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

• Asthma• Anaphylaxis• Shock• Seizures• Congestive heart

failure• DKA• Epistaxis• Drug overdose• Cardiac arrest

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)

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 • 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 bleedingIf 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– IV/IO access supplies– Cardiac monitoring– Pulse oximetry– External pacing– Airway management

• Medications– Normal saline– O2– Antibiotics– Pressors (Levophed,

Dopamine)– Epinephrine

Seizures • Equipment– IV/IO access– Pulse oximetry– Glucometer– Cardiac monitor– Airway management

• Medications– Lorazepam– Fosphenytoin– Rectal diazepam– Propofol

Pulmonary edema • Equipment– IV/IO access– ECG– Pulse oximetry– Cardiac monitor– NRB mask– Airway management

• Medications– 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– IV/IO access– ECG– Cardiac monitoring– Pulse oximetry– AED– Airway management

• Medications– 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 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.

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?– 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 1004-1005.e4

• 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