Emergencies: Be prepared for inevitable

May 1, 2005

New Orleans — Whether it is serious intraoperative bleeding, the presence of a life-threatening disease or a lethal drug reaction, the dermatologist's office should be prepared for the emergent crisis that can happen at any time and anywhere, Glenn D. Goldman, M.D., says.

"Most importantly, you must have a plan. Even though most emergencies can be handled quickly, it is imperative that services like an EMS can respond within 10 to 15 minutes," according to Dr. Goldman, associate professor, dermatology, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, Vt.

"Our policy is that if we have a patient who is not stabilized, an EMS can respond within one minute. Overall, you must be prepared to deal with anything that can happen."

How to be prepared Surgical emergencies happen. The best way to prepare for them is by first having a complete surgical tray that can address whatever is presented, including small hemostats or mosquito clamps, 4.0 or 5.0 Vicryl suture for ligature and simple sterilized pipette tip for suction. Serious intraoperative bleeding most likely occurs when a large vessel, such as the temporal or angular artery, is lacerated by a scalpel, according to Dr. Goldman.

"To stop intraoperative bleeding, clamp the vessel where it is pumping, making certain to suction in order to visualize where to clamp," he tells Dermatology Times. "Of course, the best treatment is avoidance with preventative ligature prior to lacerating the vessel. You must be meticulous with hemostasis. If you can't stop the bleeding, it is usually because the vessel has retracted, keeping you from gaining access to it. Keep the pressure on the vessel and have your staff call EMS."

After-hour emergencies After-hour bleeding emergencies typically occur six hours to 10 days postoperatively. The presentation in an open wound is free, painless bleeding, while closed wounds are painful and swollen. Patients should be directed to apply pressure to open wounds until the dermatologist's examination, where electrocoagulation or ligature PRN is performed. Closed wounds should be seen immediately for evacuation of the hematoma.

While serious bleeding may be rare, intraoperative chest pain is not. Most commonly, angina develops from elevated blood pressure or is pulse-related to epinephrine or anxiety, according to Dr. Goldman. In the event of a serious event, he recommends considering the purchase of an automated defibrillator to be prepared.

"Chest pain is usually resolved with a few simple maneuvers, but it's important to remember that it may represent myocardial infarction," Dr. Goldman says. "To avoid any complications use a minimum of anesthesia containing epinephrine, and perform operations on patients with cardiac disease in the afternoon. If an episode occurs and does resolve, finish the procedure quickly, and always follow through with the patient's primary doctor to let them know of the episode and ask if the patient should be seen."

Rarer occurrences?

Although it may be inevitable that intraoperative bleeding or chest pain will occur at some time in a dermatology practice, life-threatening diseases caused by bacterial toxins are viewed as more rare in occurrence - or are they?

"Conditions such as Kawasaki disease and toxic shock syndrome are relatively rare, but they can often hide in the background of other symptoms," says Dr. Krusinski, professor and chairman of dermatology, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, Vt. "For the treatment of toxic shock syndrome (whether due to Staphylococcus aureus or streptococcus), clindamycin and IVIg are utilized. IVIg is still the treatment of choice for Kawasaki disease."