IS THERE A DOCTOR IN THE HOUSE?

Transcription

1 IS THERE A DOCTOR IN THE HOUSE? FAMILY MEDICINE WINTER REFRESHER COURSE FEBRUARY 4, 2016 Matthew Tews, DO, MS John Ray, MD Kathleen Williams, MD Bradley Burmeister, MD Angelo Perino, MD

2 Real Life... You witness a gentleman become unresponsive at the gym You are the first on the scene of a car accident You are on an airplane and the stewardess asks for a doctor There is an explosion nearby and you arrive on the scene before anyone else What do you do in all of these cases?

3 Objectives Describe an approach to an acutely ill or injured patient Discuss updates to basic life support Identify steps to take when arriving at the scene of a car accident Explain how you can best provide assistance to a patient on an airplane in flight Describe how to approach the scene of a disaster

4 APPROACHING THE ACUTELY ILL OR INJURED PATIENT Outside of the Healthcare Setting

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6 The Approach Stay Calm Stay Alert Stay Organized Remember Your Alphabet Stay Focused

7 Stay Calm Take a few seconds to collect yourself Encouraging points You DON T have to figure it all out You re goal is to identify potential problems and treat emergencies You DON T have to definitely manage every complaint Focus on identifying what needs to be done now You CAN and SHOULD get help call 911! The emergency response system is designed for this

8 Stay Alert Be aware of your surroundings Make sure the scene is safe! Two victims are worse than one Identify your resources Bystanders (CPR trained?) Is there a defibrillator available? First Aid kit? Medical Alert bracelets/necklaces?

9 Stay Organized Evaluate for life-threatening processes A: Airway Is it open? Are they moving air? Can they speak? Is it at risk for closing (stridor, muffled voice, throat swelling)? B: Breathing Wheezing? Equal breath sounds? C: Circulation Can you feel a pulse? Is it fast? Signs of good perfusion? D: Disability Are they alert? Do they response to pain? Are they moving limbs? E: Exposure Are they cold? Are the clothes wet?

10 Int J Gen Med 2012:

11 Stay Focused Focus on the problem Identify the patient has a breathing problem and go from there Think AMPLE: A: Allergies M: Medications P: Past History L: Last meal E: Events Get the individual into the healthcare system

12 PUBLIC MEDICAL EMERGENCIES Somebody get a doctor!

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14 Common Medical Emergencies What do you do in the case of: Anaphylaxis Seizure Overdose Hypoglycemia Stroke Myocardial infarction Cardiac arrest

15 Basic Life Support Principles Immediate recognition of cardiac arrest Activation of emergency response system Early CPR Rapid defibrillation with an AED

16 Adult BLS and CPR Updates The recommended sequence for a single rescuer has been confirmed: the single rescuer is to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C) to reduce delay to first compression. There is continued emphasis on the characteristics of highquality CPR: Compressing the chest at an adequate rate and depth Allowing complete chest recoil after each compression Minimizing interruptions in compressions Avoiding excessive ventilation The recommended chest compression rate is 100 to 120/min (updated from at least 100/min). The clarified recommendation for chest compression depth for adults is at least 2 inches (5 cm) but not greater than 2.4 inches (6 cm). Bystander-administered naloxone may be considered for suspected life-threatening opioid-associated emergencies AHA Guidelines Update

17 2015 AHA Guidelines Update

19 Pediatric BLS Updates Reaffirming the C-A-B sequence as the preferred sequence for pediatric CPR New algorithms for 1-rescuer and multiple-rescuer pediatric HCP CPR in the cell phone era Establishing an upper limit of 6 cm for chest compression depth in an adolescent Mirroring the adult BLS recommended chest compression rate of 100 to 120/min Strongly reaffirming that compressions and ventilation are needed for pediatric BLS 2015 AHA Guidelines Update

21 Opioid Overdose IM or IN naloxone Unresponsive, no breathing, + pulse Not cardiac arrest 2014 naloxone autoinjectors approved by USFDA for lay rescuers and HCP s MMWR Report, 6/2015 Increasing number of clinics and pharmacies providing kits to laypersons 2015 AHA Guidelines Update

22 EXERCISE #1 Public Medical Emergencies

23 CAR ACCIDENT SCENES You re a doctor - we need to pull over and help

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25 Initial Actions Call 911 Approach the scene carefully Be careful where you park Turn on hazards Watch for debris Turn off the ignition Tell the victim not to move don t move them Do not pull someone from a car wreck if they are not moving on their own Unless car is on fire or they are in immediate danger

26 Initial Actions If responsive, ask if they want assistance Protect the victim until help arrives Cover victim with blanket or coat Protect them from the elements Stabilize neck/spine Medical interventions If unresponsive, check your ABC s Only looking for life-threatening issues Compress bleeding

27 Traumatic Arrest What do MVC victims die from? Head injury Spinal cord injury Airway injury Chest injury Abdominal injury Blood loss at scene When should you start CPR? Survival rate in traumatic cardiac arrest is low Treat reversible causes What came first? Trauma or non-traumatic cardiac arrest? Resuscitation 84 (2013)

28 Liability Wisconsin's Good Samaritan statute for emergency medical care states the following: Any person who renders emergency care at the scene of any emergency or accident in good faith shall be immune from civil liability for his or her acts or omissions in rendering such emergency care. This immunity does not extend when employees trained in health care or health care professionals render emergency care for compensation and within the scope of their usual and customary employment or practice at a hospital or other institution equipped with hospital facilities, at the scene of any emergency or accident, enroute to a hospital or other institution equipped with hospital facilities or at a physician's office. WI Stat (2012 through Act 45)

29 Liability There are 3 requirements: 1) emergency care must be rendered at the scene of the emergency 2) the care rendered must be emergency care 3) any emergency care must be rendered in good faith. The phrase "emergency care" refers to the initial evaluation and immediate assistance, treatment, and intervention rendered to the plaintiff during the period before care could be transferred to professional medical personnel. Clayton v. American Family Mutual Insurance Company, 2007 WI App 228, 305 Wis. 2d 766, 741 N.W.2d 297, WI Stat (2012 through Act 45)

30 EXERCISE #2 Traumatic Emergencies

31 IN FLIGHT MEDICAL EMERGENCIES Is there a doctor on board?

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33 Background Estimated incidence of reported in-flight medical emergencies is about 1 per 604 flights 48.1% of cases involved on-board physician assistance

34 Common Emergencies Chest pain Syncope Asthma exacerbations GI complaints "economy class syndrome," A midair version of Virchow's triad: dehydration, immobilization, and predisposing factors increasing the risk of deep vein thrombosis.

35 On Board Resources FAA regulations require all U.S. commercial airlines weighing 7,500 pounds or more and serviced by at least one flight attendant to carry a defibrillator and enhanced emergency medical kit Flight attendants must be certified in CPR, including the use of an AED, every 2 years Pilots must also be trained in the use of the AED Enhanced Emergency Medical Kits

36 N Engl J Med 373;

37 Air Carrier Access Act of 1998 Limited protection and guidance for physicians and other medical professionals who volunteer their services during flight Must be "medically qualified," render care in good faith, and receive no monetary compensation to be protected under this Act

38 Air Carrier Access Act of 1998 An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct. There are no documented cases of a physician being sued for providing assistance during an in-flight emergency.

39 Disposition You don t determine the ultimate disposition Work in conjunction with the airline s medical team You can always contact the ground medical team 15,000 in-flight emergencies found that the aircraft was diverted in only 7% of the cases Ultimately the decision to divert the plane lies with the pilot and the airline It takes at minimum 25 minutes to get from maximum altitude to being on the ground

40 In-Flight Advice Introduce yourself to the cabin crew and state your qualifications. Ask the patient for his or her permission before performing a thorough history and physical exam. Use an interpreter if necessary. If the patient's condition is critical, request diversion to the nearest appropriate airport. Cooperate with a medical response center and coordinate with airport medical staff. Keep a written medical record of your patient encounter. Perform only treatments you are qualified to administer. N Engl J Med 373;

41 EXERCISE #3 In Flight Emergencies

42 BASIC DISASTER MEDICINE Is anybody a doctor?

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44 Approaching a Blast Disaster Be safe you don t know what else might happen First responders are trained to do this some more than others Don t try to be a hero Help those who need immediate assistance Wait for help to arrive

45 Blast Disaster Principles Types of blast injuries Primary from blast wave Secondary from projectiles Tertiary from being displaced Quaternary crush, burn, toxic exposure

46 Blast Disaster Principles Injuries to be concerned for: Lung Abdominal Ear sign of other injuries Amputation

47 Triaging Patients: Think SALT Sort-Assess-Lifesaving Interventions-Treatment and/or Transport The only system compliant with CDC recommendations Taught by NDLS and other national courses Endorsed by numerous Emergency Medicine and Trauma societies

48 SALT Triage Simple Easy to remember All Hazards and all types of patients Groups large numbers of patients together quickly Applies rapid life-saving interventions early SALT Slides Courtesy of E. Brooke Lerner, PhD

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50 Dead Patient is not breathing after opening airway In Children, consider giving two rescue breaths If still not breathing must tag as dead Tag dead patients to prevent re-triage Do not move Except to obtain access to live patients Avoid destruction of evidence If breathing conduct the next assessment

51 Immediate Photo Source: Public Domain Serious injuries Immediately life threatening problems High potential for survival Examples Tension pneumothorax Exposure to nerve agent Severe shortness of breath or seizures

52 Immediate No to any of the following C: Follows commands or makes purposeful movements? R: Not in respiratory distress? A: Hemorrhage is controlled? [controlled arterial bleeding] P: Has a peripheral pulse? Likely to survive given available resources

53 Expectant No to any of the following C: Follows commands or makes purposeful movements? R: Not in respiratory distress? A: Hemorrhage is controlled? [Uncontrolled arterial bleeding] P: Has a peripheral pulse? Unlikely to survive given available resources

54 Expectant DOES NOT MEAN DEAD! Important for preservation of resources Should receive comfort care or resuscitation when resources are available Serious injuries Very poor survivability even with maximal care in hospital or prehospital setting Examples 90% body surface area burn Multiple trauma with exposed brain matter

55 Delayed Examples Long bone fractures 40% BSA exposure to Mustard gas Serious injuries Require care but management can be delayed without increasing morbidity or mortality Photo Source: Phillip L. Coule, MD

56 Delayed Yes to all of the following C: Follows commands or makes purposeful movements? R: Not in respiratory distress? A: Hemorrhage is controlled? [Uncontrolled arterial bleeding] P: Has a peripheral pulse? Injuries are not Minor and require care

57 Minimal Yes to all of the following C: Follows commands or makes purposeful movements? R: Not in respiratory distress? A: Hemorrhage is controlled? [Uncontrolled arterial bleeding] P: Has a peripheral pulse? Injuries are Minor

58 Minimal Injuries require minor care or no care Examples Abrasions Minor lacerations Nerve agent exposure with mild runny nose Photo source: Phillip L. Coule, MD

59 After Patients are Categorized Prioritization process is dynamic Patient conditions change Correct misses Resources change

60 EXERCISE #4 Blast Disaster Emergencies

61 EXERCISE #5 Putting it all together

62 References Centers for Disease Control. Blast Injuries: Fact Sheets for Professionals. Available at: Injury-Fact-Sheet.pdf Highlights of the 2015 AHA Guidelines Update for CPR and ECC. Available at: Lockey DJ, et al. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation 84 (2013) Nable, et al. In-Flight Medical Emergencies during Commercial Travel. NEJM. 373; Peterson, et al. Outcomes of Medical Emergencies on Commercial Airline Flights. NEJM. 368; SALT Mass Casualty Triage. Disaster Medicine and Public Health Preparedness Thim T, et al. Initial Assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med 2012; 5: Wheeler E, et al. Opioid Overdose Prevention Programs Providing Naloxone to Laypersons United States, MMWR (23):