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

Disclosures Nothing to disclose

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

Congestive heart failure DKA Epistaxis Drug overdose Cardiac arrest 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 necessary to utilize all available equipment 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 bleeding If you feel a patient has symptoms that may signal an emergency, alert the following office staff: .

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

Have a plan

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

Am Fam Physician. 2007 Jun 1;75(11):1679-1684 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