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

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
  

  1. The exact address where the victim is located

  
  

  2. The telephone number at the scene of the incident

  
  

  3. What happened to the victim

  
  

  4. The person(s) involved

  
  

  5. The condition of the victim

  
  

  6. The care being given

  
  

  7. 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.

• 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:

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.

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

Pathophysiology

The organs of the body require a continuous supply of oxygen in order to survive. Thus, an acute obstruction of the airway by foreign material poses a potential life-threatening emergency. Without a patent airway and adequate gas exchange, other resuscitative measures will usually not be successful. Respiration may be interrupted by either obstruction or compression.

Etiology

Choking is a common breathing emergency. Aspiration of any foreign material may cause asphyxia if the substance aspirated is large or the cough reflex is impaired. However, one of the most common obstructions of the upper airway is by food. This condition, often referred to as a “cafe coronary,” could easily occur in an office setting.

The Patient

The clinical presentation of a choking individual will depend on whether the airway is partially or completely blocked and on the site of obstruction. In general, one should look for the following symptoms or signs.

Clinical Symptoms

• Coughing, choking, gagging
  
• Wheezing
  
• Difficulty talking

Note: A partially blocked airway can become completely obstructed. A person whose airway is totally blocked cannot speak, cough forcefully, or breathe.

Clinical Signs

• Clutching the throat with one or both hands (the universal distress signal for choking)
  
• Tachypnea
  
• Labored breathing with inadequate movement of air
  
• Stridor
  
• Substernal notch retraction
  
• Agitation or lethargy
  
• Cyanosis
  
• Rapid pulse initially and then decreased pulse
  
• Respiratory arrest
  
• Cardiac arrest

Significant History

History of an aspiration event may be absent in 30% to 50% of patients. Lack of a positive history often delays diagnosis, so foreign bodies should be suspected, especially in children, as the airway is smaller. Aspiration of food is more likely to occur in the following patients:

Demographics

More than 3,000 deaths annually are due to choking. While most airway obstruction due to foreign bodies occurs between the ages of 1 and 5 years, more adults than children die each year because of choking.

Ancillary Tests

Lab testing per se is not indicated. Ultimately, the patient may have plain radiographic films, fluoroscopy, or bronchoscopy to assist in the diagnosis of airway obstruction. If a foreign body is not recovered, the patient should undergo radiological imaging for localization.

The Treatment

Management of foreign bodies in the airway is dictated by the location of the object and the age and condition of the patient.

If the choking person is coughing, do not interfere; the normal reflexes will often clear the airway. Allow the patient to assume a position that is comfortable and that facilitates respiration.

If there is total obstruction, abdominal thrusts/Heimlich maneuver should be attempted in patients ≥1 year of age. These maneuvers should be repeated until effective or until the patient becomes unresponsive.

In infants (<1 year of age), back blows and chest thrusts are recommended. Continue these maneuvers until the airway has cleared or the patient loses consciousness.

If the foreign body is visible, the airway may be cleared with a manual sweep in an unresponsive patient. Blind sweeps are not recommended.

If there is no success at clearing the airway and if the patient loses consciousness, EMS should be activated. In the meantime, place the patient in a supine position; tilt the head backward and continue to attempt to open the airway; check for respiratory sounds and ventilate if possible. Continue CPR until advanced life support arrives on the scene.

If these methods are unsuccessful, a surgical airway (access to the airway by tracheotomy) may be necessary.

Ultimately, the patient may require removal of the foreign body under general anesthesia with a laryngoscope or bronchoscope.

Syncope

Nicky R. Holdeman

ICD-9: 780.2

     THE DISEASE

Pathophysiology

Syncope, or fainting, is a sudden and transient loss of consciousness due to inadequate cerebral blood flow and oxygenation, followed by spontaneous recovery. Except for the risk of physical injury from falling, simple fainting itself is often not a major health concern. However, fainting can be a sign of a serious underlying disorder and must be distinguished from conditions such as epileptic seizures, transient ischemic attacks (TIAs), vertigo, hysteria, and hypoglycemia.

Etiology

An attempt to establish the etiology of syncope is important because the symptom is common and potentially fatal. While the list of possible causes is long and diverse, the major categories include the following:

The Patient

In general, syncope will be characterized by loss of consciousness, unresponsiveness, loss of postural tone, and spontaneous recovery. However, certain symptoms and signs will often manifest depending on the underlying cause. Since vasovagal episodes are the most common entity seen in outpatient facilities, the following descriptors pertain to this particular type of syncope.

Clinical Symptoms

Clinical symptoms include brief prodrome of warmth, nausea, anxiety, dizziness, light-headedness, weakness, sweating, salivation, and blurred vision. The prodrome usually lasts from 10 seconds to a few minutes.

Clinical Signs

Initially, tachycardia, diaphoresis, and pallor are seen. These signs are soon followed by bradycardia, decreased blood pressure, pupillary dilation, weak pulse, and transient loss of consciousness. Abnormal movements, which may mimic a seizure, are often noted, but urinary incontinence and tongue biting are rare.

Demographics

Vasovagal disorders are very common and occur in all age groups, affecting men and women equally.

Syncope, from all causes, accounts for about 1% to 6% of hospital admissions and about 3% of emergency room visits. Five to twenty percent of adults will have one or more episodes of syncope by age 75.

Significant History

The evaluation for syncope depends heavily on a careful history if the underlying cause is to be discovered. Witnesses to the event may provide additional insight. The clinician should obtain the following information:

Ancillary Tests

In addition to a careful history, a thorough physical examination and an ECG are important procedures in determining a diagnosis. Depending on the outcome of these standard procedures, a given patient may also require hematology testing and blood chemistries (e.g., CBC, electrolytes, glucose, toxicology), cardiac studies (e.g., transtelephonic ECG, echocardiogram, stress testing, electrophysiologic studies), neurologic investigations (e.g., EEG, CT, or MRI of the head), and/or psychiatric evaluation (e.g., exclude anxiety, depression, alcohol, and drug abuse).

Unfortunately, even after careful evaluation and testing, the cause of syncope will be determined in only 63% of patients.

The Treatment

Since syncopy itself is not a disease but can indicate a wide range of conditions and disorders, the ultimate treatment will be directed toward the underlying etiology. If no serious cause is found, the only interventions that may be necessary are avoiding situations that lead to fainting and protecting from an injury due to a fall.

In-office care should include the following:

Note: Vasovagal syncope has an excellent prognosis, and the risk of death is not increased by these events.