Centre for Remote Health
A joint centre of Flinders University and Charles Darwin University
CARPA Standard
Treatment Manual
5th edition
Main Changes
Protocol Format
• Ask - getting the person’s story
• S
• Check - observations, assessments, • O
tests, to help with diagnosis
(includes look, feel, listen, do)
• D
• Do – treatments or interventions
• A
• Follow Up - ongoing care or actions • F
New protocols
• Low blood glucose – Emergency and assessment
• Breathing problems in children – Child health
• Rashes – Child health – includes Measles
• Amphetamines and other stimulants – Mental health and
drug problems
• Interpreting results – Chronic diseases
• Assessing and reducing cardiovascular risk – Chronic
diseases
• Combined checks for chronic diseases – Chronic diseases
• Leprosy – General topics
New protocols 2
• Child growth and development – Child health – replaces Child
growth and malnutrition, includes developmental issues
• Sick babies under 2 months – Child health – replaces Babies
less than 3 months old who are sick
• Messages for healthy food choices, physical activity, size and
weight – Chronic diseases – replaces Healthy choices for food
and activity and Healthy weight for adults
•
Joint problems – General topics – replaces Joint infection
(septic arthritis), includes other swollen, painful joint
presentations
• Joint sprains and strains – General topics – replaces Sports
injuries
• Pain management – General topics – includes Paracetamol
doses and Pain relief
Changed protocols
Moved
• Breathing problems in adults – from Emergency and
assessment to General topics
• Asthma in Adults – from Chronic diseases to General topics
• Chronic lung disease in adults – from Chronic diseases to
General topics
• Adult health check – from General topics to Chronic diseases
• Brief interventions –from General topics to Chronic disease
• Nose bleed – from General topics to Emergency and
assessment
Name change
• Psychiatric emergencies – now Mental health emergency
• Kidney (renal) disease in adults – now Chronic kidney disease
• High fats in the blood (lipids) – now Abnormal blood fats
(lipids)
Removed protocols
• Mental health introduction
• Overview of chronic diseases
• Immunisation/vaccination
• Babies less than 3 months old who are sick – replaced by Sick
babies under 2 months
• Child growth and malnutrition – replaced by Child growth and
development
• Joint infection (septic arthritis) – replaced by Joint problems
• Sports injuries – replaced by Joint sprains and strains
Removed protocols
• Procaine penicillin reactions – combined with Anaphylaxis
• Healthy choices for food and activity – included in Messages
for healthy food choices, physical activity, size and weight
• Healthy weight for adults – included in Messages for healthy
food choices, physical activity, size and weight
• Syphilis – included in Sexually transmitted infections (STIs) in
men
• Chest pain assessment – included in Chest pain
• Pain relief – included in Pain management
• Paracetamol doses – included in Pain management
• Measles – included in Rashes
Emergency and assessment
General changes
• O by non rebreathable mask 10L/min child, 15L/min
adult (was 8L/min with reservoir bag)
2
• O 6L/min children (was 4)
2
• Put in IV cannula (was a drip)
• Normal saline (was Hartmanns, normal saline or
Haemaccel)
• O stats added to observations
2
Emergency and assessment
DR ABC D
• Aligned with Australian Resuscitation Council guidelines
Abdominal pain
• Buscopan removed as treatment for gallstones and diarrhoea
Anaphylaxis
• Use of hydrocortisone and antihistamines removed
Bites – animal and human
• Use clindamycin (was roxithromycin) if allergic to penicillin
Fits
• Glucose (was dextrose) doses changed
• Manage BGL less than 4mmol/L (was less than 2mmol/L)
Emergency and assessment 2
Burns
• Additional criteria to send to hospital – major and minor burns
• Working out children’s fluids
 Need maintenance and replacement fluids
 Fluid replacement at 4ml (was 3ml) x weight in kgs x % body
surface burnt
• Infected - cephazolin (was roxithromycin) if allergic to
penicillin
Chest pain
• Treatment
 Initial – all
 STEMI
 AMI without ST elevation
• More details on thrombolysis
Emergency and assessment 3
Injuries
• Bleeding – manage shock
• Severe head injury – give flucloxacillin (was ceftriaxone)
• Spinal injury - check for erection (priapism)
• Abdominal injury – do not spring pelvis
• Infected wounds
 dicloxacillin OR flucloxacillin AND probenecid (was procaine
penicillin)
 Trimethoprim-sulfamethoxazole (was roxithromycin) if allergic to
penicillin
• Old wounds
 Amoxicillin-clavulanate (was procaine penicillin) and
 Clindamycin if allergic to penicillin (was roxithromycin)
Emergency and assessment 4
Low blood glucose – new protocol
Meningitis
• Added - give dexamethasone IV OR if not available, give
hydrocortisone IV
Near hanging
• Give fluids if low BP (was unless)
Nose bleed
• Details on Merocel pack and balloon catheter now in CPM
Unconscious person
• Section on immediate management added
Child health
Anaemia
• Diagnosis of anaemia – Hb by age
• Prevention of iron deficiency in preterm and small babies
• Information on screening
• Hb measurements in g/L (was g/dL)
• Do FBE if Hb less than 90g/L (was 11g/dL)
• Follow-up – check Hb at 4 then 12 weeks (was 4 then 4)
Chest infection – 2 months to 5 years (was 3 months)
• Fast breathing in children table
• Reliever – 3 doses 20min apart (was 2 doses 15min apart)
• Mild pneumonia - Procaine penicillin or amoxycillin oral for 3
days (was 5 days)
Child health 2
Breathing problems in children – new protocol
• CSLD
 3rd line treatment azithromycin (was rozithromycin)
• Asthma
 How bad is the asthma – O2 saturation: mild 95-100%, moderate
91-94% (was 94-100% and 90-94%)
 Severe asthma – hydrocortisone IM/IV 5mg/kg/dose up to 100mg
– can repeat after 6 hours (was hydrocortisone IM/IV 0.25mg/kg)
 Very severe asthma – Put 5mg salbutamol in nebuliser, mix with
normal saline to make 5ml (was put 5ml of undiluted salbutamol
in nebuliser)
 Very severe asthma – hydrocortisone IM/IV 5mg/kg/dose up to
100mg (was hydrocortisone IM/IV 0.25mg/kg)
Child health 3
Child growth and development
• Child heath assessments
• Developmental issues
• Fetal alcohol syndrome
Dental and oral problems – 6 months to 5 years – new
protocol
Infant and child growth and nutrition
• Growth faltering
 Oral zinc doses by age
 Metronidazole oral or tinidazole to treat Giardia, give if there is
diarrhoea
 Give vitamin A removed
Child health 4
Diarrhoea
• Persistent diarrhoea
 Age categories for zinc doses
 Diarrhoea lasting more than 7 days (was 14)
 Give vitamin A removed
Ear problems
• Prevention strategies
• Assessing/diagnosing ear problems
• Drowning insects – Use lignocaine 1% or amethocaine 1%
• Hearing tests and results
• Otitis media with effusion – Amoxyicillin for 14 days (was 1014 days)
Child health 5
Ear problems
• AOM with bulge or perforation - Amoxyicillin for 7 days (was
14 days. If still bulge – double amoxyicillin to 50mg/kg/dose
(was think about using45mg/kg)
• Ciprofloxacin 5 drops 2 times a day (was dexamethasoneframycetin-gramicidin 2-4 drops 2-4 times a day)
• CSOM - Ciprofloxacin 5 drops 2 times a day (was
dexamethasone-framycetin-gramicidin 2-4 drops, 2-4 times a
day)
• Softening wax
 Sodium bicarbonate solution 4 drops twice a day for 3–4 days
 Docusate sodium eardrops (was Waxsol/Coloxyl eardrops)
Rashes – new protocol
Child health 6
Sexual abuse & sexual assault – children & young people
• Requirement to know legislation and protocols around
mandatory reporting
• Presentations of child sexual abuse
• Guideline for suspected sexual assault/abuse/maltreatment of
person under 18yrs
• STIs (includes screening and reporting)
Sick babies under 2 months (was under 3 months)
• Signs of serious sickness can be non specific - be aware of
warning signs – table of warning signs
• Give gentamicin (was think about gentamicin)
• Do U/A removed
Child health 7
Urine problems – 2 months (was 3 months) to 12 years
• Urinary tract infection
 Reasons to suspect UTI – and think about balanitis, phimosis or
paraphimosis
 Table - collecting urine samples
 Amoxycillin-clavulanate for 5 days (was 7 days)
 If allergic to penicillin, give trimethoprim-sulfamethoxazole
oral for 5 days (was 7 days)
 MCUG for all children under 1 year with confirmed UTI (was child
under 5 years with abnormal renal US)
 References to ‘preventer antibiotic’ removed
Child health 8
• Vesico-ureteric reflux
 Explanation of VUR – involves urine flowing back up to kidneys
 Child with VUR may be on long-term antibiotics
 No age for MCUG (was under 5years)
•
Blood or protein in urine
 Subclinical cases added
 Other cause of blood in urine (haematuria) added
 Protein in urine added
•
Problems in boys
 New heading
Mental health
Mental health assessment
• Prompts for mental health examination: A-Appearance,
B-Behaviour, C-Conversation, A-Affect, P-Perception,
C-Cognition, I-Insight, R-Rapport
Mental health emergency
• Olanzapine - anti-psychotic of choice
• Do not give benzodiazepines, eg diazepam to child, or person
who is drunk – wait 6–8 hours after last drink
• Give diazepam 5-10 every 2-6 hours max 40mg daily (was 1020mg every 2-6hours max 60mg daily)
• Give risperidone oral 0.5–2mg (was 2mg)
Anxiety
• Panic attacks
Mental health 2
Confusion – delirium and dementia
• Cognitive assessment
Depression
• Depression assessment – Kessler K -10
• Medical review at 6 and 12 months (was 12 months)
• Stopping treatment – reduce by ½ tablet (was ¼-½)
Family and domestic violence
• Signs that child may be exposed or involved
• Checklist for intervention (ABCDEF)
Mental health 3
Grief and loss
• Clinical treatment section
• Sleeping tablets 1–3 nights (was temazepam 10mg 3–4
nights)
Psychosis
• Neuroleptic Malignant Syndrome
• Medicine – see AMH or Medicines Book (was risperidone 2-4mg
oral daily)
Suicide risk
• Suicide risk assessment
• Stay Strong Plan
Drug and alcohol
Alcohol information
• Safe drinking levels (per day) – safe: 0-2 , risky:3-4,
dangerous: more than 4. None if pregnant
Alcohol problems – acute
• Mild withdrawal – taper diazepam dose to nothing over 3-5
days (was 5 days)
• Diazepam oral doses – medical consult before giving more
than 80mg in first 24 hours – 90kg or under, 100mg in first 24
hours – over 90kg (was if you need to give more than 100mg
in a day)
Amphetamines and other stimulants – new protocol
Drug and alcohol 2
Cannabis
• Medicines for cannabis withdrawal
• Follow up
Petrol and solvent sniffing
• Immediate and long term effects
• Olanzapine oral 5-10mg – up to 20mg daily (was diazepam
10-20mg every 2-6 hours)
Sexual health
STIs in men
• Full STI check up table
• If oral or anal gonorrhoea – give ceftriaxone IM 500mg
• Confirmed/secondary syphilis give benzathine penicillin 1.8g
• If pain on passing urine or discharge from penis and outside
local area – Ceftriaxone IM 500mg (was 250mg)
• Herpes - first episode – Valaciclovir 5-10days (was 5 days),
recurrent – Valaciclovir oral 500mg twice a day for 3 days
(was 5 days) OR Famciclovir oral 500mg once then 250mg 12
hourly for 3 doses (was 250gm 3 times a day for 5 days)
• Viral warts – Use podophyllotoxin 0.15% cream (was
podophyllotoxin 0.25% cream or podophyllin)
• Putting on a condom pictures (see CPM)
Chronic diseases
Adult health check
• Age ranges added – older person 55 years (was 50 years)
• Have every 2 years (was every year)
• Older person – check vision, ask about hearing and dental
problems, osteoporosis risks
• Follow up – medical review, dental review, treatment if
cardiovascular risk over 15%
Brief intervention
• Sticking to it
• FRAMES
• Messages for healthy food choices, physical activity,
size and weight
• BMI table and information (see CPM)
Chronic diseases 2
Tobacco information
• Fagerstom test for nicotine dependence
• Details on medicines
• ‘5As’ approach to help people stop smoking
Assessing and reducing cardiovascular risk – new protocol
Combined checks for chronic diseases – new protocol
Chronic diseases 3
Interpreting results
• ACR results
 Male 0-2.4, Female 0-3.4 – normal (was 0-3.4)
 Male 2.5-34, Female 3.5-34 – Micro-albuminuria (was 3.4-35)
• Waist circumference
• Target levels for blood fats
• HbA1c and non-fasting OGTT for diagnosing diabetes
• Cardiovascular risk levels in relation to BGL results
• Normal BP results - 130/80 or more but less than 140/90 (was
less than 140/90)
Chronic diseases 4
Abnormal blood fats
• 2 yearly checks, annual checks for high risk
• Target level for blood fats
 TC – less than 4 (was 4 or less)
 HDL-C more than 1 (was 1 or more)
 LDL-C less than 2.5 or less than 2 if known vascular disease (was
2.5 or less)
 TG – less than 1.5 (was 2 or less)
• Try life style changes for 6-12 weeks before starting medicines
(was 3-6 months)
• Lipid controlling medicines include statins and fibrates
• Check LFTs, CK after 4 weeks on medicine (was check LFTs
after 6 weeks on medicine)
• Combined checks
Chronic diseases 5
Chronic kidney disease
• Glomerular filtration rate replaces calculated kidney function
• Need 2 abnormal ARC at least 3 months apart, or 2 reduced
eGFR to diagnose chronic kidney disease (was If ACR more
than 3.4 repeat within 1 month to confirm kidney disease)
• Action by stage
 Stage 1 – ACEi (was not specified)
 Stage 2 – ACEi (was ACEi or ARB)
 Stage 3 – ACEi and ARB (was not specified)
• Target Hb is 110-130g/L (was 120g/L)
• Do not give metformin
Coronary artery disease
• Medicines for chest pains (angina)
Chronic diseases 6
Diabetes
• Impaired glucose tolerance – think about starting metformin
• Gestational diabetes
• Adjusting insulin dose for low blood glucose readings
• Metformin maximum dose 3g (was 1g)
• Think about starting insulin if 2 or more HbA1c results of more
than 7% (was 9%) or BGLs always more than 8-10mmol/L
(was 10 mmol/L)
• Foot examination details (see CPM)
Heart failure
• Chronic heart failure treatment significantly revised
Chronic diseases 7
High BP
• Routine check every 2 years (was 1 year)
• Management by absolute cardiovascular risk
• May take 4 weeks to see full response to medicine change
(was 3-4 weeks)
General topics
Bone infection
• If delay in sending to hospital – give cephazolin (was
flucloxacillin )
Chest infection – over 5 years and adults
• Looking for signs of chronic problem
• Mild/moderate pneumonia – doxycycline
• Severe pneumonia – ceftriaxone (was benzyl penicillin or
procaine penicillin)
• Sinusitis and bronchitis separated
 Bronchitis – antibiotics no longer recommended
 Sinusitis – doxycycline
General topics 2
Chronic lung disease
• Questions flagging obstructive sleep apnoea
• Comparison of chronic lung diseases
• Progression of medicines for COPD
• Separation of management of COPD and bronchiectasis
Asthma in adults
• Doses of inhaled corticosteroids
• Puffer and spacer use (see CPM)
Chickenpox and shingles
• Doses for antivirals removed
General topics 3
Coral and sea cuts
• Cellulitis
 Treatment time frame – 5-7 days
 If penicillin allergy – Clindamycin
• Pustule
 Treatment time frame – 10 days
 If penicillin allergy – Roxithromycin
• Moderate/severe
 Send swab for MC&S
 Follow up – repeat cephtriaxone and send to hospital if not
getting better
• Doxycycline – over 8 years (was over 10 years)
General topics 4
Dental and oral problems
• Oral health messages
• Severe infection – clindamycin if penicillin allergy
• Broken tooth
• Pain and significant swelling
 Amoxycillin (was phonoxymethyl penicillin and probenecid)
 If penicillin allergy clindamycin (was roxithomycin)
• Broken jaw – Amoxycillin (was procaine penicillin)
Heat illness
• Heat cramps
• Features of heat exhaustion and heat stroke
General topics 5
Eye problems
• Antibiotic eye ointment 4 times a day (was 2 times a day)
• Penetrating eye injury – give cephtriaxone (was give
cephtriaxone and gentamicin). If ceftriaxone not available give
cephazolin
• Conjungtivitis
 Treatment for bacterial and viral separated
• Gonococcal conjunctivitis
 Think of in babies under 6 weeks (was under 4 weeks)
 Ceftriaxone (was procaine penicillin or amoxycillin with
probenecid)
 Babies under 2 weeks send to hospital urgently (was under 1
month)
General topics 6
• Cellulitis
 Orbital cellulitis – Check for relative afferent pupil defect
 Periorbital cellulitis – Severe infection give ceftriaxone or
flucloxacillin and send to hospital
 Orbital cellulitis – Give flucloxacillin (was only if signs of infection)
 If stye, blocked tear duct or wound (was procaine penicillin until
better AND docloxacillin or flucloxacillin if abscess/sty, impetigo,
infected cut)
• Trachoma
 Azithromycin for young children (was erythromycin)
 Anti-glaucoma drops as advised by eye doctor (was timolol and
pilocarpine)
General topics 7
Hepatitis
• When to refer to a specialist – non-viral hepatitis infection
• Management of chronic hepatitis B and C
• Cirrhosis
• Tests for viral hepatitis infection
• Classification of hepatitis B status
Joint problems – new protocol
Joint sprains and strains – new protocol
Leprosy – new protocol
Meliodosis
• Give ceftriaxone and gentamicin (was ceftriaxone only)
General topics 8
Pain management
• Combines Pain relief, Chronic pain and Paracetamol doses
•
Acute pain
 Visual pain scale
 Paracetamol-codiene – do not use for children under 7 years
 Do not use NXAIDs – Kidney function/eGFR less than 60 or
unknown or high cardiovascular risk
 Dosing regimen for opioid injections changed
 Naloxone given every 2 minutes (was 3 minutes)
 Ibuprofen not used for moderate pain
 IM Naloxone not used
 Metoclopramide not used for children
• Chronic pain
 Managing chronic pain
General topics 9
Painful scrotum
• Infected testes can be due to mumps virus
• Table Assessing a painful scrotum combines Ask and Check
tables
• Suspected UTI – Give cephalexin or amoxicillinclavulanate (was ceftriaxone or ciprofloxacin)
• Review at day 3 (was review next day, if getting better review
again at day 3)
General topics 10
Palliative care
• Expanded description including advanced care plan
• Working out pain medicine doses
• Other treatments
• Managing care (was Treating symptoms)
• Pain management (was giving medicines)
Rectal bleeding
• Ask about family history of bowel cancer
• Do abdominal examination
General topics 11
Skin conditions
• School sores
 If injection not possible give amoxycillin oral
 Follow-up
 Clean sores with soap and water (was providone-iodine)
 If there are clearly infected sores (was If more than 6 infected
sores or sores look severe)
 If allergic to penicillin give trimethoprim-sulphamethoxazole
(was roxithromycin)
• Scabies
 Leave crotamiton cream on babies under 2 months for 24 hours
 Follow-up
 For children 2 months and over and adults repeat treatment in 1
week ( was (was repeat after 2 weeks if moderate to severe, or
still itchy)
General topics 12
• Crusted scabies
 Descriptions of mild moderate and severs crusted scabies
 Give ivermectin if over 5 years. Best with full cream milk or food
(was Give ivermectin on empty stomach)
• Boils, carbuncles, abscesses
 Keep boils covered with a dressing, was and change every day
until healed to prevent cross-infection to other parts of body. Most
important preventive measure
 If allergic to penicillin give clindamycin
 Ask family to wash all clothes and bedding in hot soapy water
while on antibiotics, encourage regular hand washing
 Follow-up
 BGL (was if person keeps getting boils)
 Swab for MC&S if severe or several boils (was if person keeps
getting boils)
 Give dicloxacillin or flucloxacillin for 5 days (was 5-7 days)
General topics 13
• Head lice
 Treat with permethrin 1% shampoo if causing problems (was
treat with permethrin 1% shampoo)
 Advice for avoiding head lice removed
• Cellulitis
 If not improving after 2 days – medical review, treat as severe
cellulitis
 If allergic to penicillin give clindamycin (was cephalexin)
 Severe cellulitis – give cephazolin 3-5days (was give
dicloxacillin or flucloxacillin IV every 6 hours)
• Cold sores
 Make sure they get enough fluids – may need IV fluids if severe
 Medical consult if severe or recurrent – may need antiviral
treatment
 Dab with povidone-iodine, if first day removed
General topics 14
• Molluscum contagiosum
 May need antibiotics if it gets infected removed
• Tinea
 Tinea of the scalp
 Collecting samples for tinea diagnosis
 Nails – Give terbafine continuously for 4 weeks OR 1 cycle (14
days) = 7days with treatment, 7 days without treatment : For
fingernails 4 treatment cycles, for toenails 8 treatment cycles
(was daily for 6 weeks for fingernails and 12-16 weeks for
toenails)
 Tinea versicolor – Put ketaconazole 2% shampoo on affected skin,
leave on overnight (was selenium sulphide 2.5% shampoo on
affected skin. Leave for 60 minutes)
 For small areas on skin – Terbinafine cream
 For large areas of skin – Griseofulvin tablets
General topics 15
Sore throat
• Warning about difficulty of using oral antibiotics for full 10
days
• If allergic to penicillin give roxithromycin
Tetanus immunisation
• Giving tetanus immunisation
• Giving tetanus immunoglobin
• Follow-up
• Think about when treating a wound – injury, bite, lost tooth,
burn (was wound or burn)
• Indications for tetanus immunisation
General topics 16
Tuberculosis
• Think of tuberculosis if CSLD or bronchiectasis
• Treatment is usually given 3 times a week (was daily or 2-3
times a week)
Urine problems
• UTIs
 Treatment – Give trimethoprim or nitrofurantoin or
amoxycillin-clavulanate (was cephalexin or amoxycillinclavulanate)
 Female resistant – Treat as advised on pathology result for 7 days
(was 5-7 days, might need norfloxacin)
 Female recurrent – Medical review (was treat as advised on
pathology result for 5-7 days, may need longer course)
 Complicated UTIs – medical review (was give cephalexin or
amoxycillin-clavulanate or nitrofurantoin)
General topics 17
• Kidney infection
 Follow-up mild kidney infection – review at 3 days, if not getting
better medical consult, EUC and refer for renal US
 Mild kidney infection – Give cephalexin or amoxycillin-clavulanate for
10 days (was single dose gentamycin and cephalexin for 14 days)
• Blood in urine
 Can be caused by cancer
 Feel (palpate) abdomen and flanks/loins
General topics 18
Worms
• More information on individual worms
• Dwarf tapeworm
• Strongyloides – can cause growth faltering, low potassium
especially in young child
• Faeces testing – include strongyloides culture
• Test for strongyloides if on corticosteroids for at least 2 weeks
(was course of less than 1 week not likely to lead to
strongyloides)
• Community deworming – 6 months – 16 years give
albendazole single dose twice a year (was 6months – 5 years
albendazole single dose 3 times a year, 5- 16 years twice a
year)
Reference Section
• Reference Table
 Normal values, fluid and oxygen rates
• Antibiotics doses table
• Abbreviations
• Contact Numbers
• Index detailed