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Preparing for Office Emergencies OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM), FCFP OCFP Scientific Meetings November 29, 2013 L. Malo.

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Presentation on theme: "Preparing for Office Emergencies OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM), FCFP OCFP Scientific Meetings November 29, 2013 L. Malo."— Presentation transcript:

1 Preparing for Office Emergencies OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM), FCFP OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM), FCFP

2 Faculty / Presenter Disclosure Faculty: Dr. Larry Malo Program: 51 st Annual Scientific Assembly Relationships with commercial interests: NONE Faculty: Dr. Larry Malo Program: 51 st Annual Scientific Assembly Relationships with commercial interests: NONE

3 Disclosure of Commercial Support This program has NOT received any financial support This program has NOT received in- kind support Potential for conflict of interest: Illustrative photographs may identify a particular brand or product in a market where others may exist. This program has NOT received any financial support This program has NOT received in- kind support Potential for conflict of interest: Illustrative photographs may identify a particular brand or product in a market where others may exist.

4 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

5 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…… Everyone has a different tolerance for emergencies. You may have deliberately chosen to work in an environment where emergencies are less likely but……

6 Inevitably, emergencies WILL find you!

7 Preparing for Office Emergencies What is the extent of the problem? How common are office emergencies? What should I prepare for? What is the extent of the problem? How common are office emergencies? What should I prepare for?

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9 Preparing for Office emergencies Not much literature regarding the frequency of office emergencies. Nonetheless, it is unanimous is that we are unprepared!!!

10 Preparing for Office emergencies 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 doctors office, the expectation is that you will receive an immediate, skilled intervention. AED costs ~$ 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 doctors office, the expectation is that you will receive an immediate, skilled intervention. AED costs ~$

11 Preparing for Office emergencies Excellent article in Canadian Family Physician 2009 Can Fam Phys 55(10);Oct 2009: Claire Liddy, Heather Dreise, and Isabelle Gaboury look at The Frequency of In-office Emergencies in Primary Care Excellent article in Canadian Family Physician 2009 Can Fam Phys 55(10);Oct 2009: Claire Liddy, Heather Dreise, and Isabelle Gaboury look at The Frequency of In-office Emergencies in Primary Care

12 Can Fam Phys 55(10);Oct 2009: Liddy et. al. They looked at Code 4 calls in the Ottawa area for a 3 yr period from 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! They looked at Code 4 calls in the Ottawa area for a 3 yr period from 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!

13 Preparing for Office emergencies

14 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 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

15 The CPSO has provided guidelines for preparing for office emergencies. November 2005, Updated May lines/office/Safe-Practices.pdf

16 Preparing for Office emergencies Community characteristics Prone to severe weather? Is there a hospital in the community? Is 911 available? What is the ambulance response time? 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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19 Practice characteristics Scope of practice? Parenteral medications? High risk procedures? High volumes of sick patients? Practice characteristics Scope of practice? Parenteral medications? High risk procedures? High volumes of sick patients?

20 Preparing for Office emergencies Its 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 Its 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

21 Preparing for Office emergencies Essential equipment 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 (?) Essential equipment 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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23 Optional equipment (as determined by your risk assessment) Intubating equipment IV access and tubing ECG monitor Defibrillator Interosseus needles Optional equipment (as determined by your risk assessment) Intubating equipment IV access and tubing ECG monitor Defibrillator Interosseus needles

24 Preparing for Office emergencies Basic Medications ASA 80 mg (chewable)* NTG spray or tabs* Lorazepam 1mg sl tabs, Midazolam Epinephrine 1:1000* Diphenhydramine (Benadryl)* Glucagon Dextrose (injectable or gel) * essential Basic Medications ASA 80 mg (chewable)* NTG spray or tabs* Lorazepam 1mg sl tabs, Midazolam Epinephrine 1:1000* Diphenhydramine (Benadryl)* Glucagon Dextrose (injectable or gel) * essential

25 Preparing for Office emergencies More medications Ventolin* Atrovent* Cogentin Haldol Furosemide (Lasix) Oxytocin *essential More medications Ventolin* Atrovent* Cogentin Haldol Furosemide (Lasix) Oxytocin *essential

26 Preparing for Office emergencies Basic training BLS ACLS PALS Basic training BLS ACLS PALS

27 Preparing for Office emergencies Useful paperwork Death Certificate Form 1 Useful paperwork Death Certificate Form 1

28 Preparing for Office emergencies CPSO Self review How does your facility and equipment t into the risk assessment model and recommendations? -Based on your risk assessment, are you satised 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?

29 Preparing for Office emergencies 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 ofce within ve minutes? K -Are emergency plans posted in the medical facility for easy reference? K SELF-EVALUATION: Risk Assessment Model

30 Preparing for Office emergencies 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.

31 Preparing for Office emergencies The emergency kit should also include: Rx doses Breslow tapes, treatment algorithms The emergency kit should also include: Rx doses Breslow tapes, treatment algorithms

32 Preparing for Office emergencies Part II common office emergencies Ischemic chest pain Anaphylaxis Asthma Seizure Acute hemorrhage Syncope Form 1 intervention Ischemic chest pain Anaphylaxis Asthma Seizure Acute hemorrhage Syncope Form 1 intervention

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34 Preparing for Office emergencies 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 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

35 Preparing for Office emergencies Unstable Ischemic Chest Pain ECG where available AED where available Unstable Ischemic Chest Pain ECG where available AED where available

36 Preparing for Office emergencies Medication ASA 160mg po (2 x 80mg chewable) NTG if systolic BP > 100 mmHg mg 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 Medication ASA 160mg po (2 x 80mg chewable) NTG if systolic BP > 100 mmHg mg 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

37 Preparing for Office emergencies Complications Sudden death CHF, cardiogenic shock Hypotension Dysrhythmias Complications Sudden death CHF, cardiogenic shock Hypotension Dysrhythmias

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39 Preparing for Office emergencies Severe asthma attack Allay anxiety, calm, reassuring voice O2 by mask Monitor vitals and O2 sats PEFR (severe <50% predicted) Severe asthma attack Allay anxiety, calm, reassuring voice O2 by mask Monitor vitals and O2 sats PEFR (severe <50% predicted)

40 Preparing for Office emergencies 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 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

41 Preparing for Office emergencies 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 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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43 Seizures Most seizures are brief and self limited Protect patient Secure patients 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. Seizures Most seizures are brief and self limited Protect patient Secure patients 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.

44 Preparing for Office emergencies Seizures +/- IV access for unremitting episode Glucometer Most seizures are self limited and intervention is rarely required beyond assisting the patient. Seizures +/- IV access for unremitting episode Glucometer Most seizures are self limited and intervention is rarely required beyond assisting the patient.

45 Preparing for Office emergencies Seizures Medications Dextrose gel po or D50W IV 50ml if hypoglycemic Lorazepam 2mg/min to a max of 10mg or Diazepam rectally 0.5mg/kg up to 20mg or Midazolam mg/kg IM Seizures Medications Dextrose gel po or D50W IV 50ml if hypoglycemic Lorazepam 2mg/min to a max of 10mg or Diazepam rectally 0.5mg/kg up to 20mg or Midazolam mg/kg IM

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47 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 30% drop from baseline 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 30% drop from baseline

48 Preparing for Office emergencies 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) 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)

49 Preparing for Office emergencies 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 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

50 Preparing for Office emergencies Anaphylaxis 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 Anaphylaxis 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

51 Preparing for Office emergencies Anaphylaxis - Medications Epinephrine 0.3ml 1:1000 IM q20min (adult) Epinephrine 0.01ml/kg 1:1000 IM q20min (peds) Anaphylaxis - Medications Epinephrine 0.3ml 1:1000 IM q20min (adult) Epinephrine 0.01ml/kg 1:1000 IM q20min (peds)

52 Preparing for Office emergencies 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 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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55 Preparing for Office Emergencies Sepsis Definition: A clinical syndrome characterized by systemic inflammation due to infection The challenge: RECOGNISE IT Sepsis Definition: A clinical syndrome characterized by systemic inflammation due to infection The challenge: RECOGNISE IT

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58 Preparing for Office emergencies Sepsis Therapeutic priority: 1. Transport patient to nearest ER 2. Correct hypoxemia, hypotension 3. Identify and treat infection Sepsis Therapeutic priority: 1. Transport patient to nearest ER 2. Correct hypoxemia, hypotension 3. Identify and treat infection

59 Preparing for Office emergencies Sepsis - Treatment Treatment - Supplemental oxygen -Continuous SO2 monitoring -Large bore IV (depending on access to EMS) and fluids +++ Sepsis - Treatment Treatment - Supplemental oxygen -Continuous SO2 monitoring -Large bore IV (depending on access to EMS) and fluids +++

60 Preparing for Office emergencies Sepsis – Treatment -Assess perfusion: colour, temperature, restlessness, confusion - Hypoperfusion can occur in the absence of hypotension - transport to ER STAT Sepsis – Treatment -Assess perfusion: colour, temperature, restlessness, confusion - Hypoperfusion can occur in the absence of hypotension - transport to ER STAT

61 Preparing for Office emergencies Serotonin Syndrome In the US in 2005 there were 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 Serotonin Syndrome In the US in 2005 there were 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

62 Preparing for Office emergencies Serotonin Syndrome Classic triad: 1. Altered mental status 2. Autonomic hyperactivity 3. Neuromuscular abnormalities Incidence increasing with use of SSRIs Serotonin Syndrome Classic triad: 1. Altered mental status 2. Autonomic hyperactivity 3. Neuromuscular abnormalities Incidence increasing with use of SSRIs

63 Preparing for Office emergencies Serotonin Syndrome Mental status changes: Anxiety, agitated delirium, restlessness Autonomic changes: Diaphoresis, tachycardia, hyperthermia, vomiting, diarrhea, HTN Neuromuscular changes: Tremor, rigidity, myoclonus, hyperreflexia, Serotonin Syndrome Mental status changes: Anxiety, agitated delirium, restlessness Autonomic changes: Diaphoresis, tachycardia, hyperthermia, vomiting, diarrhea, HTN Neuromuscular changes: Tremor, rigidity, myoclonus, hyperreflexia,

64 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 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

65 Preparing for Office emergencies Serotonin Syndrome Treatment Call 911 and prepare for transport Supportive care: O2 Monitor vitals +/- IV fluids Benzodiazepines (Midazolam) Cyproheptadine 8mg Serotonin Syndrome Treatment Call 911 and prepare for transport Supportive care: O2 Monitor vitals +/- IV fluids Benzodiazepines (Midazolam) Cyproheptadine 8mg

66 Preparing for Office emergencies 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…….. 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……..

67 Preparing for Office emergencies 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. 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.

68 Preparing for Office emergencies Part III Build the Box Be Ready

69 Preparing for Office emergencies Build the Box- Medications Epinephrine 1: 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 Build the Box- Medications Epinephrine 1: 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

70 Preparing for Office emergencies 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 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

71 Preparing for Office emergencies Build the Box- Equipment OPTIONAL (depends on practice risk assessment): ETT sizes Laryngoscope handle and blades 2-4 MacIntosh McGill forceps AED Interosseous needles IV tubing, IV needles (24-16g), Normal saline Build the Box- Equipment OPTIONAL (depends on practice risk assessment): ETT sizes Laryngoscope handle and blades 2-4 MacIntosh McGill forceps AED Interosseous needles IV tubing, IV needles (24-16g), Normal saline

72 Preparing for Office emergencies 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 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

73 Preparing for Office emergencies Build (or buy) the Box m Approx $600 U.S.

74 Preparing for Office emergencies 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 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

75 Prepared for Office emergencies Questions/Discussion Questions/Discussion


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