Preparing for Office Emergencies OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM), FCFP
Faculty / Presenter Disclosure Faculty: Dr. Larry Malo Program: 51 st Annual Scientific Assembly Relationships with commercial interests: NONE
Disclosure of Commercial Support § This program has NOT received any financial support § This program has NOT received inkind support § Potential for conflict of interest: Illustrative photographs may identify a particular brand or product in a market where others may exist.
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
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……
Inevitably, emergencies WILL find you!
Preparing for Office Emergencies What is the extent of the problem? § How common are office emergencies? § What should I prepare for?
Preparing for Office emergencies Not much literature regarding the frequency of office emergencies. Nonetheless, it is unanimous is that we are unprepared!!!
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 doctor’s office, the expectation is that you will receive an immediate, skilled intervention. § AED costs ~$1000. 00
Preparing for Office emergencies § Excellent article in Canadian Family Physician 2009 Can Fam Phys 55(10); Oct 2009: 1004 -1005 § Claire Liddy, Heather Dreise, and Isabelle Gaboury look at “The Frequency of In-office Emergencies in Primary Care”
Can Fam Phys 55(10); Oct 2009: 1004 -1005 Liddy et. al. § They looked at ‘Code 4’ calls in the Ottawa area for a 3 yr period from 20042006. § 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!
Preparing for Office emergencies
Preparing for Office emergencies § 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
The CPSO has provided guidelines for preparing for office emergencies. November 2005, Updated May 2012 http: //www. cpso. on. ca/uploaded. Files/policies/guid elines/office/Safe-Practices. pdf
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?
Preparing for Office emergencies
Preparing for Office emergencies Practice characteristics § Scope of practice? § Parenteral medications? § High risk procedures? § High volumes of ‘sick’ patients?
Preparing for Office emergencies § It’s 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
Preparing for Office emergencies Essential equipment § § § § Stethoscope, BP measuring device O 2, bag valve mask(adult and pediatric) Oral airways Oxygen tubing and masks Pulse oximeter Needles and syringes Aerochamber (Pediatric and Adult) N 95 masks (? )
Preparing for Office emergencies
Preparing for Office emergencies Optional equipment (as determined by your risk assessment) § § § Intubating equipment IV access and tubing ECG monitor Defibrillator Interosseus needles www. officeemergencies. ca
Preparing for Office emergencies Basic Medications § § § § ASA 80 mg (chewable)* NTG spray or tabs* Lorazepam 1 mg sl tabs, Midazolam Epinephrine 1: 1000* Diphenhydramine (Benadryl)* Glucagon Dextrose (injectable or gel) * essential
Preparing for Office emergencies More medications § § § Ventolin* Atrovent* Cogentin Haldol Furosemide (Lasix) Oxytocin *essential
Preparing for Office emergencies Basic training § BLS § ACLS § PALS
Preparing for Office emergencies Useful paperwork § Death Certificate § Form 1
Preparing for Office emergencies CPSO Self review How does your facility and equipment fit into the risk assessment model and recommendations? -Based on your risk assessment, are you satisfied 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?
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 office within five minutes? K -Are emergency plans posted in the medical facility for easy reference? K SELF-EVALUATION: Risk Assessment Model
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.
Preparing for Office emergencies § The emergency kit should also include: Rx doses Breslow tapes, treatment algorithms
Preparing for Office emergencies Part II common office emergencies § § § § Ischemic chest pain Anaphylaxis Asthma Seizure Acute hemorrhage Syncope Form 1 intervention
Preparing for Office emergencies Unstable Ischemic Chest Pain § Call 911 for urgent transport to local emergency facility § Monitor BP, pulse and when available continuous O 2 saturation § Supplemental O 2 by mask or prongs § Remain in attendance until paramedics assume care § IV access if possible
Preparing for Office emergencies Unstable Ischemic Chest Pain § ECG where available § AED where available
Preparing for Office emergencies Medication § ASA 160 mg po (2 x 80 mg chewable) § NTG if systolic BP > 100 mm. Hg 0. 3 -0. 4 mg sl q 5 min x 3 doses* § Morphine 2 -4 mg IV q 5 minutes for pain and anxiety *Caution in Right ventricular MI, Hypotension, use of a phosphodiesterase inhibitor, aortic stenosis
Preparing for Office emergencies Complications § § Sudden death CHF, cardiogenic shock Hypotension Dysrhythmias
Preparing for Office emergencies Severe asthma attack § § Allay anxiety, calm, reassuring voice O 2 by mask Monitor vitals and O 2 sats PEFR (severe <50% predicted)
Preparing for Office emergencies Severe Asthma Attack Medications § Ventolin MDI with aerochamber, 4 -6 inhalations STAT, then 2 inhalations q 30 min PRN § Prednisone 1 mg/kg po § Atrovent MDI, 2 inhalations following Ventolin
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
Preparing for Office emergencies
Preparing for Office emergencies Seizures § Most seizures are brief and self limited § Protect patient § Secure patient’s airway by positioning, chin lift or jaw thrust if required. § O 2 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.
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.
Preparing for Office emergencies Seizures Medications § Dextrose gel po or D 50 W IV 50 ml if hypoglycemic § Lorazepam 0. 1 mg/kg @ 2 mg/min to a max of 10 mg or § Diazepam rectally 0. 5 mg/kg up to 20 mg or § Midazolam 0. 1 -0. 3 mg/kg IM
Preparing for Office emergencies
Preparing for Office emergencies 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 <90 or >30% drop from baseline
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)
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
Preparing for Office emergencies Anaphylaxis § § § Remove offending allergen Call for help, call 911 O 2 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
Preparing for Office emergencies Anaphylaxis - Medications § Epinephrine 0. 3 ml 1: 1000 IM q 20 min (adult) § Epinephrine 0. 01 ml/kg 1: 1000 IM q 20 min (peds)
Preparing for Office emergencies Anaphylaxis - Medications § If patient is taking Beta blockers, epinephrine may be less effective, in this setting: § Glucagon 1 -2 mg IM in adults § 20 -30 mcg/kg up to 1 mg in children
Preparing for Office Emergencies Sepsis § Definition: A clinical syndrome characterized by systemic inflammation due to infection § The challenge: RECOGNISE IT
Preparing for Office emergencies Sepsis § Therapeutic priority: 1. Transport patient to nearest ER 2. Correct hypoxemia, hypotension 3. Identify and treat infection
Preparing for Office emergencies Sepsis - Treatment § Treatment -Supplemental oxygen -Continuous SO 2 monitoring -Large bore IV (depending on access to EMS) and fluids +++
Preparing for Office emergencies Sepsis – Treatment -Assess perfusion: colour, temperature, restlessness, confusion - Hypoperfusion can occur in the absence of hypotension - transport to ER STAT
Preparing for Office emergencies Serotonin Syndrome § In the US in 2005 there were 8000+ cases with 103 deaths. Most require ICU admit. § Often results from a combination of meds that increase serotonergic neurotransmisssion § Often presents within 24 hrs of new Rx or change in dose
Preparing for Office emergencies Serotonin Syndrome Classic triad: 1. Altered mental status 2. Autonomic hyperactivity 3. Neuromuscular abnormalities § Incidence increasing with use of SSRIs
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,
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
Preparing for Office emergencies Serotonin Syndrome Treatment § Call 911 and prepare for transport § Supportive care: § O 2 § Monitor vitals § +/- IV fluids § Benzodiazepines (Midazolam) § Cyproheptadine 8 mg
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……. .
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 10 mg 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.
Preparing for Office emergencies Part III Build the Box Be Ready
Preparing for Office emergencies Build the Box- Medications § § § Epinephrine 1: 1000 3 amps ASA 80 mg* NTG 0. 4 mg sublingual spray* Benadryl 50 mg tabs* Glucagon, preloaded syringes Ventolin MDI with aerochamber, adult / peds* Atrovent MDI* Dextrose gel, tabs* Ativan 1 mg s. l. tabs Midazolam 5 mg/ml injectable Cogentin 2 mg/ml injectable *essential
Preparing for Office emergencies § § § § § Build the Box - Equipment Syringes 3 cc-10 cc* Needles 18 g, 25 g 1”, 1 1/2”* O 2 sat probe Glucometer O 2 tubing* O 2 masks, peds to adult* O 2 supply* Oral airways, nasal trumpets* Bag valve mask* *essential
Preparing for Office emergencies Build the Box- Equipment OPTIONAL (depends on practice risk assessment): § ETT sizes 4. 5 -8. 0 § Laryngoscope handle and blades 2 -4 Mac. Intosh § Mc. Gill forceps § AED § Interosseous needles § IV tubing, IV needles (24 -16 g), Normal saline
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
Preparing for Office emergencies Build (or buy) the Box www. stores. criticalcaresolutionsstore. com Approx $600 U. S.
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
Prepared for Office emergencies Questions/Discussion
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