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Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 1 of 66
Lakeridge Health Corporation
Emergency
Medical Directives
MAC Approved:
October 18, 2005
2005
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 2 of 66
TABLE OF CONTENTS
GENERAL PREAMBLE: .................................................................................................. 3
ADULT ASTHMA MEDICAL DIRECTIVE (replaced by Nov 2009 directive) ................... 5
ADULT FEVER MANAGEMENT ..................................................................................... 6
ANKLE AND FOOT XRAYS ............................................................................................ 8
CHEST PAIN (ISCHEMIC) MEDICAL DIRECTIVE ....................................................... 11
CONSCIOUS OVERDOSE MEDICAL DIRECTIVE ...................................................... 13
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (replaced by Nov 2009 directive) ....... 16
EMLA CREAM OR PATCH ........................................................................................... 17
FOREARM/ELBOW XRAY ............................................................................................ 19
FRACTURED HIP ......................................................................................................... 21
HAND AND/OR FINGER XRAYS ................................................................................. 23
HYPOGLYCEMIA.......................................................................................................... 25
HYPOTENSIVE VAGINAL BLEEDING ......................................................................... 27
INGESTED FOREIGN BODY ....................................................................................... 29
INSTILLATION OF TOPICAL ANESTHETIC FOR EYE DISCOMFORT ....................... 30
KNEE XRAY .................................................................................................................. 32
TOPICAL LIDOCAINE, EPINEPHRINE, TETRACAINE (LET) ...................................... 35
PEDIATRIC ASTHMA MEDICAL DIRECTIVE (replaced by Nov 2009 directive) .......... 36
PEDIATRIC FEVER MANAGEMENT ............................................................................ 37
PEDIATRIC HYPOGLYCEMIA ..................................................................................... 39
PEDIATRIC SEIZURE (UNDER THE AGE OF 10) ....................................................... 41
PULMONARY EDEMA .................................................................................................. 43
RENAL COLIC .............................................................................................................. 45
SALINE IRRIGATION OF THE TREATMENT OF CHEMICAL EYE BURNS ................ 47
SEIZURE IN PATIENTS OVER THE AGE OF 10 YEARS ............................................ 49
TETANUS/DIPTHERIA/PERTUSSIS IMMUNIZATION ................................................. 50
URINE SAMPLING........................................................................................................ 52
URINARY CATHETERIZATION .................................................................................... 53
WRIST AND SCAPHOID X-RAYS ................................................................................ 55
LIST OF AUTHORIZING PHYSICIANS: LAKERIDGE HEALTH OSHAWA .................. 57
LIST OF AUTHORIZING PHYSICIANS: LAKERIDGE HEALTH BOWMANVILLE ........ 58
LIST OF AUTHORIZING PHYSICIANS: LAKERIDGE HEALTH PORT PERRY ........... 59
SIGNATURE LIST OF COMMITTEE AND PROGRAM APPROVALS (Chairs) ............ 60
REVIEW AND APPROVAL TRACKING FORM ................................................................... 61
APPENDIX 1 REFERENCES ........................................................................................ 62
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 3 of 66
GENERAL PREAMBLE: These Medical Directives are applicable to the Lakeridge Health Corporation Emergency Departments at the Bowmanville, Oshawa and Port Perry Sites. The Authorizing Physicians are the practicing Emergency Physicians at the 3 hospital sites as outlined in the Authorizing Physicians Section of the preamble. These Authorizing Physicians will be authorizing all the medical directives outlined in this document. The directives are not applicable to Consulting Physicians or Family Physicians seeing their own patients directly in one of the Emergency Departments unless that Physician is a listed signatory to this document. “Appropriately Educated” Health professionals will refer to those employees of Lakeridge Health who have successfully attained certification by a course of self study supplied by the Clinical Education leader of the Emergency Program and successfully passed a written examination. The content of the Educational package will be approved by the Corporate Emergency Council. The Authorizing Physicians expect that only appropriately educated Health Care Practitioners; who are employees of Lakeridge Health Corporation: with the specific professional qualifications as outlined in each medical directive will implement these medical directives. The Authorizing Physicians also expect that the Health Care Practitioners performing the medical directives will adhere to the specific clinical conditions/circumstances and contraindications. Deviation from these medical directives is not authorized by the Emergency Physicians. The Authorizing Physicians expect that Lakeridge Health Corporation will provide the initial and ongoing education and ongoing continuous quality improvement of these medical directives as directed by the Emergency program. It is expected that all staff authorized to perform a medical directive will obtain and document appropriate informed consent prior to carrying out the medical directive. Documentation of the use of a Medical Directive will be made with a notation in the space provided on the Emergency Department Health Record and a copy of the specific Medical Directive will be attached to the permanent Emergency Department Health Record.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
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This will apply to the 2005 Emergency Department Directives listed: Adult Asthma Adult Fever Management Ankle & Foot X-rays Chest (Ischemic) Pain Conscious Overdose COPD Emla Cream Patch Forearm Elbow X-rays Fractured Hip Hand or Finger X-ray Hypoglycemia Hypotensive Vaginal Bleeding Ingested Foreign Body Instillation of topical Anesthetic for Eye discomfort Knee X-ray LET Pediatric Asthma Pediatric Fever Pediatric Hypoglycemia Pediatric Seizure Pulmonary Edema Renal Colic Saline irrigation of the eye Seizure Tetanus Diptheria Pertussis Immunization Urinalysis Urinary Catheterization Wrist & Scaphoid X-ray
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 5 of 66
NOTE: Please see revised “Adult Asthma” Medical Directive, approved Nov 10, 2009, posted separately on the WAVE in Medical Directives>Emergency folder.
Adult Asthma (LHC) revised Nov 10, 2009
ADULT ASTHMA MEDICAL DIRECTIVE
Previous version of this medical directive approved by MAC Oct 2005 Has been ARCHIVED
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 6 of 66
ADULT FEVER MANAGEMENT MEDICAL DIRECTIVE
Authorized to who: An appropriately educated Registered Nurse in the Emergency Department may initiate the following therapies for patients who present with a documented febrile episode. Medical Directive Description: Adults may be given Acetaminophen 650 mg per os or per rectum prn for temperature >38 Celsius x 1 dose OR One dose of Ibuprofen 400 mg PO The temperature should be reassessed 30 minutes after administration of medication. Patient Description/Population:
Adults with a temperature > 38 celsius
The patient should be alert and have an intact gag reflex for use of oral medications
Vital signs assessment prior to administration
History of antipyretic therapy (adequacy of dose, response) must be documented. If a sub-therapeutic dose has been given, calculate the difference between the inadequate dose and the therapeutic dose and administer that amount.
Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
Adults must have a temperature > 38 Celsius
The patient must be greater than 12 years of age, have a patent airway, an intact gag reflex
Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Patient must be conscious Contraindications to the implementation of the Directive:
Lack of patient/family consent
All pregnant patients must be assessed by a physician prior to implementing medication components of the directive.
Allergy to acetaminophen or ibuprofen
History of cirrhosis, chronic liver disease or alcoholism
Recent anti-pyretic administration (<3 hours)
Lakeridge Health Corporation
Emergency Medical Directives - 2005
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Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 8 of 66
ANKLE AND FOOT XRAYS MEDICAL DIRECTIVE
Authorized to who: Appropriated educated Registered Nurses who work in the Emergency Department may initiate the following therapies for any adult patients who present with possible symptoms of a fractured ankle or foot. Bony tenderness or inability to weight bear must be established according to Ottawa Ankle Rules. Medical Directive Description:
Establish baseline vital signs (B/P, P, R, O2 Sat) as indicated
Patient to remain NPO until examination with Emergency Physician has been achieved
Establish history of trauma or significant injury – document
Document date of LMP on females of child bearing years – if pregnancy is suspect document in order entry screen
An Ice pack or cold compress is to be applied to injuries less than 8 hours old
Assess patient according to the Ottawa Ankle Rules - X-ray ankle and/or foot as indicated by examination
Patient Description/Population: Patient must present with pain suggestive of a fractured ankle or foot on initial assessment by nurse. Affected leg may be swollen and painful on examination. A history of significant injury or trauma must be present.
Patient must be 18 years of age or older and not pregnant. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 9 of 66
Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray
Intoxicated patients are excluded
Patients with multiple painful injuries are excluded
Patients with head injuries are excluded
Patients with diminished sensation due to a neurological deficit are excluded (eg. CVA, Unconscious)
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 10 of 66
Figure 1 Ottawa Ankle Rule
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 11 of 66
CHEST PAIN (ISCHEMIC) MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following for adult patients arriving to the Emergency Department with chest pain suggestive of cardiac ischemic pain. Medical Directive Description:
12 Lead EKG - notify physician immediately if ST elevation, ST segment depression or new onset LBBB
obtain additional leads; 15 lead ECG, if inferior or posterior myocardial infarction suspect.
Request old charts and old ECG’s
Initiation of Normal Saline (N/S) IV at 30 mL/hr (tkvo)
O2 to keep oxygen saturation above 95%
CCU blood work
Portable Chest X-ray if available on site
Nitroglycerin 0.4 mg spray sublingually every five minutes until pain is relieved or a maximum of three doses have been administered
Acetylsalicylic Acid (ASA) 160 mg chewed if no ASA in last 24 hours
Morphine 2.5 - 5 mg IV increments (if Nitrospray is ineffective) titrate until pain is relieved or a maximum of 20 mg has been given
Dimenhydrinate (Gravol) 25-50 mg IV prn for one dose
Administer a fluid bolus of 250 mL Normal Saline if BP <90 mm Hg in the absence of any signs of respiratory distress
Patient Description/Population Patient must present with chest pain suggestive of an acute coronary syndrome on initial assessment by nurse. Identify relevant Delegated Control Act or Added Skill associated with this Directive: IV Insertion certification. Specific conditions/circumstances that must be met before the Directive can be implemented:
The patient must have Chest pain suggestive of Cardiac Ischemia on initial assessment by the Zone Nurse
Explanation of each of the above procedures must be provided to the patient.
The patient must verbally consent to each of these procedures
Include the doses of Nitroglycerin and Morphine given by Paramedics (in the prehospital care of the patient) in the calculation of maximal doses
All female patients of childbearing age must be assessed to rule out pregnancy prior to performing chest x-ray.
IV access must be established prior to administration of Nitroglycerin.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 12 of 66
Contraindications to the implementation of the Directive:
Lack of patient consent.
Blood Pressure must be checked after each Nitroglycerin and Morphine increment and medication is to be held if BP< 90 systolic
Nitroglycerin and Morphine are to be held if HR<40 or >140
ASA is to be held if a history of bleeding Peptic Ulcer, NSAID induced Gastritis Or a history of ASA precipitated Asthma
Prior to ordering x-rays, the Physician should assess a woman who suspects she might be or is pregnant.
Allergies to ASA, Morphine, Nitroglycerin or Dimenhydrinate will preclude administration of that drug.
If patient has a history of erectile dysfunction medication use within 24 hours ie. sildenafil (Viagra) or tadalafil (Cialis) or vardenafil (Levitra) then hold Nitroglycerin and report ingestion to physician.
Hold ASA dose if it has been administered in the Pre-hospital phase by Paramedics
Hold Nitrates if a right ventricular infarct is suspected on 15-lead ECG Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 13 of 66
CONSCIOUS OVERDOSE MEDICAL DIRECTIVE Authorized to who: Appropriately educated Registered Nurses working in the Emergency may initiate the following for a conscious patient with intact gag reflex if the ingestion has occurred within the last 1 hour: Medical Directive Description:
Activated Charcoal 1 gm/Kg per os All children will have an accurate weight recorded and dose will be weight based Adults who cannot be weighed will be given a 50 Gm dose initially. Contact Poison Control Print out the toxicology information from Micromedex (PoisonIndex) on Emergency Department computer.
Poison Control HSC 1-800-268-9017 or 1-416-813-5900 Ottawa Poison Control (CHEO) 1-800-267-1373 Canutec HazMat Information 1-613-996-6666
Patient Description/Population: The patient must have a history of ingestion of a quantity of medication or noxious material deemed appropriate for treatment with activated charcoal by a provincial poison advice centre. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented: The patient must have a patent airway, an intact gag reflex. Contraindications to the implementation of the Directive: Lack of patient/family consent All pregnant patients must be assessed by a physician prior to implementing medication components of the directive. Patient must be conscious. Patients who are somnolent, have reduced LOC or are obtunded must not be given activated charcoal per os Patients with recent abdominal surgery, trauma or suspected obstruction Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council
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Emergency Medical Directives - 2005
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Related Documents: LHC POISON CENTRE COMMUNICATION RECORD Appendix 1 References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 15 of 66
LAKERIDGE HEALTH CORPORATION Name: Unique #: POISON CENTRE COMMUNICATION RECORD H.C.#: Physician: If possible complete the first section of the form before call the Poison Centre in: TORONTO 1-800-268-9017 OTTAWA 1-800-267-1373
AGE SEX WT/KG TIME SINCE
INGESTION
BLOOD PRESSURE
PULSE RESP TEMP
SUBSTANCE OR PRODUCT NAME AMOUNT ROUTE OR AREA CONTAMINATED
1.
2.
3.
SYMPTOMS: none headache drowsy hyperactivity tachycardia nausea coma coughing convulsions bradycardia vomiting vertigo dyspnea eye irritation dysrhythmias diarrhea ataxia resp. dep. skin irritation oral irritation cyanosis hallucinations other/specify: ADVICE RECEIVED FROM H.S.C. – TIME:________ FROM WHOM:_______________ oral fluids___________________ activated charcoal_________________________ IV fluids ____________________ cathartic________________________________ eye irrigation_________________ cardiac monitor___________________________ skin irrigation ________________ lab work________________________________ Ipecac_______________________ gastric lavage____________________________ x-ray________________________ other/specify_____________________________ _____________________________________________________________________________________________ Signs and symptoms of toxicity:____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Date____________________SIGNATURE:_________________________________RN
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 16 of 66
Note: Please see revised COPD medical directive, approved Nov 10, 2009, posted separately on the WAVE.
COPD (LHC) revised Nov 10, 2009
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
MEDICAL DIRECTIVE Previous version of this medical directive approved by MAC Oct 2005
Has been ARCHIVED
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 17 of 66
EMLA CREAM OR PATCH MEDICAL DIRECTIVE
Authorized to who: An appropriately educated Registered Nurse in the Emergency Department. Medical Directive Description: A Registered Nurse working in the Emergency Department may apply EMLA topical anesthetic to reduce the pain or anxiety of venipuncture or procedures. Patient Description/Population:
Patient must be >6 months age.
In adults reserve for patient's with extreme anxieties to interventions.
Contact with skin is at least 60 minutes.
Use 1 – 2 patches or apply 2.5g (prilocaine 2.5% and lidocaine 2.5%) thickly covering the area and apply an occlusive dressing.
EMLA may be left on 4-5 hours without risks. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
The Nurse doing the procedure should look for optimal site preference & note the time it is applied on the site
Guardian or patient consent
Guardian presence to ensure supervision of safety instructions with EMLA as per policy.
Intact skin
Stable non-emergent patients
No more than 2 patches may be applied at the same time
Contact with skin is at least 60 minutes
Use 1-2 patches or apply 2.5g (prilocaine 2.5% & lidocaine 2.5%) thickly covering the area and apply an occlusive dressing
EMLA may be left on 4-5 hours without risks Contraindications to the implementation of the Directive:
Not for use around genitals, mouth, or eyes (mucous membranes)
Not for use in emergent situations where time is essential
Hypersensitivity to lidocaine, prilocaine or other anesthetics of the Amide type
Nonintact skin
PMH of methemoglobinemia
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 18 of 66
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every two years by Corporate ER Council Related Documents: References: Refer to appendix 1.
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 19 of 66
FOREARM/ELBOW XRAY MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses who have worked in the Emergency Department may initiate the following therapies for any adult patients who present with symptoms of a fractured forearm. Bony tenderness or inability to use the affected part must be established. Medical Directive Description:
Establish baseline vital signs (B/P, P, R, O2 Sat) as indicated
Patient to remain NPO until examination with Emergency Physician has been achieved
Establish history of trauma or significant injury – document
Document date of LMP on females of child bearing years – if pregnancy is suspect document in order entry screen
An Ice pack or cold compress is to be applied to injuries less than 8 hours old
Assess patient to establish tenderness and/or displacement of radius or ulna - X-ray forearm as indicated by examination
Assess for scaphoid tenderness and if positive go to the Scaphoid Xray medical directive
Apply splint as needed to stabilize the affected part Patient Description/Population: Patient must present with pain suggestive of a fractured forearm on initial assessment by nurse. Affected arm may be swollen and painful on examination. A history of significant injury or trauma must be present.
Patient must be 18 years of age or older and not pregnant. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented: Each intervention will be explained to the patient and/or family and verbal consent will be obtained. Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray
Intoxicated patients are excluded
Patients with multiple painful injuries are excluded
Patients with head injuries are excluded
Patients with diminished sensation due to a neurological deficit are excluded (eg. CVA, Unconscious)
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 20 of 66
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Review/Evaluation Process (how often/by who): every two years by Corporate ER Council Related Documents: References: Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 21 of 66
FRACTURED HIP MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses who are working in the Emergency Department may initiate the following therapies for any adult patients who present with symptoms of a fractured hip. Medical Directive Description:
Hip Fractures: AVOID internal/external rotation, flexion & adduction of affected limb.
Establish initial vital signs (B/P, P, R, O2 Sat)
Establish IV N/S TKVO (30 mL/hr)
Insert foley catheter and monitor urine output
Oxygen therapy per nasal prongs prn ( target Oxygen saturation >92%)
Patient to remain NPO until consultation with Orthopedic Surgeon has been achieved – if no transfer possible may offer patient full fluid diet - Reassess q shift for opportunity to increase diet.
CBC, Lytes, Creatinine, aPTT, INR, Albumin, Urinalysis, BhCG (females between 12-55 years of childbearing potential)
ECG
CXR , X-ray pelvis and affected hip
Morphine 2.5- 5 mg IV prn titrate to relieve pain or until a maximum of 20 mg has been given
Dimenhydrinate 25 mg IV prn nausea or vomiting x 1 dose
Patient Description/Population: Patient must present with pain suggestive of a fractured hip on initial assessment by nurse. Affected leg may be shortened or externally rotated on examination.
Patient must be 18 years of age or older and not pregnant. Identify relevant Delegated Control Act or Added Skill associated with this Directive: IV insertion certification. Specific conditions/circumstances that must be met before the Directive can be implemented:
IV access must be established prior to administration of Morphine
Vital signs pre & post administration of Morphine – consult physician if systolic BP< 90 mm Hg or pulse/heart rate < 40 bpm
Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Medications given by prehospital personnel or taken by patient just prior to arrival must be included in the calculation of maximum doses of Morphine.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
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Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray and medication components of the directive.
Allergy to Morphine or Dimenhydrinate will preclude administration of that drug. Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years by Corporate Er Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart. There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 23 of 66
HAND AND/OR FINGER XRAYS MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses who are working in the Emergency Department may initiate the following therapies for any adult patients who present with symptoms of a fractured hand or finger. Bony tenderness or inability to use affected part must be established. Medical Directive Description:
Establish baseline vital signs (B/P, P, R, O2 Sat) as indicated
Patient to remain NPO until examination with Emergency Physician has been achieved
Establish history of trauma or significant injury – document
Document date of LMP on females of child bearing years – if pregnancy is suspect document in order entry screen
An Ice pack or cold compress is to be applied to injuries less than 8 hours old
Assess patient for tenderness and/or obvious displacement/deformity of metacarpal bones, MCP joints and phalanges.
Assess for scaphoid tenderness, if positive go to the scaphoid Xray medical directive Patient Description/Population: Patient must present with pain suggestive of a fractured hand or finger on initial assessment by nurse. Affected hand may be swollen and painful on examination. A history of significant injury or trauma must be present Patient must be 18 years of age or older and not pregnant. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray
Intoxicated patients are excluded
Patients with multiple painful injuries are excluded
Patients with head injuries are excluded
Patients with diminished sensation due to a neurological deficit are excluded (eg. CVA, Unconscious)
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 24 of 66
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 25 of 66
HYPOGLYCEMIA MEDICAL DIRECTIVE
Authorized to: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following therapies for patients who present with symptoms or signs of hypoglycemia.
Medical Directive Description: Blood sugar result of < 4 mmol/L and patient remains conscious with an intact gag reflex – supply the patient with 15 g of carbohydrate or equivalent as outlined in table 1.
Table 1. Examples of 15 g of carbohydrate for the treatment of mild to moderate hypoglycemia - Canadian Diabetes Association 2003 Clinical Practice Guidelines
15 g of glucose in the form of glucose tablets
15 mL (3 teaspoons) or 3 packets of table sugar dissolved in water
175 mL (3/4 cup) of juice or regular soft drink
6 Life Savers (1=2.5 g of carbohydrate)
15 mL (1 tablespoon) of honey
avoid orange juice in renal patients because of potassium (K) content and replace with apple or cranberry juice with granulated sugar added
If blood sugar of < 4 mmol/L and patient has a change in mental status such that he/she cannot tolerate oral intake then: Keep NPO and attempt IV of D5W (5% Dextrose in water solution) TKVO at 30 mL/hr Administer 50 mL of pre-packaged 50% Dextrose solution IV
If unable to administer IV or if the patient is combative: Glucagon 1 mg may be administered IM or SC Patient Description/Population: Patients who present with symptoms suggestive of hypoglycemia 12 years of age and over Identify relevant Delegated Control Act or Added Skill associated with this Directive:
Lakeridge Health Corporation
Emergency Medical Directives - 2005
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Specific conditions/circumstances that must be met before the Directive can be implemented: The patient must appear to be hypoglycemic (pale, shaking, diaphoretic, headache, tremors, confusion). There may be an established history of diabetes and use of oral hypoglycemic agents or insulin injections. Certification in the use of Point of Care Glucometer testing IV Certification Contraindications to the implementation of the Directive:
Established allergy to Glucagon
Avoid orange juice in Renal Patients (relatively high potassium content)
Refusal of patient/family consent for treatment – notify Dr immediately Documentation requirements
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process: every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 27 of 66
HYPOTENSIVE VAGINAL BLEEDING MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department. Medical Directive Description: Initiate the following for adult patients arriving to the Emergency Department with vaginal bleeding and hypotension (Systolic BP<90):
Initiation of large bore Normal Saline IV and start 500 mL bolus
O2 to keep oxygen saturation above 95%
CBC, Type and Screen
Urine for beta-HCG
Draw blood for Quantitative beta-HCG and send to the lab if urine beta-HCG positive
Insert Foley Catheter prn
Bring ER portable Ultrasound to bedside if available Patient Description/Population: The patient must be over 13 years of age and capable of consenting to the procedures and treatment. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented: The patient must have Vaginal Bleeding and a systolic blood pressure <90 mmHg on initial assessment by the Nurse Explanation of each of the above procedures must be provided to the patient. Contraindications to the implementation of the Directive: Lack of patient consent. Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
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Emergency Medical Directives - 2005
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Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 29 of 66
INGESTED FOREIGN BODY MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department. Medical Directive Description: Registered Nurses in the Emergency Department may order a flat plate x-ray of the abdomen and chest. Patient Description/Population: The patient can be any age. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
Patient presents with a history of ingestion of a foreign body.
Women of childbearing age must be asked if they are pregnant. If a woman suspects she may be pregnant a urine pregnancy test must be completed and negative prior to having x-rays.
Contraindications to the implementation of the Directive:
Confirmed pregnancy.
Any respiratory distress
Lack of consent Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References:
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
Lakeridge Health Corporation
Emergency Medical Directives - 2005
Page 30 of 66
INSTILLATION OF TOPICAL ANESTHETIC FOR EYE DISCOMFORT MEDICAL DIRECTIVE
Authorized to who: An appropriately educated Registered Nurse in the Emergency Department. Medical Directive Description: Prior to the Emergency Physician assessing the patient, a Registered Nurse, in the Emergency Department may:
Instill 1-2 drops Proparacaine HCL 0.5% or Tetracaine 0.5% topical anesthetic in the affected eye(s) for comfort while awaiting Physician Assessment to facilitate Visual Acuity testing by the Registered Nurse.
This can be repeated q 10-15 minutes prn x 4 doses. Patient Description/Population: Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
The patient has eye discomfort due to an abrasion or foreign body
The Patient or Guardian must be able to provide informed consent
Patient must be able to cooperate in the performance of the procedure Contraindications to the implementation of the Directive:
Perforation of the globe
Hypersensitivity to the Topical Anesthetic or related local anesthetics
Malignant hyperthermia Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented
Vital signs pre and q15 to 30 minutes post pain medication Review/Evaluation Process (how often/by who): every two years Corporate ER Council Related Documents:
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References:
Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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KNEE XRAY MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses who are working in the Emergency Department may initiate the following therapies for any adult patients who present with symptoms of a knee injury. Bony tenderness or inability to weight bear must be established according to Ottawa Knee Rules. Medical Directive Description:
Establish baseline vital signs (B/P, P, R, O2 Sat) as indicated
Patient to remain NPO until examination with Emergency Physician has been achieved
Establish history of trauma or significant injury – document
Document date of LMP on females of child bearing years – if pregnancy is suspect document in order entry screen
An Ice pack or cold compress is to be applied to injuries less than 8 hours old
Assess patient according to the Ottawa Knee Rules - X-ray knee if indicated by examination
Patient Description/Population: Patient must present with pain suggestive of a fracture, ligamentous or meniscal injury on initial assessment by nurse. Affected leg may be swollen and painful on examination. A history of significant injury or trauma must be present. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
Each intervention will be explained to the patient and/or family and verbal consent will be obtained. Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray
Intoxicated patients are excluded
Patients with multiple painful injuries are excluded
Patients with head injuries are excluded
Patients with diminished sensation due to a neurological deficit are excluded (eg. CVA, Unconscious)
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
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Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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TOPICAL LIDOCAINE, EPINEPHRINE, TETRACAINE (LET) MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following directive. Medical Directive Description:
may apply LET topical anesthetic to simple lacerations.
Apply 3 mL of the LET solution on a cotton ball and apply to non intact skin
Apply for 25-30 minutes and note the time on the ED chart. Patient Description/Population: Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
For use on simple lacerations not involving the mucous membranes or peripheral extremities or sign of injury to underlying structures
Tape must not be used on hair bearing areas
On the scalp have the parent or patient put on a glove, apply a small amount of Vaseline to the surrounding hair, and have the cotton ball soaked with LET firmly held in place by the patient or parent
Parental or Guardian consent and supervision for safety instructions as per policy (Do not let it run into eyes, mouth, ears, or nose)
Contraindications to the implementation of the Directive:
Lack of patient or guardian consent
Complicated lacerations
Lacerations involving mucous membranes or peripheral extremities (digits)
Hypersensitivity to Lidocaine, Epinephrine, Tetracaine or Metabisulfite Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart. There is a space on the chart to indicate the use of a Medical Directive.
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Note: Please see revised Pediatric Asthma Medical Directive, approved Nov 10 2009, posted separately on the WAVE.
Paediatric Asthma (LHC) - revised Nov 10, 2009
PEDIATRIC ASTHMA MEDICAL DIRECTIVE
Previous version of this medical directive approved by MAC Oct 2005 Has been ARCHIVED
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PEDIATRIC FEVER MANAGEMENT MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department. may initiate the following therapies for patients who present with a documented febrile episode. Medical Directive Description: Give an anti-pyretic to children with a temperature > 38 Celsius The temperature should be reassessed 30 minutes after administration of medication Either: One dose of Acetaminophen based on weight calculated as 15 mg/kg PO/PR (maximum dose 650 mg)
Wk kg Age Group Single/Dose (mg) 6-7.9 6-11months 80 8-10.9 12-23 months 120
11-15.9 2-3 years 160 16-21.9 4-5 years 240 22-26.9 6-8 years 320 27-31.9 9-10 years 400 32-43.9 11 years 480 OR One dose of Ibuprofen 5-10 mg/kg PO Motrin Dosing for Children Under 12 Years
Wk kg Age Group Single/Dose (mg) 6-7.9 6-11months 50 8-10.9 12-23 months 75
11-15.9 2-3 years 100 16-21.9 4-5 years 150 22-26.9 6-8 years 200 27-31.9 9-10 years 250 32-43.9 11 years 300 Patient Description/Population:
Children (3 months – 12 years) with a temperature >38 Celsius
For use of oral meds, the patient should be alert and have an intact gag reflex for use of oral medications
An accurate weight must be documented on the chart
Vital signs including capillary refill assessment prior to administration
History of antipyretic therapy (adequacy of dose, response) must be documented. If a sub-therapeutic dose has been given, calculate the difference between the inadequate dose and the therapeutic dose and administer that amount.
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Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
Child must have a temperature >38 Celsius
The patient must be greater than 3 months of age, have a patent airway, an intact gag reflex and active bowel sounds on auscultation.
Each intervention will be explained to the patient and/or family and verbal consent will be obtained
Patient must be conscious Contraindications to the implementation of the Directive:
Age less than 3 months with pyrexia – notify ER Dr stat
Lack of patient/family consent
Allergy to acetaminophen or ibuprofen
History of cirrhosis, chronic liver disease
Recent acetaminophen administration (<3 hours) or > 5 doses of acetaminophen in previous 24 hour period (>65 mg/kg).
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders.
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every two years by Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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PEDIATRIC HYPOGLYCEMIA MEDICAL DIRECTIVE
Authorized to: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following therapies for patients who present with signs or symptoms of hypoglycemia.
Medical Directive Description: Blood sugar result of < 4 mmol/L and patient remains conscious with an intact gag reflex – supply the patient with 10 g of carbohydrate or equivalent as outlined in table 1 Table 1. Examples of 10 g of carbohydrate for the treatment of mild to moderate hypoglycemia - Canadian Diabetes Association 2003 Clinical Practice Guidelines
10 g of glucose in the form of glucose tablets
10 mL (2 teaspoons) or 2 packets of table sugar dissolved in
water
100 mL (1/2 cup) of juice or regular soft drink
4 Life Savers (1=2.5 g of carbohydrate)
10 mL (2 teaspoons) of honey
If blood sugar of < 4 mmol/L and patient has a change in mental status (i.e. GCS<14 or unable to cooperate such that he/she cannot tolerate oral intake) then:
Establish an IV D5W tkvo at 30 mL/hr
Keep NPO and administer 0.5 g/kg (2 mL/kg) 25% DEXTROSE IN WATER, IV slowly, to maximum of 12.5g (50mL).(Prepare the D25W solution by wasting 25 mL of a D50W preload and then drawing up 25 mL Sterile water or Normal Saline into the syringe).
If unable to administer IV or if the patient is combative: Glucagon 1 mg sc may be administered IM or SC (Wt > 20 kg) Glucagon 0.5 mg sc may be administered IM or SC (Wt < 20 kg) Patient Description/Population: Patients who present with symptoms suggestive of hypoglycemia under the age of 12 Identify relevant Delegated Control Act or Added Skill associated with this Directive:
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Specific conditions/circumstances that must be met before the Directive can be implemented: The patient must appear to be hypoglycemic (pale, shaking, diaphoretic, headache, tremors, confusion). There may be an established history of diabetes and use of oral hypoglycemic agents or insulin injections. Certification in the use of Point of Care Glucometer testing IV Certification Contraindications to the implementation of the Directive:
Established allergy to Glucagon
Refusal of patient/family consent for treatment – notify Dr immediately Documentation requirements
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process: every 2 years Corporate ER Council Related Documents: Hypoglycemia Medical Directive References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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PEDIATRIC SEIZURE (UNDER THE AGE OF 10) MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department initiate the following for a pediatric patient who is an active seizure state in the ER: Medical Directive Description:
Ensure airway is patent
Administer oxygen therapy at 100% by mask to maintain saturation above 94%
Place patient in the recovery position to prevent aspiration and injury.
Estimate child’s weight based on Broselow tape measurement or the following formula Estimated Wt = 2 x age + 8 (kg)
Administer Midazolam 0.2 mg/kg IM
If an IV is established prior to IM drug administration or Seizure has not abated then attempt to establish an IV of Normal Saline to run at 10-15 mL/hr
Monitor vital signs q5-10min and ECG continuously
Administer Midazolam 0.1 mg/kg IV or alternatively lorazepam 0.05 mg/kg IV (to a maximum dose of 1 mg of lorazepam)
If the seizure does not abate within five minutes administer a 2nd dose of the chosen drug at ½ the previous dose by the same route
Test Blood sugar and if <4mmol/l refer to paediatric hypoglycemia directive
Obtain a baseline set of vital signs including a temperature
If temperature is >38.0 degrees centigrade administer acetaminophen 15 mg/kg per rectum to a maximum of 650 mg
Patient Description/Population: The patient must be exhibiting active seizure activity Patient must be under the age of ten Identify relevant Delegated Control Act or Added Skill associated with this Directive: IV Insertion Certificate Specific conditions/circumstances that must be met before the Directive can be implemented: The patient must present with active tonic clonic seizure activity and have a patent airway Contraindications to the implementation of the Directive:
Lack of patient/family consent
Allergy to lorazepam or midazolam
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Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every two years by Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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PULMONARY EDEMA MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following therapies for patients who present with symptoms suggestive of acute pulmonary edema. Medical Directive Description:
Administer oxygen therapy by mask to maintain saturation above 92%
Position patient in Semi to high Fowlers to facilitate chest expansion if tolerated by patient and systolic BP > 90 mm
12 Lead EKG - notify physician immediately if ST elevation, ST segment depression or new onset LBBB
obtain additional leads; 15 lead ECG, if inferior or posterior myocardial infarction suspect.
Initiated IV N/S at 30 mL/hr TKVO
Monitor vital signs q5-10min and cardiac rhythm continuously
Chest x-ray
Insert foley catheter and monitor urine output hourly
Nitroglycerin 0.4 mg spray titrated to BP as follows o If the SBP > 140 mmHg, administer 0.8 mg NTG (2 stacked sprays) SL,
q5 min to a maximum of 8 administrations. o If SBP 100 mmHg -140 mmHg, administer 0.4 mg NTG SL, q5 min to a
maximum of 8 administrations. o BP<100 systolic hold
Enalaprilat 1.25 mg IV or Captopril 12.5 mg po x 1 dose after review with MD
Dimenhydrinate 25-50 mg IV q1hr prn nausea & vomiting
Furosemide 40 mg IV or double the patient’s usual oral dose to a maximum of 80 mg and administer IV
Obtain charts of previous visits. Patient Description/Population: Patients who present with symptoms suggestive of acute pulmonary edema. The patient must have shortness of breath and symptoms suggestive of Pulmonary Edema (dyspnea, tachypnea, orthopnea, crackles throughout the lung fields). The patient may expectorate pink, frothy sputum. Identify relevant Delegated Control Act or Added Skill associated with this Directive: IV Insertion Certificate
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Specific conditions/circumstances that must be met before the Directive can be implemented:
The patient must have shortness of breath and symptoms suggestive of Pulmonary Edema (dyspnea, tachypnea, orthopnea, crackles throughout the lung fields). The patient may expectorate pink, frothy sputum.
Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Medications given by pre-hospital personnel or taken by patient just prior to arrival must be included in the calculation of maximum doses of ASA and Nitroglycerin
IV access must be established prior to administration of Nitro spray
Vital signs pre & post administration of Nitro, Furosemide ,Enalapril and Captoril – consult physician if systolic BP< 90 mm Hg or pulse/heart rate < 40
Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray and medication components of the directive.
Allergy to ASA, Morphine, Nitroglycerin or Dimenhydrinate will preclude administration of that drug.
If patient has history of erectile dysfunction medication use within 24 hours ie. sildenafil (Viagra) or tadalafil (Cialis) or vardenafil (Levitra) then hold Nitroglycerin and report ingestion to physician.
Hold ASA if Hx of recent GI bleed or peptic ulcer disease Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented
Vital signs pre & post administration of Nitroglycerin and Furosemide Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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RENAL COLIC MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following for patients who present to the ER with symptoms indicative of renal colic and who are exhibiting significant distress. Medical Directive Description:
Urine test when able to void – test for blood, rule out pregnancy with Beta HCG
Monitor vital signs q15min
Administer (Non parenteral option) Ketorolac 10 mg P.O. may repeat x 1 after 30 minutes
Metochlopramide 10 mg P.O. Indocid 50 mg suppository P.R.
If patient unable to tolerate oral medications due to nausea and vomiting: IM Option:
Ketorolac 30 mg IM
Metochlopramide 10 mg IM IV Option:
o Establish IV Normal Saline at 30 mL/hr o Patient to remain NPO o Administer Ketorolac 30 mg IV q20min x 2 doses or Morphine 5 mg IV
increments titrate for pain relief to a maximum of 20 mg o Dimenhydrinate 25-50 mg IV prn nausea or vomiting x 1 dose
Patient Description/Population: Patients who present to the ER with symptoms indicative of renal colic and who are exhibiting significant distress. Identify relevant Delegated Control Act or Added Skill associated with this Directive: IV Insertion Certification Specific conditions/circumstances that must be met before the Directive can be implemented:
Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Patient must be 18 years of age or older
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Contraindications to the implementation of the Directive:
Allergy to Morphine, Ketorolac, Metochlopramide or Dimenhydrinate will preclude use of that medication
Lack of patient consent
All pregnant patients must be assessed by physician prior to implementing x-ray and medication components of the directive.
Caution with IVP if patient taking oral hypoglycemic agents
Hold Ketorolac / Indomethacin: if patient has a history of GI distress/bleed, peptic ulcer disease, a history of renal disease, liver disease or congestive heart failure
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented
Vital signs pre and q15 to 30 minutes post pain medication Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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SALINE IRRIGATION OF THE TREATMENT OF CHEMICAL EYE BURNS IN THE EMERGENCY DEPARTMENT
MEDICAL DIRECTIVE Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department. Medical Directive Description: Prior to the Emergency Physician assessing the patient, a Registered Nurse, in the Emergency Department may:
Test pH of affected eye in cases of Alkali burns and if pH>8 after irrigation then irrigate a second time for an additional 20-30 minutes
Retest pH after 30 minutes
Instill 1-2 drops Proparacaine HCL 0.5% or Tetracaine 0.5% topical anesthetic in the affected eye(s) for comfort
Place the Morgan Lens as per protocol Patient Description/Population: Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
The patient has had an accidental chemical splash into one or both eyes
The Patient or Guardian must be able to provide informed consent
Patient must be able to cooperate in the performance of the procedure Contraindications to the implementation of the Directive:
Perforation of the globe
Other associated life threatening injuries
Hypersensitivity to topical anesthetic or related local anesthetics Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents:
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References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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SEIZURE IN PATIENTS OVER THE AGE OF 10 YEARS MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following for patients actively seizuring in the Emergency Department. Medical Directive Description:
Ensure airway is patent and supply Oxygen 100%
Place the patient in recovery position
Initiate an IV of Normal Saline at 30 mL/hr
Administer diazepam 5 mg IV given slowly over 1 minute or per rectum initially, then 2.5 mg increments every 15-30 seconds up to a maximum of 10 mg or until the seizure abates.
Test blood sugar if <4 mmol/L administer 50 mL 50% Dextrose IV Patient Description/Population: Patients 10 year of age or older Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented:
The patient presents with an active tonic clonic seizure in the Emergency Department.
Contraindications to the implementation of the Directive:
Allergy to diazepam.
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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TETANUS/DIPTHERIA/PERTUSSIS IMMUNIZATION MEDICAL DIRECTIVE
Authorized to who: An appropriately educated Registered Nurse in the Emergency Department. Medical Directive Description: Prior to the Emergency Physician assessing the patient, a Registered Nurse, in the Emergency Department may:
Administer 0.5 mL tetanus diphtheria (Td) IM to eligible patients
Administer 0.5 mL Adacel (DTaP “tetanus diphtheria acellular pertussis) IM to 14-16 year old patients who require immunization instead of Td
Determine if primary series of injections were ever given (if not patient will need to follow up with their Family Physician or Public Health for immunizations in 1 month and 6 months time)
Patient Description/Population: The patient is over the age of 7 and the patient has sustained a laceration, abrasion, burn, bite or foreign body injury. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented: The Patient or Guardian must be able to provide informed consent. The patient has not had a Td immunization within 10 years or the patient's Td booster status is unknown Contraindications to the implementation of the Directive: Tetanus prone wounds (ie. Wounds contaminated by bites, with soil, feces or severe crush injuries allowing for anaerobic conditions) notify the Physician who will assess and decide on the use of tetanus immune globulin if >5 years since last immunization Lack of consent Hypersensitivity to tetanus, diphtheria or pertussis immunizations
Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented
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Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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URINE SAMPLING MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may initiate the following directive for Urine R & M screening and/or beta HCG testing. Medical Directive Description: Urine specimens are to be collected and sent to the lab prior to patient assessment by an Emergency Physician when the specific conditions outlined below are present. Patient Description/Population: Patients with specific complaints of flank pain, abdominal pain, back pain, pelvic pain or discomfort, genitor-urinary symptoms and vaginal bleeding. Female patients of child bearing age without a previous history of a hysterectomy; with either the above complaints or anticipated to require Radiography will have a urine beta-HCG sent to the lab. Identify relevant Delegated Control Act or Added Skill associated with this Directive: The procedure is not a controlled act but falls with the plan of care. Specific conditions/circumstances that must be met before the Directive can be implemented: The patient must fall under one of the patient populations described above Contraindications to the implementation of the Directive:
Lack of patient or guardian consent
Patients obviously pregnant in the third trimester may have the beta-HCG waived
CTAS 1 patients require resuscitation first then the directive may be implemented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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URINARY CATHETERIZATION MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses working in the Emergency Department may insert a urinary catheter for adult patients arriving to the Emergency Department prior to being assessed by the Emergency Physician Medical Directive Description: ● Insert a14-18 Foley Catheter (or consider a 20-22 three way foley for
suspected blood clot retention) ● Use a 2% Lidocaine jelly (Urojet) for male patients ● The catheter will be left in and document drainage amount and catheter
size.
Patient Description/Population: Adult patients 18 years of age or older Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented: Explanation of each of the above procedures must be provided to the patient. The patient must verbally consent to each of these procedures. The patient presents with ● A history of self catheterization and is requesting one be inserted ● Urinary retention or gross hematuria with clots ● Pulmonary Edema (for output measurement and symptomatic relief of bedpan
use) ● Multiple trauma (but no blood in urethral meatus or signs of GU trauma) Contraindications to the implementation of the Directive: ● Lack of patient consent. ● Allergy to Lidocaine (do not use urojet) or latex (use latex free
materials) ● Stop if resistance is encountered Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Response to medications administered must be documented Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council
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Related Documents: References: Refer to appendix 1
The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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WRIST AND SCAPHOID X-RAYS MEDICAL DIRECTIVE
Authorized to who: Appropriately educated Registered Nurses who are working in the Emergency Department may initiate the following therapies for any adult patients who present with symptoms of a fractured Wrist. Bony tenderness must be established. Medical Directive Description:
Establish baseline vital signs (B/P, P, R, O2 Sat)
Patient to remain NPO until examination with Emergency Physician has been achieved
Establish history of trauma or significant injury – document
Document date of LMP on females of child bearing years – if pregnancy is suspect document in order entry screen
An Ice pack or cold compress is to be applied to injuries less than 8 hours old
Assess patient pain must be present over the distal radius and ulna and/or the carpal bones for a wrist x-ray
If tenderness is elicited over the anatomical “snuff box” or over the scaphoid tubercle add Scaphoid views to the wrist x-ray views.
Patient Description/Population: Patient must present with pain suggestive of a fractured wrist on initial assessment by nurse. Affected wrist may be swollen and painful on examination. A history of significant injury or trauma must be present.
Patient must be 18 years of age or older and not pregnant. Identify relevant Delegated Control Act or Added Skill associated with this Directive: Specific conditions/circumstances that must be met before the Directive can be implemented: Each intervention will be explained to the patient and/or family and verbal consent will be obtained.
Contraindications to the implementation of the Directive:
Lack of patient consent
All pregnant patients must be assessed by a physician prior to implementing x-ray
Intoxicated patients are excluded
Patients with multiple painful injuries are excluded
Patients with head injuries are excluded
Patients with diminished sensation due to a neurological deficit are excluded (eg. CVA, Unconscious)
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Documentation requirements:
Implementation of the Medical Directive must be documented on the ER chart under physician orders
Review/Evaluation Process (how often/by who): every 2 years Corporate ER Council Related Documents: References: Refer to appendix 1 The use of this Medical Directive must be documented on the Emergency Chart.
There is a space on the chart to indicate the use of a Medical Directive.
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LIST OF AUTHORIZING PHYSICIANS: LAKERIDGE HEALTH OSHAWA
Physician’s Name Signature Date
Dr. P. Blecher ________________________________ ________________
Dr. T. Chin _________________________________ ________________
Dr. F. Fung _________________________________ ________________
Dr. K. Green _________________________________ ________________
Dr. L. Irish _________________________________ ________________
Dr. P. Moran _________________________________ ________________
Dr. F. Moss _________________________________ ________________
Dr. T. Novak _________________________________ ________________
Dr. E. Paidra _________________________________ ________________
Dr. J. Shipley _________________________________ ________________
Dr. N. Stein _________________________________ ________________
Dr. R. Stuparyk _________________________________ ________________
Dr. R. Vandersluis _________________________________ ________________
Dr. C. Walker _________________________________ ________________
Dr. S. Whittaker _________________________________ ________________
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LIST OF AUTHORIZING PHYSICIANS: LAKERIDGE HEALTH BOWMANVILLE
Physician’s Name Signature
Date
Dr. M. Albert ___N/A___________________________ ________________
Dr. H. Burke _________________________________ ________________
Dr. V. Dubey _________________________________ ________________
Dr. L. Durante _________________________________ ________________
Dr. S. Finlay _________________________________ ________________
Dr. B. Fuller _________________________________ ________________
Dr. V. Ho _________________________________ ________________
Dr. A. Hollander _________________________________ ________________
Dr. L. Irish _________________________________ ________________
Dr. D. Jefferson _________________________________ ________________
Dr. A. Kassirer _________________________________ ________________
Dr. S. Kim _________________________________ ________________
Dr. T. Kiran _________________________________ ________________
Dr. C. Lennox _________________________________ ________________
Dr. R. Lombardi _________________________________ ________________
Dr. W. Lottering _________________________________ ________________
Dr. R. Moolla _________________________________ ________________
Dr. L. Nijmeh _________________________________ ________________
Dr. E. Osborne _________________________________ ________________
Dr. L. Salamon ___N/A___________________________ ________________
Dr. D. Shiu _________________________________ ________________
Dr. A. Stone _________________________________ ________________
Dr. H. Williams _________________________________ ________________
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LIST OF AUTHORIZING PHYSICIANS: LAKERIDGE HEALTH PORT PERRY
Physician’s Name Signature Date
Dr. M. Adams ________________________________ ________________
Dr. F Ali _________________________________ ________________
Dr. M. Brown _________________________________ ________________
Dr. A. Dayal _________________________________ ________________
Dr. K. Ferguson _________________________________ ________________
Dr. M. Gilmour _________________________________ ________________
Dr. S. Hyshka _________________________________ ________________
Dr. N. Kazarian _________________________________ ________________
Dr. R. Lombardi _________________________________ ________________
Dr. G. Mercer _________________________________ ________________
Dr. S. Russell _________________________________ ________________
Dr. S. Shepherd _________________________________ ________________
Dr. K. Smith _________________________________ ________________
Dr. J. Tuck _________________________________ ________________
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SIGNATURE LIST OF COMMITTEE AND PROGRAM APPROVALS (Chairs)
Approvals and Signatures
Name Position Signature Date
Dr. R. Vandersluis Chief ____________________________ _________
Dr. B. Fuller Physician
Leader
____________________________ _________
Ms. M. Tink Program
Leader
____________________________ _________
Mr. T. Sellers Clinical
Educator
____________________________ _________
Program Committee/Council LHC ER Council _________
Mr. T. Chambers
Chair of CHPC
or PPC
____________________________
_________
Dr. J. Eisenstaat Chair of P & T ____________________________ _________
Final Approval:
Dr. D. Atkinson
Chair, MAC
____________________________
_________
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REVIEW AND APPROVAL TRACKING FORM
Delegated Controlled Act / Medical Directive / Routine Order
Document Title: LHC Emergency Department Medical Directives – see attached listing
Contact Person:
(name of key physician or health professional)
Dr R Vandersluis
Sponsored by:
(Program/Discipline)
LHC Emergency Program
Reviewed by Stakeholders: Please check
or type N/A Date Reviewed
Peer Program(s) Medical Program Respiratory Therapy
√ November 2004
Medication Committee √ May 2005
Laboratory Council √ January 2005
Diagnostic Imaging Council √ January 2005
Infection Control n/a
P & T Committee √ May 2005
Profession Leader(s) √ May 2005
Other stakeholders (identify) Paediatrician
√ May 2005
Recommended by: Please check or type N/A Date Approved
Program/Discipline Council
Corporate Nursing Practice Council √ May 2005
Professional Practice Council √ May 2005
FINAL APPROVAL
Medical Advisory Committee
√ October 2005
References used in the development:
TO BE COMPLETED BY CORPORATE MEDICAL STAFF OFFICE:
Posted Electronic:
Communication:
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MEDICAL DIRECTIVE APPENDIX 1 REFERENCES
Informed Plus Document #9103 – Institute for Clinical Evaluative Sciences (ICES) Canadian Asthma Consensus Report – Canadian Medical Association Journal 1999; 161:S1-S12. McKenzie, N. (1998). Upping the body’s thermostat. Learn how to maneuver the peaks, valleys of body temperature. Nursing 98, October. p. 41-45. Compendium of Pharmaceuticals and Specialties. (2004). Dosing chart for acetaminophen. p. 18. Compendium of Pharmaceuticals and Specialties. (2004). Dosing chart for Ibuprofen. P. 1258. Rourke, K. (2003). An orthopedic nurse practitioner’s practical guide to evaluating knee injuries. Journal of Emergency Nursing, 29(4). p. 366-372. Barry, M.E. (2001). Ankle sprains: Prompt and accurate diagnosis is critical to proper healing. American Journal of Nursing, 101(10). p. 40-42. Larsen, D. (2002). Assessment and management of foot and ankle fractures. Nursing Standard. 17(6). p. 37-48. Institute for Clinical Evaluative Sciences. (nk). Ottawa ankle rules- Physician information. p. 1-2. Stiell, I.G., McKnight, R.D., Greenberg, G.H., et al. (1994). Implementation of the Ottawa ankle rules. Journal of American Medical Association. 271. p. 827-832.
Institute for Clinical Evaluative Sciences. (1994). Twist and shout: deciding when to x-ray a sprained ankle. Informed Newsletter, 1(1). p. 1-2. McGraw, R.C., & Miller, M. (1998). Chest pain in the ER: The new serum markers. Patient Care Canada, 9(10) p. 33-35. Lazzara, D., & Sellergren, C. (1996). Chest pain. Making the right call when pressure is on. Nursing 96, November p. 42-51. Wood, D.G. (2001). Rapid assessment of chest pain: The rationale is clear, but evidence is needed. British Medical Journal, 323(7313). p. 586-587. Substance Abuse and Toxicoloical Emergencies – Rouge Valley Centenary Advance Triage Learning Package Emergency Nurses Association. (2003). Sheehy’s emergency nursing: Principals and practices. 5
th
Edition. Mosby: Philadelphia. Kidd, P.S., Sturt, P.A., & Fultz, J. (2000). Emergency nursing reference. 2
nd Edition. Mosby: Philadelphia.
Perry, A.G., & Potter, P.A. (2002). Clinical nursing skills and techniques. 5
th Edition. Mosby: St.Louis.
Orthopedic Trauma and Musculoskeletal System Assessment – Rouge Valley Centenary Advanced Triage. Hanson, M.J.S. (1997). Caring for a patient with COPD. Nursing 97, December. p. 39-44. Whatling, J. (1995). Managing chronic obstructive disease. Nursing Standard, 10(8). p. 34-37.
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Informed Plus – Document # 8231 ICES 2002 Institute for Clinical Evaluative Sciences. (1998). The (k) need for x-rays. The Ottawa knee rule- x-rays in acute knee injuries. Informed Newsletter, 4(3). p. 1-3. Rourke, K. (2003). An orthopedic nurse practitioner’s practical guide to evaluating knee injuries. Journal of Emergency Nursing, 29(4). p. 366-372 Hooper, M. (1997). Prompt treatment for chemical eye injuries. Nursing Standard, 11(36). p. 40-43. CHN Emergency Medical Directives for Children Draft #2 – August 2002 Asthma Management Guidelines – The Hospital for Sick Children Drug Formulary CPS 2004 Fever dosing charts, p. 18, 1258 CHN Emergency Medical Directives for Children – Draft #2 – August 2002 Compendium of Pharmaceuticals and Specialties. (2004). Dosing chart for acetaminophen. p. 18. Compendium of Pharmaceuticals and Specialties. (2004). Dosing chart for Ibuprofen. P. 1258. Weeks, S.M. (1996). Caring for patients with heart failure. Nursing 96 March p. 52-53. Informed Plus – Document # 8120 ICES 2001 Goshorn, J. (NK). Kidney stones. Strategies for managing this common, excruciating condition. Clinical Snapshot. p. 1-2. Jelinek, G. (2000). Ketorolac versus morphine for severe pain: Ketorolac is more effective, cheaper, and has fewer side effects. British Medical Journal, 321(7272). p. 1236-1237. Wright, P. J., Hurgin, A.P.S., & Marsden, S.N.E. (2002). Managing acute renal colic across the primary-secondary care interface: A pathway of care based in evidence and consensus. British Medical Journal, 325(7377). p. 1408-1412. Hooper, M. (1997). Prompt treatment for chemical eye injuries. Nursing Standard, 11(36). p. 40-43. Kidd, P.S., Sturt, P.A., & Fultz, J. (2000). Emergency nursing reference. 2
nd Edition. Mosby: Philadelphia.
Emergency Nurses Association. (2003). Sheehy’s emergency nursing: Principals and practices. 5
th
Edition. Mosby: Philadelphia. McGraw, R.C., & Miller, M. (1998). Chest pain in the ER: The new serum markers. Patient Care Canada, 9(10) p. 33-35. Lazzara, D., & Sellergren, C. (1996). Chest pain. Making the right call when pressure is on. Nursing 96, November p. 42-51. Weeks, S.M. (1996). Caring for patients with heart failure. Nursing 96 March p. 52-53. Institute for clinical Evaluative Sciences. (1997). Breathing easier. A new asthma continuum facilitates the diagnosis and treatment of asthma. Informed Newsletter 3(4) p. 1-5. Hanson, M.J.S. (1997). Caring for a patient with COPD. Nursing 97, December. p. 39-44.
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Reising, D.L. (1995). Acute hypoglycemia. Keeping the bottom from falling out. Nursing 95, February. p. 41-48. McKenzie, N. (1998). Upping the body’s thermostat. Learn how to maneuver the peaks, valleys of body temperature. Nursing 98, October. p. 41-45. Cain, M. 91998). Treating pediatric fever: Helpful or harmful? Patient Care Canada, 9(10). p. 13. McNew, C.D., Hunt, S., & Warner, L.S. (1997). How to help your patient with epilepsy. Nursing 97. September. p. 57-62. Smith, R. (1997). Diagnosing headache. Hospital Medicine. July. p. 26-42. Goshorn, J. (NK). Kidney stones. Strategies for managing this common, excruciating condition. Clinical Snapshot. p. 1-2. Peden, A.C. (1996). Action stat. Ruptured ectopic pregnancy. Nursing 96, May. p. 33. Lerner-Durjava, L. (1996). Combating infection. Protecting against tetanus. Nursing 96, February. p. 26-27. Institute for Clinical Evaluative Sciences. (1998). The (k) need for x-rays. The Ottawa knee rule- x-rays in acute knee injuries. Informed Newsletter, 4(3). p. 1-3. Institute for Clinical Evaluative Sciences. (1994). Twist and shout: deciding when to x-ray a sprained ankle. Informed Newsletter, 1(1). p. 1-2. Institute for Clinical Evaluative Sciences. (nk). Ottawa ankle rules- Physician information. p. 1-2. Kidd, P.S., Sturt, P.A., & Fultz, J. (2000). Emergency nursing reference. 2
nd Edition. Mosby: Philadelphia.
Emergency Nurses Association. (2003). Sheehy’s emergency nursing: Principals and practices. 5
th
Edition. Mosby: Philadelphia. Lakeridge Health Oshawa/Whitby Pharmacy- IV Monographs. Accessed April 8, 2005. Kaniecki, R. (2003). Headache assessment and management. The Journal of the American Medical Association, 289(11). p. 1430-1433. Canadian Asthma Consensus report. (1999). Diagnosis and evaluation of asthma in adults. Canadian Medical Association Journal, 161(11). p. 56-57. Wright, J. (1997). Seven abdominal assessment signs every emergency nurses should know. Journal of Emergency Nursing, 23(5). p. 446-450. Perry, A.G., & Potter, P.A. (2002). Clinical nursing skills and techniques. 5
th Edition. Mosby: St.Louis.
Stiell, I.G., McKnight, R.D., Greenberg, G.H., et al. (1994). Implementation of the Ottawa ankle rules. Journal of American Medical Association. 271. p. 827-832. Compendium of Pharmaceuticals and Specialties. (2004). Dosing chart for acetaminophen. p. 18. Compendium of Pharmaceuticals and Specialties. (2004). Dosing chart for Ibuprofen. P. 1258. Informed Plus Document #9103 – Institute for Clinical Evaluative Sciences (ICES). (1999). Canadian Asthma Consensus Report – Canadian Medical Association Journal, 161. p. S1-S12.
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Whatling, J. (1995). Managing chronic obstructive disease. Nursing Standard, 10(8). p. 34-37. Wood, D.G. (2001). Rapid assessment of chest pain: The rationale is clear, but evidence is needed. British Medical Journal, 323(7313). p. 586-587. Wright, P. J., Hurgin, A.P.S., & Marsden, S.N.E. (2002). Managing acute renal colic across the primary-secondary care interface: A pathway of care based in evidence and consensus. British Medical Journal, 325(7377). p. 1408-1412. Jelinek, G. (2000). Ketorolac versus morphine for severe pain: Ketorolac is more effective, cheaper, and has fewer side effects. British Medical Journal, 321(7272). p. 1236-1237. Rourke, K. (2003). An orthopedic nurse practitioner’s practical guide to evaluating knee injuries. Journal of Emergency Nursing, 29(4). p. 366-372. Barry, M.E. (2001). Ankle sprains: Prompt and accurate diagnosis is critical to proper healing. American Journal of Nursing, 101(10). p. 40-42. Larsen, D. (2002). Assessment and management of foot and ankle fractures. Nursing Standard. 17(6). p. 37-48. Hooper, M. (1997). Prompt treatment for chemical eye injuries. Nursing Standard, 11(36). p. 40-43. Child Health Network. (2002). Medical directives for children. Draft #2. August. Orthopedic Trauma and Musculoskeletal System Assessment – Rouge Valley Centenary Advanced Triage. Ottawa Ankle Rules – Dr. I. Stiell et.al. ICES. 1993. Substance Abuse and Toxicological emergencies – Rouge Valley Centenary Advance Triage Learning Package. Informed Plus- Document # 8231. ICES 2002. Asthma Management Guidelines- The Hospital for Sick Children Drug Formulary. Government of Ontario. (nk). Emergency guidelines for managing the child with type 1 diabetes. Compendium of Pharmaceuticals and Specialties (2004). Drug Monographs. Pgs. 2153, 204, 47, 16, 1340, 185, 412, 462, 684, 14, 960, 1074. Canadian Immunization Guide Edition 6 http://www.phac-aspc.gc.ca/publicat/cig-gci/pdf/cdn_immuniz_guide-2002-6.pdf Canadian Diabetes Association 2003 Clinical Practice Guidleines http://www.diabetes.ca/cpg2003/chapters.aspx?periacutecoronarysyndromeglycemiccontrol.htm Rainbow J. et al (2002) Controlling seizures in the prehospital setting: diazepam or midazolam, J Pedaitr Child Health, Dec;38(6): 582-6 Fisgin T, et al (2002) Effects of intranasal midazolam and rectal diazepam in acute consulsions in children: prospective randomized study, J Child Neurol. 2002 Feb;17(2): 123-6 Classen J. etal (2002) Treatment of refractory status epilepticus with pentobarbital,propofol or midazolam: a systematic review. Epilepsia. 2002 Feb;43(2):146-53
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Harbord MG etal (2004) Use of intranasal midazolam to treat seizures in pediatric community settings, J Pediatr Child Health. 2004 Sept-Oct;40(9-10):556-8 Yoshikawa H etal (2000) Midazolam as a first line agent for status epilepticus in children, Brain Dev. 2000 Jun;22(4):239-42 Towne AR etal (1999) Use of intramuscular midazolam for status epilepticus. J Emerg Med. 1999 Mar-Apr;17(2):323-8 Scott RC etal (1999) Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomized trial. Lancet. 1999 Feb 20;353(9153):623-6 Pellock JM (1998) Use of midazolam for refractory status epilepticus in pediatric patients. J Child Neurol. 1998 Dec;13(12):581-7 Yakinci C etal (1997) Midazolam in treatment of various types of seizures in children, Brain Dev. 1997 Dec;19(8):571-2