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

2. Disclosures
Nothing to disclose

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

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

5. Equipment needed 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 T-connectors
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)

6. 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

7. Training necessary to utilize all available equipment
Training needed
BLS
PALS
ACLS
IV/IO access
Airway management
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. Equipment Medications Asthma Nebulizer / tubing Pulse oximetry
Airway management
Medications O2
Albuterol
Atrovent
Corticosteroids
Epinephrine (1:1000)
Terbutaline

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

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

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

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

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

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

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

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

18. This is not considered the standard of care
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

19. Buying an AED Cost Ease of use Maintenance and upkeep
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

20. Buying an AED Safety Self-testing Training availability
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 self-testing; 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.

21. 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)?

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

23. Develop a protocol to recognize and respond to office emergencies
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

24. Have a plan

25. Routinely restock supplies Track office emergency occurrences
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

26. Am Fam Physician. 2007 Jun 1;75(11):1679-1684
References
Am Fam Physician Jun 1;75(11):
Canadian Family Physician October 2009 vol. 55 no e4
Pediatrics Vol. 120 No. 1 July 1, 2007 pp (doi: /peds )
accessed June 1, 2012