British Journal of Anaesthesia 85 (1): 80±90 (2000)Anaesthetic management of patients with diabetes mellitusG. R. McAnulty1, H. J. Robertshaw2 and G. M. Hall1*1Department of Anaesthesia and Intensive Care Medicine, St George's Hospital Medical School, LondonSW17 0RE, UK. 2Department of Anaesthesia, Imperial College of Science, Technology and Medicine,Hammersmith Hospital, Du Cane Road, Londo
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Camp manatawnyGeneral Introduction: In order to promote the health and well being of our campers and staff, the camp administration has adopted the following policies and procedures. These will be reviewed annually and updated as indicated. 1. Each camper and staff member must have a health history form on file at the beginning of the camp session. This history must include pertinent medical history, immunization history, current medications (with a physicians instruction on how to administer them) and a list of allergies. At the beginning of the camp session the health care personnel for that week should review these forms, familiarizing themselves with the special needs of that sessions campers and convey pertinent information to the counselors and staff as needed. 2. Any medication brought to camp (prescription and non-prescription) must be collected by the nurse and kept in the nurse’s station in a locked area accessible only to the health personnel. The health personnel are responsible for administration of all medications. Each dose must be documented including name of medication, amount given, time and date. 3. All encounters must be documented in the nurses’ log (including administration of first aid, medication, etc.) Information to be noted should include (but is not limited to): Name of patient, date and time of incident, nature of incident, treatment rendered, and outcome. If the patient is sent off site for treatment note the location of treatment and outcome. If EMS is called, please note the ambulance company and destination. If a camper is sent to a hospital please see to it that a copy of the camper’s health history and insurance information accompanies the camper. Please also see to it that a copy of the consent for emergency medical treatment go along as well 4. Per OSHA guidelines, universal precautions should be followed at all times. a. Gloves should be worn when administering first aid. Please be aware of those who may have a latex allergy and use non-latex gloves. b. Hand washing after every patient contact is essential. c. All surfaces involved in patient care should be cleaned with a solution of 1 part chlorine bleach and 10 parts water. d. Any reusable equipment must be properly cleaned and disinfected with e. Any materials used in patient care, which becomes saturated with blood, or other body fluids should be disposed of properly using Hazardous Waste (red) bags. Please contact the director for instruction in proper dispensation of this waste. f. Any patient requiring injectable medications must provide an appropriate sharps disposal unit (such container must meet OSHA guidelines, items such as jars and empty bottles are not appropriate). These should be taken home with the patient for proper disposal. g. Please report any accidental needle sticks to the session director for further instructions regarding needle stick protocol. 5. The following guidelines are provided to lend guidance in treatment of illness and injury, which may arise at a camp session. The protocols were written and
reviewed by a licensed physician and may be interpreted as standing orders.
Deviation from these protocols is not considered as authorized treatment. The
camp or its medical advisor will assume no responsibility for unauthorized
Some phone numbers you may need: Emergency Medical System (EMS/ambulance): 911 Medical Advisor: Beverly J. Niehls, MD Home: 610-385-4548 Cell: 484-769-2129 Office: 610-779-1330 (If you must call the office during the physician’s hours, please be aware that you may need to leave a message for a return call, the physician may not be immediately available to speak to.) Pottstown Memorial Medical Center: Main Switchboard: 610-327-7000 Emergency Room: 610-327-7100 Saint Joseph Medical Center: Main Switchboard: 610-378-2000 Emergency Room: 610-378-2330 Reading Hospital and Medical Center Main Number: 610-988-8000 Emergency Room: 610-988-8218 Poison Control Center: 610-375-9115 Urgent Care Centers: “Immediate Medical Care” Rte 422 (Benjamin Franklin Highway) Douglassville, PA Local Pharmacies: Rite Aid Douglassville (Redner’s Plaza) 610-385-6643 CVS Douglassville (next to Immediate Medical Care) 610-385-4300 Giant Pharmacy Exeter 610-370-1961 Local Dentists: Harry Eshbach Rte 422 & 662 Douglassville, PA James Mason 5th and Montgomery Sts Boyertown, PA David Szymanski 100 S. Chestnut St Boyertown, PA Local Physicians: Family Medical Center E. 1st and Spruce Streets Birdsboro, PA 18 Church Lane Douglassville, PA Oley Valley Medical Center Some general principles to keep in mind: If you are considering sending a camper off site for treatment, please communicate this with the director as soon as possible. Also, bring the parents into the discussion as soon as possible. Families who live locally may want to pick up the child and take them to their regular physician if possible, or may have a preference of hospital if necessary. If a camper can be transported for care safely by automobile this is preferable to calling an ambulance as these transports are often not covered by insurance and can be quite costly. The camps insurance covers accidents only, not illness or preexisting conditions. It is a secondary insurance and the parents insurance is considered primary so send along insurance information if a camper is taken for treatment. In the event you call an ambulance for a child, once the child is in the hands of Emergency Personnel, have someone accompany the child with whom the child is comfortable. Do not leave the camp unattended while you go with the child. Any questions or concerns should be addressed to the director as soon as they arise. Welcome! Thank you for your help this week! Please make sure there is a copy of your license and malpractice insurance verification on file in the camp office. 1. There is “Health Policies and Procedures” book available in the Nurses Cabin. Please familiarize yourself with this manual. The protocols contained in this manual were written by a licensed physician and may be construed as standing orders. 2. At registration you will collect the Health History forms for all campers. Please review them for any campers with special needs (medications to be given, dietary needs, allergies, etc.) Please make the counselors aware of any special situations. These forms should be kept with the Nurse for the extent of the week and returned to the office at the end of the week. 3. Keep a log of all incidents. Copies of the form you need are in the Nurses Cabin. Additional copies are available at the camp office. These logs should be turned into the office at the end of the week. 4. Keep all “Individual Medication Forms” up to date, documenting medication given, amount and time. Accurate records protect the Camp and you from liability. 5. There are others on staff, which are trained in first aid and CPR (such as the lifeguards). You should familiarize yourself with them in case their expertise is needed. 6. If someone needs to leave the camp to receive medical treatment, transportation by car should be used whenever appropriate. A responsible adult, not the nurse who should not leave the other camper unattended, must accompany campers who leave the camp. Insurance and medical information should be sent along with the camper. 7. Check with your director concerning the use of 2-way radio for emergencies and needed communication. Cell phones may also be useful for this purpose. 8. You will receive keys to the Nurses Cabin from the camp office at the beginning of the session. Please return them to the camp office at the conclusion of the week. 9. If you have any questions please contact the Director. Administration of Over the Counter Medications The Nurses Cabin will be stocked with commonly used over the counter medications. These are for use at the discretion of the health care staff and according to the protocols set forth in the following pages. Below are dosing instructions for some common products according to age group, in some cases the children’s doses are based on weight. To convert a weight from pounds to kilograms (kg), take the weight in pounds and divide by 2.2. 1. Acetaminophen (Tylenol): Children: Not recommended for children/adolescents due to increased risk of Reyes syndrome. Adults: 325-650mg every 4-6 hours Age 2-6 12.5 mg every 4-6 hours Age 6-12 12.5-25 mg every 4-6 hours Age over 12 25mg every 4-6 hours Adults 25-50mg every 4-6 hours Children: 4-10 mg/kg every 6-8 hours Adolescents: 200-400 mg every 6-8 hours Adults: 400 mg every 6-8 hours Children age 2-5 (13-20 kg): 1mg after each loose stool up to three doses in 24 hours Children age 6-8 (20-30 kg): start with 2mg dose and repeat dose at 1mg after loose stools, no more than 4mg per day Children age 8-11 (30-40 kg): start 2mg dose and repeat dose at 1mg per dose up to 6mg per day. Children 12 and older: start with 4mg initial dose, repeat doses at 2mg up to 8mg per day Adults: start with 4 mg initial dose, repeat doses at 2mg up to 16 mg per day Children: 5-15 ml up to 4 times a day Adults: 15-30 ml up to 4 times a day Children >12 yrs: 220mg tablets - one every 8-12 hrs Adults: 220mg tablets – two every 8-12 hrs Children >12 yrs: 2 tabs or 30 ml up to every hour as needed for diarrhea Adults: 2 tabs or 30 ml up to every hour as needed for diarrhea Maximum dose: 16 tablets or 8 oz in 24 hours. From time to time donations of other over the counter medications are made to camp, the use of these medications is at the nurses discretion but it may be advisable to check with parents first, especially combination cold medications, as children may be sensitive to one or more ingredient. There are several topical medications stocked in the nurse’s cabin as well. These include: Antibiotic cream or ointment (Neosporin, Bacitracin, etc.) Baking soda (to apply as a paste for beestings, etc.) Calamine lotion (for rashes such as poison ivy) Hydrocortisone Cream for itchy rashes and bites Adolf’s Meat Tenderizer (for bee stings) Generally these are applied 2-4 times a day at the health care staff’s discretion. Campers and Staff may bring other over the counter medications with them to Camp. They should be handled the same as prescriptions medications brought from home. They will be collected at registration, and will need written instructions from a physician for their use. Abdominal Pain
Abdominal Pain may represent something as simple as homesickness or something more serious as appendicitis. Deciding who simply needs TLC and who needs urgent hospital evaluation is a challenge. Usually a child who “looks well” is well, and a child who “looks sick” is. Most of the time a child who comes to you with a “belly ache” will have a bit of upset from the food, the heat, or too much “canteen”. Viral gastroenteritis is known to go around in the summer though and may cause a mini-camp epidemic. Pre-adolescent and adolescent girls may have menstrual cramps (or something more serious such as a ruptured ovarian cyst or pregnancy). For the adults, don’t forget things like gall bladder attacks and kidney stones as possibilities. Acute treatment: For abdominal pain in an individual who does not look acutely ill: rest, clear liquids and Tylenol (in age appropriate doses). For those with menstrual cramps, Aleve or Advil should be given. If symptoms persist, considering calling the parent to have the child seen by a physician. Physician consultation advised: Pain accompanied by fever, severe vomiting, or urinary complaints. Pain that doesn’t improve or worsens with above treatment Pain localized to the right lower quadrant of the abdomen. Pain with a known or possible pregnancy Pain with persistent vomiting and/or diarrhea with signs of dehydration, Colicky pain with history of kidney stones Pain accompanied by blood in vomitus or bloody diarrhea. Ambulance transport advised: Person who appears acutely ill with sweating, low blood pressure, tachycardia, high fever, dehydration, lethargy Animal Bites
All animal bites penetrating the skin need to be evaluated by a physician. Treatment will include wound care, antibiotics, tetanus prophylaxis if needed, and possibly rabies prophylaxis. If the bite is from a domestic animal, the animals shot records should accompany the patient for evaluation. If the bite is from a wild animal, capturing the animal is advised (if it can be done without risk to other individuals, killing the animal for capture is acceptable.) If there is snakebite, the same first aid measures are to be applied and the patient should be transported for Emergency Room evaluation as soon as possible. Do not apply a tourniquet or attempt to remove the venom. Cleanse the area with soap and water, or betadine if available. Apply pressure to control bleeding. Apply a sterile dressing. Tourniquets are not advised for the treatment of animal bites, including snakebites. Uncontrollable bleeding Disfiguring wounds Potential Venomous snakebite Asthma is the most common chronic disease of childhood. You will have campers on asthma meds. It is imperative for these children to have their medication regularly. Children with asthma should be able to participate in all camp activities if their asthma is well controlled. Asthma is also a potentially life threatening disease and should be given due diligence in treatment. Asthma medications fall into two categories: Maintenance Steroid inhalers or nebulized steroids (fluticasone, betamethasone, etc.) Long acting beta-agonists (serevent, foridil) Theophylline (this is rarely used in children) Multidose inhalers (albuterol, maxair, etc.) Nebulized medications (albuterol, xopenex) A camper may arrive on oral steroids; these are generally used to treat an acute, severe asthma attack. If a parent brings a child to camp on oral steroids, be especially watchful of that child, they may be at increased risk for a flare up. Maintenance medications should be given according to the prescribing physician’s directions. Rescue medications should also be given according to the prescribing physician’s directions. If a camper is involved in an activity, which takes them away from the camp central location, it may be advisable to send the rescue inhaler along either with the camper if he or she is old enough, or with the counselor. The following are general guidelines and do not override the prescribing physicians directions. Initial treatment of an acute asthma exacerbation: Move the child to an air-conditioned environment. Administer the rescue medication according to the prescription. If no improvement after 20 minutes, the rescue medication may be repeated. If the child remains short of breath, physician evaluation is advised. If there is evidence of severe respiratory distress, such as inability to converse, posturing with the torso leaning forward, retractions of the abdominal or supraclavicular areas with inhalation, rescue medication should be given and EMS called. Back Pain
Complaints of back pain are more likely to come from the staff, from acting like kids. Common strains and sprains are usually minor and occur from overuse or incorrect lifting technique. Other causes of back pain include renal stones, kidney infection, herniated discs, sciatica, etc. Initial treatment: Ice to area 20 minutes at a time every 2-3 hours Ibuprofen, Naprosyn or Tylenol in age appropriate doses Restrict lifting to 10 –15 pounds until pain subsides Physician consultation advised: Back pain with weakness or numbness in a lower extremity Back pain accompanied by fever Back pain, which worsens or does not improve with conservative measures The type of burn will direct management. First-degree burns are superficial. They cause the area to become reddened and painful. They will heal without a scar. Second-degree burns are a bit deeper into the epidermis and will cause blistering. They are painful and are at risk of developing secondary infection. Third degree burns are through the epidermis into the dermis. They cause the skin to slough and cause extensive scarring. Risk of infection is high. The area involved is also important to management. Burns tend to cause the body to lose fluids, the greater the area of involvement, and the higher the risk of dehydration. Initial treatment: Cool the area with cool, moist compresses. NOT ICE, ice can cause greater tissue damage. Apply non-stick dressing (telfa). If there is a blister, leave the blister intact. If there is an area of denuded skin, antibiotic cream and a non-stick dressing should be applied. Change the dressing twice a day, cleansing the area gently and reapplying antibiotic if indicated. Age appropriate doses of Tylenol or Ibuprofen can be given. If there is evidence of infection developing seek physician consultation. Transport to the emergency room if any of the following situations exist: Second degree burns covering more than 5% body surface (1% is about the size of the victims palm), or involve the face or perineum Any second degree burn which extends circumferentially around a digit or Chest Pain
Traumatic Chest Pain:
When someone comes to you with chest pain associated with a trauma, like getting
kicked in the pool, etc., the concern is whether there may be rib fractures or organ
Apply cool compresses to the area 20 minutes every 2-3 hours Age appropriate doses of Tylenol, ibuprofen or Naprosyn Non-traumatic Chest Pain: When someone presents with chest pain not associated with a trauma, the risk for heart attack must be assessed. In a child or adolescent this is not likely, not impossible but not likely. In adults the complaint of chest pain must be taken seriously and dealt with as a life-threatening situation. Such things as reflux, indigestion, gall bladder disease, and muscle strain may cause chest pain but that determination should not be made at camp. All adults with chest pain should be sent for physician evaluation. Call an ambulance if the chest pain is accompanied by: Fainting History of high blood pressure, angina, or previous heart attack Diabetes
There may be campers as well as staff members who are diabetic. Diabetes is becoming
more common among children and adolescents as our population becomes heavier.
There is a direct correlation between weight and the onset of non-insulin requiring
diabetes. Individuals with diabetes should bring to camp, their medicines, their glucose
monitor, any protocols for dealing with high and low blood sugars, and glucagons
injection or glucose tablets if they have them. The change in diet and activity levels may
cause fluctuations in blood sugars.
Children with insulin requiring diabetes should come to the nurse cabin for their
chemstrips and insulin injections, even if they take care of it on their own at home. This
will give you an opportunity to check on them periodically.
Early signs of hypoglycemia (low blood sugars) may include confusion, disorientation,
sleepiness, sweating, and tremors. Symptoms may start to occur at 70mg/dl. Checking a
chemstrip may be helpful but do not delay intervening in the situation. If glucose tablets
are available, 4 tablets should be given and the blood sugar checked in 5-10 minutes. If
glucagons injection is available it should be given. If neither of these are readily
available sugar or a sugary substance should be used. Orange juice is naturally high in
sugar so additional sugar need not be added. Soft drinks are appropriate if the only thing
available. Crackers or bread are high in carbohydrate and can be given, keep in mind that
the medication Precose blocks the break down of carbohydrates so if the diabetic is on
this med using crackers won’t help.
If you have trouble bringing the sugar up or the person becomes unconscious do not
hesitate to call 911.
High blood sugars may not result in symptoms at first. Blood sugars that are persistently
high may put someone at risk for diabetic coma or ketoacidosis. If a camper's blood
sugars start to show a trend upwards and they have not brought a protocol with them, you
may want to call the parents and see if they have instructions from their physician.
Abdominal pain, vomiting, lethargy, and a fruity odor on the breath may herald onset of
ketoacidosis. Call 911 if a diabetic develops any of these signs.
There are many causes of diarrhea, change in diet, anxiety, viruses, food poisoning, etc.
Fluid replacement with clear liquids, avoid dairy products, citrus juices and heavy foods.
Adhere to a bland diet (BRAT diet – bananas, rice, applesauce, and toast).
You may use pepto bismal (in children over 12 yr old or adults) or Imodium if desired.
Physician consultation advised:
Diarrhea accompanied by:
Vomiting which persists beyond 24 hours Severe abdominal pain High fever Signs of dehydration (dry mucous membranes, decreased tears, decreased Bloody diarrhea Diarrhea persisting more than 3-5 days Earache
Earache can be caused by an infection or inflammation of the external ear canal
(swimmer’s ear) or by pressure or infection of the middle ear (otitis media).
Age appropriate doses of Tylenol or Motrin can be given.
Several drops of hydrogen peroxide may be placed in the ear and a warm compress
Physician consultation suggested:
Significant earache accompanied by fever, sore throat, etc.
Pain that lasts more than 24 hours
Children get fevers often, usually they are a sign of minor illness such as viruses. Low-
grade fever can occur from environmental heat exposure as well.
Rest in an air-conditioned environment and age appropriate doses of Tylenol or Advil
should be given. Fever and a hot environment create a situation where dehydration can
easily occur so be careful to make sure these children are adequately hydrated.
Physician consultation when:
Fever that persists beyond 48 hrs with conservative intervention
Fever accompanied by signs or symptoms of localized infection such as, sore throat,
earache, abdominal pain, vomiting or diarrhea, pain on urination or signs of dehydration
You may want to consult with the parents; they may want to take the child to their regular
Head injury may be a fairly common occurrence and most often is minor. Be careful not
to dismiss a head injury too lightly as complications can be sudden and potentially
If the camper or staff member sustains a head injury with NO loss of consciousness,
check the orientation, vital signs, pupillary response, strength and coordination. If there
are any concerning findings, evaluation by a physician is recommended. If there are no
alarm signs, ice to the area, Tylenol or Motrin for pain if needed and observation are
recommended. Recheck the camper/staff member every 2-4 hours for the first 12-24
hours. If there is any change in status or if lethargy or vomiting develop, consult a
Physician evaluation recommended:
If there is a head injury with a loss of consciousness, always have the person seen in an
urgent care center or emergency room! Give nothing to eat or drink until the person is
seen. In the event that the person has a seizure clear the area around the person to prevent
injury, do not attempt to restrain them, do not place anything in the mouth, and call 911.
When the seizure stops, secure the airway and protect the victim from further injury.
Monitor the victim until EMS arrives.
If there is a head laceration with no other concerning symptoms, see the laceration
Head lice outbreaks occur at camp once in a while. If you notice a child who is
scratching the scalp, particularly at the nape of the neck and behind the ears, check for
nits. Nits are very small white specks that adhere to the hair shaft, as opposed to
dandruff, which can easily be brushed off the hair. If you find a camper with head lice,
notify their parents. They must be isolated until treated. Check the other campers in their
cabin as well. If you find 2 cases from different cabins, check the camp.
Treatment of Head Lice:
Isolate the child until treated. Shampoo the scalp with medicated shampoo, such as Rid
(Available over the counter.) Remove as many nits as possible with a fine-toothed comb.
Brushes and combs are to be washed in hot water mixed with bleach (1 part bleach to 9
parts water.) Clothing, linens and hats should be laundered in hot water. Stuffed animals
and pillows should be placed in a plastic trash bag for 3 weeks before used again.
Headache may occur as a result of sun exposure, fatigue, homesickness, viruses, bacterial
infections, hypertension, tension or migraines to name a few. Evaluation must take into
consideration the diversity of conditions that may result in this symptom.
Check vital signs. This may direct you to the cause of the headache. Fever would
suggest the presence of an infection and should be dealt with accordingly. Elevation in
blood pressure should prompt a call to the parent or the staff member’s physician. Low
blood pressure might suggest dehydration, which also should be dealt with accordingly.
Age appropriate doses of Tylenol or Motrin should be given
Reevaluate in a few hours to see if things have improved, if not recommend a physician
Urgent physician evaluation recommended:
Headache accompanied by fever, stiff neck, lethargy or confusion,
Headache accompanied by the sudden onset of inability to speak or loss of function.
Heat Stroke/Sun Stroke
Overexposure to heat and sun can lead to what is commonly referred to as sun poisoning,
heat stroke, or sunstroke. Generally this is secondary to dehydration and an elevation in
core body temperature because the body’s natural cooling mechanisms are compromised.
Early symptoms are fatigue, headache, abdominal pain and muscle cramps. Treatment
consists of removing the victim to a cool environment and rehydration with oral
electrolyte solution such as Pedialyte or Gatorade (in older children and adults).
Later symptoms are as above accompanied by vomiting, confusion, disorientation and
lethargy. In this situation, treatment should be in a medical facility for IV fluids, and
monitoring. Call EMS for transport.
Homesickness is included here to remind everyone to be sensitive to the young child who
needs some “mothering”. Some children will come in with physical symptoms and
others will be very up front about being home sick. Gentle comfort and encouragement
will heal a lot of ills. Just a word of caution though, a homesick child will try to make a
case to allow a phone call home. This generally backfires and once they have heard
Mom or Dad’s voice on the phone the desire to leave becomes worse. Also, once having
comforted the child and they have returned to their counselor and regular activities, you
should keep an eye on them to make sure they aren’t harboring an illness.
Over the years, the camp has played host of a variety of biting insects and arachnids,
bees, wasps, mosquitoes, spiders and ticks have plagued campers and counselors alike.
Most often a local reaction is all that results from any of these bites. Redness, swelling,
itching and burning are common. Wasp stings can result in significant swelling,
occasionally involving an entire extremity.
Cold compresses to control swelling 20 minutes every 2-3 hours
Hydrocortisone (1/2 %) 2-3 times a day
Benadryl in age appropriate doses for the itching
Generalized allergic reaction:
Observe anyone who is bitten or stung for an hour or so for signs of allergic reaction such
as hives, facial swelling, shortness of breath or tightness of the throat. If there is a history
of allergic reaction, the victim may have brought an epipen kit and physician instructions.
If so, administer the epipen injection and give the appropriate dose of benadryl. Most
often the patient is instructed to proceed to the emergency room if the kit is administered.
If this is the case, follow through with that protocol. Occasionally, there is a protocol that
calls for observation for several hours and 1-2 days of regular benadryl doses. Again if
this is the physician protocol, follow it. When in doubt, send them out. If there is any
sign of respiratory compromise, call 911.
Lacerations are an area where you will have to rely on your own judgment. A small or
superficial laceration can be managed appropriately at camp. If you believe sutures are
necessary for adequate wound closure, consult with the director and camper’s parents and
have the patient taken to the local urgent care center or the emergency room. In the event
a laceration is severe and is life or limb threatening, call an ambulance.
Wash the area with mild soap and water
Apply direct pressure to control bleeding; under no circumstances should you apply a
tourniquet. If bleeding is severe, call 911.
If minor, the wound may be steri-stripped or closed with derma bond (glue)
Apply antibiotic ointment and a dressing.
Check the wound once a day for signs of infection (redness, swelling, drainage, etc), if
the wound appears to be getting infected, physician consultation is advised.
Check the patient’s tetanus status, all campers should have a record of the last tetanus
shot. If it has been more than 10 years since the last tetanus shot, physician consultation
is recommended. The tetanus shot can be given up to 48 hours after the laceration if
Girls will get their periods at camp from time to time; occasionally it will be a first period
that will catch them unaware and unprepared. There is usually a stock of pads and
tampons in the nurse’s cabin for just such an occasion (some parents may not want their
daughter to use a tampon so a quick phone call to Mom or Dad may be in order). In the
event that a young lady gets her period and hasn’t been prepared by her parent or teacher
you may need to brush up on your “birds and bees” talk.
Symptoms occurring with menses differ from person to person but may include cramps,
aching the legs and pelvis, and nausea.
Warm compresses can be soothing and age appropriate doses of Advil or Aleve can be
helpful. Tylenol can be used in women allergic to NSAIDs, but is less efficacious.
Seek physician evaluation:
If there is severe bleeding or if there is a chance that the bleeding may represent a
If you are presented with the complaint of PMS, good luck.
Nosebleeds generally occur as a result of trauma to the nose, either internal (i.e. Picking)
or external, as well as forced blowing and occasionally spontaneously.
Tip the head slightly forward, and pinch the nose just below the bony ridge. Apply
constant pressure for 5 minutes without releasing. Encourage the patient to breathe
through the mouth and cough out blood. They should not swallow it. Blood in the
stomach causes nausea and vomiting which can restart the bleeding.
After 5 minutes gently release the pressure. If the bleeding resumes, repeat pressure for 5
minutes and check again. If after 3 tries, the bleeding persists, take the patient to the
emergency room or urgent care center.
Call an ambulance if:
The patient complains of dizziness or passes out
If there is an elevation of blood pressure greater than 160/90 in someone who has no
history of hypertension or greater than 180/100 in someone with a known history of
hypertension (I have never seen a patient with a nose bleed who didn’t have some
elevation in blood pressure.)
After the bleeding is controlled encourage the patient to take it easy for the rest of the
day, no strenuous exercise, no heavy lifting. Encourage them to NOT manipulate or
blow their nose for the next 12 hours. Wipe below the nostrils, not across them.
If someone has 3 nosebleeds in one day, physician consultation is advised.
Pinkeye (conjunctivitis) is a superficial inflammation of the conjunctiva, the membrane
covering the eye. Allergies, viruses, irritants and bacteria all can cause conjunctivitis.
Prescription antibiotic drops are only needed for bacterial conjunctivitis. Allergic,
irritant, and viral conjunctivitis can be managed with symptomatic treatment.
Cool compresses can be very soothing. A moist washcloth is appropriate, make sure it is
not shared and is laundered in hot water after use.
Irrigation with saline can be helpful in the event of irritant conjunctivitis.
Anti histamine drops (available over the counter) can be helpful with itching and burning.
Consult a physician if there is purulent drainage (yellow or green discharge). Consider
isolating a child with bacterial conjunctivitis until treated for at least 24 hours.
(Insurance companies do not regard conjunctivitis as an emergency so it would be better
to utilize an urgent care center in this situation.)
*Anyone who develops conjunctivitis and is a contact lens wearer MUST remove his or
her lenses. Wearing contact lenses with conjunctivitis may cause permanent damage to
the conjunctiva. Lenses must be properly disinfected or discarded.
A pregnant camper or staff member may be treated as any other camper or staff member
with a few exceptions.
1. Do not give any other medications except for Tylenol unless instructed by the 2. Encourage hydration and decreased activity in very hot weather. 3. If the patient is experiencing morning sickness, the best approach is usually keeping something in the stomach at all times. (Nibbling on crackers, pretzels, and dry cereal can be helpful.) 5. A pregnant woman with any complaints of pelvis pain or vaginal bleeding (including spotting) needs to be evaluated by her obstetrician or in the emergency room. Common rashes you may see at camp include: Contact dermatitis (including poison ivy and poison oak): presents with small red papules (bumps) and vesicles (blister like lesions). These are itchy and spread in the exposed area. Heat rash: areas of tiny red bumps, rarely itch, often in skin folds These can all be safely treated conservatively with cool compresses, hydrocortisone cream twice daily, and benadryl for itching. Other rashes you may encounter: Hives: (Diffuse itchy red blotches) Hives usually indicate an allergic reaction and should be evaluated by a physician. If there is any associated respiratory difficulty, throat itching or swelling, dizziness, or passing out, or if there is exposure to a known allergen call 911 immediately. If an Epipen is available administer per instructions. Chicken Pox: Most children will have had a Chickenpox vaccine so this is becoming uncommon. If a child develops a rash, which looks like small blisters on a red base, isolate the child and have the parents come and take the child for evaluation. Scabies: a mite that burrows under the skin causes Scabies. The lesions are minute red bumps that are intensely itchy and form small lines primarily in the webs of the fingers and in the area of the waistband and groin. If you suspect scabies, the child should be isolated until a physician can evaluate them. Shingles: Since the advent of the varicella vaccine, there has been an increase in the incidence of shingles in children. Shingles occurs as a result of the reactivation of the varicella virus. It appears very similar to chickenpox but is limited to one area of the body. If you suspect shingles, a physician should see the patient ASAP, as early treatment is important to limit complications. Sore Throat
Sore throat occurs frequently and is most often caused by viruses (including
mononucleosis). Occasionally a case of strep throat will occur at camp. Deciding who
can be managed at camp and who needs physician evaluation can be difficult.
Lozenges, chloroseptic and age appropriate doses of Tylenol can be helpful in treating a
camper/staff member with a sore throat. Gargling with salt water can be soothing, mix ¼
tsp of salt with 4 oz of water and gargle 3-4 times a day or as desired.
Physician evaluation recommended:
Fever over 101.5 F, worsening symptoms, lethargy, vomiting, shortness of breath,
difficulty swallowing or rash should prompt a physician evaluation.
Children may attend camp that have a seizure disorder and are on anticonvulsant
medication. In this case, it is absolutely critical they receive their medications as
prescribed. Seek the kids out if need be. If they are persistently difficult to find and resist
their medications, call the parents. If the parents are unsuccessful in improving the
child’s compliance, send the child home. The child’s safety cannot be compromised.
Even children with controlled seizure disorders and who comply with treatment may have
a break through seizure.
Management of a seizure:
Clear the area to avoid injury to the child.
When the seizure subsides, roll the patient onto their side to avoid aspiration.
Don’t put anything in their mouth – especially not your fingers. People don’t really
swallow their tongue. They may have an airway obstruction, which can be relieved by
rolling the patient onto their side.
When the seizure activity subsides, the patient may be very confused and disoriented.
Gentle reassurance is needed until the “post ictal” period resolves. Hospital evaluation is
necessary even if the patient comes out of it to check their medication levels and assure
that nothing else is wrong.
Splinters can be tricky, especially in small children.
Cleanse the area with soap and water, if it appears that you can easily remove the foreign
body with tweezers, do so. If it appears that the object is imbedded, seek physician
If you choose to remove the object, wash the area again and apply antibiotic ointment and
a bandage. Check on the area in 24 hours to make sure infection hasn’t set in.
In the event you are faced with a foreign body of the eye, try and irrigate the object free
using saline solution. If you are unsuccessful, do not use any instrument to remove it,
seek physician consultation.
Injuries will occur at camp. You will be in a position to triage these injuries to watchful
waiting, physician consultation and calling EMS. Some general guidelines follow.
If there is an open fracture or visible deformity of the limb, it is recommended that EMS
be called. Transporting this patient in a private vehicle is a potential liability. Do not
give the patient anything to eat or drink, not even water, while waiting for the ambulance.
These injuries usually require surgery and giving the patient anything by mouth will
delay the procedure.
Injuries that present with pain with or without swelling can be treated conservatively with
ice elevation and rest. If there is significant loss of function or if things do not start to
improve with conservative management, physician evaluation is advised. You can give
age appropriate doses of Tylenol or Motrin for pain.
After a water rescue, the victim should be evaluated thoroughly. If the victim was
conscious throughout the incident, and is in no distress, observation in the nurse’s cabin
for a couple hours is advised. If the victim has been unconscious for any period, however
short, if CPR was started or if there is any residual respiratory distress, the victim should
be sent to the emergency room for evaluation. If CPR was initiated the victim should be
transported by ambulance so they can be monitored.
(It is recommended that you are aware of other staff members that are First Aid/CPR
certified and are able to utilize their expertise in this area.)
Sunburn is fairly common and relatively minor. Minor cases can usually be managed
with cool compresses 20-30 minutes every 2-3 hours. Avoid ice directly on the skin as
more tissue damage may result. Apply hydrocortisone ½ % twice a day to the area. Age
appropriate doses of Tylenol or Ibuprofen can be given for pain. If a significant are of
skin is involved, there may be significant fluid loss as well. Make sure to replace fluids
and encourage adequate hydration. If there is significant blistering, physician evaluation
is advised. As sunburn heals, there may be a lot of itching. Benadryl in age appropriate
doses may be helpful to relieve itching.
There are two species of ticks endemic to eastern PA.
The common wood tick, these are the kind that you pull of your dog. They are about 3-4
mm in diameter. They are dark colored with white marks near the head. The wood tick
can carry Rocky Mountain Spotted Fever. The incubation period for Rocky Mountain
Spotted Fever is 3-10 days and presents with fever, chills, body aches and abdominal
pain. Diffuse red papules usually develop on the third day.
The deer tick, these are much more difficult to see. They are ½-1mm diameter and are
dark orange brown with black markings near the head. These ticks can carry lyme
disease. The incubation period for lyme disease is 10-14 days. Lyme disease presents
with flu like symptoms. 40% of patients with lyme disease will develop the classic
“bull’s eye” rash.
If someone comes to you with a tick on the skin, remove the tick by grasping the tick at
the skin surface and pull firmly, use tweezers if they are available. It is a common
misconception that the tick burrows into the skin, the pincers may become imbedded, but
the tick will not burrow. If the pincers remain after you pull the tick off, resist the
temptation to dig it out; they will be expelled by the bodies natural defense mechanism.
Apply antibiotic ointment and a dressing. Keep an eye on the area for signs of secondary
Both Rocky Mountain Spotted Fever and Lyme Disease are easily treated with oral
antibiotics. If a child comes to you with a tick, let the parent know so they can keep an
eye on them and take them to a doctor if they become ill.
*There is now a recommendation from the CDC to give preventative antibiotics to any
one who gets bitten by a deer tick and it has been attached for more than 24 hours. You
may want to discuss this with the patient or their parents and they can contact their
personal physician for instructions.
This is more likely to be a staff complaint than a camper complaint. Toothaches usually
occur as a result of dental caries or abscess. Age appropriate doses of Tylenol or Motrin
can be given. If pain is severe Tylenol and Motrin can be given together, but do not give
more than the recommended dose. Higher than recommended doses of Tylenol has been
associated with liver failure. High doses of Motrin can cause ulcers.
If the pain is not controlled with over the counter analgesics, consult a local dentist (see
the list of numbers at the beginning or check the yellow pages). The emergency room
and local urgent care centers do not have dentists on duty and can provide antibiotics for
infection and stronger analgesics but a dentist will still be needed for definitive treatment.
Nausea and vomiting can be a symptom of viral gastroenteritis, food poisoning (pray this
never happens at camp) or heat stroke. Less frequently, pregnancy or appendicitis may
1. Rest in air-conditioned environment. 2. When the vomiting subsides, start fluid replacement. a. Wait until there has been no vomiting for 1 hour. Start small amounts of clear liquids: flat soda, sweetened tea, Jell-O, Kool-Aid, apple juice: avoid plain water, milk, and orange juice. Gradually increase the amount. When there has been no vomiting and clear liquids are being tolerated for 4-6 hours, small amounts of bland foods like saltines, dry toast, dry cereal, plain rice or pasta, applesauce, bananas can be given. When clears and blands are well tolerated for 24 hours, the diet can be expanded but continue to avoid greasy, heavily spiced and dairy products for 72 hours. b. Activities can start to return to normal after no vomiting for 24 hours. a. The vomiting cannot be controlled after 8-12 hours in a child, or 12-24 b. Dehydration develops as evidenced by decrease in urination, dry mouth,
Cartilla de Cobertura -------------------- PLAN CORAL ------------------- PRESTACIONES MÉDICAS Todas las prestaciones serán reconocidas sólo en los prestadores incluidos en la Cartilla de PREME. La atención se brinda mediante la sola presentación de la credencial de afiliado en la nómina de prestadores del presente plan. I ) ATENCIÓN PRIMARIA La atención se bri