Systemic Emergencies
Systemic Emergencies in an Office-Based Practice
Nicky R. Holdeman
Most of the problems encountered by an eye care provider are not life threatening, but many conditions can become serious if not identified early and managed appropriately. Eye care providers need to be aware that over the course of one’s career, offices or ASCs are going to be the scene of at least a few emergencies. Therefore, every health care practitioner should be prepared to properly oversee various office emergencies until professional help arrives (i.e., manage iatrogenic complications, initiate resuscitative efforts, stabilize the patient, and make prompt referrals). In addition, one should be able to assess, in most cases, whether a person is experiencing a true emergency, thus summoning EMS appropriately.
The more one can do to reduce the potential for accidents and emergencies, the less chance a patient will be injured, and the less chance the practitioner will be subject to litigation. Dealing successfully with a patient emergency requires preparation, training, and teamwork. Emergency preparedness will vary depending on the type of practice, the transport time to an emergency facility, the types of medications used, and the types of procedures performed. However, there are basic steps each office should take to prepare for emergencies. These steps include the following:
Posting current, emergency numbers in various locations throughout the office
Keeping a first aid kit and other medical supplies readily available
Learning and practicing first aid and CPR—basic life support with automated external defibrillator (AED) training or advanced cardiac life support (ACLS)
Preparing and rehearsing emergency procedures with the office staff
Ensuring that the office address numbers are posted and easy to read for emergency personnel
Note: The best way to reduce the risk of an emergency in a private office is to know the patient’s medical background. The doctor should establish a complete baseline history on all new patients and update the record on all return patients. A comprehensive history should incorporate the patient’s current medications (including nonprescription drugs, vitamins, dietary supplements, home remedies, and medications not prescribed to the patient), allergies (medications and/or environmental agents), past and current medical conditions, previous surgeries/hospitalizations, and family history. Patients who are most likely to have complications are the elderly, those with advanced comorbid conditions, those taking multiple medications, and those with a history of previous complications. Most would agree that a general eye care provider serves a patient base that is heavily populated with seniors, diabetics, and individuals with vision impairments. Recognizing and recording
any predisposing history may help to avoid problems or help to recognize them early should problems occur.
any predisposing history may help to avoid problems or help to recognize them early should problems occur.
In an office setting, anyone who interacts with patients should have basic CPR training for infants, children, and adults. Doctors should consider being certified in ACLS and should certainly be trained in the use of a defibrillator and in the administration of oxygen and epinephrine.
EQUIPMENT
A standard first aid kit will typically contain an antiseptic ointment, small bandages, scissors, tweezers, Band-Aids, gauze pads, and adhesive tape. In addition, one may consider equipping the office with the following:
O2 (E-size portable cylinder) with a low flow regulator
Pocket face mask with one way valve
Nasal cannula
Ambu bag or bag-valve mask with an O2 reservoir
Oropharyngeal airways
Examination gloves
Stainless steel basins
Stethoscope
Sphygmomanometer with several size cuffs
Cold/hot packs
Thermometer
Glucometer
4×4 pads
Skin cleanser (Hibiclens, Betadine)
Syringes (I.M. 3 cc disposable; S.C. tuberculin)
Tourniquets
AED
Given below is a Web site from a large ophthalmic insurer with emergency equipment requirements for coverage: http://www.omic.com/products/bus_products/downloads/OSF%20requirements.rtf
OFFICE EMERGENCY DRUGS
Protocols should be established for common office emergencies, especially those resulting from iatrogenic complications of medications and procedures. Recognition and prompt action lead to appropriate management. Several in-office drugs should be readily available, assuming the proper level of training. These medications include
Ammonia capsules
Glucose tablets/paste
Aspirin
Bulk saline
Epinephrine preloaded syringe (AnaKit/EpiPen)
Albuterol
Dexamethasone, hydrocortisone, or methylprednisolone
Diazepam
Diphenhydramine
Glucagon
Nitroglycerin
Oxygen
In general, emergencies should be sent immediately, by the best means possible, to a qualified acute care facility. Occasionally, it is unclear whether a patient requires an EMS unit or whether they can be referred to a physician’s office for further management. Some general guidelines to consider would be calling for an ambulance if the victim
Is unconscious, confused, or seems to be losing consciousness
Has abnormal vital signs
Has trouble breathing or is breathing in a strange way
Has chest pain or pressure
Has pressure or pain in the abdomen that does not go away
Has seizures, severe headache, or slurred speech
Appears to have been poisoned
Has injuries to the head, neck, or spine
Has severe bleeding
Has the possibility of broken bones
Has paralysis or inability to move
When summoning Emergency Medical Services (EMS), it is important to follow several basic rules. Each caller should
Identify themselves
Supply necessary information to the dispatcher, such as
The exact address where the victim is located
The telephone number at the scene of the incident
What happened to the victim
The person(s) involved
The condition of the victim
The care being given
Any special instructions for the drivers
Hang up last, allowing the dispatcher to hang up first
Return to offer further assistance
Lastly, it is usually helpful (and courteous) to the EMS and the receiving facility to have a copy of any relevant medical information and examination findings from the referring practitioner. However, copying records should never delay prompt transport of an emergent patient.
For additional information: www. acep.org, American College of Emergency Physicians
Hypoglycemia
Nicky R. Holdeman
ICD-9: 251.2
THE DISEASE
Pathophysiology
Hypoglycemia is a condition in which glucose is moving out of the bloodstream and into cells more rapidly than it is being produced. Since glucose normally furnishes 98% to 100% of the brains’ energy needs, hypoglycemia may result in permanent brain damage or death if emergency care is not provided immediately.
“Clinical hypoglycemia” is described as low blood glucose along with the symptoms and signs consistent with hypoglycemia. While the classic definition of hypoglycemia is a plasma glucose concentration of ≤70 mg/dL, the actual modicum of glucose needed to maintain the brain cells is poorly defined and will vary among different individuals.
Etiology
Hypoglycemia may occur for many reasons (Table 14-1). Most commonly, hypoglycemia results from oral hypoglycemic agents or a relative excess of exogenous insulin in insulin-treated diabetic patients. As intensive (or tight control) therapy increases in order to reduce the well-known complications of diabetes mellitus (DM), the incidence of both mild and severe hypoglycemia (i.e., blood glucose <30 to 35 mg/dL) will also increase.
Less common causes of hypoglycemia include inanition, accidental, and/or malicious acts to induce low glucose levels.
The Patient
Clinical Symptoms
Headache
Hunger
Shakiness
Visual disturbances (blurred vision, diplopia)
Tingling and numbness in the extremities
Dizziness
Profuse sweating
Speech difficulties
Difficulty concentrating, confusion
Pounding heart (palpitations)
TABLE 14-1 Causes of Hypoglycemia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Clinical Signs
Hypotension
Tachycardia
Full and bounding pulse
Diaphoresis (cold and clammy)
Pale skin coloration (pallor)
Tremors
Incoordination
Muscle weakness or paralysis
Dilated pupils
Anxiety, nervousness, combativeness, or irritability
Disorientation, confusion, or changes in personality
Convulsions, syncope, and/or coma in late stages
Note: In insulin-treated diabetics, it may be difficult to distinguish patients in ketotic hyperglycemia from those with severe hypoglycemia. In contradistinction to severe hyperglycemia, patients with severe hypoglycemia will have no unusual odor on the breath, will manifest normal or depressed respirations, and will appear adequately hydrated. However, if in doubt, administer glucose to the patient in these situations.
Significant History
Since the majority of cases of hypoglycemia result from the effects of exogenous insulin or oral hypoglycemic agents, diabetics should be carefully questioned. The clinician should ask the following:
Have you eaten today? If so, did you eat less than your doctor recommended?
Have you taken your insulin today?
Have you taken your insulin and skipped a meal?
Have you vomited a meal after taking your insulin?
Has your diabetes medication(s) or your insulin dosage recently been increased?
Have you recently worked or exercised strenuously?
Do you vary the sites of insulin injection?
Is there a history of infection?
Since drugs other than insulin and conditions besides diabetes may also cause or contribute to clinical hypoglycemia, patients should be questioned regarding the following:
Renal failure
Hepatic disease
Pancreatic tumors (B-cell tumors)
Excessive ethanol intake
Aspirin overdose
Use of β-blockers, pentamidine, or disopyramide
Demographics
The signs and symptoms of hypoglycemia manifest at varying levels among different individuals. Hypoglycemia is much less common among insulin-treated Type 2 diabetic patients than among Type 1 patients. Insulin shock may occur more often in children because of their broadly varied activity and diet.
Ancillary Tests
Determine the patient’s blood glucose by in-office glucometer. The patient should be referred to their primary physician for further evaluation. The physician will differentiate whether the patient has reactive hypoglycemia (e.g., early DM, idiopathic, etc.) or fasting hypoglycemia (e.g., insulinoma, extrapancreatic neoplasms, hepatic or renal failure, insulin reactions, adverse side effects of various medications, ethanol abuse, etc.). Testing to detect or exclude these conditions will be performed as deemed appropriate.
The Treatment
The definitive treatment of hypoglycemia will be determined by identifying the specific underlying disease. However, in-office care may include the following procedures.
If the patient is conscious (mild hypoglycemia), place him or her in a semi-reclining position and give him or her about 15 g of rapidly acting carbohydrates (i.e., commercially repared glucose paste or three glucose tablets). If commercial glucose is not available, 4 oz of juice, a sugar-containing soft drink, corn syrup, honey, jelly, sugar cubes, or hard candy will help to increase the glucose level. It is, however, important not to over treat as there is a risk of inducing a swinging cycle of high and low blood glucose levels.
The goal is to raise the patient’s blood glucose to a minimum level of 70 to 80 mg/dL. It takes about 15 minutes for the carbohydrates to be digested and to enter the blood stream as glucose. After giving the 15 g of rapidly acting carbohydrates, recheck the blood glucose level in 15 minutes (the rule of 15’s). Once the blood glucose level is normalized, provide a small snack containing carbohydrates, fat, and protein to maintain the appropriate blood glucose concentration. Gels or liquids should never be forced into the mouth of an unarousable patient due to the risk of aspiration.
If the patient is unconscious or seizing and cannot swallow (severe hypoglycemia), make sure that there is an adequate airway and administer oxygen if available. If properly trained, the patient should have an indwelling catheter placed in a large vein (e.g., brachial vein) and given 50% dextrose in water, 50 mL at 10 mL/min. Most patients regain consciousness within 5 to 10 minutes.
If an IV is not available or cannot be established, patients more than 10 years of age should be given 1.0 mg of glucagon injected IM or SC in the deltoid or anterior thigh. If the patient is a child, 0.5 mg of glucagon should be administered. Glucagon kits are available by prescription and glucagon can be quickly reconstituted in the office.
Oral gel glucose (Glutose 15) may be applied for oral mucosal absorption as long as it does not obstruct the airway.
Activate EMS and transport immediately to the hospital, even if the patient seems to be completely recovered. Patients with hypoglycemia secondary to oral hypoglycemic agents should be monitored for 24 to 48 hours since hypoglycemia may recur.
Note: A diabetic patient who has a sudden change in mental function or level of consciousness is more likely to be hypoglycemic than hyperglycemic. Consequently, if the patient is a known or suspected diabetic, and insulin shock cannot be excluded, when in doubt, give glucose!
Choking/Airway Obstruction
Nicky R. Holdeman
ICD-9: 934.9
THE DISEASE
