Managing acute emergencies in the cosmetic clinic

In the event of a medical emergency, does your clinic have a protocol in place? At COSMEDICON 2020 Dr Sean Arendse presented on the equipment, drugs and knowledge required to effectively manage lifethreatening emergencies.

Dr Sean Arendse, cosmetic physician and senior emergency physician at The Alfred Hospital in Melbourne, recently gave a practical and informative presentation at COSMEDICON 2020 on managing acute emergencies in the aesthetic practitioner’s clinic.

‘While aesthetics is a relatively low risk branch of medicine, we have a responsibility to our patients to ensure we have a clinic protocol in place in the unlikely event of a medical emergency,’ he says. ‘We must be able to immediately institute what can be simple but lifesaving interventions.’

Equipment

Every clinic should have a basic medical kit which contains a stethoscope, a 1L bag of normal saline, a volumatic spacer and a blood pressure machine. A more advanced kit would also include a bag valve mask, a selection of airway adjuncts (oropharyngeal, nasopharyngeal airways), an oxygen cylinder, a pulse oximeter, the ability to obtain IV access, a blood glucose monitor and an automated defibrillation device. It is worth the expense to have these basic items on hand.

Most common medical emergencies in the cosmetic practice

  • Anaphylaxis
  • Asthma
  • Cardiac emergencies
  • Epileptic seizures
  • Hypoglycaemia
  • Stroke
  • Syncope
  • Eye injuries
  • The choking child

Scenario: Anaphylaxis

Symptoms of mild to moderate anaphylaxis: include facial swelling hives and vomiting.

First aid: Call for help, use EpiPen

Symptoms of anaphylactic shock: difficult/noisy breathing, swelling of tongue and throat, difficulty talking and/or hoarse voice, persistent dizziness or collapse

First aid: Call for help, lay patient flat (consider elevation of legs), place in recovery position if indicated, administer EpiPen, repeat EpiPen if no response after 5 minutes, administer CPR if indicated.

Scenario: Asthma

Symptoms: Difficulty breathing, coughing, chest tightness, shortness of breath, wheezing.

First aid: Sit the patient upright, put 1 puff of salbutamol inhaler into spacer, have the patient take 4 breaths from spacer. Repeat 4 times. If no improvement after 4 minutes, repeat 4 puffs again. If still no improvement, call for help.

Scenario: Cardiac arrest

Symptoms: Chest pain, epigastric pain, arm pain, nausea, dizzy spells, palpitation, syncope, sweating, confusion.

First aid: Presume cardiac arrest if breathing absent; and highly likely cardiac arrest if breathing is inadequate. Start Basic Life Support (BLS) and immediately administer chest compressions and pulmonary ventilation. How to perform rescue breaths and chest compressions:

  • Place the heel of one hand in the lower half of the sternum
  • Place other hand on top
  • Interlock fingers
  • Compress the chest
  • Rate 100 min-1
  • Depth 4-5 cm
  • Equal compression: relaxation
  • When possible change CPR operator every 2 minutes

Remember: minutes count – when the heart stops, damage occurs to the brain within < 5 minutes. Basic life support BLS keeps the brain alive until an automated external defibrillator (AED) or help is available.

If CPR is started:

  • In first 4 minutes, brain damage is unlikely
  • 4 – 6 minutes, brain damage possible
  • 6 – 10 minutes, brain damage probable
  • > 10 minutes, severe brain damage certain

What’s new in Basic Life Support

  • CAB (Compressions-Airway-Breathing) is now the focus (perfusion)
  • Emphasis on maximising compressions
  • Ensuring chest compressions of adequate rate
  • Ensuring chest compressions of adequate depth
  • Allowing full chest recoil between compressions
  • Minimising interruptions in chest compressions
  • Avoiding excessive ventilation

Scenario Patient faints or has a seizure

First aid: Protect the patient, place patient in recovery position, protect the airway, check BP, check blood glucose, administer IV Fluids, stand them up slowly after regaining consciousness, keep the patient for 30 minutes to monitor, consider giving food and drink.

Life-threatening emergencies such as cardiac arrest or anaphylactic shock may be uncommon in the cosmetic clinic, however every practitioner has a responsibility to their patients to have a written emergency protocol for the most common scenarios. Initiating lifesaving treatment while you wait for the ambulance to arrive will save precious time – and possibly save a life. AMP


Drugs

All doctors have access to the PBS government-funded ‘Prescriber Bag’, where they can obtain for free an extensive list of emergency drugs. Eligible providers can order a Prescriber Bag Supply Order Book by completing a request form available online from Services Australia. Dr Arendse suggests each clinic stock at the very least: adrenaline, aspirin, glucagon, glyceryl trinitrate, midazolam and a short-acting beta agonist such as salbutamol.

Drug Indication Adult dose & route
Adrenaline Annaphylaxis 500μg (0.5ml 1:1000) IM. May be repeated at 5-minute intervals if no improvement
Aspirin Suspected heart attack 300mg oral (crushed or chewed)
Glucagon Hypoglycaemia (patient unable to swallow safely, eg unconscious) 1mg IM
Glucose (fast acting) Hypoglycaemia (patient cooperative 15-20g fast-acting glucose, eg 3-4 glucose and able to swallow safely) tablets, glass of orange juice or glucose gel
Glycerin Trinitrate Spray Angina or suspected heart attack 2 actuations sublingually
Midazolam Prolonged convulsive seizures Midazolam oromucosal solution can be given (≥ 5 minutes) or repeated seizures by the bucca route in adults as a single dose (≥3 in an hour) of 10mg (unlicensed)
Short-acting beta agonist (eg salbutamol) inhaler Asthma attack 2 actuations inhaled. Use spacer device if necessary. Repeated doses may be necessary

 

In association with Monash University, The Alfred Emergency and Trauma Center and the Dermatology Institute of Victoria, Dr Arendse has developed a course ‘Medical Emergencies in Cosmetic Practice, equipping cosmetic practice doctors and staff with the skills to implement potentially lifesaving interventions. His next course is 11 May, 2020. For information, visit cvent.me/0l8qXx