Download Preparing for a Phlebologic Emergency

Emergency Protocols
For The Office
Robert Cushing, MD, FACPh
Carmel, California
I have no disclosures relative to
this presentation
Photo Courtesy of Joann Dost Golf
Negligence (law) – “failure to
use reasonable care, resulting
in damage or injury to
another”
“Primun Non Nocere”
Above all, do no harm
“Be Prepared” – motto of the
Boy Scouts of America
“An ounce of Prevention is worth
a Pound of cure”
Benjamin Franklin, 1735
The Physician is responsible for
preparing the patient for, looking
after their well being during,
minimizing the potential for
complication or risk of, and, being
trained to provide appropriate initial
care if a complication occurs during,
a procedure.
Protect
- These are essentially elective procedures
which are promoted by the physician
desired by the patient, and, are for profit
- Improved physician reimbursement and
patient convenience if office-based
- There are more procedural safeguards
in operating room or surgi-center settings
- Even though minimally invasive, they
entail a degree of anxiety and/or pain
- Treatments entail some degree of
cardio- or vaso-active drug
administration
- Incidence of vein disease increases with
age – so does the probability of an
untoward event
Prevent
- Some adverse events are unpredictable
but most are, or should be, anticipated
and prepared for to minimize the
potential of precipitating such an event
- Can’t assume or rely on the fact that the
PMD has the patient properly managed
- Dialogue with the PMD often helpful to
clarify / uncover concomitant health
issues
Consider accomplishing an ER type
focused mini-H&P for the patient
Past History
Medications
Antabuse (alcohol in sclerosant)
Coumadin (phlebectomy?)
Allergies
Local anesthetics
Amide or ester
Epinephrine?
Habits
Alcohol usage – how much?
Substance abuse
Comorbidities
ASCVD, HT, hx MI, angina, CHF, TIAs,
hx CVA, PFO, arrhythmia, arrhythmia
equivalents (spells), unexplained
syncope, hx Holter monitoring, seizure
disorder, COPD, reactive airway
disease, sleep apnea, liver disease, hx of
VTE, thrombophilia, coagulopathy
Patient Idiosyncrasies
Motion sickness, needle phobia,
significant procedural anxiety, prior
adverse reaction to anesthesia
(local, regional, general)
Things To Have Considered
Use of epi in tumescent, tolerance of
recumbency, metabolism of meds,
sensitivity to meds (incl. pre-meds)
precipitation of vasovagal reaction,
increased sympathetic tone
(venospasm, tachyarrhythmia),
susceptibility to hypoventilation
(hypercapnea / hypoxia)
Physical exam
BP, O2 sat, cardiac rate/rhythm,
bruits, murmurs, lung sounds, neck
vein
distension, peripheral pulses,
edema, overt anxiety
Prepare
Office emergency plan
Written plans and protocols
In-services to enact plans
Drills in usage of equipment
Resuscitation protocols, cue cards,
and easily located and understood
references readily available
Resuscitation training
ABCs
Basic Life Support
Advanced Cardiac Life Support
To what extent for the physician?
To what extent for the staff ?
American Heart Association programs
Monitoring equipment
Pulse
Blood Pressure
O2 saturation
Cardiac rhythm
How much equipment is enough?
Resuscitation equipment
O2 mask
ambu-bag
suction/McGill forceps
laryngoscope/endotracheal tubes
automatic defibrillator
Again, how much is enough?
Self-assembled or repackaged?
Is equipment maintained?
Battery levels checked?
Resuscitation medications
Oxygen
Atropine
Benadryl (oral and IV / IM)
Epinephrine (IV / subq)
Lidocaine
Nitrogycerline (sublingual / paste)
Adenocard
Rescue inhaler
Fluids
Self assembled or pre-packaged?
Meds expired?
O2 tank full?
Prepackaged or self-assembled?
Know the capabilities of your local EMS
and general response time but …
do not rely on EMS to provide acute
intervention no matter how close-by!
Know about your local ER – how far
away?, contact number for assistance,
notification if transferring
Post Script
The Physician is the one in charge and
responsible for the patient’s well-being
especially during office based procedures
The Physician is the one charged with
initiating resuscitative measures
The Physician should not rely on EMS to
provide immediate initial care
Physicians must decide to what degree they
need to be able to respond to patient
emergencies, and then they need to be
prepared to do so. What is reasonable?
What is your comfort level of preparedness,
ethically, professionally, medically and
medico-legally.
References
American Heart Association – www.aha.org
Tarascon Publishing – www.tarascon.org
Circulation - circ.ahajournals.org
The 2015 American Heart Association’s
“Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care” (Nov 3,
2015, Vol 132, Issue 18, Supplement 2)
Thank you for your attention
Photo Courtesy of Joann Dost Golf