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Management of Medical Emergencies in the Office Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University.

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Presentation on theme: "Management of Medical Emergencies in the Office Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University."— Presentation transcript:

1 Management of Medical Emergencies in the Office Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

2 ƒAcute asthma ƒDystonic reactions ƒHyperthermia ƒHypertensive crisis ƒForeign body aspiration ƒDiabetic hypoglycemia ƒAddisonian crisis ƒObstetrical concerns ƒMandibular dislocation Medical Emergencies in the Office ƒAllergic reactions / anaphylaxis ƒOversedation / vomiting ƒSyncope ƒSevere hyperventilation ƒBleeding disorders ƒAcute chest pain ƒSeizures ƒStrokes (CVA's)

3 Allergic Reactions / Anaphylaxis ƒDefinition : –Anaphylaxis = acute systemic allergic reaction that occurs after antigen-antibody interaction causing release of chemical mediators

4 Mediator Substances Causing Anaphylaxis ƒMost released by mast cells & basophils : –Histamine –Bradykinins –Leukotrienes –Prostaglandins –Thromboxane –Platelet aggregating factor –Miscellaneous

5 Major Effects of Anaphylactic Mediators ƒVasodilation ƒSmooth muscle spasm ƒIncreased vascular permeability ƒEdema formation

6 ƒ2. Respiratory –Throat "tightness" –"Lump in throat" –Hoarseness –Stridor –Dysphagia –Rhinorrhea –Brochospasm : wheezing, cough, dyspnea, chest tightness Clinical Manifestations of Anaphylaxis ƒ1. Cutaneous –Pruritis –Flushing –Urticaria –Angioedema

7 ƒ3. Cardiovascular –Weakness –Hypotension –Lightheadedness –Shock (inadequate perfusion) –Loss of consciousness ƒ4. Gastrointestinal –Cramps –Nausea –Vomiting –Diarrhea ƒ5. Miscellaneous –Sense of impending doom –Metallic taste –Uterine contractions Clinical Manifestations of Anaphylaxis

8 Causes of Death from Anaphylaxis ƒUpper airway edema : 70 % of deaths ƒCirculatory collapse : 20 % ƒBoth : 10 %

9 Anaphylaxis : Causes ƒAntibiotics : most common ƒLocal anesthetics ƒLatex –Should question all patients about latex allergy ; If allergic, use plastic or nitrile gloves, nozzles, etc.

10 Penicillin (Pcn) Allergy ƒ1. Applies to pcn and all derivatives ƒ2. Overall incidence : 2 % ƒ3. Anaphylaxis in 1 to 5 cases / 10,000 courses of treatment ƒ4. Fatal in 1 to 2 cases / 100,000 courses ƒ5. ? 400 to 800 deaths / year in U.S. ƒ6. 75 % of deaths in patient with no history of pcn allergy ƒ7. Increased risk : multiple short courses, or topical treatment

11 Penicillin Allergy (cont.) ƒ8. No predisposition if family member allergic ƒ9. Parenteral route : reactions more frequent and severe ƒ10. Skin test to prove allergy available (not usually relevant to non-life-threatening situation) ƒ11. Should always observe in office 30 min. after dose

12 Cephalosporin Allergy ƒMuch less likely to cause reactions than pcn ƒCross reactivity : 2 to 5 % (with pcn) ƒNegative pcn skin test does not R/O allergy to cephalosporin ƒLow incidence of GI side effects

13 Erythromycin Allergy ƒAllergic reactions uncommon ƒMost common "allergy" symptoms reported is vomiting / GI upset ƒIncidence of GI symptoms probably similar between different forms of erythromycin (base, stearate, estolate, ethylsuccinate, etc.)

14 Guidelines for Suspected Antibiotic Allergy ƒIf penicillin allergic : use erythromycin ƒUsually OK to use cephalosporin if pcn allergic (but not if anaphylaxis to pcn) ƒTetracycline (doxycycline) may substitute for erythromycin in adults ƒChloramphenicol only indicated if multiple antibiotic allergies ƒClindamycin sometimes useful but increased incidence of pseudomembranous colitis

15 Allergy to Steroids ƒYes, it is real ƒRare however ƒUsually sensitive to succinate ester ƒIf real : use acetate ester form

16 General Treatment of Allergic Reactions ƒ1. Remove offending agent if possible –Stop drug being administered –Wipe off area if topical –Consider PO activated charcoal (if drug given PO)

17 General Treatment of Allergic Reactions (cont.) ƒ2. If only local reaction (only localized redness, pruritis, swelling) : –Often no treatment needed –Or PO antihistamine ƒ Benadryl 1/2 mg/Kg ƒ Atarax or ƒ Vistaril 25 to 50 mg (adults)

18 General Treatment of Allergic Reactions (cont.) ƒ3. If systemic (diffuse pruritis, hives, any throat or chest symptoms) : –Place IV or heplock –Assess vital signs ƒ If vital signs OK, treatment : SQ epi, PO or IV antihistamine, PO or IV steroid, Observe one hour ƒ Emergent treatment if VS not OK

19 Emergent Treatment of Systemic Allergic Reaction ƒStart this sequence if VS not OK (increased HR, decreased BP, or any throat tightness, SOB or wheezing) : –1. Place patient recumbent / supine & start FMO2 –2. SQ epi 0.3 mg (0.01 mg / Kg) ; rub area ; If hypotensive : dilute epi (1:10,000) & give 0.1 to 0.2 mg IV slowly (never more than 0.1 mg IV at a time) –3. IV diphenhydramine or hydroxyzine 1 mg / Kg (50 mg in adults) –4. IV steroids (100 mg hydrocortisone)

20 Emergent Treatment of Systemic Allergic Reaction (cont.) ƒ5. IV fluid bolus (LR or NS 1 liter or 20 cc / Kg) ƒ6. Metaproteronol or albuterol aerosol if wheezing (0.2 to 0.5 cc in 3 cc NS) ƒ7. Consider IV ranitidine or cimetidine ƒ8. Atropine if bradycardic Dopamine if hypotensive despite IV fluids Racemic epi aerosol if throat swelling Early intubation if airway compromise ƒ9. Call EMS unless rapid resolution with O2 / epi

21 Local Anesthetic Allergy ƒTrue allergy uncommon ƒTrue allergy more likely with esters ƒMost "allergies" reported by patients are really due to intravascular injection / vasodilation ƒIf allergic to one ester, assume allergic to all ester forms

22 Amide Local Anesthetic Allergy ƒTrue allergy rare ƒMay really be allergy to preservative ƒCan use cardiac lidocaine (100 mg ampules) if allergy to preservative suspected (cardiac lido has no preservative)

23 Amide Local Anesthetics ƒLidocaine (Xylocaine) ƒBupivacaine (Marcaine, Sensorcaine) ƒMepivacaine (Carbocaine, Polocaine) ƒDibucaine (Nupercaine, Nupercainal) ƒPrilocaine (Citanest) ƒEtidocaine (Duranest)

24 Ester Local Anesthetics ƒBenzocaine ƒProcaine (Novocaine) ƒChloroprocaine (Nesacaine) ƒCocaine ƒTetracaine (Pontocaine, Cetacaine) ƒButethamine (Monocaine) ƒProparacaine (Alcaine, Ophthaine, Ophthetic) ƒMetabutethamine (Unacaine) ƒMeprylcaine (Oracaine) ƒIsobucaine (Kincaine)

25 "Toxic" Reactions to Local Anesthetics ƒDue to direct effects of the drug ƒNot due to allergy ƒUsually (but not always) occur in three phases : –Excitation phase –Convulsive phase –CNS / Cardiovascular depression phase

26 Phases of "Toxic" Reaction to Local Anesthetic ƒExcitation phase –Confusion –Restlessness –Sense of impending doom –Tinnitus –Perioral paresthesias –Metallic taste –Lightheadedness

27 Phases of "Toxic" Reaction to Local Anesthetic (cont.) ƒConvulsive phase –Loss of consciousness –Gran mal tonic-clonic seizure ƒCNS / Cardiovascular depression phase –Drowsiness –May be in coma –Respiratory depression / apnea –Hypotension –Bradycardia –Heart block

28 Treatment of Toxic Reaction to Local Anesthetic ƒStop infiltrating anesthetic if any Stage 1 symptoms ƒStart an IV ƒSupport ventilation as needed ƒValium 2.5 to 5 mg IV (or 0.2 mg / Kg in children) for seizures ƒInfuse normal saline or Lactated Ringers bolus if hypotensive (1 liter in adults, 20 cc / Kg in children) ƒAtropine IV (0.5 mg) if bradycardic (often not effective however), and other standard ACLS measures as needed

29 Alternatives if Patient Has Multiple Local Anesthetic Allergies ƒInjectable diphenhydramine (Benadryl) : use 1 % solution (dilute 5% solution 50 mg vials with 4cc NS, limit dose to 10 cc) ƒInjectable chlorpheniramine ƒSlow normal saline infiltration (benzyl alcohol preservative)

30 Skin Testing for Local Anesthetic Allergy ƒUnreliable (same for antibiotics) ƒMay have negative test and still have allergy ƒMay have positive test and tolerate drug OK

31 Treatment of Systemic Allergic Reactions ƒShould observe patient with systemic reaction at least 2 hours before release ƒKeep patient on 3 to 7 day course of steroids ƒKeep patient on 3 to 7 day course of antihistamines ƒNot necessary to taper steroid dose (unless patient on them repetitively) ƒAdvise patient of allergy ; consider getting Medic Alert bracelet

32 Constituents of Emergency Self-Treatment Kits EpiPen Auto-Injector Spring-loaded automatic injector with 0.3 ml (0.3 mg) of (1:1,000) aqueous epinephrine EpiPen Jr. Auto-Injector Spring-loaded automatic injector with 0.3 ml (0.15 mg) of (1: 2,000) aqueous epinephrine Ana-Kit Manually operated syringe with 0.6 ml (0.6 mg) of (1:1000) aqueous epinephrine ; delivered as 0.3 ml to a locking point, with the ability to deliver a second identical dose if necessary Chlorpheniramine : 2 mg chewable tablets (# 4)

33 Oversedation / Vomiting ƒMajor causes : –Anesthetic "sensitivity" –Anesthetic "overdose" –Narcotic effect –Drug (+ ETOH) interactions ƒBest treatment : prevention ƒMajor risks : –Vomiting leading to aspiration, leading to airway obstruction, pneumonia, cardiovascular collapse

34 Treatment of Oversedation ƒDiscontinue anesthetic agent ƒPlace patient in head-down position (or turn head to side) ƒSupport ventilation : most important –O2 high flow (10 to 15 L /min) by FM –BVM support –Attach O2 saturation monitor

35 Treatment for Emesis / Oversedation ƒHead-down position or turn head to side ƒSuction with Yankauer catheter ƒEMS referral if : –Any obvious aspiration –Any chest symptoms (pain, SOB, cough, wheeze) ƒDo not give steroids for treatment

36 Treatment of Oversedation (cont.) ƒCheck VS (patient may have decreased response due to decreased BP instead of oversedation) ƒConsider IV reversal agents –Naloxone (2 mg) for narcotics –Flumazenil (0.2 to 1 mg) for benzodiazepines ƒConsider checking blood sugar (R/O hypoglycemia) ƒCall EMS if does not resolve quickly or if patient hypotensive

37 Addisonian (Acute Adrenal) Crisis ƒDue to failure of adrenal glands to produce sufficient corticosteroids ; can present as acute emergency ƒCauses –Most common is sudden cessation of corticosteroids in a patient on chronic steroid treatment (given for chronic lung disease, autoimmune disease, etc), exacerbated by any stress (such as dental surgery or infection) –Can also occur if patient on chronic maintenance steroids has stressful procedure or infection and does not receive steroid dose to "cover" the added stress of the procedure or infection

38 Acute Adrenal Crisis ƒSuspect diagnosis when : –Sudden hypotension in response to stress / procedure –Hypotension does not improve with usual initial treatments

39 Acute Adrenal Crisis ƒTreatment : –High flow O2 –Place IV –Normal saline bolus 1 liter (20 cc / kg in children) –IV hydrocortisone 100 mg –Call EMS

40 Acute Adrenal Crisis ƒPrevention : –Should double the daily corticosteroid dose (in a patient on chronic steroid treatment) before and for at least several days after a stressful procedure or when an active infection is present (may need medical consult if infection is present since the steroids of course may interfere with immune response to the infection)

41 Acute Dystonic Reactions ƒDefinition : –An idiopathic reaction to major tranquilizers and related drugs such as phenothiazenes (i.e., Compazine or Prochlorperazine), haloperidol (Haldol), metaclopramide (Reglan), etc, consisting of abnormal muscle contractions –Can occur after single, first time dose, or in patients who have had the same medicine before without problem

42 Features of Acute Dystonic Reactions ƒAny of these may be present : –Protrusion of tongue –Contorsion (spasm) of facial muscles –Opisthotonos (painful extension of neck and back) –Oculogyric crisis (eyes rolled back) – +/- laryngospasm

43 Acute Dystonic Reactions ƒTreatment is very simple : –Stop the offending drug –Give 25 to 50 mg Benadryl IV (be sure to flush the dose in) : immediate relief –Continue Benadryl 25 to 50 mg PO QID X 3 to 5 days to prevent recurrence ƒSometimes difficult to differentiate from psychotic reactions ; use Benadryl as "test dose" for this ƒOnly need to call EMS if does not resolve with IV Benadryl

44 Hyperventilation : Associated Symptoms ƒParesthesias (perioral, distal) ƒLightheadedness ƒChest pain ƒCramps / tetany ƒConfusion ƒSyncope

45 Hyperventilation: Differential Diagnosis ƒAnxiety ƒIdiopathic ƒPain response ƒPulmonary embolus ƒPneumonia ƒPneumothorax ƒAcute MI ƒSepsis ƒAcidosis ƒAsthma

46 Severe Hyperventilation ƒMost important is to make sure it is only due to anxiety ; if not sure or possibly due to drug reaction or cardiac or pulmonary disease, call EMS ƒPreviously recommended rebreathing into a paperbag has been shown to cause significant hypoxia and probably should not be done ; can have patient hold both their hands with fingers interdigitated in front of face to "pretend" to get same effect ; this may have some placebo effect

47 Hyperventilation ƒConsider use of PO or IM hydroxyzine (Vistaril or Atarax) 50 mg (or 1 mg / kg in children) as an anxiolytic or use Valium 2 to 5 mg PO or Ativan 1 mg IM or PO ƒOK to use oxygen initially ; does not exacerbate hyperventilation (and is important to use if cause is other than anxiety)

48 Hypoglycemia ƒUsually IDDM patient –Decrease PO intake –Increase activity (exercise) ƒAlso in NIDDM patient –Oral hypoglycemic drugs cause longer duration hypoglycemia than does insulin excess

49 Hypoglycemia ƒCan occur in non-diabetic patient : –ETOH ingestion –Toxic salicylate ingestion –Malnourished states –Insulin-producing tumors ƒPatients on beta blockers susceptible

50 Hypoglycemia : Symptoms (any of these may be present) ƒAnxiety ƒSleepiness ƒLethargy ƒCold, clammy skin ƒWeakness ƒDizziness ƒLightheadedness ƒHeadache ƒAny focal neuro sign ƒMay have seizure or coma ƒFatigue ƒConfusion ƒPalpitations ƒTremulousness ƒSweating ƒHunger ƒCombativeness

51 Hypoglycemia : Diagnosis ƒConfirm with fingerstick glucose (ChemStrip) ƒAdditional serum verification by lab not always required

52 Hypoglycemia : Treatment ƒ1. If reasonably alert and able to manage own airway, then give glucose-containing gel or fluid PO ƒ2. Otherwise start IV (draw red top or green top tube of blood if possible also so that diagnosis can be confirmed later in lab) and give 1 amp (50 cc) of 50 % dextrose in water (for child give 1 gm / kg IV of 25 % dextrose in water) ƒ3. May need to repeat dose once ƒ4. If unable to start IV : consider glucagon 1 mg IM (only works if glycogen stores OK in liver) ƒ5. Call EMS if patient not a known diabetic or if no rapid response to initial treatment with sugar ƒImportant to diagnose and treat quickly to prevent hypoglycemic neuronal damage

53 Hypertension Emergencies ƒHypertensive crisis (emergency) : –Severe elevation in blood pressure with rapid or progressive CNS, cardiac, renal, or hematologic deterioration ƒHypertensive " urgency " : –Elevated BP but no symptoms of end- organ damage –BP reduction over 24 to 48 hrs. recommended

54 Hypertension : Treat, Refer, or Ignore ? ƒLevel of BP requiring acute treatment in the asymptomatic patient is controversial among M.D.'s –Usually however does not need STAT Rx ƒBe sure to repeat BP in both arms and after patient has relaxed for 15 minutes before considering referral ƒRemember BP will increase in non-hypertensive patient due to pain, stress, anxiety, etc. ƒProbably should document patient advised of increased BP if checked in office

55 Specific Criteria for Hypertensive Crisis (Presence of Listed Item and BP) ƒStart treatment and transfer to ED to admit –Encephalopathy (altered mental status) –Vomiting : protracted –Seizures –CVA / intracranial hemorrhage –Angina / MI / pulmonary edema –Aortic dissection –Eclampsia (toxemia) –? ARF ? grade III / IV retinopathy ? hemolytic anemia / DIC ? epistaxis

56 Conditions That May Mimic Hypertensive Crises ƒAcute left ventricular failure ƒUremia from any cause, particularly with volume overload ƒCerebral vascular accident ƒSubarachnoid hemorrhage ƒBrain tumor ƒHead injury ƒEpilepsy (postictal)

57 Conditions That May Mimic Hypertensive Crises (cont.) ƒCollagen diseases, particularly lupus erythematosus, with cerebral vasculitis ƒEncephalitis ƒAcute anxiety with hyperventilation syndrome ƒDrug ingestion (phenacetin) ƒAcute intermittent porphyria ƒHypercalcemia ƒMalignant hyperthyroidism

58 Causes of Hypertensive Crises ƒAccelerated hypertension –Hypertensive encephalopathy (malignant hypertension) –Uncontrolled primary hypertension –Renal vascular disease –Toxemia of pregnancy –Pheochromocytoma –Intake of catecholamine precursors in patients taking monoamine oxidase inhibitors –Head injuries –Severe burns or trauma –Rebound hypertension after withdrawal of antihypertensive drugs

59 Causes of Hypertensive Crises (cont.) ƒSevere to moderate hypertension accompanying : –Acute left ventricular failure –Intracranial hemorrhage –Dissecting aortic aneurysm –Postoperative bleeding –Severe epistaxis

60 ƒBlood pressure –Diastolic usually greater than 130 mm Hg ƒFunduscopic findings –Hemorrhages –Exudates –Papilledema ƒRenal symptoms –Oliguria –Azotemia ƒGastrointestinal symptoms –Nausea –Vomiting Signs and Symptoms of Hypertensive Crises

61 ƒNeurologic status –Headache –Confusion –Somnolence –Stupor –Visual loss –Focal deficits –Seizures –Coma ƒCardiac findings –Prominent apical impulse –Cardiac enlargement –Congestive heart failure Signs and Symptoms of Hypertensive Crises (cont.)

62 Specific BP Levels For Emergent Treatment ƒHypertensive encephalopathy ƒCerebral infarction ƒIntracerebral hemorrhage >200/130 ƒSubarachnoid hemorrhage ƒEclampsia >140/90 ƒMI / CHF / Aortic dissection >130 to 140 / 90 to 100

63 Treatment of Hypertensive Crisis in the Office ƒHigh flow O2 ƒCall EMS ƒConsider placing IV / heplock ƒConsider IV narcotic or benzodiazepine ƒConsider SL TNG to decrease BP acutely (0.4 mg) ƒRecheck BP frequently till EMS arrives

64 Options for Office Treatment of Hypertensive Emergency ƒOral / SL Nifedipine 10 to 20 mg ƒClonidine 0.1 mg to 0.2 mg PO ƒLabetolol 100 mg PO or 20 to 40 mg IV ƒ+ IV furosemide 20 to 80 mg ƒTNG ointment 1/2" to 1" ƒMgSO4 2 gms IV if eclamptic ƒMorphine 2 to 4 mg IV (if CHF)

65 Use of Esmolol (Breviblock) ƒIV cardioselective beta-blocker ƒChemically similar to metroprolol ƒElimination half-life : 9 min ƒDuration of action : <30 min ƒMay try in ? CHF or ? asthma ƒPreparation : 5 g dissolved in 500cc D5W ƒLoading dose : 500 mcg/kg/min / 1 min ƒMaintenance : 50 mcg/kg/min to 300 mcg/kg/min ƒ+ repeat loading dose before each increase in drip rate at 4 minute intervals

66 Antihypertensive Meds for Eclampsia ƒDrugs of choice : Hydralazine, Labetolol ƒInhibit uterine contractions : Diazoxide, Calcium antagonists ƒUse only if refractory to other agents : nitroprusside ƒContraindicated : Trimethaphan (meconium ileus), "Pure" beta blocker agents ( decreased uterine blood flow), Diuretics (patient already volume depleted) ƒDon't forget magnesium

67 Drug Induced Hypertensive Crisis ƒCocaine ƒAmphetamines ƒPhencyclidine (PCP) ƒDiet pills ƒOTC sympathomimetics ƒMAO Inhibitors / Tyramine

68 Treatment of Drug Induced Hypertensive Crisis ƒLabetalol : preferred ƒNitroprusside ƒNifedipine / Verapamil ƒPhentolamine ƒSince duration of HBP often brief, may not need treatment ƒNote : Pure Beta blockers may cause increased BP (from unopposed alpha effect)

69 Recommended Minimal Emergency Drugs / Equipment for the Office ƒOxygen masks / nasal prongs ƒReliable O2 tank supply ƒSuction catheters : flexible and Yankauer ƒIV catheters : 20 g, 18 g (22 g if children treated) ƒ500 cc or 1000 cc bags of NS ƒIV tubing sets ƒEpinephrine 1 : 1000 vials (1 mg per cc)

70 Recommended Minimal Emergency Drugs / Equipment for the Office (cont.) ƒAtropine 1 to 2 mg vials or amps ƒ50cc D50W amps (can dilute these 1:1 with sterile water for pediatric use) ƒBenadryl 25 or 50 mg amps ƒValium 5 to 10 mg amps or Ativan 1 to 2 mg amps ƒNarcan : 0.4 or 2 mg amps

71 Optional Meds for Office Emergencies ƒVistaril (or Atarax) 25 or 50 mg amps ƒAlupent or albuterol solution for aerosols or MDI's ƒHydrocortisone 100 mg amps ƒGlucagon 1 mg amps

72 Office Emergencies Lecture Summary ƒBe prepared and educate the office staff about management of emergencies ƒCheck office emergency equipment and meds regularly ƒKnow how to access local EMS for help

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