STANDING ORDERS

ROBERT KATZ MD
Phone: 718/516-470-3495
Beeper: 888-634-3863
FAX: 718-347-0468
Email: katz@lij.edu
4/30/04

rev. 5/02
 CONTENTS

Topic Page
Abdominal Pain ....................................................…………........... 4
Abrasions ............................................................................................ 4
Allergic Dermatitis ............................................................................... 4
Allergic Rhinitis............................................................................... 5
Anaphylaxis ............................................................................................ 5
Asthma ............................................................................................ 6
Bites - Bee Stings ............................................................................... 6
Bites - Animal ............................................................................... 6
Bites - Human ............................................................................... 6
Bites - Insect ............................................................................... 7
Bites - Snake ............................................................................................ 7
Bites - Spider ........................................................................................ 7
Bites – Tick ………………………………………………………… 8
Burns - Superficial ............................................................................... 8
Burns - Partial Thickness .................................................................. 9
Burns - Full Thickness ............................................................................... 9
Conjunctivitis - Allergic ............................................….................. 10
Conjunctivitis - Infectious .................................................................. 10
Constipation ............................................................................................ 10
Diarrhea ............................................................................................ 11
Fever ......................................................................................................... 11
Fractures ............................................................................................ 11
Headache ............................................................................................ 12
Head Injury ............................................................................................ 12
Heat Cramps ............................................................................... 12
Heat Exhaustion ............................................................................... 13
Heat Stroke ............................................................................................ 13
Infection - Skin ............................................................................... 13
Ingestions ............................................................................................ 14
Lacerations ............................................................................................ 14
Lice ......................................................................................................... 14
Menstrual Cramps ............................................................................... 15
Nosebleed ............................................................................................ 15
Otitis Externa ............................................................................................ 15
Otitis Media ............................................................................................ 16
Pharyngitis ............................................................................................ 16
Poison Ivy ............................................................................................ 17
Scabies ............................................................................................ 17
Sprains ............................................................................................ 18
Strains ............................................................................................ 18
Seizures ............................................................................................ 18
Sunburn ............................................................................................ 8
Upper Respiratory Infection .................................................................. 19
Urinary Tract Infection ............................................................................... 19
Vomiting ............................................................................................ 11

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 ABDOMINAL PAIN

1. Obtain history of abdominal pain.

2. Palpate abdomen and check for rebound tenderness.
3. If febrile, observe in Infirmary and have seen by MD at next clinic.
4. Refer to hospital if RLQ pain or rebound tenderness is present.
5. Ask child about bowel habits. If constipated give Milk of Magnesia 15-30 cc BID until BM.
If no BM for 2 days, give Fleets enema.
6. If pain is caused by bowel hyperactivity, give Mylanta 1 tab or 30 cc and have checked at next
clinic by MD.
7. Peptobismol 15-30 cc may be given for minor discomfort without positive findings.
Remember – Peptobismol may cause black discoloration of stools.
8. Avoid the use of analgesics.

ABRASIONS

1. Scrub superficial wounds with soap and water.

2. Irrigate deep wounds with normal saline and refer to hospital for suturing.
3. Apply antibiotic ointment.
4. Cover wound with appropriately sized bandage or gauze pad.
5. Change dressing, apply antibiotic and check wound healing every 24 hrs.
6. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.

ALLERGIC DERMATITIS

Delayed hypersensitivity response to an allergen.

1. Obtain history of rash.

2. Determine potential allergen.
3. If possible, remove source of allergen. If potential origin is drug, D/C medication and contact
MD.
4. Benadryl 1 mg/kg to a max of 50 mg Q 4-6 hrs until rash subsides.
5. Hydrocortisone cream 1% locally Q 4 hrs.
6. Soothing baths with Aveeno or oatmeal are helpful.

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 ALLERGIC RHINITIS

1. Determine if history of allergic rhinitis is present.

2. Give Dimetapp 5-10 cc or Chlortrimeton 4 mg TID till symptoms subside.
3. Check for medication side effects, including drowsiness and dryness of secretions.
4. Consult with parent if medication not effective after 48 hours.
5. Have seen by MD as needed.

ANAPHYLAXIS

Anaphylaxis is a severe allergic response to an allergen. Symptoms begin with flushing, increased
warmth, generalized itching, and followed by urticaria and angioedema. Severe breathing
problems are a sign of anaphylaxias and are a MEDICAL EMERGENCY.

1. Call 911 and request an ambulance immediately.

2. Epinephrine auto-injector should be given immediately. The Pediatric auto-injector should be
used in children < 65 lbs, and the Adult auto-injector for those > 65 lbs.
3. If available, a high concentration of oxygen should be given.
4. Remove the auto-injector cap and check to see that the fluid is clear and colorless and the unit
has not expired. If fluid is discolored, discard auto-injector.
5. Place the tip of the injector against the patient’s bare outer thigh.
6. With a quick motion, push the auto-injector firmly against the thigh until the spring-loaded
needle is activated.
7. HOLD IN PLACE FOR 10 SECONDS.
8. Remove the auto-injector from the thigh and discard after re-inserting the unit into the carrying
tube and then re-cap tube.
9. Nebulized Albuterol 0.5-1.0 cc in 3 cc NS if wheezing is present.
10. Monitor ABC’s and vital signs.

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 ASTHMA

Recurrent, reversible lower airway obstruction. Exam shows wheezing, high-pitched expiratory
sounds and difficulty breathing.

1. Obtain documentation of patient’s triggers, past history and baseline peak flow values.
2. During an attack, obtain peak flow, vital signs. Obtain duration of symptoms and distress.
3. Follow protocol as per child’s own doctor, or
4. Nebulized Albuterol 0.5-1.0 cc in 3 cc NS or 2 puffs Albuterol MDI. If no improvement, call
MD for further directions or transport to hospital.
5. Benadryl 1 mg/kg to a max of 50 mg if wheezing is due to an allergic reaction.

BITES - Animal / Human

1. Identify animal if possible. Check health status if a domestic animal.

2. Was attack provoked or unprovoked? If unprovoked, transport to hospital for possible rabies
vaccination. Rodents and rabbits do not transmit rabies.
3. Check patient’s tetanus immunity.
4. For wounds on hand or face, or if extensive, contact MD.
5. If last tetanus less than 5 years ago, give Tetanus booster.
6. If bite is minor, wash with soap and water, apply antibiotic ointment and observe for signs of
infection - increasing redness, swelling, pain or discharge.
7. For all cat, dog, human bites and puncture wounds - contact MD.
8. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.
9. Transport all lacerations to hospital.

BITES - Bee Stings

1. If there is history of an allergy, give Benadryl 1mg/kg to a max of 50 mg PO.

2. Observe for an hour for signs of a generalized reaction - wheezing or angioedema.
3. If generalized reaction occurs, give Epinephrine as per “Anaphylaxis” protocol and transport
to hospital.
4. To remove bee stinger - scrape site, wash with soap and water and apply cold compress.
5. Apply Hydrocortisone 1% cream BID to TID for itching.

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 BITES - Insect

1. Wash with soap and water.

2. Apply cold compresses.
3. Hydrocortisone 1% cream BID to TID for itching.
4. Benadryl 1mg/kg to a max of 50 mg Q 6 hrs for itching.
5. Observe for signs of infection - increasing redness, swelling, pain or discharge.

BITES - Snake

Envenomation is indicated by a puncture wound causing pain, swelling, blister formation and
ecchymosis that occurs within 2-3 hrs of bite. Non-venomous snakes cause scratch marks.

1. Identify snake if possible.

2. Examine wound for puncture (venomous) or scratch marks (non-venomous).
3. If envenomation has occurred - splint extremity to reduce motion, keep patient quiet and warm,
and transport to hospital.
4. If non-venomous, cleanse wound with soap and water; give tetanus booster and contact MD.

BITES - Spider

Potentially fatal spider bites include Black Widow (red hourglass marking on abdomen) and Brown
Recluse (orange violin-shaped marking on back). Black Widows may produce pain, muscle spasm,
headache, nausea, vomiting and hypertension. Brown Recluses produce pain and a violaceous
blister that becomes an ulcer. Other spiders may cause local discomfort but are not fatal.

1. Apply ice compresses to bite site to reduce toxin absorption and reduce pain.
2. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.
3. Transport to hospital if Black Widow or Brown Recluse bite.

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 BITES - Tick

1. Use fine-point tweezers to grasp the tick at the point of attachment, as close to the skin as
possible.
2. Gently pull the tick straight out.
3. Should any mouthparts remain behind, leave them in place and they will fall out on their own.
4. Ticks that were not attached for at least 48 hours do not transmit Lyme disease.
5. If tick was attached longer than 48 hours, consider serologic testing after 4 weeks have
elapsed.
6. Antibiotic prophylaxis is not needed.
7. Should a rash at the site or neurologic symptoms develop, have seen by MD at next clinic visit
for evaluation and consideration of antibiotic treatment.

SUNBURN / BURNS - Superficial

Skin is pink to light red and blanches to pressure. There are no blisters. Common example is mild
to moderate sunburn.

1. Document location and body surface involved.

2. Soak in very cool water for 15-20 minutes or apply cold compresses.
3. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.
4. Apply moisturizing cream or Aloe Vera to reddened areas.
5. Emphasize the importance of the use of sunscreen, and use 15-30 SPF.

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 BURNS - Partial Thickness

Bright red or mottled skin with blisters or bullae. Common examples are severe sunburn and
chemical burns.

1. Document location and body surface involved.

2. Determine presence of smoke inhalation.
3. Check tetanus immunity.
4. Remove hot or chemical-laden clothing.
5. Apply sterile gauze with cooled saline to affected areas.
6. Leave blisters intact and contact MD for debridement.
7. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain. Contact MD for severe pain.
8. Apply Silvadene (if not sulfa-allergic) or antibiotic ointment lightly and cover with a dry,
sterile dressing.
9. Change dressing daily and check for signs of impaired circulation or infection.
10. Hydrocortisone 1% cream may reduce the pain and swelling of severe sunburn.
11. If burns involve the face, genitalia, both hands or > 20% body surface area, contact MD.
12. Emphasize the importance of the use of sunscreen.

BURNS - Full Thickness

Skin is dry, white, charred, with sensation to deep pressure only. Usually caused by flame, hot
grease, chemicals or prolonged immersion.

1. Document location and body surface involved.

2. Determine presence of smoke inhalation.
3. Check tetanus immunity.
4. Remove hot or chemical-laden clothing.
5. If < 2% body surface area, and does not involve face, hands, feet or perineum - treat as partial
thickness burns.
6. Otherwise transport to hospital.

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 CONJUNCTIVITIS - Allergic

Conjunctiva is reddened with a cobblestone appearance, itching and tearing.

1. Apply cool compresses to the eyes.

2. Visine AC TID X 24 hrs.
3. If no improvement, instill Naphcon A 2 gtts BID. Have child seen by MD at next visit.

CONJUNCTIVITIS - Infectious

Conjunctiva is reddened, with purulent discharge, itching and tearing.

1. Clean drainage from eye with clean gauze pad.

2. Check for redness and discharge.
3. If no discharge is present, no treatment is necessary.
4. If discharge is present, instill antibiotic ophthalmic gtts 2 in both eyes TID.
5. Have seen by MD at next clinic visit.

CONSTIPATION

Infrequent bowel movements or hard stools.

1. Document diet, stooling pattern.

2. Examine abdomen.
3. Increase fluids; discourage milk, cheese, rice and banana products.
4. Try prunes or prune juice.
5. Milk of Magnesia 15-30 cc BID until BM. If no BM for 2 days, give Fleets enema.
6. Encourage diet high in fiber - whole grains, fruits and vegetables.

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 DIARRHEA / VOMITING

Usually secondary to viral infections. Does not contain blood.

1. Document diet and stool pattern, fever, cramping, vomiting, presence of blood in stool.
2. If abdominal exam is normal and there is no vomiting, offer starchy foods and clear liquids
such as Gatorade, ginger ale or cola. Avoid caffeine, apple or pear juice, tea, coffee and milk.
3. Yogurt with active cultures is helpful.
4. If vomiting is present, give clear liquids only for 12-24 hrs then begin a starchy (BRAT) diet.
5. Peptobismol or Kaopectate 15-30 cc may be given for minor discomfort without positive
findings. Remember – Peptobismol may cause black discoloration of stools.
6. Observe for adequate urination, blood in stool and abdominal pain.

FEVER

1. Determine probable cause of fever.

2. Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs.
3. Try Ibuprofen 10 mg/kg to a max of 400 mg Q 6 hrs if unresponsive to Tylenol.
4. Observe in Health Center.
5. Repeat physical assessments for evolution of signs and symptoms.
6. Have child seen by MD at next clinic visit.

FRACTURES

A break in the continuity of bone.

1. Assess and determine nature and cause of the injury.

2. Complete accident report.
3. Assess range of motion and check for signs of fracture - pinpoint tenderness, swelling,
ecchymosis.
4. Immobilize area. Apply ice and elevate.
5. If open fracture, apply sterile dressing.
6. Transport to hospital.

HEADACHE

Usually secondary to an infectious or allergic cause.

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1. Document location, quality or character of pain. Also duration, associated nausea or vomiting
and history of head injury.
2. If no history of head injury and negative examination, give Tylenol 15 mg/kg to a max of 1000
mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400 mg Q 6 hrs.
3. If headache is severe or lasts > 24 hrs, contact MD.

HEAD INJURY

1. Document loss of consciousness, nature of injury, memory loss, presence of bleeding,

discharge from ears or nose and presence of seizures.
2. Check vital signs, mental status, level of consciousness and presence of neck injury.
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3. If bleeding scalp wound present, cover, apply pressure and elevate head to 30 . Apply cold
compress to site.
4. Contact MD for any laceration, loss of consciousness or abnormal neurological exam.

HEAT CRAMPS

Occur on hot days after strenuous exercise and electrolyte loss. The calf muscles are most
commonly affected.

1. Give fluids - water or electrolyte drinks. Avoid juices.

2. Gentle massage of the affected muscles until cramps are relieved.
3. Apply ice.
4. If unrelieved, contact MD.
5. Emphasize the importance of adequate fluid intake on hot days.

HEAT EXHAUSTION

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Occurs when the body temperature begins rising (usually < 104 ) on hot days due to lack of
adequate hydration. May see profuse perspiration, skin warm to touch and slight disorientation.

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1. Assess level of alertness.
2. Take temperature.
3. Provide gentle cooling and rest.
4. Elevate feet and loosen clothing.
5. Give plenty of fluids - water or electrolyte drinks. Avoid juices.
6. Place in room with blowing fan to increase evaporative losses.
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7. If disoriented or temperature > 104 , contact MD.
8. Emphasize the importance of adequate fluid intake on hot days.

HEAT STROKE

May not be preceded by heat exhaustion. It is life-threatening as the core body temperature is
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rising, usually > 104-105 .

1. Assess level of consciousness.

2. Take temperature and monitor vital signs.
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3. Undress and provide rapid cooling in cool, not cold water, to a temperature of 102 , then
gently cool to avoid chills.
4. If alert, give sips of water.
5. If unconscious or no improvement, transport to hospital.

INFECTION - Skin

1. Document type of lesion, presence of discharge, redness and warmth.

2. If skin integrity compromised, wash with soap and water or 5% Burow’s solution.
3. Apply antibiotic ointment TID and cover with clean dressing.
4. If spreading or worsens in 24 hrs, consult MD.

INGESTIONS

1. Identify agent ingested, amount and time of ingestion.

2. Assess level of consciousness, vital signs and presence of oral lesions.

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3. Contact local Poison Control Center and follow instructions.
4. Have syrup of ipecac and activated charcoal at hand.

LACERATIONS

1. Apply sterile or clean dressing with pressure to site of wound.

2. Elevate wounded extremity.
3. Assess nature of laceration and depth.
4. Cleanse or soak wound for 10 minutes in Betadine and hydrogen peroxide solution if wound
does not require suturing.
5. After drying wound with sterile gauze, approximate edges of wound and apply cover strips.
6. Observe on a daily basis for signs of infection and leave cover strips in place for 5-7 days.
7. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.
8. If wound requires suturing, cleanse with normal saline and transport to hospital.
9. All facial lacerations should be sutured by a plastic surgeon and the parent should be notified
prior to suturing to decide the choice of doctor.

LICE - Head

Nits attached to hair shafts. Itchy scalp.

1. Permethrin (Nix) shampoo for 10 minutes.

2. Remove nits with fine-tooth comb.
3. Launder clothing and linens in water > 125o.
4. Place combs, hats and headgear in a sealed bag for 1 week.

MENSTRUAL CRAMPS

1. Assess history of onset of menses and dysmenorrhea.

2. Question as to medications taken at home.
3. Ibuprofen 400 mg may be given.
4. Increase Ibuprofen dose to 600 mg if no relief in 4 hours.

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5. Consult MD if no relief of symptoms.

NOSEBLEED

1. Pinch nares together for a full 5-10 min with child sitting upright.
2. If unsuccessful, soak cotton ball with aqueous Epinephrine 1:1000 or 0.25% Neosynephrine
and place in nasal cavity.
3. May instill petrolatum-impregnated gauze into affected nare.
4. If bleeding continues, transport to hospital.

OTITIS EXTERNA

External ear canal is reddened and inflamed secondary to trapping of excess moisture in the
external canal.

1. Assess the status of the ear canal and ear drum with otoscope.
2. If external ear is reddened and inflamed, clean with alcohol wick and insert Corticosporin otic
gtts 2 in each canal followed by a moist cotton wick QID until seen by MD.
3. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.
4. For those prone to “Swimmer’s ear” use 50:50 solution of isopropyl alcohol and hydrogen
peroxide after swimming and at bedtime to prevent recurrence.
5. No swimming for 2 days, then only with ear plugs in place.

OTITIS MEDIA

Acute, suppurative infection of the middle ear. May be associated with fever & URI.

1. Assess the status of the ear canal and ear drum with otoscope.
1. If ear drum is inflamed and child has pain or is febrile, give Tylenol 15 mg/kg to a max of
1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400 mg Q 6 hrs for pain.

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2. For pain, may give Glycerin with benzocaine analgesic otic gtts (Auralgan, Americaine) -
2 gtts QID.
3. Consult MD.

PHARYNGITIS

Acute, suppurative infection of the throat and tonsillar area. May be associated with adenopathy,
difficulty swallowing or breathing.

1. Document fever and presence of associated symptoms.

2. Examine throat for signs of erythema, exudate and tonsillar swelling.
3. Culture throat if any signs of infection or if exposed to camper with documented Strep throat.
4. Salt water gargles and lozenges TID. Increase fluids.
5. Tylenol 15 mg/kg to a max of 1000 mg for pain or fever or Ibuprofen 10 mg/kg to a max of
400 mg Q 6 hrs for pain.
6. If culture positive, give Penicillin VK 250-500 mg TID for 10 days.
7. If Penicillin allergic, give Erythromycin 250 mg TID for 10 days.
8. Notify MD at next clinic visit.
9. Reculture throat 3 days after last dose of antibiotics, and if positive, notify MD.

POISON IVY

Itchy, red, blistering rash often with linear lesions. Lesions may swell and ooze.

1. Check history of rash, exposure and location on body.

2. Shower with a solution designed to remove oils of the plant.
3. Wash shoes and laces with same solution.
4. Scrub under nails to remove oils.

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5. Atarax 0.5 mg/kg to a max of 25 mg Q 6 hrs, or Benadryl 1 mg/kg to a max of 50 mg Q 6 hrs
for itching.
6. Hydrocortisone 0.5-1% cream to affected areas on body.
7. Calamine lotion to affected areas (not face) prn.
8. Facial poison ivy should be cleansed TID with soap and water followed by Hydrocortisone
0.5% cream.
9. Soothing baths with Aveeno or oatmeal are helpful.
10. Consult MD for widespread rash, facial or genital swelling and signs of secondary infection.

SCABIES

Itchy rash, with macules, wheals, burrows and excoriation. Commonly in web spaces of fingers.

1. Permethrin (Elimite) 5% cream to body overnight, or for at least 8 hrs.

2. Launder all clothing and linens in water > 125o.
3. Repeat treatment 2 and 7 days later.

SPRAINS / STRAINS

Sprains are a disruption of ligaments. Strains are a disruption of the musculo-tendinous unit.

1. Determine nature of injury.

2. Complete accident report.
3. Assess range of motion of injured joint and check for pinpoint tenderness.
4. Assess pulses distal to the injury site. If absent, transport to hospital.
5. If signs of fracture, immobilize and transport to hospital.
6. Elevate affected extremity and apply ice. Apply elastic bandage for compression.

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7. Apply ankle brace for ankle sprain.
8. Tylenol 15 mg/kg to a max of 1000 mg or Ibuprofen 10 mg/kg to a max of 400 mg Q 6 hrs for
pain.
9. A well tied high top shoe will provide support to an affected ankle.

SEIZURES

A paroxysmal event resulting in abnormalities of motor, sensory, autonomic or psychic function.

1. Document duration of seizure, types of movement, eye deviation, focal findings, loss of
consciousness or cyanosis.
2. Do not forcefully restrain.
3. Do not insert anything into mouth.
4. Ensure an adequate airway.
5. Place on side to prevent aspiration.
6. Provide oxygen if available.
7. Consult MD if seizure is short-lived and patient has a seizure history. Otherwise transport to
hospital.

UPPER RESPIRATORY INFECTION

1. Obtain history of symptoms and duration, including fever, cough, pharyngitis and nasal
congestion.
2. Sudafed 1 mg/kg to a max of 60 mg Q 6 hrs as needed.
3. Tylenol 15 mg/kg to max of 1000 mg Q 4 hrs for fever or achiness.
4. If cough disturbs sleep, Robitussin DM 15-30 cc at bedtime.
5. Encourage adequate rest and increased fluids.
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6. Consult MD for earache, fever > 102 for > 3 days, or abnormal chest sounds.

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 URINARY TRACT INFECTION

May present with frequency, urgency, dysuria and enuresis.

1. Give Tylenol 15 mg/kg to a max of 1000 mg Q 4 hrs or Ibuprofen 10 mg/kg to a max of 400
mg Q 6 hrs for pain.
2. Check vital signs including blood pressure.
3. Encourage fluid intake and have seen by MD at next clinic visit.

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