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STANDING
ORDERS
2013
The Council Risk Management Committee annually updates standing orders
for medical situations, a unified health care plan, and standard operating
procedures for all of our camps, programs, and activities.
Silicon Valley Monterey Bay Council
Boy Scouts of America
Standing Orders
CONTENTS
preface ............................................................................................................................................ 0
Contents .......................................................................................................................................... 2
Reference to specifc brands of medication .................................................................................... 5
AEDs: (Automated External Defibrillators) .................................................................................... 5
Abrasions......................................................................................................................................... 5
Minor........................................................................................................................................... 5
Severe.......................................................................................................................................... 5
Animal Bites .................................................................................................................................... 5
Antibiotics ....................................................................................................................................... 6
Anaphylactic Shock ......................................................................................................................... 6
Angioedema .................................................................................................................................... 6
Asthmatic Attack ............................................................................................................................. 7
Emergency Treatment of acute shortness of breath with a history of asthma or bronchitis .... 7
Proventil HFA: ......................................................................................................................... 7
Asmanex:................................................................................................................................. 7
Blisters ............................................................................................................................................. 7
Burns ............................................................................................................................................... 7
Heat or Chemical – First Degree ................................................................................................. 7
Sunburn – First Degree ............................................................................................................... 8
All – Second and Third Degree .................................................................................................... 8
Cough .............................................................................................................................................. 8
Ear Ache .......................................................................................................................................... 8
Emergency Hypersensitivity Reaction Intervention Procedure...................................................... 8
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Standing Orders
Emergency intervention procedure (For MD, RN, PA, or NP only)................................................. 8
All Patients: ................................................................................................................................. 8
Adult or Large Child .................................................................................................................... 9
Child ............................................................................................................................................ 9
Eye ................................................................................................................................................... 9
Foreign body in eye..................................................................................................................... 9
All other problems ...................................................................................................................... 9
Flu Syndrome .................................................................................................................................. 9
Fever ........................................................................................................................................... 9
Nausea ........................................................................................................................................ 9
Diarrhea .................................................................................................................................... 10
Head Injuries ................................................................................................................................. 10
Heat Stroke/Exhaustion ................................................................................................................ 10
Stroke ........................................................................................................................................ 10
Exhaustion ................................................................................................................................. 10
Hives .............................................................................................................................................. 10
Insect Bites or Severe Allergic Reactions to Foods, e.g. Nuts ....................................................... 10
Severe Bee, Wasp or Yellow Jacket .......................................................................................... 10
Minor......................................................................................................................................... 11
Lacerations .................................................................................................................................... 11
Minor - Less than 1cm with no fat protruding.......................................................................... 11
Major – Greater than 1 cm with fat protruding. ...................................................................... 11
Extensive and deep ................................................................................................................... 11
Nettles, Poison Oak or Poison Ivy ................................................................................................. 11
Nose – Epistataxis ......................................................................................................................... 11
Oxygen Use ................................................................................................................................... 11
Pain................................................................................................................................................ 12
Mild ........................................................................................................................................... 12
Back pain ................................................................................................................................... 12
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Boy Scouts of America
Standing Orders
Puncture Wounds ......................................................................................................................... 12
Snake ............................................................................................................................................. 12
Poisonous .................................................................................................................................. 12
Non Poisonous .......................................................................................................................... 12
Sore Throat ................................................................................................................................... 12
Spider ............................................................................................................................................ 13
Sprain/Fracture ............................................................................................................................. 13
Sprain ........................................................................................................................................ 13
Closed Fracture ......................................................................................................................... 13
Open Fracture ........................................................................................................................... 13
Universal Precautions ................................................................................................................... 13
Upper Respiratory ......................................................................................................................... 14
APPENDIX: Suggested Revisions UNDER REVIEW ........................................................................ 15
Epinephrine auto injector (Lucas) ............................................................................................. 15
Subcutaneous administration of epinephrine (adrenalin) (Lucas) ........................................... 16
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Silicon Valley Monterey Bay Council
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Standing Orders
Reference to specifc brands of medication
Throughout the document, brand names for medication may be included for better
understanding of the medication but not as a directive to only use that brand and not a generic
or other medicine that is of the same pharmaceutical compound.
AEDS: (AUTOMATED EXTERNAL DEFIBRILLATORS)
There are AEDs present at Chesebrough, Hi-Sierra, and council activities. They will be kept in
the Health Lodge. They should be accessible to all camp staff as well as adult leaders and Scouts
trained in their use. The protocol and testing should be performed by the Health Lodge medical
officer.
All camp staff who are CPR/AED certified should be familiar with the use of this unit. In an
emergency, CPR protocols should be followed including the initiation of EMS (Emergency
Medical System or 911). The AED should be brought to the scene of resuscitation as soon as
possible. Many cardiac arrests, particularly in adults, may have “shockable” rhythms, and the
AED should be employed as soon as possible even if it means delaying CPR for a brief time.
The AEDs can be shown to all Scouters during camp experiences by an AED trained individual.
This demonstration may be the motivation for everyone, at all ages, to become CPR certified
with training in their usage.
ABRASIONS
Minor
Clean thoroughly with soap and water.
Apply antiseptic or antibiotic ointment (check for allergies)
If bleeding or open apply dry sterile dressing.
Question date of last tetanus booster.
Return following day if signs of infections.
Severe
Gently scrub abrasion with soap and warm water, removing all particles.
Follow minor abrasion process.
ANIMAL BITES
Wash area with soap and water.
Apply Neosporin ointment with small dressing.
Check Tetanus date.
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Standing Orders
ANTIBIOTICS
Antibiotics are not to be given.
ANAPHYLACTIC SHOCK
(Which may be secondary to sting, bite or ingestion of allergic foods)
Symptoms: Allergic Reaction – Rapid pulse – Clammy – Typical Shock Symptoms – Shortness of
breath – Respiratory distress.
Bring patient to Health Officer immediately.
Shock treatment (blanket, oxygen, head lowered and feet elevated, etc.).
Contact EMS if P>140 or systolic <80.
Monitor breathing until help arrives.
Administer epinephrine from camper’s kit, if applicable.
ANGIOEDEMA
Angioedema is the rapid swelling (edema) of the dermis, subcutaneous issue, mucosa and sub
mucosal tissues. It is very similar to urticaria, but urticaria, commonly known as hives, occurs in
the upper dermis.
Signs and Symptoms: The skin of the face, normally around the mouth, and the mucosa of the
mouth and/or throat, as well as the tongue, swell up over the period of minutes to several
hours. The swelling can also occur elsewhere, typically in the hands. The swelling can be itchy or
painful. There may also be slightly decreased sensation in the affected areas due to
compression of the nerves. Urticaria (hives) may develop simultaneously.
In severe cases, stridor of the airway occurs, with gasping or wheezy inspiratory breath sounds
and decreasing oxygen levels. Tracheal intubation is required in these situations to prevent
respiratory arrest and risk of death.
Sometimes, there has been recent exposure to an allergen (e.g. peanuts), but more often the
cause is either idiopathic (unknown) or only weakly correlated to allergen exposure.
As to our treatment regimen, I would add give oxygen at 4 liters/minute and note that I have
never seen a patient who could tolerate a position other than sitting up due to the airway
involvement. Elevating the legs may be contraindicated due to the venous return and
consequent increased venous congestion that occurs most especially in the head and neck
region. Keeping the patient cool is helpful (Ice helps slow edema - Ice chips to mouth, ice bag
around neck, in armpits and/or groin)
Treatment: If available, the administration of an inhaled corticosteroid after the albuterol
should be considered. I would increase the dose of Ranitidine to 150 mg or Famotidine to
40mg as it is more effective and is the usual recommended prescription dose. Also, the dosing
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Standing Orders
of Diphenhydramine, a 50mg loading dose is great (it's probably safe even in those under 100
lbs., just highly sedating) but is probably the only dose we will be giving so a discussion about
later dosing is perhaps unnecessary.
ASTHMATIC ATTACK
Bring patient to Health Lodge.
Determine if patient has their own asthmatic medication; let them administer dosage to
themselves.
If severe, contact Emergency Services; provide oxygen until help arrives.
Emergency Treatment of acute shortness of breath with a history of asthma or bronchitis
Many campers who have been stable with their breathing disorder do not bring their inhalers to
camp. Camp is an environment full of respiratory triggers to which these individuals are not
normally exposed and their symptoms often return while at camp. In view of this experience
and in a desire to stabilize these individuals so that they may arrive at the emergency facility in
a recoverable state, the following protocol is approved:
Proventil HFA:
Shake the canister and activate inhaler by pressing down on the bottom of the canister.
Have the patient exhale and then while inhaling place the inhaler mouth at the patient’s
mouth and have the patient press down on the canister, inhaling the medication deeply
and then hold their breath for up to ten seconds. If the patient’s shortness of breath
does not resolve the distress, repeat the procedure. Provide oxygen if required.
Contact EMS and have the patient transported to an emergency care facility if
necessary.
Asmanex:
After the application of Proventil HFA, shake the Asmanex container and give one puff
of the Asmanex in the same manner as the Proventil HFA. One minute later, give
another puff. Patient should be seen at an emergency care facility.
BLISTERS
Avoid breaking – eliminate cause.
If opened – triple antibiotic and dressing
Have patient return next day for redressing.
BURNS
Heat or Chemical – First Degree
Cool water immediately – loose, dry dressing.
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Return following day for redressing
Sunburn – First Degree
Apply “Over the counter” sunburn product.
All – Second and Third Degree
Take to hospital.
COUGH
Check temperature, if elevated isolate from other campers.
If persistent or causing distress take to hospital.
EAR ACHE
Check temperature, if elevated and ear ache is persistent take to hospital.
No swimming.
EMERGENCY HYPERSENSITIVITY REACTION INTERVENTION PROCEDURE
Recognizing early signs and symptoms is crucial in the management of hypersensitivity
reactions. The most common symptoms seen in anaphylaxis are hives (reddened wheals on the
skin) and angioedema (giant wheals that may include face, lips, hands, feet or larynx) in about
88% of patients while respiratory tract involvement (difficulty breathing, shortness of breath,
cough) occurs in approximately 50% of patients.
1.
2.
3.
4.
Call for assistance (911/Camp Director)
Assist patient to position of comfort (lying down if comfortable)
Treat for shock
Take vital signs every 5 minutes until advanced care arrives.
EMERGENCY INTERVENTION PROCEDURE (FOR MD, RN, PA, OR NP ONLY)
All Patients:
Call for assistance (911 and Camp Director)
Assist patient to recumbent position
Treat for shock
Loosen clothing
Take vital signs every 5 minutes, then every 15 minutes when stable
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Adult or Large Child
Adrenaline Chloride 1:1000: Give .3cc subcutaneously. If it is an insect bite, give it as near the
bite site as is clinically safe. May use Epipen if available. May repeat every 15 minutes if
symptoms persist or return
Albuterol (Proventil HFA) 2 puffs orally. May repeat in 15 minutes if there is shortness of
breath
Give Benadryl 50mg orally (or another antihistamine if Benadryl is not available)
Give an HR2 inhibitor (i.e., Zantac 150mg (Ranitidine HCL) orally
Child
Adrenaline Chloride 1:1000: Give .15cc subcutaneously. If it is an insect bite, give it as near the
bite site as is clinically safe. May use child Epipen if available. May repeat every 15 minutes if
symptoms persist or return
Albuterol (Proventil HFA) 1 puff orally. May repeat in 15 minutes if there is shortness of breath
Give Benadryl 25mg orally (or another antihistamine if Benadryl is not available)
Give an HR2 inhibitor (i.e., Zantac 75mg (Ranitidine HCL) orally
EYE
Foreign body in eye
Remove with 4 x 4 gauze if not embedded.
Rinse with tepid water.
If embedded, cover eye and take to hospital.
All other problems
Take to hospital.
FLU SYNDROME
Fever
Monitor temperature – check every two hours.
If persistent or high, take to hospital.
Nausea
Monitor temperature – check every two hours.
If persistent more than 24 hours send patient home.
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Diarrhea
Determine source – clear liquids only – no solid food for 24 hours.
No milk – isolate patient – send home if problem persists.
HEAD INJURIES
If any head injury is accompanied by an altered level of consciousness, dizziness, headache with
vomiting, change in blood pressure or nose/ear bleeding:
If intracranial hemorrhage or cervical spine injury is suspected, splint head and neck with sand
bags, etc. and call paramedics.
Monitor blood pressure until they arrive.
HEAT STROKE/EXHAUSTION
Stroke
Symptoms: Headache – Dry skin – Rapid pulse – Dizziness – Nausea – Elevated temperature.
Move patient to cool location.
Remove or loosen clothing.
Contact Emergency Services.
Exhaustion
Symptoms: Tired – Headache – Nausea – May be diaphoretic – Pale – Clammy. Normal
temperature.
Move to cool location.
Treat cramps with warmth and massage.
HIVES
A welt-like raised rash that comes on suddenly and disappears rapidly maybe hives. The cause
of the hives should be sought out if possible (an insect sting, a medication being taken, a known
food allergy, etc.) Take vital signs and listen carefully to the lungs. Assess for any difficulty
breathing or swallowing. If any signs of swelling of lips or airway or if the blood pressure is
dropping, call 911 and state that the patient is having an ANAPYLACTIC reaction. Give an Epipen
injection. This may be repeated in 20” if necessary. Keep the patient lying down, and feet up.
Monitor blood pressure and pulse rate until the EMS arrives.
INSECT BITES OR SEVERE ALLERGIC REACTIONS TO FOODS, E.G. NUTS
Severe Bee, Wasp or Yellow Jacket
Remove stinger if present with scraping motion.
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Monitor for allergic reaction, if present determine if patient has an Epipen Kit.
Allow patient to administer.
Call paramedic if major.
Minor
Apply cold compress (ice).
LACERATIONS
Minor - Less than 1cm with no fat protruding.
Clean thoroughly with soap and water.
Tape securely with steri-strip and cover with sterile dressing.
Verify last Tetanus, take to hospital if over 5 years.
Monitor for infection and change dressing every 24 hours.
Major – Greater than 1 cm with fat protruding.
Take to hospital for treatment
Extensive and deep
Apply direct pressure and elevate.
Cover with dry sterile dressing.
Contact EMS.
NETTLES, POISON OAK OR POISON IVY
Wash area with soap and water.
Apply ice to decrease swelling.
NOSE – EPISTATAXIS
Sit patient erect with head forward.
Gently compress nostrils with thumb and forefinger against nasal septum.
Hold for 5 to 20 minutes.
Apply cool cloth on forehead and back of neck if patient is warm or hot.
OXYGEN USE
Oxygen is occasionally used in the camp setting. These guidelines will help you understand the
policies the council has set up to better provide you with the use of oxygen in the camp setting.
Oxygen is a treatment for hypoxemia (lack of oxygen in the blood), not breathlessness. (Oxygen
has not been shown to have any effect on the sensation of breathlessness in non-hypoxemic
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patients.) The essence of this guideline can be summarized simply as a requirement for oxygen
to be prescribed according to a target saturation range and for those who administer oxygen
therapy to monitor the patient and keep within the target saturation range. The guideline
suggests aiming to achieve normal or near-normal oxygen saturation for all acutely ill patients
apart from those at risk of hypercapnic (excessive amounts of carbon dioxide in the blood)
respiratory failure or those receiving terminal palliative care.
PAIN
Mild
Recommend Tylenol
Monitor until gone.
Back pain
Apply heating pad.
Rest.
PUNCTURE WOUNDS
All significant puncture wounds (other than slivers) of the head, chest, abdomen, or genital
area, should be cleaned carefully, irrigated, and transported for physician evaluation. If there is
a suspicion that a piece of foreign matter broke off inside the wound, (unless it is readily visible
and easily removed with a sterile needle), a physician should evaluate the wounds. Minor
wounds should be cleaned, possibly soaked in Beta dine or Hibiclens, and dressed. Even minor
puncture wounds especially of the feet and hands have a large propensity to infection. These
should be inspected daily for redness, swelling, or increased pain.
SNAKE
Identify the snake
Poisonous
Keep patient calm and transport immediately.
Keep area lower than the heart and immobilize.
Identify snake if possible.
Do not use ice on bite area.
Non Poisonous
Clean and treat like any wound
SORE THROAT
Encourage fluids.
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Monitor for temperature if elevated send home.
Inspect throat for swelling or inflammation or redness.
If so, transport to hospital.
SPIDER
Attempt to identify spider (if Black Widow or Brown Recluse, take to hospital).
Ice pack for 30 minutes.
Watch for signs of infection.
If unable to stop bleeding, call paramedics.
SPRAIN/FRACTURE
Sprain
Ice to prevent swelling (on 15 minutes off 15 minutes etc.).
Elevate.
Ace bandage.
Provide crutches to keep weight off of it or sling if arm.
Closed Fracture
Splint to immobilize (joint to joint).
Elevate if possible
Transport to hospital.
Open Fracture
Cover with dry, sterile dressing.
Contact Emergency Services.
UNIVERSAL PRECAUTIONS
Blood and body fluid precautions must be used with all campers/staff.
Gloves are to be worn when touching blood, body fluids, mucus membranes and non-intact skin
of all campers/staff
If it is necessary to give CPR, a protective mask with a one-way valve is highly recommended.
Gloves are to be worn with the cleaning of any items or surfaces contaminated with blood or
body fluids
Hands are to be washed after gloves are removed
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Hands and other skin surfaces are to be washed with soap and water immediately after contact
with blood or body fluids. If there is no water supply, use a waterless hand sanitizer.
All blood and body fluid spills are to be cleaned up immediately with appropriate disinfectant
and gloves are to be worn
Clean-up materials are to be handled as hazardous waste and disposed of in special bags kept in
the Health Lodge
“Sharps” should be handled with care to avoid accidental cuts and disposed of in red sharps
containers without recapping, bending or cutting
Avoid overfilling sharps containers, empty when three-quarters full
Seal the container prior to removal to prevent spillage with disposal
Replace old sharps container immediately with new container
Any material used in health care that has blood or body fluid contamination will be
appropriately disposed
UPPER RESPIRATORY
A history of symptoms should include length and type of symptoms, fever, cough, wheezing,
shortness of breath, sore throat, and associated allergies. Examination should include vital
signs and temperature. Examine the throat and listen to lungs.
If the patient has a low grade temperature (<101) has no sore throat a clear chest and the
camper is not short of breath, then symptoms can be treated. Ibuprofen can help with achy
feelings. If the nose is so congested that sleep is difficult, then a decongestant (Sudafed) can be
used. If there is a cough then treatment can be with throat lozenges or Robitussin D. M. can be
given.
If the patient has significant other symptoms including high temperature, sore throat, and
cough, then an examination by a physician would be indicated. If the camper has a history of
asthma, allow the camper to carry his asthma medications (pills, inhalers) and use them as the
camper has been directed by their physician. Hay fever with itchy eyes, nose, and throat with a
dry cough (nonproductive) along with clear nasal drainage can be treated with an
antihistamine/decongestant combination. If breathlessness, cough or wheeze do not respond,
or if there is a lot of green or yellow mucus the camper should be referred to a higher level of
care, so their parent(s) should be notified to transport those campers home.
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Standing Orders
APPENDIX: SUGGESTED REVISIONS UNDER REVIEW
Epinephrine auto injector (Lucas)
Intramuscular (IM) administration of epinephrine: auto injector (Epipen, Epipen Jr, Twinject,
Anapen)
May be performed by all staff trained in the use of epinephrine auto injectors
1. Administer one dose of epinephrine. May repeat every 5 to 15 minutes. Use the
patient’s epinephrine auto injector if available.
a. IM administration into the middle third of the anterolateral aspect (middle outer
side) of the thigh is preferred, through clothing if necessary.
b. Administration into the buttocks should be avoided.
2. Albuterol (Proventil, Ventolin) 2 puffs orally. May repeat in (5-15) minutes if shortness
of breath continues. Use patient’s supply if available.
a. Alternately levalbuterol (Xopenex) may be administered if patient uses instead of
albuterol (use patient’s own supply)
3. Administer diphenhydramine (Benadryl) 50mg (2 x 25mg capsules or oral liquid)
4. Give a dose of histamine-receptor 2 antagonist (HR2) such as ranitidine (Zantac) 75mg
or famotidine 20mg (Pepcid)
5. Transport via advanced medical care to the nearest medical facility. Ensure advanced
medical care is fully informed of medications given and vital signs.
6. If camper returns to camp, ensure that scheduled antihistamine doses are administered
as prescribed.
Drug Notes: There are no absolute contraindications to the use of injectable epinephrine in a
life-threatening situation.
Discussion points:
Notes and References: World Health Organization (WHO) recommends the availability of one
dose of epinephrine for every 10-20 minutes of travel time to a medical emergency facility.
More than 2 doses of epinephrine should only be administered under direct medical
supervision (Lexi)
The original procedure divided dosing into sections for adults and large children (15 years or
greater, or 100 pounds and greater). Dosing in the medical literature and the package insert is
as follows:
EPINEPHRINE DOSING: 0.01mg/kg (max single dose 0.3mg) every 5 to 15 minutes (LexiComp, PI)
Children 15 – 30 kg (33 to 66 pounds),
Children and adults > 30 kg (66 pounds)
0.15mg; may repeat every 5 – 15 minutes.
0.3mg; may repeat every 5-15 minutes
Alternate dose: (Sicherer 2007)
Children 10-25kg (22-55 pounds)
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Children >25kg (55 pounds)
0.3mg
If the original procedure is followed the pediatric Epipen must be supplied stocked in the health
lodges as well as the Epipen or we would be unable to treat campers who weigh less than 100
pounds.
If the pediatric dose is not supplied at camp, the Health Officer should note any campers under
the procedure weight (especially those with severe allergies - although allergies to insect bites
such as bee stings can escalate at any time) and plan alternative measures in case of an
incident.
Recommend following dosing in the literature and package insert using 0.3mg (standard
Epipen) for all campers.
DIPHENHYDRAMINE DOSING: 5mg/kg/24 hours divided in 4 to 6 doses, maximum dose of
300mg per day (PI)
In the original document it is suggested that you may give another antihistamine if
diphenhydramine is not available. Caution: onset of action for most antihistamines other than
diphenhydramine is 1 – 3 hours. It would be better than nothing but could delay onset of
effective antihistamine coverage.
Original document recommended dose of 25mg of diphenhydramine for patients under the age
of 15 or under 100 pounds. A patient of 30kg would be allowed 150mg of diphenhydramine in
24 hours.
Recommend an initial dose of 50mg for patients over 30kg (66 pounds). Repeat doses of 25mg
would allow 4 additional doses to be given in 24 hours.
ALBUTEROL DOSING: dose for adults and children 12 years of age and older is 2 puffs every 4
hours as needed (PI).
Original document recommended 1 puff for children under the age of 15 or under 100 pounds.
Recommend a dose of 2 puffs for all campers.
There are instructions in the original document to give the injection as near the bite site as
clinically safe for an insect bite. This might be effective for subcutaneous injections, but the
Epipen should be given intramuscularly into the thigh if possible.
Subcutaneous administration of epinephrine (adrenalin) (Lucas)
MD, RN, PA or NP only
Subcutaneous administration results in a slower absorption and is less reliable than
intramuscular (IM) administration. IM administration is preferred in the setting of anaphylaxis.
Kathi Lucas commentary: Feel that this section is not necessary, as epinephrine ampoules,
needles, syringes, and adequate level of training are not consistently available at camps at all
times and route is not recommended as first line for anaphylaxis.
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