Transcript Preparing for Office Emergencies

Preparing for Office
Emergencies
OCFP Scientific Meetings
November 29, 2013
L. Malo MD, CCFP(EM), FCFP
Faculty / Presenter Disclosure
Faculty: Dr. Larry Malo
Program: 51st Annual Scientific
Assembly
Relationships with commercial
interests:
NONE
Disclosure of Commercial Support
 This program has NOT received any
financial support
 This program has NOT received inkind support
 Potential for conflict of interest:
Illustrative photographs may identify
a particular brand or product in a
market where others may exist.
Mitigating Potential Bias
 Wherever slides depict a
commercially available product, this
will be explicitly identified and the
participants will be made aware
that the product may be available
from other manufacturers
Preparing for Office emergencies
Part I
Are you ready???
 Everyone has a different tolerance for
emergencies.
 You may have deliberately chosen to
work in an environment where
emergencies are less likely but……
Inevitably, emergencies WILL find you!
Preparing for Office Emergencies
What is the extent of the problem?
 How common are office
emergencies?
 What should I prepare for?
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Not much literature regarding the
frequency of office emergencies.
Nonetheless, it is unanimous is that we are
unprepared!!!
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 The public has become hyperaware of
safety issues and has great expectations.
 If you collapse at the hockey rink you
may expect to be defibrillated (AED),
similarly, if you collapse at your doctor’s
office, the expectation is that you will
receive an immediate, skilled
intervention.
 AED costs ~$1000.00
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 Excellent article in Canadian Family
Physician 2009
Can Fam Phys 55(10);Oct 2009: 1004-1005
 Claire Liddy, Heather Dreise, and Isabelle
Gaboury look at
“The Frequency of In-office Emergencies in
Primary Care”
Can Fam Phys 55(10);Oct 2009: 1004-1005
Liddy et. al.
 They looked at ‘Code 4’ calls in the
Ottawa area for a 3 yr period from 20042006.
 Overall, there were 272,752 code 4 calls
over the 3 yr period with 2% (3033) from
primary care offices.
 On average 1000 calls per year from
community based offices!
35
30
25
20
15
10
5
0
GU
Hematologic
MSK
GI
Endocrine
CNS
Respiratory
Other
Cardiovascular
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Preparing for Office emergencies
 Office emergencies are actually
NOT that rare!
 Despite this fact, community based
offices are often poorly prepared for
emergency presentations!
 J. Emerg Med 1986;4(1):71-74
 Am. Acad. of FP 2005;12(1):34-36
The CPSO has provided guidelines for
preparing for office emergencies.
November 2005,
Updated May 2012
http://www.cpso.on.ca/uploadedFiles/policies/guide
lines/office/Safe-Practices.pdf
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Community characteristics
 Prone to severe weather?
 Is there a hospital in the
community?
 Is 911 available?
 What is the ambulance response
time?
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Practice characteristics
 Scope of practice?
 Parenteral medications?
 High risk procedures?
 High volumes of ‘sick’ patients?
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 It’s important to assess your practice for
the kinds of risks you may have to deal
with.
 eg. Psychotherapists vs geriatricians
vs practices that may encounter
mostly children.
 Predicting the likely types of emergencies
you may encounter will help guide
establishing needed equipment and
meds
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Essential equipment
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Stethoscope, BP measuring device
O2, bag valve mask(adult and pediatric)
Oral airways
Oxygen tubing and masks
Pulse oximeter
Needles and syringes
Aerochamber (Pediatric and Adult)
N95 masks (?)
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Preparing for Office emergencies
Optional equipment (as determined
by your risk assessment)
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Intubating equipment
IV access and tubing
ECG monitor
Defibrillator
Interosseus needles
www.officeemergencies.ca
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Basic Medications
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ASA 80 mg (chewable)*
NTG spray or tabs*
Lorazepam 1mg sl tabs, Midazolam
Epinephrine 1:1000*
Diphenhydramine (Benadryl)*
Glucagon
Dextrose (injectable or gel)
* essential
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More medications
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Ventolin*
Atrovent*
Cogentin
Haldol
Furosemide (Lasix)
Oxytocin
*essential
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Basic training
 BLS
 ACLS
 PALS
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Useful paperwork
 Death Certificate
 Form 1
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CPSO Self review
How does your facility and equipment fit into the risk assessment model
and recommendations?
-Based on your risk assessment, are you satisfied that your facility
is equipped with appropriate emergency equipment?
-Is your staff educated in the use of emergency equipment?
-Does your staff participate in a regular review of emergency equipment
to maintain competence?
-Do you or your staff routinely check for expired drugs?
-Are emergency equipment and associated supplies stored together
for easy access in an emergency?
-Is your staff aware of the steps to take in the event of an emergency?
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CPSO Self review
-Does your staff have updated training in CPR? K
-Does your medical facility have a documented plan to
follow in the event of the following:
• Fire/evacuation K
• Disruptive patient K
• Need to obtain security K
-Is 911 service available in the community? K
-Would it be possible for appropriate emergency personnel
to reach the office within five minutes? K
-Are emergency plans posted in the medical facility for
easy reference? K
SELF-EVALUATION: Risk Assessment Model
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All emergency equipment should be located
in ONE place that is easily accessible and
known to ALL
All staff should be trained in the proper use of
emergency equipment.
One staff member should regularly review
contents of the emergency stock, checking
exp. dates and reviewing content.
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 The emergency kit should also
include:
Rx doses
Breslow tapes,
treatment algorithms
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Part II
common office emergencies
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Ischemic chest pain
Anaphylaxis
Asthma
Seizure
Acute hemorrhage
Syncope
Form 1 intervention
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Unstable Ischemic Chest Pain
 Call 911 for urgent transport to local emergency
facility
 Monitor BP, pulse and when available
continuous O2 saturation
 Supplemental O2 by mask or prongs
 Remain in attendance until paramedics assume
care
 IV access if possible
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Unstable Ischemic
Chest Pain
 ECG where
available
 AED where
available
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Medication
 ASA 160mg po (2 x 80mg chewable)
 NTG if systolic BP > 100 mmHg 0.3-0.4mg sl
q5min x 3 doses*
 Morphine 2-4mg IV q 5minutes for pain
and anxiety
*Caution in Right ventricular MI, Hypotension, use of a
phosphodiesterase inhibitor, aortic stenosis
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Complications
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Sudden death
CHF, cardiogenic shock
Hypotension
Dysrhythmias
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Severe asthma attack
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Allay anxiety, calm, reassuring voice
O2 by mask
Monitor vitals and O2 sats
PEFR (severe <50% predicted)
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Severe Asthma Attack
Medications
 Ventolin MDI with aerochamber, 4-6
inhalations STAT, then 2 inhalations
q30min PRN
 Prednisone 1mg/kg po
 Atrovent MDI, 2 inhalations following
Ventolin
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Severe asthma attack
 If PEFR remains <50% expected after Tx,
transport patient to the ER
 If PEFR is not available, transport patient
to the ER by EMS
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Seizures
 Most seizures are brief and self limited
 Protect patient
 Secure patient’s airway by positioning,
chin lift or jaw thrust if required.
 O2 by prongs or mask, Bag valve mask
 For a prolonged seizure or when there is
airway compromise a nasal trumpet, oral
airway and suction if available.
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Seizures
 +/- IV access for unremitting episode
 Glucometer
 Most seizures are self limited and
intervention is rarely required beyond
assisting the patient.
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Seizures
Medications
 Dextrose gel po or D50W IV 50ml if
hypoglycemic
 Lorazepam 0.1mg/kg @ 2mg/min to a
max of 10mg or
 Diazepam rectally 0.5mg/kg up to 20mg
or
 Midazolam 0.1-0.3mg/kg IM
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Anaphylaxis
 Prompt diagnosis essential for good
outcome
 90% have skin manifestation or mucous
membrane Sx (itch, urticaria, erythema)
 Criteria 1: Acute onset, skin or mucous
membrane involvement + either
i. respiratory symptoms or,
ii. Hypotension (sys <90 or >30%
drop from baseline
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Anaphylaxis
 Criteria 2: Known exposure to a likely
allergen with at least 2 of the following:
i. skin or mucous membrane
ii. Respiratory symptoms
iii. hypotension
iv. GI symptoms (abdo pain,diarrhea)
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Anaphylaxis
Criteria 3: hypotension after exposure to a
known allergen.
In a review of 164 deaths from anaphylaxis,
time to death from iatrogenic injectable=
5 minutes! Commonest error on part of
medical care= delay in epi administration
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Anaphylaxis
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Remove offending allergen
Call for help, call 911
O2 by prongs or mask
Epinephrine (1:1000) IM
IV if available, NS or RL wide open*
* establishment of an IV should not delay
administration of epinephrine
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Anaphylaxis - Medications
 Epinephrine 0.3ml 1:1000 IM q20min
(adult)
 Epinephrine 0.01ml/kg 1:1000 IM q20min
(peds)
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Anaphylaxis - Medications
 If patient is taking Beta blockers,
epinephrine may be less effective, in this
setting:
 Glucagon 1-2mg IM in adults
 20-30mcg/kg up to 1mg in children
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Sepsis
 Definition: A clinical syndrome
characterized by systemic
inflammation due to infection
 The challenge: RECOGNISE IT
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Sepsis
 Therapeutic priority:
1. Transport patient to nearest ER
2. Correct hypoxemia, hypotension
3. Identify and treat infection
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Sepsis - Treatment
 Treatment
-Supplemental oxygen
-Continuous SO2 monitoring
-Large bore IV (depending on
access to EMS) and fluids +++
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Sepsis – Treatment
-Assess perfusion: colour,
temperature, restlessness,
confusion
- Hypoperfusion can occur in the
absence of hypotension
- transport to ER STAT
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Serotonin Syndrome
 In the US in 2005 there were 8000+ cases
with 103 deaths. Most require ICU admit.
 Often results from a combination of meds
that increase serotonergic
neurotransmisssion
 Often presents within 24hrs of new Rx or
change in dose
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Serotonin Syndrome
Classic triad:
1. Altered mental status
2. Autonomic hyperactivity
3. Neuromuscular abnormalities
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Incidence increasing with use of SSRIs
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Serotonin Syndrome
 Mental status changes:
Anxiety, agitated delirium, restlessness
 Autonomic changes:
Diaphoresis, tachycardia, hyperthermia,
vomiting, diarrhea, HTN
 Neuromuscular changes:
Tremor, rigidity, myoclonus, hyperreflexia,
Preparing for Office emergencies
Serotonin Syndrome
Hunter Toxicity Criteria Decision Rules:
Ingestion of serotonergic agent + 1 of:
 Spontaneous clonus
 Inducible clonus + agitiation or delerium
 Ocular clonus + agitation or delerium
 Tremor or hyperreflexia
 Hypertonia
 Temp > 38 + ocular or inducible clonus
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Serotonin Syndrome
Treatment
 Call 911 and prepare for transport
 Supportive care:
 O2
 Monitor vitals
 +/- IV fluids
 Benzodiazepines (Midazolam)
 Cyproheptadine 8mg
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Form 1 Intervention
 46 yrs old male patient reports depressive
symptoms worsened by suspicions that his wife is
having an affair with a neighbor.
 He tells you that he harbours thoughts of killing
himself, but not before settling a “few scores”.
 He is vague but you are left feeling very
uncomfortable and anxious about homicidal
ruminations.
 You should……..
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 1. Reassure him that he is likely incorrect and
arrange for a family meeting next week.
 2. Start him on Celexa 10mg po qam and titrate
to effect.
 3. Discuss voluntary hospital admission and
involuntarily admit him if he refuses. (Form 1)
 4. Contract with the pt to do no harm, refer to
psychiatry and follow up with him in 48 hrs.
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Part III
Build the Box
Be Ready
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Build the Box- Medications
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Epinephrine 1:1000 3 amps
ASA 80mg*
NTG 0.4mg sublingual spray*
Benadryl 50mg tabs*
Glucagon, preloaded syringes
Ventolin MDI with aerochamber, adult / peds*
Atrovent MDI*
Dextrose gel, tabs*
Ativan 1mg s.l. tabs
Midazolam 5mg/ml injectable
Cogentin 2mg/ml injectable
*essential
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Build the Box - Equipment
Syringes 3cc-10cc*
Needles 18g, 25g 1”, 1 1/2”*
O2 sat probe
Glucometer
O2 tubing*
O2 masks, peds to adult*
O2 supply*
Oral airways, nasal trumpets*
Bag valve mask*
*essential
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Build the Box- Equipment
OPTIONAL (depends on practice risk
assessment):
 ETT sizes 4.5-8.0
 Laryngoscope handle and blades 2-4
MacIntosh
 McGill forceps
 AED
 Interosseous needles
 IV tubing, IV needles (24-16g), Normal saline
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Build the Box- Algorithms
 Laminated sheets with clearly
defined, step by step algorithms.
 Box may be organized according to
emergency type and are
commercially available
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Build (or buy) the Box
www.stores.criticalcaresolutionsstore.co
m
Approx $600 U.S.
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SUMMARY:
1. It will happen
2. Be ready:
1. Assess your practice
2. Office staff should have clear
responsibilities
3. Have an emergency response kit that is
up to date and readily available
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Questions/Discussion