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When Patients Have Medical Emergencies In Podiatry Practices

Saleena Niehaus DPM

01/15/2016

As podiatrists, we see and treat a wide variety of patients with complex medical histories on a daily basis. When medical emergencies within the clinical setting threaten the life of patients, this challenges healthcare professionals to provide expeditious and satisfactory treatment. Prompt recognition and execution of an emergency management plan are keys to a positive outcome.¹

The first step to preparedness is familiarity with a patient’s past and current medical and surgical history.¹ In the office setting, management may be limited to supporting vital functions until an emergency medical service team arrives. At a minimum, one should perform basic life support and vital sign monitoring.

A number of first aid and emergency kits exist on the market. Many of these contain the vital medications and devices — such as glucose tablets, a glucagon injector, nitroglycerin and epinephrine — necessary to administer in an emergency situation. It is important to review these kits on a regular basis to ensure they have not expired.

Treating An Anaphylactic Reaction

Anaphylaxis is a rapid-onset, severe, life-threatening, generalized or systemic allergic or hypersensitivity reaction.^2,3 One diagnoses anaphylaxis primarily based upon clinical signs and symptoms.³ These may include but are not limited to generalized hives, itching, flushing, swollen lips or tongues, periorbital edema, nasal discharge or congestions, sensation of throat closure, shortness of breath, stridor, coughing or wheezing. Additional gastrointestinal and cardiovascular symptoms may include nausea, vomiting, diarrhea, syncope, dizziness and hypotension.³ It is difficult to predict the course and severity of anaphylaxis. Symptoms may be limited to the skin and mucosa, or may rapidly progress to airway obstruction and cardiovascular collapse.³

The treatment of anaphylaxis should begin with removal of the inciting agent or discontinuing the causative medication. Any food or drug may cause an anaphylactic reaction.² The most common medications to cause anaphylaxis include antibiotics, muscle relaxants and non-steroidal anti-inflammatory drugs (NSAIDs).² If indicated, such as with cardiovascular or respiratory collapse, begin the steps of basic life support and cardiopulmonary resuscitation (CPR) while waiting for EMS to arrive.³

Epinephrine is the most important drug for the treatment of anaphylaxis.² It acts as a suppressor of histamine and leukotriene release, reduces edema, dilates the airways, and increases the force of myocardial contraction.² One may perform an intramuscular injection of epinephrine in the thigh over the vastus lateralis muscle.³ The epinephrine dilution for an intramuscular injection is 1 mg per mL (1:1000). The recommended single dose of this dilution in adults is 0.3-0.5 mg.³

In mild allergic reactions without symptoms of cardiac or pulmonary involvement, an antihistamine can be a first-line treatment. Physicians commonly use diphenhydramine (Benadryl) with adult dosing of 25-50 mg PO q4-6 h until symptoms subside. The maximum daily dose is 300 mg.³

How To Address Vasovagal Syncope

Vasovagal syncope occurs when a neural reflex results in systemic hypotension, bradycardia and/or peripheral vasodilation.⁴ Associated symptoms include nausea, vomiting, pallor, diaphoresis, bradycardia, hypotension, loss of consciousness, and feelings of anxiety or doom. Vasovagal syncope is the most common cause of syncope and is usually self-limiting. In the podiatric office setting, this reaction often occurs before, during or after injection therapy, and any painful stimuli may elicit it.

Initial treatment includes removing the noxious stimulus and placing the patient in the supine position with the legs elevated.⁴ Again, this response is typically self-limiting and patients will begin to feel better after several minutes. Further supportive treatment may include dimming the treatment room lights, offering a cool compress or wet towel to place across the eyes, and/or offering a glass of water.

When Patients Hyperventilate In Your Practice

Similar to the vasovagal syncope response, injection therapy or other noxious stimuli may precipitate hyperventilation syndrome. Hyperventilation syndrome is a condition in which there is an increase in ventilation beyond normal, metabolic needs.5 It is often associated with an underlying panic attack or anxiety disorder. Symptoms of hyperventilation include dyspnea, light-headedness, chest pain, palpitations, diaphoresis and feelings of anxiety or impending doom.

If your patients begin hyperventilating, first try to reassure and calm the patient.5 Usually, the attack is self-limiting and symptoms subside once the patient is more relaxed. If any noxious stimulus is present, remove it. Apply a pulse oximeter to monitor the patient’s oxygen status. Having the patient breathe into a paper bag to normalize carbon dioxide levels may be done only while the clinician is monitoring for hypoxia.⁵

Current Insights On Treating Hypoglycemia

Hypoglycemia is a common problem of insulin-dependent patients with diabetes. We can define hypoglycemia as abnormally low plasma glucose concentrations with or without symptoms.⁶ Consider a finger-stick blood glucose measurement of less than or equal to 70 mg/dL as hypoglycemia in patients with diabetes.6 Signs and symptoms of hypoglycemia include diaphoresis, pallor, tachycardia, weakness, fatigue, confusion, behavioral changes, seizures and loss of consciousness.⁷

When one suspects hypoglycemia, obtain a finger-stick plasma glucose reading. If there is any concern or doubt, repeat this test to confirm the reading. When a patient is exhibiting symptoms of hypoglycemia but is conscious, administer a fast-acting carbohydrate immediately. Fast-acting carbohydrates must be readily available in the podiatric office. These may include glucose gels or tablets, sweetened fruit juice, soda pop (non-diet) or candy. One can confirm the blood glucose level again through finger-stick monitoring as well as appreciating a decrease in the patient’s symptoms.⁸

If a patient loses consciousness, follow the steps of basic life support and CPR accordingly while awaiting EMS. Obtain a finger-stick blood glucose level. After confirming hypoglycemia, one may administer a subcutaneous or intramuscular injection of 0.5 to 1.0 mg of glucagon to the buttock, the arm or the thigh.^7,8 Typically, patients regain consciousness within 10 to 15 minutes after glucagon injection.^7,8

When Patients Present With Chest Pain

There are many cardiac and non-cardiac causes of chest pain. An acute myocardial infarct or angina pectoris are common cardiac causes of chest pain.¹ Patients experiencing either cause may describe feelings of tightness in the chest, squeezing, pressure and/or pain that radiates down the left arm or back, or radiates up into the neck and jaw. They often describe the pain as severe and sharp in nature.

Alert an EMS team for any patient with chest pain of cardiovascular origin. While waiting the team’s arrival, monitor vital signs. If the patient remains conscious, give him or her 0.4 mg of sublingual nitroglycerin as well as 325 mg of aspirin.¹

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