Common office emergencies

The remainder of this chapter highlights typical emergencies seen in an ambulatory care practice or in telephone triage situations.

EMERGENCY SITUATION	SCREENING QUESTIONS
Syncope	Was the patient injured? Does the patient have a history of heart disease, seizures, or diabetes?
Animal bites	What kind of animal (pet or wild)? How severe is the injury? Where are the bites? When did the bites occur?
Insect bites and stings	Does the patient have a history of an anaphylactic reaction to insect stings? Does the patient have any of these: difficulty breathing, a widespread rash, or trouble swallowing?
Asthma	Does the patient show signs of cyanosis? Has the patient used prescribed inhalers?
Burns	Where are the burns located, and what caused them? Are signs of shock present—moist, clammy skin; altered consciousness; and rapid breathing and pulse? If the burn is more than 2 days old, are signs of infection present—foul odor, cloudy drainage?
Wounds	Is the bleeding steady or pulsating? How and when did the injury occur? Does the patient have any bleeding disorders, or is the patient taking anticoagulant drugs? Is the wound open and deep?
Head injury	Did the patient pass out or have a seizure? Is the patient confused or vomiting? Is a clear fluid draining from the nose or ears? If the answer is yes to any of these questions; activate EMS.

Fainting (syncope)

Fainting, or syncope, is a common emergency. It usually is caused by a transient loss of blood flow to the brain (e.g., a sudden drop in blood pressure), which results in a temporary loss of consciousness. It can occur without warning, or the patient may appear pale; may feel cold, weak, dizzy, or nauseated; and may have numbness of the extremities before the incident. The greatest danger to the patient is an injury from falling during the attack. Therefore, if a patient has syncopal symptoms, immediately place the individual in a supine position. Loosen all tight clothing and maintain an open airway. Apply a cold washcloth to the forehead. Measure and record the patient’s pulse, respiratory rate, and blood pressure, and report the findings to the provider. Keep the patient in a supine position for at least 10 minutes after the person regains consciousness. A complete patient history can help determine the possible causes of the attack (e.g., a history of heart disease or diabetes). Document the details of the episode and how long it took the patient to recover completely.

If the patient does not recover quickly, the provider may activate EMS for transport to the hospital. Syncope might be a brief episode in the development of a serious underlying illness, such as an abnormal heart rhythm or shock, that could lead to sudden cardiac death.

Poisoning

Poisonings are considered medical emergencies and are the sixth leading cause of accidental pediatric death in the United States. Poisoning can occur by oral intake, absorption, inhalation, or injection. Over-the-counter (OTC) medications (e.g., acetaminophen); detergents and bleach; plants; cough and cold medicines; and vitamins cause most cases of poisoning seen in young children. Other typical household poisons include drain cleaner, turpentine, kerosene, furniture polish, and paint. Signs and symptoms of poisoning, which vary greatly, include burns on the hands and mouth, stains on the victim’s clothing, open bottles of medicines or chemicals, changes in skin color, nausea or stomach cramps, shallow breathing, convulsions, heavy perspiration, dizziness or drowsiness, and unconsciousness.

If you receive a phone call about a suspected poisoning, tell the caller not to hang up and not to leave the victim unattended. Call the local poison control center and forward all directions to the caller. Syrup of ipecac has been recommended in the past for home use when a child ingests a poisonous substance, but the American Academy of Pediatrics now recommends that syrup of ipecac not be kept in the home. There are several reasons for this decision:

• Ipecac should not be given if the child swallowed chemicals that cause burns on contact because the substance can burn the gastrointestinal tract again when it is vomited.
• People with eating disorders often use ipecac to make themselves throw up.
• Ipecac may make it difficult to keep down other drugs that are needed to treat the poison.

If parents believe a child has ingested a poisonous substance, they should call the national poison control center at 1-800-222-1222, or call 911. (Always remember, though, that the best treatment is prevention; parents should be reminded to keep poisonous substances out of sight and out of reach of children). If the patient is to be seen by the provider or sent to the hospital, tell the caller to bring the container of poison or a sample of the vomitus so that the chemical contents of the substance can be verified.

What to ask when a poisoning is reported:

• Victim’s name, weight, and age
• Name of the poison taken and any information on the label
• How much was taken
• How long ago the poison was ingested
• Whether vomiting has occurred
• Whether the person has any pertinent symptoms, such as difficulty breathing or an altered state of consciousness
• Whether any first aid has been given, and if so, what

Animal bites

Possible complications from animal bites include rabies, tetanus, and local skin infection. Any animal bite that is extensive or deep should be seen by a provider. Human infection with rabies is rare; however, if the bite is made by a domestic animal, the animal should be kept quarantined and under observation for 10 days to be monitored for signs of the disease. The animal should not be killed, because a positive finding of rabies is almost impossible to make if the animal has been dead for an extended time. If the bite is made by a bat, raccoon, or any other wild animal, the animal is assumed to be rabid, and the patient must undergo a series of rabies vaccine injections. Local skin infection can be prevented by immediately cleansing the area with antimicrobial soap and water. If the bite breaks the skin (including human bites), the patient’s tetanus immunization status must be checked and, if needed, a booster or the entire four-dose tetanus series must be administered as indicated.

Insect bites and stings

The bite or sting of an insect can be irritating and painful because of the chemical toxin injected by the insect, but it usually is not serious. Typical symptoms—inflammation, itching (pruritus), and edema—are local and are confined to the area of the bite. In rare cases, a severe allergic reaction may occur; this is a potentially dangerous situation that can lead to anaphylaxis. Signs and symptoms of a systemic allergic reaction include a dry cough, a feeling of tightening in the throat or chest, swelling or itching around the eyes, widespread hives (urticaria), wheezing, dyspnea, and hypotension. Difficulty talking is a sign of urticaria or edema in the throat and may indicate the onset of complete airway obstruction. This is a sign of a true emergency. Epinephrine and oxygen should be ready for immediate administration on the provider’s orders. Antihistamines and corticosteroids may be used, but these agents act considerably slower than epinephrine. If acute anaphylactic shock develops, death may occur within 1 hour without medical intervention.

If the stinger is still lodged in the skin, scrape it off with a dull knife, a credit card, or a fingernail. Be careful not to squeeze the stinger, because this injects more venom into the skin. Apply an ice bag to the site to relieve pain and slow absorption of venom. Calamine lotion or hydrocortisone cream may be applied to relieve itching. If the patient has a history of allergies, especially to insect venom, he or she should have access to an EpiPen injection system; this should be used immediately after the sting. In this case, the patient should be transported to the nearest hospital for immediate care.

Removal of a tick

Ticks can cause a number of diseases, including Rocky Mountain spotted fever and Lyme disease. The tick embeds its head into the skin to obtain blood, and it should be removed intact by the following method:

1. Do not handle ticks with uncovered fingers; use tweezers to prevent personal contamination.
2. Place the tips of the tweezers as close as possible to the area where the tick has entered the skin.
3. With a slow, steady motion, pull the tick away from the skin. Try not to squeeze or crush the tick. If the tick’s entire body is not removed, make an appointment with a provider to have the site evaluated.
4. After removal, place the tick directly into a sealable container. Disinfect the area around the bite site using standard procedures.
5. If the tick is removed at home, the provider may suggest that it be brought to the office to be tested for disease.

Asthma attacks

Asthma is characterized by expiratory wheezing, coughing, a feeling of tightness in the chest, and shortness of breath. During an asthma attack, two different physiologic responses occur. The lining of the respiratory tract becomes inflamed and edematous and produces mucus, which results in narrowing of the air passages. At the same time, bronchospasms occur, which also constrict the airways. The quality and severity of attacks vary greatly among patients, and treatment must be individualized to minimize or eliminate chronic 309 symptoms. If the patient is prescribed a bronchodilator inhaler, it should be used at the first indication of symptoms. Depending on the severity of the attack, give the patient an appointment for the same day as the call, or consult the provider. The provider may recommend that the patient go directly to the ED for emergency respiratory care.

Seizures

Seizures may be idiopathic, or they may result from trauma, injury, or metabolic alterations, such as hypoglycemia or hypocalcemia. A febrile seizure is transient and occurs with a rapid rise in body temperature over 101.8° F (38.8° C). Febrile seizures typically occur in children between 6 months and 5 years of age. Many different types of seizures occur, but all are caused by a disruption in the electrical activity of the brain.

If a patient suffers a grand mal seizure, which involves uncontrolled muscular contractions, the most important point is to protect the patient from possible injury. Clear everything away from the patient that could cause accidental injury, and observe him or her until the seizure ends. Do not place anything into the person’s mouth, because it may damage the teeth or tongue and force the tongue back over the trachea. Do not hold the patient down, because this may result in muscle injuries or fractures. If unconsciousness persists after the seizure has subsided, place the patient in the recovery position to maintain an open airway and allow drainage of excess saliva. After the seizure is over, let the patient rest or sleep, but never leave the person alone. If the provider is not in the office, check the office policies and pro­cedures manual to determine how to manage the situation.

Call 911 for emergency assistance in any of the following situations:

• The patient does not regain consciousness within 10 to 15 minutes.
• The seizure does not stop within a few minutes.
• The patient begins a second seizure immediately after the first one.
• The patient is pregnant.
• Signs of head trauma are present.
• The patient is known to have diabetes.
• The seizure was triggered by a high fever in a child.