Emergencies in primary care - PowerPoint PPT Presentation

About This Presentation
Title:

Emergencies in primary care

Description:

This lecture is about 1. How often do Family Physicians deal with serious emergencies- (statistics) 2.What types of emergencies do they encounter- (diseases) 3.What interventions are used to manage them (management) 4. What training needs are identified by doctors in the area (education) – PowerPoint PPT presentation

Number of Views:857

less

Transcript and Presenter's Notes

Title: Emergencies in primary care


1
Emergencies in Primary Care
  • Dr Moien khan

2
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

3
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)

4
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)
5
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

6
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
7
  • 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.

8
  • 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? 

9
  • Unpreparedness
  • Emergency equipment and supplies
  • the practitioners' skills
  • the distance to the nearest emergency department.
  • Physicians Skills
  • Written emergency protocol
  • Unfavorable outcome.

10
  • 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.

11
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
12
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
13
Training
  • Emergency medicine experience
  • Resuscitation skills
  • Defibrillator
  • Care of acutely ill people

14
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

15
  • Resuscitation outcomes
  • Management of cardiac emergencies
  • Training and planning needs
  • Organizational issues
  • Training, preparation, ongoing support and audit
    in general practice.

16
  • 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.

17
(No Transcript)
18
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.
19
(No Transcript)
20
(No Transcript)
21
Emergency use of oxygen in pre-hospital and
hospital care
  • Pulse oximeter
  • Oxygen cylinder
  • Documentation
  • Monitoring
  • Handing over

22
Symptoms
  • Cvs chest pain , haemorrhage , shock
  • Respiraory wheeze , stridor, breatlesness
  • CNS convulsion , GCS , confusion, syncope
  • Mental health threatened self harm , delusional
    sate , violent patient

23
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

24
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

25
(No Transcript)
26
Resources
  • Use of emergency service
  • Logistics
  • Familiarization with own equipment
  • Maintenance of appropriate equipment

27
Prevention
  • Advise patients on prevention
  • Ischemic heart disease
  • Asthma

28
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

29
Practice management
  • Significant event
  • Near misses

30
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

31
  • Referral letters
  • Resuscitation equipment's
  • Drugs / medications

32
Drugs
  • Doctors bag

33
Resuscitation
  • Basic life support
  • Defibrillator

34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
Cardiovascular Emergencies
  • Mi and Undstable angina
  • Sinus Tachycardia
  • Paroxysmal SVT
  • Atrial Fibrillation
  • Atrial Flutter
  • Sinus Bradycardia
  • Av node block

38
Cardiovascular
  • Acute LVF
  • Mesenteric Limb Ischemia
  • Acute limb Ischemia
  • Malignant HTN
  • DVT

39
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.
40
Chest pain
  • MI
  • Unstable Angina
  • Pericarditis
  • Dissecting Thoracic Aneurysm
  • PE
  • Pleurisy
  • Pneumothorax
  • Oesophagitis
  • MSK
  • Shingles
  • costochondritis
  • Idiopathic

41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
Fitting patient
45
Collapsed patient
  • Sinus bradycardia
  • Av node block
  • Second and third degree heart block -Mortality
    35
  • Stokes Adam

46
Difficulty in breathing
47
Abdominal pain
48
(No Transcript)
49
(No Transcript)
50
Good Samaritan
51
Conclusion
  • Certainty
  • Preparedness Risk stratification
  • Specific patient population
  • Policies
  • Education and Training
  • Education of patients
  • Implementation
Write a Comment
User Comments (0)
About PowerShow.com