CHAPTER 2 -- EMERGENCIES AND INJURIES
THESE NOTES MUST BE READ
to use this chapter’s protocol revision materials successfully.
This does not substitute for a thorough reading of the introduction as well.
I have previously published three sets of protocols, specifically Nurse Practitioner Protocols, First Edition (1989), Second Edition (1994); Physician Assistant Protocols, First Edition (1989); Physician Assistant Protocols, Second Edition (1994); and Ambulatory Family Practice, First Edition (1989), Ambulatory Family Practice, Second Edition (1994); all of which were updated by the 1995 Supplement. At the time of publication of the Nurse Practitioner Protocols, Third Edition, hereafter NPP3 (2000), I published a much smaller printing run of Physician Assistant Protocols, Third Edition (2000) hereafter PAP3 (2000); and an even shorter run of Ambulatory Family PracticeThird Edition (2000), hereafter AFP3 (2000). The size of the runs reflected number of sales. I made this decision knowing I could use NPP3 as the single update for all three sets should the shorter runs sell out, since the distinctions between the three books were minor and easily noted by the clinician as the protocols were adapted in practice.
The protocols now being posted online are intended for users of all three prior sets. Ideally, however, a user of these updates will have in hand the NPP3 (2000), PAP3 (2000) or AFP3 (2000) Edition. Specific recommended changes in the text of the protocols are written as if they apply generally to all three 2000 texts, however for simplicity I will refer to NPP3 (2000) or just NPP3. If there is seeming specificity to NPP3 (2000); it should be easy for the clinician to make the transition to the other two books.
In publishing online these protocol revisions, I am providing three things: a thorough discussion of new developments in medicine and changes in medical practice since the publication of NPP3, PAP3, and AFP3; extensive references (primarily online with hyperlinks) to valuable resources for primary care clinicians, along with recommendations for the use of such resources; and in many instances, specific recommended changes to the language of the these 2000 protocols consistent with the changes in medicine and medical practice since its publication.
Practice notes are written in regular 12-point typeface and are not changes in protocol language.
Changes to the language of specific protocols are in 10-point bold typeface, and the layout of the change follows the layout of the former protocol.
Headings from the layout of NPP3 protocols are also in 10-point bold type, which distinguishes them from headings related to my own practice notes which are in regular 12-point type.
Within the discussion ofprotocols (original and changes to originals),
clinical notes are in bold type and centered,
and practice notes are left justified and in regular (not bolded) 12-point type.
Centered text in 14-point bold type
is used to emphasize issues which are critical for the clinician’s consideration.
Endnotes for all the protocols in a given chapter (e.g., “Gynecology”) are found at the end of that chapter. Hyperlinks (in blue type) to important online materials are embedded in the relevant text of the protocol revisions and also provided in a corresponding endnote. The clinician on our website can immediately access these hyperlinks and usually download useful materials. CAUTION: the hyperlinks are to websites current at the time the protocol is posted; it behooves the clinician to compliment the use of the hyperlinks I have provided with further relevant web searches. I also make note of websites which should be frequently consulted in practice as a matter of course (e.g., the links for Healthcare Providers and for immunization recommendations, the homepage, and the website of the Agency for Healthcare Research and Quality (AHRQ), the body which sets the standards for healthcare quality, at Clinicians should recognize that many references or sources of information can be found on multiple websites. I have tried to select for you the most helpful sites, though several others may be equally accessible and useful.
I have followed the AMA citation style, with some exceptions for simplification; information sufficient for further research is always provided in the citation. I will also be posting a blog on this website, and any suggestions for clarification of the text and its formatting will be welcomed.
MMC MD
Note: An office well prepared to handle emergencies[1] makes good sense. Non-clinical staff as well as clinical staff must have current CardioPulmonary Resuscitation (CPR) certification. Clinical staff must be fully trained to deal with life-threatening emergencies, at least until the patient can be transferred appropriately. Consequently, training of clinicians and their clinical staff must be a priority in all offices where patients are seen. Required areas of training include Basic Cardiac Life Support ( BCLS); Advanced Cardiac Life Support (ACLS); Pediatric Advanced Life Support (PALS); Neonatal Advanced Life Support (NALS), which is sometimes known as Neonatal Resuscitation Program (NRP); Advanced Life Support – Obstetrics (ALSO); and the requirements for training of medical staff in these methods must include the following:
- All staff, non-clinical and clinical alike, must be certified in CPR.
- Clinicians and key clinical staff should be certified in BCLS and preferably ACLS if taking care of adults
- Clinicians should be certified in PALS if taking care of children; certified in NALS/NRP if taking care of Neonates; and certified in ALSO if taking care of obstetrical patients.
It is the responsibility of management to see that each clinician and their staff receive training appropriate to their role in the clinic, and that training is certified and current at all times.The latter – current training – is especially important given the frequent changes in recommended methods of life support and resuscitation. Each area of training has specific training modules, e.g., initial training, provider training, renewal training, instructor training, which can be tailored to the needs of specific staff.
NOTE: The protocols in this section assume that the foregoing admonitions are adhered to in the clinical practice.
NOTE: In many of these 18 protocols the clinician is providing early intervention until the arrival of emergency medical transport. Do not let family drive to the emergency room transporting the patient.
Cardiac or Respiratory Arrest, Infants ...... 2-1
Cardiac or Respiratory Arrest, Children ...... 2-2
Cardiac or Respiratory Arrest, Adults ...... 2-3
Acute Chest Pain ...... 2-4
Seizures, Children ...... 2-5
Seizures, Adults ...... 2-6
Accidental Ingestion, Infants and Children ...... 2-7
Anaphylaxis, Infants and Children ...... 2-8
Anaphylaxis, Adults ...... 2-9
Insect Sting, Local Reaction, Children and Adults ...... 2-10
Insect Sting, Diffuse Reaction, Children and Adults ...... 2-11
Animal Bites, Non-Venomous ...... 2-12
Human Bites ...... 2-13
Minor Lacerations ...... 2-14
Minor Burns ...... 2-15
Head Trauma ...... 2-16
Non-Traumatic Abdominal Pain (Children) ...... 2-17
Abdominal Pain (Non-Gynecologic & Non-Traumatic), Adults ...... 2-18
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