Emergencies in primary care

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Emergencies in Primary Care

• Dr Moien khan

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1.   Liddy, C., Dreise, H., Gaboury, I. (2009).
Frequency of in-office emergencies in primary
care. Canadian Family Physician, 55(10),
1004-1005. 2. HeathBWCoffeyJSMalonePCourtneyJPedi
atric office emergencies and emergency
preparedness in a small rural statePediatrics20001
06613916

• Adult patients (91.3) 1
• Average age (51.5 years) 1
• One child per week requiring hospitalization 2
• Cardiovascular, respiratory, and neurological
  (60) 1

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Liddy, C., Dreise, H., Gaboury, I. (2009).
Frequency of in-office emergencies in primary
care. Canadian Family Physician, 55(10),
1004-1005.

• Ischemic chest pain(74.3)
• Asthma, respiratory distress, obstruction, and
  inhalation injury(12.8)
• Neurologic complaints including stroke, syncope,
  and headache(12.7)

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Liddy, Clare, Heather Dreise, and Isabelle
Gaboury. "Frequency of in-office emergencies in
primary care." Canadian Family Physician 55, no.
10 (2009) 1004-1005.
BODY SYSTEM AFFECTED CALLS () MEAN AGE OF PATIENT, Y (SD)
Cardiovascular (ischemic pain, palpitations, CHF, cardiac medical, cardiac trauma, etc) 32.7 58.76 (14.89)
Other (general illness or weakness, other medical or trauma, infectious disease, hypothermia or exposure, near drowning, etc) 20.0 53.10 (21.57)
Respiratory (respiratory distress, respiratory disease, inhalation injury, obstruction or foreign body, etc) 12.8 49.49 (28.06)
CNS (post ictal, syncope, TIA, stroke, headache, psychiatric, behavioural, head trauma, etc) 12.7 46.45 (24.09)
Endocrine (local allergic reaction, anaphylaxis, diabetic emergency, etc) 7.1 33.49 (20.32)
GI (abdominal pain NYD, nausea, vomiting, etc) 6.6 48.93 (20.39)
MSK (back pain, paralysis or spinal trauma, chest wall pain) 4.1 48.53 (23.86)
Hematologic (major and minor hemorrhage, hypotension, etc) 1.6 58.17 (20.38)
Genitourinary (gynecologic emergency, obstetric emergency, etc) 1.5 36.48 (16.34)
Pharmacologic (poisoning or toxic exposure, alcohol  lt 0.1 36.62 (12.46)
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5.Johnston CL, Coulthard MG, Schluter PJ, Dick
ML. Medical emergencies in general practice in
south-east Queensland prevalence and practice
preparedness. Med J Aust. 200117599103. 6. Flo
res G, Weinstock DJ. The preparedness of
pediatricians for emergencies in the office. What
is broken, should we care, and how can we fix it
Published correction appears in Arch Pediatr
Adolesc Med 1996150592?. Arch Pediatr Adolesc
Med. 199615024956. 7. American Academy of
Pediatrics, Division of Child Health Research.
Periodic Survey No. 27. Emergency readiness of
pediatric offices. Elk Grove Village, Ill.
American Academy of Pediatrics, 1995

• Investigation ???
• Treatment pre-hospital management of convulsion
  , acute dyspnoea

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Liddy, Clare, Heather Dreise, and Isabelle
Gaboury. "Frequency of in-office emergencies in
primary care." Canadian Family Physician 55.10
(2009) 1004-1005.

• Seasonal variation in the primary complaint of
  emergencies presenting to community medical
  clinics

PRIMARY COMPLAINT WINTER (JAN-MAR), SPRING (APR-JUN), SUMMER (JUL-SEP), FALL (OCT-DEC),
Cardiovascular 26.7 26.6 22.7 24.0
Central nervous system 25.1 28.8 23.6 22.5
Respiratory 32.0 25.3 15.5 27.3
Gastrointestinal 21.0 29.0 26.0 24.0
Genitourinary 15.9 34.1 29.5 20.5
Musculoskeletal 28.8 21.6 22.4 27.2
Endocrine 20.1 30.4 29.4 20.1
Hematologic 35.4 16.7 27.1 20.8
Pharmacologic 34.5 10.3 20.7 34.5
Other 26.5 24.9 23.9 24.7
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• Family Physician calling ambulance - in
  preceding year (88)
• Family Physician managing Myocardial Infarction
  (84)
• Seizures, serious injuries, paediatric
  emergencies and hypoglycemia (50)
• Intravenous access in a medical emergency (69)
• Intravenous fluid administration (51)
• Intravenous morphine (54)
• Cardiopulmonary resuscitation (37)
• Defibrillation (21)
• Use of airway adjuncts (28)
• Use of advanced life support drugs in cardiac
  arrest (24)
• Bury, G., H. Prunty, M. Egan, and B. Sharpe.
  "Experience of pre-hospital emergency care among
  general practitioners in Ireland." Emergency
  Medicine Journal 25, no. 7 (2008) 450-454.

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• How often do Family Physician deal with serious
  emergencies?
• What types of emergencies do they encounter?
• What interventions are used to manage them?
• What training needs are identified by doctors in
  the area? 

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• Unpreparedness
• Emergency equipment and supplies
• the practitioners' skills
• the distance to the nearest emergency department.
  
• Physicians Skills
• Written emergency protocol
• Unfavorable outcome.

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• Emergencies can happen anywhere
• Not ideal in community
• Challenging and frightening
• Brief introduction for managing emergencies in
  the community
• Aside from rapid transfer to hospital, some
  interventions can be life-saving.

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Medications

• Acetaminophen (rectal suppositories)
• Albuterol (Proventil)
• Aspirin
• Ceftriaxone Corticosteroids, parenteral
• Dextrose 25
• Diazepam, parenteral (Valium)
• Diphenhydramine, oral and parenteral
• (Benadryl)
• epinephrine (11,000, 110,000)
• Flumazenil (Romazicon)
• Lorazepam, sublingual (Ativan)
• Morphine (MS Contin)
• Naloxone (narcan)
• Nitroglycerine spray
• Saline, normal

Toback S. Prepare your office for a medical
emergency. Contemp Pediat 200219107
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Equipments

• AED1
• Oxygen
• Pulse oxymeters
• Fletcher GF, Cantwell JD. Ventricular
  fibrillation in a medically supervised cardiac
  exercise program. Clinical, angiographic, and
  surgical correlations. JAMA. 197723826279.

Cost
Ease of use
Liability
Maintenance and upkeep
Safety
Testing
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Training

• Emergency medicine experience
• Resuscitation skills
• Defibrillator
• Care of acutely ill people

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Developing an Emergency Plan

• Emergency Protocol
• Skills of each employee
• Delegation and assignment of responsibility
  during resus
• Designated room
• Portable office equipment
• Algorithms
• Emergency Drill

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• Resuscitation outcomes
• Management of cardiac emergencies
• Training and planning needs
• Organizational issues
• Training, preparation, ongoing support and audit
  in general practice.

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• The initial oxygen therapy is a reservoir mask at
  15 l/min.
• Once stable, reduce the oxygen dose and aim for
  target saturation range of 9498
• c If oximetry is unavailable, continue to use a
  reservoir mask until definitive treatment is
  available.
• c Patients with COPD and other risk factors for
  hypercapnia who develop critical illness should
  have the same initial target saturations as
• other critically ill patients pending the results
  of blood gas measurements, after which these
  patients may need controlled oxygen therapy or
• supported ventilation if there is severe
  hypoxaemia and/or hypercapnia with respiratory
  acidosis.

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Sample Physician Office Emergency Protocol

STAFF ROLE
Front desk Identify patient in distress at check-in
Front desk Periodically assess waiting room for patients in distress
Front desk Alert waiting patients about potential delay
Medical assistants (runners) Situate ill patient in designated resuscitation room
Medical assistants (runners) Alert physicians and nurses of the emergency and the patient's location
Medical assistants (runners) Bring all emergency equipment to the site of the emergency (if not already in the treatment room)
Medical assistants (runners) Obtain initial set of vital signs
Medical assistants (runners) If oxygen saturation is less than 93 percent, start oxygen by face mask
Medical assistants (runners) Assist in code
Staff nurses Act as medication nurse or code nurse in resuscitation
Physicians Respond to call for assistance
Physicians One physician to act as code team leader
Physicians One physician to control airway
Physicians One physician to assist in resuscitation and/or act as float physician
Checkout desk When necessary, dial 9-1-1, give location and description of the emergency
Additional office staff Keep flow of patients moving out of office
Reference Toback S. Prepare your office for a medical emergency. Contemp Pediatr 200219113.
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Emergency use of oxygen in pre-hospital and
hospital care

• Pulse oximeter
• Oxygen cylinder
• Documentation
• Monitoring
• Handing over

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Symptoms

• Cvs chest pain , haemorrhage , shock
• Respiraory wheeze , stridor, breatlesness
• CNS convulsion , GCS , confusion, syncope
• Mental health threatened self harm , delusional
  sate , violent patient

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Common and important condition

• Shock low cardiac ouput , ACS ,, ischameia , PE
  , asthma
• Anaphylaxis after immunization , local anesthetic
  reaction , , vaso vagal attacks ,
• Suicide and parasuicide attempts
• Poisoning

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Emergency care

• ABC principles
• Appreciate response time required to optimize
  outcome
• Understand logistics and organsiational aspects
• Understand limitations and personal security and
  security to others

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Resources

• Use of emergency service
• Logistics
• Familiarization with own equipment
• Maintenance of appropriate equipment

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Prevention

• Advise patients on prevention
• Ischemic heart disease
• Asthma

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Dangerous Diagnosis

• Myocardial infarction
• PE
• Subarachnoid hemorrhage
• Appendicitis
• Limb ischemia
• Acute abdomen
• Meningitis
• Aneurysms
• Acute Psychosis / mania
• Ectopic pregnancy
• Retinal hemorrhage or problems that can lead to
  blindness

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Practice management

• Significant event
• Near misses

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Emergency patient encounters Telephone
consultation

• Staff , distressed callers, yourself
• Medico legal home visit
• Explanation to the patient
• In appropriate calls
• record history , examination time to educate the
  patient and carers about self management and
  use of emergency services

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• Referral letters
• Resuscitation equipment's
• Drugs / medications

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Drugs

• Doctors bag

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Resuscitation

• Basic life support
• Defibrillator

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Cardiovascular Emergencies

• Mi and Undstable angina
• Sinus Tachycardia
• Paroxysmal SVT
• Atrial Fibrillation
• Atrial Flutter
• Sinus Bradycardia
• Av node block

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Cardiovascular

• Acute LVF
• Mesenteric Limb Ischemia
• Acute limb Ischemia
• Malignant HTN
• DVT

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MI and unstable Angina

• Presentation
• Examination
• Investigation
• Action- Aspirin1
• Late calls

Théroux, P., Ouimet, H., McCans, J., Latour, J.
G., Joly, P., Lévy, G., ... Waters, D. D.
(1988). Aspirin, heparin, or both to treat acute
unstable angina.New England Journal of
Medicine, 319(17), 1105-1111.
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Chest pain

• MI
• Unstable Angina
• Pericarditis
• Dissecting Thoracic Aneurysm
• PE
• Pleurisy
• Pneumothorax
• Oesophagitis
• MSK
• Shingles
• costochondritis
• Idiopathic

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Fitting patient
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Collapsed patient

• Sinus bradycardia
• Av node block
• Second and third degree heart block -Mortality
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• Stokes Adam

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Difficulty in breathing
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Abdominal pain
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Good Samaritan
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Conclusion

• Certainty
• Preparedness Risk stratification
• Specific patient population
• Policies
• Education and Training
• Education of patients
• Implementation