Preparing for Office Emergencies OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM),...

Preparing for Office Emergencies

Preparing for Office Emergencies

OCFP Scientific Meetings

November 29, 2013

L. Malo MD, CCFP(EM), FCFP

OCFP Scientific Meetings

November 29, 2013

L. Malo MD, CCFP(EM), FCFP

Faculty / Presenter DisclosureFaculty / Presenter Disclosure

Faculty: Dr. Larry Malo Program: 51st Annual Scientific

Assembly

Relationships with commercial interests:

NONE

Faculty: Dr. Larry Malo Program: 51st Annual Scientific

Assembly

Relationships with commercial interests:

NONE

Disclosure of Commercial Support

Disclosure of Commercial Support

This program has NOT received any financial support

This program has NOT received in-kind support

Potential for conflict of interest: Illustrative photographs may identify

a particular brand or product in a market where others may exist.

This program has NOT received any financial support

This program has NOT received in-kind support

Potential for conflict of interest: Illustrative photographs may identify

a particular brand or product in a market where others may exist.

Mitigating Potential BiasMitigating 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

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 emergenciesPart I

Are you ready???

Preparing for Office emergenciesPart 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……

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!Inevitably, emergencies WILL find you!

Preparing for Office EmergenciesPreparing for Office Emergencies

What is the extent of the problem?

How common are office emergencies?

What should I prepare for?

What is the extent of the problem?

How common are office emergencies?

What should I prepare for?

Preparing for Office emergenciesPreparing for Office emergencies

Not much literature regarding the frequency of office emergencies.

Not much literature regarding the frequency of office emergencies.

Nonetheless, it is unanimous is that we are unprepared!!!


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

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


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”

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.

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 2004-2006.

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!

They looked at ‘Code 4’ calls in the Ottawa area for a 3 yr period from 2004-2006.

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!


0

5

10

15

20

25

30

35

Cardiovascular

Other

Respiratory

CNS

Endocrine

GI

MSK

Hematologic

GU


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

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/uploadedFiles/policies/guidelines/office/Safe-Practices.pdf

The CPSO has provided guidelines for preparing for office emergencies.

November 2005, Updated May 2012 http://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/Safe-Practices.pdf


Community characteristics

Prone to severe weather? Is there a hospital in the

community? Is 911 available? What is the ambulance response

time?

Community characteristics

Prone to severe weather? Is there a hospital in the

community? Is 911 available? What is the ambulance response

time?


Practice characteristics

Scope of practice? Parenteral medications? High risk procedures? High volumes of ‘sick’ patients?

Practice characteristics

Scope of practice? Parenteral medications? High risk procedures? High volumes of ‘sick’ patients?


It’s important to assess your practice for the kinds of risks you may have to deal with.

eg. Psychotherapists vs geriatriciansvs practices that may encounter

mostly children. Predicting the likely types of

emergencies you may encounter will help guide establishing needed equipment and meds

It’s important to assess your practice for the kinds of risks you may have to deal with.

eg. Psychotherapists vs geriatriciansvs practices that may encounter

mostly children. Predicting the likely types of

emergencies you may encounter will help guide establishing needed equipment and meds


Essential equipment Stethoscope, BP measuring device O2, bag valve mask(adult and pediatric) Oral airways Oxygen tubing and masks Pulse oximeter Needles and syringes Aerochamber (Pediatric and Adult) N95 masks (?)

Essential equipment Stethoscope, BP measuring device O2, bag valve mask(adult and pediatric) Oral airways Oxygen tubing and masks Pulse oximeter Needles and syringes Aerochamber (Pediatric and Adult) N95 masks (?)


Optional equipment (as determined by your risk assessment)

Intubating equipment IV access and tubing ECG monitor Defibrillator Interosseus needles www.officeemergencies.ca

Optional equipment (as determined by your risk assessment)

Intubating equipment IV access and tubing ECG monitor Defibrillator Interosseus needles www.officeemergencies.ca


Basic Medications

ASA 80 mg (chewable)* NTG spray or tabs* Lorazepam 1mg sl tabs, Midazolam Epinephrine 1:1000* Diphenhydramine (Benadryl)* Glucagon Dextrose (injectable or gel)

* essential

Basic Medications

ASA 80 mg (chewable)* NTG spray or tabs* Lorazepam 1mg sl tabs, Midazolam Epinephrine 1:1000* Diphenhydramine (Benadryl)* Glucagon Dextrose (injectable or gel)

* essential


More medications

Ventolin* Atrovent* Cogentin Haldol Furosemide (Lasix) Oxytocin *essential

More medications

Ventolin* Atrovent* Cogentin Haldol Furosemide (Lasix) Oxytocin *essential


Basic training

BLS ACLS PALS

Basic training

BLS ACLS PALS


Useful paperwork

Death Certificate Form 1

Useful paperwork

Death Certificate Form 1

Preparing for Office emergenciesCPSO Self review

Preparing for Office emergenciesCPSO 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


CPSO Self review-Does your staff have updated training in CPR? -Does your medical facility have a documented plan to follow in the event of the following: • Fire/evacuation • Disruptive patient • Need to obtain security -Is 911 service available in the community? -Would it be possible for appropriate emergency personnel to reach the office within five minutes? -Are emergency plans posted in the medical facility for easy reference? SELF-EVALUATION: Risk Assessment Model


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.


The emergency kit should also include:

Rx doses Breslow tapes, treatment algorithms

The emergency kit should also include:

Rx doses Breslow tapes, treatment algorithms

Preparing for Office emergenciesPart II

common office emergencies

Preparing for Office emergenciesPart II

common office emergencies

Ischemic chest pain Anaphylaxis Asthma Seizure Acute hemorrhage Syncope Form 1 intervention

Ischemic chest pain Anaphylaxis Asthma Seizure Acute hemorrhage Syncope Form 1 intervention


Unstable Ischemic Chest Pain

Call 911 for urgent transport to local emergency facility

Monitor BP, pulse and when available continuous O2 saturation

Supplemental O2 by mask or prongs Remain in attendance until paramedics

assume care IV access if possible


Call 911 for urgent transport to local emergency facility

Monitor BP, pulse and when available continuous O2 saturation

Supplemental O2 by mask or prongs Remain in attendance until paramedics

assume care IV access if possible



ECG where available

AED where available


ECG where available

AED where available


Medication

ASA 160mg po (2 x 80mg chewable) NTG if systolic BP > 100 mmHg 0.3-

0.4mg sl q5min x 3 doses* Morphine 2-4mg IV q 5minutes for pain

and anxiety

*Caution in Right ventricular MI, Hypotension, use of a phosphodiesterase inhibitor, aortic stenosis

Medication

ASA 160mg po (2 x 80mg chewable) NTG if systolic BP > 100 mmHg 0.3-

0.4mg sl q5min x 3 doses* Morphine 2-4mg IV q 5minutes for pain

and anxiety

*Caution in Right ventricular MI, Hypotension, use of a phosphodiesterase inhibitor, aortic stenosis


Complications Sudden death CHF, cardiogenic shock Hypotension Dysrhythmias

Complications Sudden death CHF, cardiogenic shock Hypotension Dysrhythmias


Severe asthma attack

Allay anxiety, calm, reassuring voice O2 by mask Monitor vitals and O2 sats PEFR (severe <50% predicted)


Allay anxiety, calm, reassuring voice O2 by mask Monitor vitals and O2 sats PEFR (severe <50% predicted)


Severe Asthma AttackMedications

Ventolin MDI with aerochamber, 4-6 inhalations STAT, then 2 inhalations q30min PRN

Prednisone 1mg/kg po Atrovent MDI, 2 inhalations following

Ventolin

Severe Asthma AttackMedications

Ventolin MDI with aerochamber, 4-6 inhalations STAT, then 2 inhalations q30min PRN

Prednisone 1mg/kg po Atrovent MDI, 2 inhalations following

Ventolin



If PEFR remains <50% expected after Tx, transport patient to the ER

If PEFR is not available, transport patient to the ER by EMS


If PEFR remains <50% expected after Tx, transport patient to the ER

If PEFR is not available, transport patient to the ER by EMS


Seizures Most seizures are brief and self limited Protect patient Secure patient’s airway by positioning,

chin lift or jaw thrust if required. O2 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.

Seizures Most seizures are brief and self limited Protect patient Secure patient’s airway by positioning,

chin lift or jaw thrust if required. O2 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.


Seizures

+/- IV access for unremitting episode Glucometer Most seizures are self limited and

intervention is rarely required beyond assisting the patient.

Seizures

+/- IV access for unremitting episode Glucometer Most seizures are self limited and

intervention is rarely required beyond assisting the patient.


Seizures Medications

Dextrose gel po or D50W IV 50ml if hypoglycemic

Lorazepam 0.1mg/kg @ 2mg/min to a max of 10mg or

Diazepam rectally 0.5mg/kg up to 20mg or Midazolam 0.1-0.3mg/kg IM

Seizures Medications

Dextrose gel po or D50W IV 50ml if hypoglycemic

Lorazepam 0.1mg/kg @ 2mg/min to a max of 10mg or

Diazepam rectally 0.5mg/kg up to 20mg or Midazolam 0.1-0.3mg/kg IM



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

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



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)

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)



AnaphylaxisCriteria 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 ofmedical care= delay in epi administration

AnaphylaxisCriteria 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 ofmedical care= delay in epi administration


Anaphylaxis Remove offending allergen Call for help, call 911 O2 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

Anaphylaxis Remove offending allergen Call for help, call 911 O2 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


Anaphylaxis - Medications

Epinephrine 0.3ml 1:1000 IM q20min (adult)

Epinephrine 0.01ml/kg 1:1000 IM q20min (peds)


Epinephrine 0.3ml 1:1000 IM q20min (adult)

Epinephrine 0.01ml/kg 1:1000 IM q20min (peds)



If patient is taking Beta blockers, epinephrine may be less effective, in this setting:

Glucagon 1-2mg IM in adults 20-30mcg/kg up to 1mg in children


If patient is taking Beta blockers, epinephrine may be less effective, in this setting:

Glucagon 1-2mg IM in adults 20-30mcg/kg up to 1mg in children

Preparing for Office EmergenciesPreparing for Office Emergencies

Sepsis

Definition: A clinical syndrome characterized by systemic inflammation due to infection

The challenge: RECOGNISE IT

Sepsis

Definition: A clinical syndrome characterized by systemic inflammation due to infection

The challenge: RECOGNISE IT


Sepsis Therapeutic priority: 1. Transport patient to nearest ER

2. Correct hypoxemia, hypotension

3. Identify and treat infection

Sepsis Therapeutic priority: 1. Transport patient to nearest ER

2. Correct hypoxemia, hypotension

3. Identify and treat infection


Sepsis - Treatment Treatment

-Supplemental oxygen

-Continuous SO2 monitoring

-Large bore IV (depending on

access to EMS) and fluids +++

Sepsis - Treatment Treatment

-Supplemental oxygen

-Continuous SO2 monitoring

-Large bore IV (depending on

access to EMS) and fluids +++


Sepsis – Treatment -Assess perfusion: colour,

temperature, restlessness, confusion

- Hypoperfusion can occur in the absence of hypotension

- transport to ER STAT

Sepsis – Treatment -Assess perfusion: colour,

temperature, restlessness, confusion

- Hypoperfusion can occur in the absence of hypotension

- transport to ER STAT


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 24hrs of new Rx or change in dose

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 24hrs of new Rx or change in dose


Serotonin Syndrome

Classic triad:

1. Altered mental status

2. Autonomic hyperactivity 3. Neuromuscular abnormalities

Incidence increasing with use of SSRIs

Serotonin Syndrome

Classic triad:

1. Altered mental status

2. Autonomic hyperactivity 3. Neuromuscular abnormalities

Incidence increasing with use of SSRIs

Preparing for Office emergenciesPreparing for Office emergenciesSerotonin Syndrome

Mental status changes: Anxiety, agitated delirium, restlessness

Autonomic changes: Diaphoresis, tachycardia, hyperthermia, vomiting, diarrhea, HTN

Neuromuscular changes: Tremor, rigidity, myoclonus, hyperreflexia,

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 emergenciesPreparing for Office emergenciesSerotonin 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

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


Serotonin SyndromeTreatment

Call 911 and prepare for transport Supportive care:

O2 Monitor vitals +/- IV fluids Benzodiazepines (Midazolam) Cyproheptadine 8mg

Serotonin SyndromeTreatment

Call 911 and prepare for transport Supportive care:

O2 Monitor vitals +/- IV fluids Benzodiazepines (Midazolam) Cyproheptadine 8mg


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……..

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……..


1. Reassure him that he is likely incorrect and arrange for a family meeting next week.

2. Start him on Celexa 10mg 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.

1. Reassure him that he is likely incorrect and arrange for a family meeting next week.

2. Start him on Celexa 10mg 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 emergenciesPart III

Preparing for Office emergenciesPart III

Build the BoxBuild the Box

Be Ready


Build the Box- Medications Epinephrine 1:1000 3 amps ASA 80mg* NTG 0.4mg sublingual spray* Benadryl 50mg tabs* Glucagon, preloaded syringes Ventolin MDI with aerochamber, adult / peds* Atrovent MDI* Dextrose gel, tabs* Ativan 1mg s.l. tabs Midazolam 5mg/ml injectable Cogentin 2mg/ml injectable *essential

Build the Box- Medications Epinephrine 1:1000 3 amps ASA 80mg* NTG 0.4mg sublingual spray* Benadryl 50mg tabs* Glucagon, preloaded syringes Ventolin MDI with aerochamber, adult / peds* Atrovent MDI* Dextrose gel, tabs* Ativan 1mg s.l. tabs Midazolam 5mg/ml injectable Cogentin 2mg/ml injectable *essential



Build the Box - Equipment Syringes 3cc-10cc* Needles 18g, 25g 1”, 1 1/2”* O2 sat probe Glucometer O2 tubing* O2 masks, peds to adult* O2 supply* Oral airways, nasal trumpets* Bag valve mask*

*essential

Build the Box - Equipment Syringes 3cc-10cc* Needles 18g, 25g 1”, 1 1/2”* O2 sat probe Glucometer O2 tubing* O2 masks, peds to adult* O2 supply* Oral airways, nasal trumpets* Bag valve mask*

*essential


Build the Box- Equipment

OPTIONAL (depends on practice risk assessment):

ETT sizes 4.5-8.0 Laryngoscope handle and blades 2-4 MacIntosh McGill forceps AED Interosseous needles IV tubing, IV needles (24-16g), Normal saline

Build the Box- Equipment

OPTIONAL (depends on practice risk assessment):

ETT sizes 4.5-8.0 Laryngoscope handle and blades 2-4 MacIntosh McGill forceps AED Interosseous needles IV tubing, IV needles (24-16g), Normal saline


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

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

Preparing for Office emergencies Build (or buy) the Box

www.stores.criticalcaresolutionsstore.comApprox $600 U.S.

http://www.stores.criticalcaresolutionsstore.com/

http://www.stores.criticalcaresolutionsstore.com/


SUMMARY:1. It will happen2. Be ready:

1. Assess your practice 2. Office staff should have clear

responsibilities3. Have an emergency response kit that is

up to date and readily available

SUMMARY:1. It will happen2. Be ready:

1. Assess your practice 2. Office staff should have clear

responsibilities3. Have an emergency response kit that is

up to date and readily available

Prepared for Office emergenciesPrepared for Office emergencies

Questions/Discussion

Questions/Discussion

Preparing for Office Emergencies OCFP Scientific Meetings November 29, 2013 L. Malo MD, CCFP(EM),...

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