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Medical Emergencies in the Dental Office

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					Medical Emergencies in the
      Dental Office
             Tomas J. Barrios DDS
         Associate Clinical Professor of
          Oral & Maxillofacial Surgery,
     St. Josephs Regional Medical Center,
           Jersey City Medical Center
•   Prevention & Preparation
•   Syncope
•   Hypoglycemia
•   Epileptic episode
•   Angina
•   Myocardial infarct
•   Anesthetic overdose
•   Drug allergy anaphylaxis
•   Asthma
      Prevention & Preparation

• BLS Certification doctors and staff
• ACLS certification : any type of sedation
  techniques
• Emergency Kits
• Staff drills
              Emergency Kits
• Contents Vary
• Purchase from any
    manufacturer
•   Refill
Components of emergency kits
                 Emergency drills
•    Most important : Keep it
     simple !
•    Designate a specific task to
     each staff member
1.   Assistant : gets kit and assist
     Dr.
2.   Receptionist : calls 911 and
     make sure EMS arrives ,
     clears area for patients
3.   Additional staff : go between,
     records vitals,
     event timing
      ABC of any emergency

• Supine position
• 100 % Oxygen
• Evaluate Airway, breathing , circulation
• Vitals
          Emergency management &
            resuscitation plan
• Primary survey              • Secondary survey
1. ABCDE                      1. Head to toe by region
2. Purpose : Identify &            exam
     treat life threatening   2.   Purpose : Identify &
     problems                      treat life threatening
3.   History                       problems
4.   Resuscitation measures   3.   History : data gathering
     are instituted           4.   System specific test
                              5.   Re evaluation: repeat
                                   surveys untill cause is
                                   identified
                              6.   Definitive care
  Vitals, Clinical signs and
symptoms of potential illness
        Tenets of primary survey
•   Proceed rapidly
•   Err on the side of aggressiveness
•   When in doubt “do”
•   Stay in sequence
•   Know what to look for , recognize and treat
•   Look for likely, treatable problems
•   Make decisions based on direct examination
•   Initiate only simple test and procedures
Generalized treatment protocol
           Documentation

• Brief history of the event
• Positive findings of primary & secondary
  survey
• Treatment provided
• Time of important events
• Disposition
         Medical legal issues

• What if its not a patient in the office ?

• Death or Hospital transfer by EMS , is a
  reportable event to the State Board
Syncope
Types of syncope
      Vasodepressor Syncope

• Most common medical emergency in
  dentistry
• 30 % of adult population
• Accounts for 3% of ER visits
                Etiology

• Decreased cerebral blood flow (CBF)
      Differential diagnosis

Anxiety attacks
hyperventilation syndrome
MI
Hypoglycemia
Epilepsy
Hypotension
Clinical manifestation presyncopal

• Early                 • Late
 Nausea                  Hypotension
 Warmth                  Bradycardia
 Perspiration            Hyperpnea
 loss of color           Pupillary dilation
 Baseline Blood press    Peripheral coldness
 Tachycardia             Visual disturbance
                          Loss of consciousness
          Syncopal phase

• All secondary to decreased CBF
• Loss of consciousness
• Loss of postural tone
• Any syncope lasting > a few minutes can
 induce seizures and cerebral ischemia
                      Treatment
•   Trendelenburg position
•   Pregnant patient lateral decubitus
•   Asses consciousness
•   ABC
•   100 % oxygen
•   Spirits of ammonia
•   Vitals ( Bradycardia < 60 administer Atropine .5mg IV
    1mg IM every 5 minutes until max dose of 3 mg
•   EMS if loss of consciousness is > 5 min or if recovery is
    > 20 min
             Postsyncope

• Evaluate discharge home with escort or
 EMS
 Dependent on recovery and Vitals
 Recovery > 20 min
 Underlying medical conditions
Hypotension
             Hypotension

• Following syncope it is the most common
 cause of loss of consciousness in the
 dental office
What affects perfusion ?
Causes of hypotension
     Orthostatic Hypotension

• Most common cause of hypotension in the
  dental office
• It is Syncope when the patient is placed
  quickly from a supine to upright position
       ( < CBF )
Why Most likely in elderly ?

• Aging decreases baroreflex mechanism
  which impairs cardioacceleratory response
  to preload reduction during upright
  posture
• May be on medications
• Most susceptible
 Vasovagal Hypotension (syncope)

• Initiated by stressful physical ,
  psychological or surgical stimuli ( coughing
  pain, gagging )

• The impulses are transmitted directly to
  the medulla in area closely related to the
  nuclei of the vagus nerve
   Clinical sign and symptoms

• Bradycardia results from Vagal stimulation
 and parasympathetic tone

• Vasodilation results from diminished
 sympathetic tone
               Treatment

• Removing the initiating stimuli
• Trendelenburg position
• Oxygen
• Vitals
 Routine treatment for a patient
with hypotension and inadequate
            perfusion
                 Treatment
• Place in Trendelenburg position
• Oxygen
• Vitals
• ABC
• Evaluate BP
 ( if no BP monitor present , remember palpate
  pulse, correlated to a systolic of: Radial 80 mm
  Hg , Brachial 70 mm Hg , Carotid 60 m Hg )
• Administer: Phenylephrine spray 0.25-0.5 mg IV
  2-3mg IM , Ephedrine 10-25 mg IV
• What if patients are receiving B-Blockers ?

 Isoproterenol 0.2mg IV slowly at 1 min
  interval and monitor patients response
Hypoglycemia
Diabetes
             Epidemiology

• Incidence 15.7 million or 5.9% of
  population of U.S
• Incidence of undiagnosed 5.4 million or
  34% of diabetic population
Why is glucose important ?
• Primary energy
  substrate for all
  functions
             Pathophysiology
• Type 1 IDDM : little or no insulin is secreted
  uptake of glucose or conversion into glycogen in
  the liver does not occur, therefore liver glucose
  production is elevated. Gluconeogenesis
  accelerates

• Type 2 NIIDM : Insulin resistance causes the
  liver to continue glucose production and
  prohibits glucose uptake by muscles
Clinical factors of diabetes
Type II NIDDM Meds
          Type I IDDM Meds




• Need to know or quick reference
           Monitoring

• Hemoglobin A1C
• Fructosamine
• Home monitoring
How are patients going to become
hypoglycemic ?
• Too much insulin
• Alcohol consumption
• Excessive exercise
• Missed delayed meals
• Reduced meals
• Medication error
• Other illness
                    Symptoms
•    Autonomic          •    Neuroglycopenic
1.   Sweating           1.   Dizziness
2.   Trembling          2.   Confusion
3.   Palpitations       3.   Difficulty speaking
4.   Anxiety            4.   Headache
5.   Nausea             5.   Inability to concentrate
                        6.   Weakness
                        7.   Blurred vision
Treatment
            Alternative TX

• Glucose tablets
• 4 teaspoons of sugar in water
• 5 oz of regular soft drink
• Orange juice

• Glucagon dosage : 0.5-1mg IM or IV
Seizures
                    Seizures
• Manifestation of brain
    dysfunction
•   Excessive neuronal
    cortical discharge
•   Secondary to toxins,
    drugs, cerebral
    hypoxia, or metabolic
    disturbances
      Prevention & preparation
•    History
1.   What type of seizure disorder do you have ?
2.   Are you on any medications for the disorder ?
3.   Are you taking the medications as prescribed ?
4.   Have you had serum level of the medication done ? If
     so when ?
5.   When was your last seizure ?
6.   What provokes it ?
7.   Do you have an Aura ?
8.   Where you hospitalized ?
9.   How long was your seizure ?
            Treatment protocol
•   Most seizures last < 2 min
•   EMS activated
•   Assure patient & staff safety
•   Administer oxygen
•   Manage airway
•   Monitor vitals , pulse oxymetry
•   Suction available
•   If seizure is lasting > 2 minutes , establish IV,
    administer Meds
             Benzodiazepine
• Diazepam                • Midazolam
 Adult : 5 to 10 mg        0.05 to 0.1 mg/kg IV
 IV/IM                     0.2 mg/kg IM ( Max
 Pediatric : 0.2 to 0.5    10 mg)
 mg/kg IV/IM
   Pharmacologic management

• EMS not arrived > 5 min
 Adult : Dextrose 50 ml bolus of 50%
 glucose
 Pediatric : 2ml/kg 25% dextrose solution

• Evaluate airway maintenance
• Evaluate cardiac rhythm
               Postictal

• Lethargy
• Disorientation
• Apnea, obstructed airway
• Cardiac arrhythmias
• Evaluate patient injury
Chest pain
• Angina : Latin for spasmodic , choking or
  suffocating pain
• Pectoris :Latin for chest
         Differential Diagnosis
•   Angina
•   Myocardial infarction
•   Dyspepsia, GERD
•   Musculoskeletal
•   Pulmonary embolus
•   Spontaneous pneumothorax
•   Aortic dissection
•   Esophageal rupture
•   Panic disorder
                Relevant factors
• Onset : time, associated
    event
•   Location
•   Radiation absence or site
•   Type of pain: deep
    visceral, superficial,
    pleuritic
•   Exacerbating or
    alleviating factors
What occurs ?
•    Increased Myocardial Demand
1.   Elevated heart rate
2.   Elevated BP
3.   Elevated endogenous catecholamines

•    Decreased Myocardial Oxygen delivery
1.   Decreased diastolic filling
2.   Myocardial vessel occlusion
3.   Hypoxia
4.   anemia
                   Treatment
•   ABC
•   oxygen
•   Position patient comfort
•   Vitals
•   EMS
•   Nitroglycerin : spray or tab .4mg repeat three
    times every 5 min ( systolic BP>90 mm Hg )
•   Aspirin
          Myocardial infarct

• If chest pain > 20 min consider MI
• Cardiac monitor
• Morphine 2 – 4 mg IV
• EMS transport
Adverse drug reactions with
     local anesthetics
Types of local anesthetic reactions

• Local anesthetic toxicity
• Drug interactions
• Vasoconstrictor interactions
• Methemoglobinemia
Dosages
How Anesthetic overdose can
          occur?
Clinical Signs
               Treatment

• ABC
• Oxygen
• Vitals
• EMS
• Monitor seizures
• Monitor respiration
• Cardiac monitor
Drug interactions
Vasoconstrictor interactions
                 Treatment

• ABC
• Patient comfort
• Vitals
• EMS
• Reassurance reaction will pass
• If BP becomes >170 systolic consider
 nitroglycerin
        Methemoglobinemia

• Dose dependent reaction
• Administration of Nitrates, amide
  containing drugs ( prilocaine, Benzocaine )
• Pathophysiology : oxidation of the iron
  within hemoglobin producing
  methemoglobin
            Clinical signs

• Cyanosis at methemoglobin levels of 10%
  to 20%
• Dyspnea and tachycardia at metHb level
  of 35% to 40%
              Treatment

• ABC
• Oxygen
• EMS
• Monitor patient vitals , Cardiac
• Most healthy adults drugs and metabolites
  are eliminated
• Methylene blue 1-2 mg/kg IV
  Airway
    Allergy
  Obstruction
   Asthma
Hyperventilation
Allergy and anaphylaxis
   Drug allergy & Anaphylaxis

• Adverse drug reactions occur in 1% to
  15% of drug regimens
• Drug allergy < 2% overall except for some
  common agents : penicillin ,
  cephalosporin, and trimethoprim-
  sulfamethoxazole ( Sulfa )
                  Risks Factors
•   Multiple intermittent exposures
•   Parenteral vs oral
•   Children less chance of developing reactions to
    meds because of shorter exposure times
•   Women higher incidence of cutaneous reactions
    secondary to their increased exposure to
    cosmetics and latex gloves
•   Individuals with multiple illnesses ,
    polypharmacy
•   Allergies to foods
     Gell & Coombs Classification
• Type 1 ( IgE – Mediated Hypersensitivity)
    most life threatening
    few minutes
•   Type 2 ( Cytotoxic / Cytolytic antibody
    mediated) IgM or IgG antibodies mediate
•   Type 3 ( Immnune complex mediated )
        1- 4 weeks, IgM – IgG soluble metabolite
•   Type 4 (delayed Hypersensitivity )
            sensitized T cell lymphocytes
Signs & Symptoms of minor allergic
            reactions
Signs & Symptoms of Anaphylaxis
               Treatment

• ABC
• Establish reaction type
• Activate EMS
• IV access
Medications for treatment
Minor reactions
Anaphylaxis
Management of allergic scenarios
Medications

• Diphenhydramine 50 mg IM , IV
• Epinephrine: .3ml 1/1000 ( 0.3mg )
• Dexamethasone : 20 mg IM , IV
Obstructed airway
                Etiology

• Foreign body aspiration
• Laryngeal edema
Basics treatment of obstructed
            airway
Cricothyrotomy
Asthma
           Types of Asthma

• Extrinsic : allergic asthma, younger
  patients , Type 1 hypersensitivity Rx
• Intrinsic : older patients, nonallergic
  factors , cold temperatures, exercise,
  stress
Asthma medications
What is asthma ?
• Basically it is slow
  progressing
  Bronchospasm
Treatment

• Terminate therapy
• Position patient
• Administer B agonist spray Albuterol
• Oxygen
• EMS
• Epinephrine SC or IM 0.3ml ( 1/1000
 dilution) Epipen
Hyperventilation
• Usually a patient which suffers from:
  panic, phobias, psychiatric disorder

• Identify patient early
           Signs and symptoms
•   Sighing                    •   Altered consciousness
•   Tachypnea                  •   Muscle cramp
•   Shortness of breath        •   Tremor
•   Pain on respiration        •   Myalgia
•   Tachycardia
•   Nonradiating chest pain
•   Lungs clear to
    auscultation
•   Normal oxygen saturation
•   Dizziness
•   faintness
              Treatment

• Reassurance
• Slow down breathing
• Comfortable position
• Remove any visual stimuli
• Vitals
• Full rebreathing bag
• Anxiolytic meds , Diazepam ?
             Bibliography

• Handbook of Medical Emergencies in the
  Dental Office, Stanley F. Malamed
• Medical Emergencies in Dentistry, Jeffrey
  D. Bennett , Morton B. Rosenberg
• ACLS provider manual , American Heart
  Association

				
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posted:11/2/2011
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