Transcript Handling Emergencies in the Office Setting

Handling
Emergencies in
the Office Setting
Daniel Elwell, D.O.
Disclosures
• Nothing to disclose
Objectives
• Discuss common
emergencies in a
primary care office
setting
• Discuss a strategy to
prepare for emergency
situations
Common
Emergencies
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Asthma
Anaphylaxis
Shock
Seizures
Congestive heart failure
DKA
Epistaxis
Drug overdose
Cardiac arrest
Equipment
needed
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Bag mask ventilator (two sizes, three mask
sizes)
Blood pressure cuff (all sizes)
Glucose meter
Intraosseous needle (18 and 16 gauge)
Intravenous catheter/butterfly needles (24
to 18 gauge)
Intravenous extension tubing and Tconnectors
Nasal airways (one set)
Nasogastric tubes
Nebulizer or metered dose inhaler spacer
and face masks
Non-rebreather (three sizes)
Oxygen mask (three sizes)
Oxygen tank and flow meter
Portable suction device and catheters, or
bulb syringe
Pulse oximeter for child and adult usage
Resuscitation tape (color-coded)
Universal precautions (latex-free gloves,
mask, eye protection)
Mediations
needed
• Acetaminophen (rectal
suppositories)
• Albuterol
• Aspirin
• Ceftriaxone
• Corticosteroids, parenteral
• Dextrose 25%
• Diazepam, parenteral
• Diphenhydramine, oral and
parenteral
• Epinephrine (1:1,000, 1:10,000)
• Flumazenil
• Lorazepam, sublingual, parenteral
• Morphine
• Naloxone
• Nitroglycerine spray
• Normal saline
Training needed
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BLS
PALS
ACLS
IV/IO access
Airway management
Training necessary to
utilize all available
equipment
Training needed
RECEPTION DESK EMERGENCY
CARD (example)
The following signs and symptoms
may signal an emergency:
● Extremely labored breathing
● Blue or pale color (cyanosis)
● Noisy breathing (wheezing or
stridor)
● Altered mental status
● Seizure
● Agitation (in the parent)
● Vomiting after a head injury
● Uncontrolled bleeding
If you feel a patient has symptoms
that may signal an emergency, alert
the following office staff: .
Asthma
• Equipment
– Nebulizer / tubing
– Pulse oximetry
– Airway management
• Medications
– O2
– Albuterol
– Atrovent
– Corticosteroids
– Epinephrine (1:1000)
– Terbutaline
Anaphylaxis
• Equipment
– IV/IO access supplies
– Pulse oximetry
– Cardiac monitoring
– Airway management
• Medications
– O2
– Corticosteroids
– Diphenhydramine
– H2 antagonist
– Epinephrine (1:1000)
Shock
• Equipment
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IV/IO access supplies
Cardiac monitoring
Pulse oximetry
External pacing
Airway management
• Medications
Normal saline
O2
Antibiotics
Pressors (Levophed,
Dopamine)
– Epinephrine
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Seizures
• Equipment
– IV/IO access
– Pulse oximetry
– Glucometer
– Cardiac monitor
– Airway management
• Medications
– Lorazepam
– Fosphenytoin
– Rectal diazepam
– Propofol
Pulmonary edema
• Equipment
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IV/IO access
ECG
Pulse oximetry
Cardiac monitor
NRB mask
Airway management
• Medications
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O2
Lasix
Nitrates
Morphine
Dobutamine
DKA
• Equipment
– IV/IO access
– Glucometer
– Pulse oximeter
– Cardiac monitor
• Medications
– Normal saline
– Anti-emetics
– Morphine
– Insulin R (K>3.3)
Epistaxis
• Equipment
– Clips
– Ice
– Nasal packing
– Nasal tampons
– Nasal balloons
– Silver nitrate sticks
• Medications
– Neo-synephrine
– Antibiotic ointment
– Vitamin K
Drug overdose
• Equipment
– IV/IO access
– Cardiac monitoring
– Pulse oximetry
– NG tube
– Airway management
• Medications
– O2
– Activated charcoal
– Naloxone
– Glucagon
– Flumazenil
Cardiac arrest
• Equipment
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IV/IO access
ECG
Cardiac monitoring
Pulse oximetry
AED
Airway management
• Medications
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O2
Epinephrine (1:10,000)
Atropine
Vasopressin
NaHCO3
Dopamine
AED in your
office?
• This is not considered
the standard of care
• Recommendations in
the literature for high
risk offices
• Others stated highly
essential for any office
that cares for children
• Public access programs
place where will be
used once in 5 years
Buying an AED
• Cost
– AEDs vary widely in price, but
typically start at about $800 to
$1,500; both the initial cost of
the unit and ongoing
replacement costs (for batteries,
carrying case, chest pads, and
training materials) should be
considered
• Ease of use
– All newer AEDs have voice and
visual prompts; some units
function with a single button
• Maintenance and upkeep
– Most units come with batteries
that will last up to three to five
years; chest pads often need to
be replaced every two years
Buying an AED
• Safety
– All AEDs are extremely safe and
are designed not to deliver a shock
when it is not indicated
• Self-testing
– All AEDs do some form of selftesting; if the unit will rarely be
used, a product that does more
frequent and extensive self-testing
is desirable
• Training availability
– Some AEDs can be converted into
a training tool with an adapter,
whereas others require the
purchase of an AED trainer unit
• Use in children
– Some AEDs are certified for use in
children as young as 12 months
and have child-size chest pads or
an attachment that decreases the
voltage delivered.
Identify your
unique needs
• What are the most common
emergencies in your practice?
• How often have office
emergencies occurred in your
practice?
• What is your office setting
(freestanding office, clinic
based, health center based,
hospital based, other)?
• Are there resources outside
your office on which you
could call during an office
emergency (eg, security, other
medical or dental
professionals in the same
building, hospital code team)?
Identify your
unique needs
• How far is your office
from a site of definitive
care, such as the nearest
ED, or the nearest
pediatric center?
• How long does it take
EMS to respond?
• What is your patient
population?
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Pediatric
Geriatric
Diabetic
Special needs
Have a plan
• Develop a protocol to
recognize and respond
to office emergencies
• Assign responsibilities
to each staff member
• Practice by having
mock drills regularly
Have a plan
Stay Current
• Routinely restock
supplies
• Track office emergency
occurrences
– What could have been
done better?
– What would you have
liked to have?
• Keep all office staff
training current
• Adapt to changing
technologies
References
• Am Fam Physician. 2007
Jun 1;75(11):1679-1684
• Canadian Family
Physician October 2009
vol. 55 no. 10 10041005.e4
• Pediatrics Vol. 120 No. 1
July 1, 2007 pp. 200 -212
(doi: 10.1542/peds.20071109)
• http://practice.aap.org/
content.aspx?aid=2057
accessed June 1, 2012