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Handling Emergencies in the Office Setting Daniel Elwell, D.O.

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Presentation on theme: "Handling Emergencies in the Office Setting Daniel Elwell, D.O."— Presentation transcript:

1 Handling Emergencies in the Office Setting Daniel Elwell, D.O.

2 Disclosures Nothing to disclose Nothing to disclose

3 Objectives Discuss common emergencies in a primary care office setting Discuss common emergencies in a primary care office setting Discuss a strategy to prepare for emergency situations Discuss a strategy to prepare for emergency situations

4 Common Emergencies Asthma Asthma Anaphylaxis Anaphylaxis Shock Shock Seizures Seizures Congestive heart failure Congestive heart failure DKA DKA Epistaxis Epistaxis Drug overdose Drug overdose Cardiac arrest Cardiac arrest

5 Equipment needed Bag mask ventilator (two sizes, three mask Bag mask ventilator (two sizes, three mask sizes) sizes) Blood pressure cuff (all sizes) Blood pressure cuff (all sizes) Glucose meter Glucose meter Intraosseous needle (18 and 16 gauge) Intraosseous needle (18 and 16 gauge) Intravenous catheter/butterfly needles (24 to 18 gauge) Intravenous catheter/butterfly needles (24 to 18 gauge) Intravenous extension tubing and T- connectors Intravenous extension tubing and T- connectors Nasal airways (one set) Nasal airways (one set) Nasogastric tubes Nasogastric tubes Nebulizer or metered dose inhaler spacer and face masks Nebulizer or metered dose inhaler spacer and face masks Non-rebreather (three sizes) Non-rebreather (three sizes) Oxygen mask (three sizes) Oxygen mask (three sizes) Oxygen tank and flow meter Oxygen tank and flow meter Portable suction device and catheters, or bulb syringe Portable suction device and catheters, or bulb syringe Pulse oximeter for child and adult usage Pulse oximeter for child and adult usage Resuscitation tape (color-coded) Resuscitation tape (color-coded) Universal precautions (latex-free gloves, mask, eye protection) Universal precautions (latex-free gloves, mask, eye protection)

6 Mediations needed Acetaminophen (rectal suppositories) Acetaminophen (rectal suppositories) Albuterol Albuterol Aspirin Aspirin Ceftriaxone Ceftriaxone Corticosteroids, parenteral Corticosteroids, parenteral Dextrose 25% Dextrose 25% Diazepam, parenteral Diazepam, parenteral Diphenhydramine, oral and parenteral Diphenhydramine, oral and parenteral Epinephrine (1:1,000, 1:10,000) Epinephrine (1:1,000, 1:10,000) Flumazenil Flumazenil Lorazepam, sublingual, parenteral Lorazepam, sublingual, parenteral Morphine Morphine Naloxone Naloxone Nitroglycerine spray Nitroglycerine spray Normal saline Normal saline

7 Training needed BLS BLS PALS PALS ACLS ACLS IV/IO access IV/IO access Airway management Airway management Training necessary to utilize all available equipment Training necessary to utilize all available equipment

8 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:.

9 Asthma Equipment Equipment – Nebulizer / tubing – Pulse oximetry – Airway management Medications Medications – O2 – Albuterol – Atrovent – Corticosteroids – Epinephrine (1:1000) – Terbutaline

10 Anaphylaxis Equipment Equipment – IV/IO access supplies – Pulse oximetry – Cardiac monitoring – Airway management Medications Medications – O2 – Corticosteroids – Diphenhydramine – H2 antagonist – Epinephrine (1:1000)

11 Shock Equipment Equipment – IV/IO access supplies – Cardiac monitoring – Pulse oximetry – External pacing – Airway management Medications Medications – Normal saline – O2 – Antibiotics – Pressors (Levophed, Dopamine) – Epinephrine

12 Seizures Equipment Equipment – IV/IO access – Pulse oximetry – Glucometer – Cardiac monitor – Airway management Medications Medications – Lorazepam – Fosphenytoin – Rectal diazepam – Propofol

13 Pulmonary edema Equipment Equipment – IV/IO access – ECG – Pulse oximetry – Cardiac monitor – NRB mask – Airway management Medications Medications – O2 – Lasix – Nitrates – Morphine – Dobutamine

14 DKA Equipment Equipment – IV/IO access – Glucometer – Pulse oximeter – Cardiac monitor Medications Medications – Normal saline – Anti-emetics – Morphine – Insulin R (K>3.3)

15 Epistaxis Equipment Equipment – Clips – Ice – Nasal packing – Nasal tampons – Nasal balloons – Silver nitrate sticks Medications Medications – Neo-synephrine – Antibiotic ointment – Vitamin K

16 Drug overdose Equipment Equipment – IV/IO access – Cardiac monitoring – Pulse oximetry – NG tube – Airway management Medications Medications – O2 – Activated charcoal – Naloxone – Glucagon – Flumazenil

17 Cardiac arrest Equipment Equipment – IV/IO access – ECG – Cardiac monitoring – Pulse oximetry – AED – Airway management Medications Medications – O2 – Epinephrine (1:10,000) – Atropine – Vasopressin – NaHCO3 – Dopamine

18 AED in your office? This is not considered the standard of care This is not considered the standard of care Recommendations in the literature for high risk offices Recommendations in the literature for high risk offices Others stated highly essential for any office that cares for children Others stated highly essential for any office that cares for children Public access programs place where will be used once in 5 years Public access programs place where will be used once in 5 years

19 Buying an AED Cost 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 Ease of use – All newer AEDs have voice and visual prompts; some units function with a single button Maintenance and upkeep 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

20 Buying an AED Safety Safety – All AEDs are extremely safe and are designed not to deliver a shock when it is not indicated Self-testing Self-testing – All AEDs do some form of self- testing; if the unit will rarely be used, a product that does more frequent and extensive self-testing is desirable Training availability 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 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.

21 Identify your unique needs What are the most common emergencies in your practice? What are the most common emergencies in your practice? How often have office emergencies occurred 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)? 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)? 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)?

22 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 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? How long does it take EMS to respond? What is your patient population? What is your patient population? – Pediatric – Geriatric – Diabetic – Special needs

23 Have a plan Develop a protocol to recognize and respond to office emergencies Develop a protocol to recognize and respond to office emergencies Assign responsibilities to each staff member Assign responsibilities to each staff member Practice by having mock drills regularly Practice by having mock drills regularly

24 Have a plan

25 Stay Current Routinely restock supplies Routinely restock supplies Track office emergency occurrences Track office emergency occurrences – What could have been done better? – What would you have liked to have? Keep all office staff training current Keep all office staff training current Adapt to changing technologies Adapt to changing technologies

26 References Am Fam Physician. 2007 Jun 1;75(11):1679-1684 Am Fam Physician. 2007 Jun 1;75(11):1679-1684 Canadian Family Physician October 2009 vol. 55 no. 10 1004- 1005.e4 Canadian Family Physician October 2009 vol. 55 no. 10 1004- 1005.e4 Pediatrics Vol. 120 No. 1 July 1, 2007 pp. 200 -212 (doi: 10.1542/peds.2007- 1109) Pediatrics Vol. 120 No. 1 July 1, 2007 pp. 200 -212 (doi: 10.1542/peds.2007- 1109) http://practice.aap.org/ content.aspx?aid=2057 accessed June 1, 2012 http://practice.aap.org/ content.aspx?aid=2057 accessed June 1, 2012 http://practice.aap.org/ content.aspx?aid=2057 http://practice.aap.org/ content.aspx?aid=2057


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