________ Date Corrected: __________________

District Public Health Nursing & Clinical Director: Printed Name ____________________________________ Signature _____________________________________

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Division of Public Health Nurse Protocols for Registered Professional Nurses for 2008

EVALUATION TOOL FOR PRACTICE DRILL

A. Response Team 1. 2. 3. 4. 5. 6. B. Team effort utilized and well-coordinated. Response team timely. Client assessment complete. Code Blue* called. Emergency Medical Services/ physician notified. Emotional support provided to significant others, if applicable. Yes ________ ________ ________ ________ ________ ________ No ________ ________ ________ ________ ________ ________

Client Outcome 1. 2. 3. 4. 5. 6. Level of consciousness assessed. Vital signs monitored. Appropriate drugs given. CPR instituted, if applicable. EMS/physician responded. Documentation complete. ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________

C.

Recommendations/Comments:

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Site__________________________________ Date___________________ Evaluator: Printed Name _______________________________________ Signature _______________________________________

*Though Code Blue is not specified in the anaphylaxis protocol/procedures, it should be used to signal the emergency.

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