D6439 E2 Notes 20100316-201005

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D6439 E2 Notes 20100316-201005 Powered By Docstoc
					Exam 2:
Lecture X: Diabetes Mellitus
Quiz:
    1. Dry warm skin most likely … hyperglycemic
    2. Patient with Kussmals respirations … hyperglycemia
    3. Which emergency drugs given IM for management of unconscious hypoglycemic patient.
        Glucagon
    4. Metaformin is used to treat which type Diabetes? Type II
    5. Ketoacidosis is occurs with …Type I Diabetes
    6. Which of the following greatest risk for overdosing with sedative drugs? Hypothryoid
    7. Which of the following greatest risk of overdosing with epinephrine? Hyperthyroid
    8. Drug of choice for management of thyroid disease emergency in dental office is? Epi, atropine,
        albuterol, valium, or… (answer was none of the above)
    9. Dry warm skin = hyperglycemic
    10. What do you give a patient unconscious from hyperglycemia before calling 911? Oxygen
    11. What two drugs are contraindicated to be used with a patient with hyperthyroidism? Atropine
        and epinephrine
    12. Which disease will eshibit exophthalmos? Cretinism, myxedema, or Graves Disease? - Graves
        Disease/Hyperthyroidism
    13. A Euthyroid patient that exhibits no clinical symptoms is what ASA class? ASA II
    14. Which disease will eshibit cold, dry skin? Hypothyroidism or hyperthyroidism? Hypothyroidism
    15. What injectable drugs are used to treat a Thyroid Disease in the dental office? No drugs are
        indicated for use. 5% Dextrose and water in an IV is not considered a drug.

Objectives
   1. The student will be able to discuss diabetes mellitus.
   2. The student will be familiar with the acute and chronic complications of diabetes mellitus
   3. The student will know the difference between a brittle and a non-brittle diabetic.
   4. The student will be familiar with the clinical manifestations of hyperglycemia and hypoglycemia.
   5. The student will be familiar with the pathophysiology of diabetes mellitus
   6. The student will be able to discuss the management of a patient with hyperglycemia or
        hypoglycemia.
   7. The student will be able to discuss thyroid gland dysfunction.
   8. The student will be able to discuss the management of a patient with thyroid disease.

S1.    Diabetes Mellitus
S2.    Diabetes Mellitus *one of the few disorders that we need to use injectible drugs for.
       Chronic systemic disease characterized by a disorder in metabolism of fats, protein, and the
       structure and function of blood vessels.
        Disorder of glucose metabolism
        Affects 20 million Americans
        2% to 4% of population
        7th leading cause of death in US
        Increases with age – 90% over 45 y/o
        Leading cause of blindness in U.S.
       *death is not usually from hypoglycemia leading to death, but more often from severe organ
       disease due to poorly controlled diabetes.
      *to determine the Type – dialog the patient history, must be careful, sometimes Type II take
      insulin too even though most are diet controlled
S3.   Type I – IDDM
       5% of diabetic patients
       More common in adolescents
       May develop in adults
       Circulating insulin absent
       Beta cells fail to respond to stimuli
       Requires exogenous insulin
S4.   Type II – NIDDM
       Milder form of diabetes
       Usually seen in adults
       85% of diabetic population *in the clinic we will see more patients with this type of diabetes
       Usually obese
       Ketoacidosis uncommon *rare to be unconscious from type II
       Clinical onset slow
       Blood sugar levels are much more stable
S5.   Hyperglycemia
       Polyuria *key signs
       Polydypsia *key signs
       Polyphagia *key signs
       Dry, warm skin
       Kussmaul’s respirations *rapid breathing then stop
       Fruity breath odor *smell like they’ve been drinking
       Rapid, weak pulse
       Altered level of consciousness
S6.   Hypoglycemia *the one we worry about the most
       Pale, moist skin
       Weakness, dizziness
       Shallow respirations
       Headache
       Altered level of consciousness
       Onset very sudden
       Blood glucose values < 50 mg/100 mL *a patient will pass out at <50 mg
S7.   Blood Glucose *check these levels with blood glucose
       Fasting range – 78 to 115 mg/100 mL
       Normal brain function > 50 mg/100 mL *??>40 mg/100mL
       Blood glucose > 180 mg = glucose in urine *in early 1800’s the physicians used to taste urine
          to determine if patients had diabetes
      *Urine is sterile without infection
      *test the patient to find out if their diabetes is in good control. HbA1c
      *well controlled – 6%
      *HbA1c of 6% has average blood glucose of 126
      *At 7%  154, 8%  189, 9%  210
      *the time frame of HbA1c is for 3 months
       *effects perio/dental diseast. The cut off for treatment is 250 mg/100 mL. These patients are
       more prone to infection. Standard is Pen VK and odontogenic infections want to error on the
       side of safety.
S8.    Management of Hypoglycemia
        Position patient comfortably – ABC
        Administer 100% oxygen
        Oral carbohydrates if conscious *cake icing
        Unconscious *supine
            - Cake icing 8in vestibule
            - 50% dextrose (20 to 50 mL) IV *won’t be trained to do IV as dentists, we will use the
                glucagon IM
            - Glucagon 1 mg IM or IV
            - Epinephrine 1/1000 0.5 mg IM *releases from glucose stores from the muscles, that is
                not typically used at 90, go ahead with procedure.
            *Know the amounts for each of these drugs
        Medical assistance
S9.    CocaCola Classic (*no Diet Coke!) M&Ms, sugar, and cake icing are all helpful *when buying cake
       icing, do not buy red icing it looks bad when the paramedics come.
S10.   Prevention of Diabetes Mellitus
        Treat uncontrolled patient only with consultation with physician
        Decrease insulin on day of treatment if patient will be eating less
        Consider chronic complication – infection
        Early morning appointments
        Good medical history *best prevention
       *if patient is allergic to Pen VK , then Clindamycin (2 150 mg) tab 4 x day 150 = generic vs. 300
       not generic
S11.   Insulin Types *learn these
       Type                                 Peak                            Duration
       Regular *most patients               1-2 hours                       5-6 hours
       NPH *most patients                   2-8 hours                       24-28 hours
       Lente                                2-8 hours                       24-28 hours
       Protomine                            8-12 hours                      36 hours
Thyroid Gland Dysfunction

S1.    Thyroid Gland Dysfunction *rare emergency
S2.    Thyroid Gland Disease – Hypothyroidism
        Atrophy of the thyroid gland
        3-10 times more common in females
        Greatest incidence in 7th decade
        Myxedema coma up to 50% mortality
        Cretinism in children
S3.    Hypothyroid Symptoms
        Paresthesias
        Loss of energy
        Intolerance to cold
        Drowsiness
        Headaches
        Hypothermia
        Dry skin
        Puffy eyelids
        Goiter
        Weight gain
        Hoarse voice
        Edema
        Yellow skin
S4.    Thyroid Gland Disease – Hyperthyroidism *no lidocaine w/epinephrine
        Thyrotoxicosis
        Incidences is 3/10,000 adults per year
        Females 8:1 ratio over males
        Occurs between 20-40 years of age
        Called Grave’s disease
        Can develop thyroid storm
S5.    Hyperthyroid Symptoms
        Exopthalmia *bulging eyes, this is not as common, usually caught and treated earlier
        Weight loss
        Dyspnea
        Nervousness
        Weakness
        Tremors
        Diarrhea
        Fever
        Tachycardia
        Thyromegaly
        CHF
        Warm, moist skin
        Extreme sweating
        Thyroid storm *temperature sky rockets, BP sky rockets, fever, and elevated BP
S6.    Dental Therapy Considerations
        Euthyroid – no modifications usually needed *patient has had treatment, thyroid is removed
         surgically or with radiation than takes supplement with synthroid. Treat these patients as
         you would other patients, can use lido and epi on these patients
       Hypothyroid – use CNS depressants with caution *no valium codeine, hydrocodiene
       Hyperthyroid – avoid us of atropine and avoid use of epinephrine *atropine will dry up the
         saliva – epi and atropine are is bad with thyroid problems.
S7.   Management
       Terminate the procedure
       Position the patient *semi upright
       Basic cardiac life support *PABC
       Summon medical assistance
       Establish an IV line if possible
       Administer oxygen
       Transport the patient to the hospital
Lecture XI: Cerebrovascular Accident
Quiz:
    1. What type of stroke is a “stress related” CVA? Hemorrhagic
    2. If a patient had a CVA (infarct) 3 months prior, what should you ask? If they are taking
        Coumadin
    3. What is the major risk factor for CVAs? Hypertension
    4. What is another name for absence seizures? Petit mal
    5. What is the drug of choice for prolonged seizures? Valium at 10 mg dose
    6. Patient has a CVA in left side of brain, he’ll have trouble using which arm and leg, left or right?
        Right
    7. Patient had a CVA recently, which lab test before extensive periodontal therapy? INR
    8. Patient is having a CVA, what drug do you use to manage it? Oxygne (You don’t administer
        aspirin, if it’s a hemorrhagic CVA, it’ll potentiate the bleeding.)
    9. What does status epilepticus mean? Prolonged seizure activity.
    10. Drug of choice for status epilepticus seizure? Valium at 10 mg dose
    11. What are the two major types of cerebral vascular accident? Infarct and hemorrhage
    12. If the patient recovered from the CVA within 10 minutes, what is it called? Transient Ischemic
        Attack (TIA)
    13. How long should you wait after a CVA to perform elective treatment? 6 months
    14. What is the BP, if a patient was above, they would not have elective treatment until it was
        lowered? 200/115
    15. If a patient had a CVA 9 months ago, what are two types of medications that you need to ask if
        they are taking? Anticoagulant (Coumadin, Antiplatelet (aspirin), Antihypertensive (Diuretic)
    16. What is the most common non-epileptic cause of seizures in the dental office? Local anesthetic
        Overdose
    17. What type of seizure can last for more than an hour and has the highest mortality rate? Status
        epilepticus
    18. True or False? A bite block or tongue blade should be place between the teeth of a patient
        having a seizure to prevent injuries to the mouth. False
    19. What are two drugs that a person might be taking for long-term control of epilepsy? Dilantin,
        tegritol, phenobarbitol
    20. What drug would be used for emergency treatment of seizures, and at what dose? Valium, 10
        mg IV
    21. Most common type of seizure? Grand mal
    22. Most serious type of seizure? Status Epilepticus
Also know – position of the Vallecula, it takes 20 seconds for an IV to work, know the ASA classifications

Objectives
   1. The student will be familiar with the two types of cerebral vascular accidents
   2. The student will be able to discuss the clinical manifestations of a CVA and know the dental
        therapy considetaions.
   3. The student will be able to discuss the management of a patient with a CVA
   4. The student will be able to discuss the various types of seizure disorders.
   5. The student will be familiar with the etiology of seizure disorders.

S1.     Cerebrovascular Accident
S2.     Cerebrovascular Accident
         Destruction of brain tissue as a result of hemorrhage, thrombosis, or embolism
       500,000 new CVA’s reported annually
       160,000 deaths reported annually
       Third leading cause of death in USA
       Average occurrence age is 64
       25% decline in incidence in past 30 years
      *severe pain in the head
S3.   Cerebral Infarction
       85% of all CVA’s
       Most common between 60 and 90 years of age
       Results from atherosclerotic disease *cheeseburgers 
       Death of brain tissue from ischemia
       Mortality rate 30%
       Males 2:1 ratio over females
S4.   Cerebral Hemorrhage *big killer!
       10-15% of all CVA’s
       Usually over age 50
       Caused by hypertension or aneurysms *these may be present form birth, they are only a
          problem is osmethign makes them burst
       Mortality rate 80%
       Usually occurs during stressful work
       Males 2:1 ratio over females
       Brain death results from displacement and edema
S5.   Transient Ischemia Attack *quick
       Called TIA’s
       Onset abrupt
       Recovery occurs rapidly
       Transient numbness of contralateral extremities
       Transient monocular blindness
       Usually lasts 2-10 minutes
S6.   Predisposing factors
       Hypertension (major risk factor)
       Cigarette smoking *may be the reason for decline of CVA in past 30 years
       Diabetes mellitus
       Hypercholesterolemia *drugs to control high cholesterol may also help with decline
       Oral contraceptives *increase the incidence of CVA
S7.   Signs and Symptoms – Cerebral Infarction
       Gradual onset         minutes        hours days
       Mild headache
       Paralysis on one side of the body
       Slurring of speech
       Pupils unequal in size
       Loss of bladder and bowel control *in later stage
S8.   Signs and Symptoms – Cerebral Hemorrhage
       Abrupt onset of symptoms
       Sudden, violent headache
       Nausea and vomiting
        Chills and sweating
        Paralysis on one side of body
        Pupils unequal in size
        Slurred speech
        Loss of consciousness
S9.    Dental Therapy Considerations
        No elective care < 6 months
        Minimize stress *N2O, keep instruments out of view of patients, use caliming non
           threatening words
        Stress reduction protocol
        Good local anesthesia
        Monitor blood pressure *200/115 is the upper limit for emergency extractions.
        Anticoagulants *must be off the anticoagulants at least 3 days.
           *plavix, NSAIDS, Ibuprofen – test bleeding time
           *Coumadin INR <=2.5
           *Aspririn – bleeding time < 9 min
           *a lot of people treatment in ?? research shows color, pain treatment not?
           BP information – the cuff width should be 20% greater than the arm width
           If the size of the cuff is too big then it will read falsely low – this is based on the width of the
           cuff being too big
S10.   Management
        Terminate the procedure
        Position the patient
           - Conscious patient – upright
           - Unconscious patient - supine
        Basic life support
        Oxygen
        IV line if possible
        Transfer to hospital
S11.   Seizures
        Excessive neuronal brain activity
        Abnormal sensory and motor activity
        Occurrence of epilepsy – 40 per 100,000 *not as common due to treatment with
           medications Dilantin or Tegretol
        Occurs equally in both sexes
        Usually lasts 2-3 minutes
        Usually begins in childhood
S12.   Causes
        Genetic predisposition
        Head trauma
        Infectious disease *high temperature
        Tumors
        Congenital abnormality
        Hypoglycemia *low blood sugar, brain sleeps, then stop breathing
        Anoxia/hypoxia secondary to syncope *more seizure in clinic are from syncope than
           anything else
        Local anesthetic overdose *most common in children
       *place the chair back to O2 to the brain quickly O2 only - ???
S13.   Petit Mal *absence seizure
        Sudden onset of immobility
        Primarily in children
        Blank stare
        Slow blinking of eyelids
        Short duration – 5-30 seconds *may not know it is happening
        Rapid recovery
        Usually no significant treatment needed *document this in the records if it occurs
S14.   Grand Mal
        Presence of aura
        Loss of consciousness
        Tonic clonic muscle contractions
        Clenched teeth, tongue biting
        Incontinence
        Usually lasts from 2-5 minutes
        Status epilepticus may last for hours *seizure, stops, seizure, stop, … immediately to the
           hospital
S15.   *Secondary to hyperventilation carpopedal spasms can be treated by rebreathing CO2
S16.   Management
        Terminate the procedure
        Position the patient
        Summon medical assistance
        Prevent injury
        BCLS
        Oxygen
        Monitor vital signs
        Valium 10 mg IV for Status Epilepticus
S17.   Pharmacotherapeutics
        A drug is a substance that when injected into a rat will produces a scientific report
Lecture XII: Drug Overdose Reactions (4/7/2010)
Quiz:
    1. A major cause of drug emergencies is the administration of what drug? Local anesthetic (or the
        fear of it…)
    2. If we give a patient 3 carpules of 3% mepivacaine (prilocaine), how many mg of prilacaine have
        we given to the patient? 162 mg (3 X 54)
    3. If we give a patient 5 carpules of 2% epi 1:100,000 how many mg of epi have we given to the
        patient? 0.09 mg (0.018 X 5)
    4. What is the maximum dose of epinephrine given to a cardiac patient? 0.04 mg
    5. If the patient is unresponsive due to a narcotic overdose, what is the drug of choice? Narcan 0.4
        mg
    6. Where are ester LA’s metabolized? Serum/Blood
    7. What is the maximum dosage per pound and maximum total dosage you can give a patient of
        carbocaine? 2 mg/lb; 300 mg total
    8. What is the maximum dosage of epinephrine you can give to a cardiac patient? 0.04 mg
    9. What drug and at what dosage is it used for the reversal of an overdose of valium? Mazicon; 0.6
        mg IV or IM
    10. What drug and at what dosage is used for the reversal of an overdose of Narcotics? Narcan; 0.4
        mg IV or IM
    11. What is the typical reaction for severe LA overdose? Seizure activity
    12. Name 5 Patient Factors that affect anesthetic overdose? Age, Body weight, Pathology, Genetics,
        Mental attitude, Sex, CHF, Liver disease, Atypical cholinesterase
    13. What is the maximum recommended doses of lidocaine 2%? 2 mg/lb or 300 mg maximum
    14. What is the maximum cardiac dose of epinephrine? 0.04 mg
    15. What is the drug and dosage for reversal fo an overdose of Narcotics? Narcan; 0.4 mg IV or IM

Objectives
   1. The student will be familiar with the classification adverse drug reactions.
   2. The student will be familiar with the drugs commonly used in dentistry.
   3. The student will be able to discuss local anesthetic overdose reactions
   4. The student will be able to discuss the etiology of overdose reactions.
   5. The student will be able to discuss the clinical manifestations of local anesthetic overdose
        reactions.
   6. The student will be able to discuss the management of local anesthetic overdose reactions.
   7. The student will be familiar with the vasoconstrictor commonly employed in dentistry.
   8. The student will be able to discuss the clinical manifestations and management of epinephrine
        overdose reactions.

S1.     Drug Overdose Reactions
S2.     Adverse Drug Reactions
        Drug                   Allergy                                    Overdose                      Side Effects
        Esters*primary drugs used in   Common *allergy extremely          Unlikely                      Rare
        LA                             common with esters
        Amides                         Rare *extremely rare to have       Very Common *mostly seen in   Rare
                                       an allergy to amides – ask         young children.
                                       patient what happened?
                                       Fainted, hematoma… not
                                       allergies; rash all over body,
                                       hives - allergy; most likely not
                                       allergic reaction
      Antibiotics                     Common *allergy very             Rare *if not allergic can give a   Rare
                                      common we will discuss this in   patient a ton of penicillin –
                                      detail next week                 body selectively takes what it
                                                                       wants and urinates excretes
                                                                       the excess. Overdose is
                                                                       extremely rare
      Non-Narcotic Analgesics         Common                           Common *if patient OD on           Common
      aspirin, ibuprofen, rare that                                    aspirin what is a symptom?
      you see this                                                     Ringing in the ears (commonly
                                                                       seen in young children –
                                                                       classic sign of aspirin
                                                                       overdose)
      Narcotic Analgesics *Tylenol    Uncommon                         Common especially when IM          Very Common *narcotic for
      with codeine, vicodin                                            or IV                              pain control worry about side
                                                                                                          effect of respiratory
                                                                                                          depression, palpitations
      Barbiturates                    Uncommon                         Very Common *very easy to          Common
                                                                       overdose someone with a
                                                                       barbiturate
      Valium *wide margin of safety   Uncommon                         Uncommon                           Common *makes patient
      unlike Versed                                                                                       sleepy – to our benefit
                                                                                                          sedation and calming effects
                                                                                                          used to relax the patient
      N2O                             Very Rare *makes this a great    Common *when using N2O             Common *major side effect
                                      drug for stress reduction        sedation patient should            nausea commonly in children
                                      protocol                         always be able to respond,
                                                                       best monitoring system is
                                                                       patient response, should
                                                                       always be able to say to
                                                                       patient are you doing okay
                                                                       and get an answer. Sedation
                                                                       to general anesthesia, some
                                                                       patients this is easy to do
S3.   Local Anesthetic Overdose *used almost everyday in professional life, LA overdose all kinds of
      LA drugs on market need to understand how they work and how to prevent overdose.
      Xylocaine (lidocaine HCl with epinephrine 1:100,000 2%) also can be available without epi
S4.   Patient Factors
       Age            Less than 6      Over 65 *most commonly OD happens in young children
       Body weight *if you have a 200 pound man that is muscular vs. 200 pound obese person,
          the fat person will be easier to overdose, the lean muscle has mostly muscle, has good
          blood vessels larger blood volume, fat no blood vessels, less blood volume, more blood
          more anesthetic. Easier to OD obese person.
       Pathology * certain conditions inhibit the take up and distribution of LA
              o CHF
              o Liver Disease
       Genetics Atypical cholinesterase *helps in breakdown of LA without it they can’t break it
          down
       Mental attitude *determines how well patient can be anesthetized, placebo effect
       Sex            Pregnancy *during pregnancy womens renal function does not work as well as
          when not pregnant drugs not eliminated as quickly from their systems.
S5.   Drug Factors
       Vasoactivity of drug *LA are vasodilators except for cocaine, anesthesiologists use cocaine
          for nasal intubation sometimes spray cocaine into nose to constrict vessels for intubation.
       Dose of drug *know amount of drug you are giving to a patient e.g., repairing fracture on
          elderly gentlemen that had broke his jaw. PVC’s anesthesiologist asked for 50 of lidocaine
          nurse gave 500 mg of lidocaine – patient survived, but must look at drug before giving to a
          patient can be scary
       Route of administration *easier to OD a patient on IV administration than IM administration
       Rate of injection *the slower you inject the drug the less likely there will be an overdose of
          that drug. Oral surgery guilty of giving drugs to fast out of all specialties. Need to be
          careful, too fast in vessels can OD very quickly rate of injection if not sedated will hurt far
          less.
       Vascularity of site
       Presence of vasoconstrictor *most LA are vasodilators, vasoconstrictor is added to help drug
          stay around longer helps prevent patient from having LA overdose.
S6.   Predisposing Factors
       Slow biotransformation
       Slow elimination through kidneys
       Too large a dose of anesthetic
       Rapid absorption *one reason why epinephrine is added
       Intravascular injection *tremors immediately following injection, tachycardia, inadvertently
          injected lidocaine into the vessel, not enough lido for OD, but enough epi for OD
S7.   Symptoms
       Confusion
       Talkativeness
       Slurred speech
       Muscular twitching
       Elevated BP and Pulse
       Seizures **this is the big thing, seizure activity, could be masked by syncope - seizure
          secondary to fainting episode; *cardinal activity the patient will usually have
       CNS depression
       Headache
       Dizziness
       Blurred vision
       Ringing in ears
       Drowsiness
       Numbness
       Unconscious
S8.   Maximum Recommended Doses *very important to know these numbers!!!!
       Lidocaine 2% with/without vasoconstrictor
          2 mg/lb up to 300 mg maximum – will 350 overdose them? Probably not… also 3 carpules
          now, then 30 minutes later can give some more LA because some LA already metabolized.
       Mepivacaine 2% or 3% (Carbacaine)
          2 mg/lb up to 300 mg maximum
       Bupivacaine 0.5% (Marcaine)
          0.6 mg/lb up to 90 mg maximum
          *this is the long acting LA
      Lidocaine *add a zero to the percentage to get the mg/cc
       2% = 20 mg/cc
       3% = 30 mg/cc
       4% = 40 mg/cc
       Carpule = 1.8 cc/carpule
        20 mg/cc X 1.8 cc = 36 mg/carpule
        30 mg/cc X 1.8 cc = 54 mg/carpule
        40 mg/cc X 1.8 cc = 72 mg/carpule
       Lidocaine 2%
        Maximum dose = 2 mg/lb
        Maximum dose = 300 mg (8 carpules)
        36 mg/carpule
        *40 lb child can only give 80mg, this is only 2 carpules…
       Marcaine 0.5%
        Maximum dose = 0.6 mg/lb
        Maximum dose = 90 mg (10 carpules)
        9 mg/carpule
S9.    Vasoconstrictors
       Maximum Doses
       Drug                Conc.             Mg/mL                 H.P. healthy      C.P. cardiac
                                                                   patient (carpule  patient (carpule
                                                                   amounts)          amounts)
       Epi                 1/50,000          0.02                  0.2(5)            0.04(1)
       Epi *one used       1/100,000         0.01 (0.018           0.2(10)           0.04(2)
       primarily in                          mg/carpule)
       dentistry
       Epi                 1/200,000         0.005                 0.2 (20)          0.04 (4)
       Neo-Cobe            1/20,000          0.05                  1.0 (10)          0.2 (2)
S10.   Epinephrine Overdose
        Anxiety
        Tremors
        Diaphoresis *sweating
        Headache
        Florid appearance *red – do not give O2 - they are breathing so rapidly do not need more
           O2
        Tachycardia *rapid heartbeat
        Elevated blood pressure
S11.   Management
        Terminate procedure
        Position patient – upright
        Reassure patient
        BCLS if indicated
        Monitor vital signs
        Oxygen *rarely used, usually do not need to do this
        Medical assistance if indicated *rare, calm them takes about 15-20 minutes epi will
           metabolize and patient should be doing well
S12.   Contraindications
        SCVD/Hypertension *HBP 200/115 will not give these patients epi
        Cardiac arrhythmia *do not use epinephrine
        Hyperthyroid *can precipitate thyroid storm and severe hypertension
        Anxiety/Depression medications may interfere with epi, may need to watch this
        Drug interaction - never give epi if patient tells you they are taking cocaine
S13.   Anesthetic Overdose Management
        Terminate procedure
        Position patient comfortably
        Reassure patient
        Oxygen *rarely needed
        BCLS if indicated
        IV anticonvulsant if indicated
        Medical assistance
S14.   Narcotic Overdose – Signs and Symptoms
        Decreased level of consciousness
        Respiratory depression
        Loss of motor coordination
        Slurred speech
        Unconsciousness
S15.   Narcotic or Valium Overdose – Management
        Terminate procedure
        Position patient - supine
        BCLS if indicated
        Medical assistance if indicated
        Oxygen
        Monitor vital signs
        Narcan 0.4 mg IV or IM for Narcotic OD
        Mazicon 0.6 mg IV or IM for Valium OD
S16.   Bradycardia – Cause
        Pulse < 60 from unexplained cause
        Can be caused by increased vagal tone, pressure on the eyes or pulling on the tongue
        Also caused by block in the conduction system
S17.   Bradycardia – Management
        Position supine
        Reassure patient
        Oxygen
        Atropine 0.4 mg IV or IM
        BCLS if indicated
Lecture XIII: Allergy
Quiz:
    1. What is in a 2% Lido carpule that causes an allergic reaction? Sodium metabisulfate
    2. If a patient has a true allergy to Tylenol 3, can you give codeine (vicodin w/hydrocodon)? No
    3. What is the drug of choice for anaphylaxis? 1:1,000 Epinephrine 0.3 mg IM
    4. What type of allergic reaction is contact dermatitis? Type IV
    5. True or False? Oral penicillin has a high incidence of anaphylaxis? False
    6. What is the most important predictor of how severe an allergic reaction will be? Speed that the
        reaction takes place.
    7. DOC for management of an anaphylactic reaction? Epi 1:1000 0.3 cc IM (0.3-0.5 cc or mg)
    8. True or False? Amide Las have a high incidence of allergic reactions. False (esters)
    9. What drug in a carpule of lidocaine 2% with 1:100,000 epi is responsible for an allergic reaction,
        especially in asthmatics? Sodium metabisulfate
    10. DOC for a delayed allergic reaction? Benadryls 50 mg PO q4h
    11. Which antibody is responsible for allergic reaction? IgE
    12. What drug in a carpule of lidocaine 1:100,000 has the highest chance of causing an allergic
        reaction? - sodium metabisulfite
    13. What is the first drug of choice to give a patient experiencing anaphylaxis (other than oxygen)?
        Epinephrine 1:1,000; 0.3 mg IM
    14. Anaphylaxis is what type of allergic reaction? Type I
    15. What is the purpose of using corticosteroids during anaphylaxis? Down regulated inflammatory
        reaction for maintaining airway and preventing its reoccurrence.
    16. What is the drug of choice for a delayed allergic reaction? Benadryl/Diphenhydramine

Objectives
   1. The student will be familiar with the classification of allergic diseases.
   2. The student will be able to discuss the clinical manifestations of allergic reactions.
   3. The student will be able to discuss the management of both immediate and delayed allergic
        reactions.

S1.     Allergy
        *Dentist’s don’t see anaphylaxis a lot, but do have incidence with allergic reaction to antibiotics
S2.     Allergic Reaction: Rapid
         Rapid onset – less than one hour *patient given a dose and have immediate reaction; these
            are the reactions that are of greatest concern.
         Type I – true IgE mediated anaphylaxis
         Antibiotics *allergies are commonly seen with antibiotis
            *most common is penicillin.
            *general dentist rarely give antibiotics IM or IV – most of the time they are prescribing oral
            doses, therefore it is very rare for them to see anaphylactic allergic reactions secondary to
            an oral dose of penicillin.
            *If patient is allergic to penicillin, give them a different antibiotic. E.g., Clindamycin, Keflex
            (Malamhed text has a chart and alternate drug list – erythromicin is listed, but rarely will a
            practioner use this a s a back up for penicillin 1. Does not kill all bacteria for odontogenic
            infections and 2. Causes GI upset “bad case of green apple two-step” )
            *There is a 6-7% crossover of Keflex and penicillin, need to ask the patient questions about
            what happens when you take penicillin – rash, hives, airway problems (if rash only – give
          Keflex, if airway problems – No Keflex use Clindamycin instead). Why not use Clindamycin if
          it is routinely good? It is expensive.
          *Pseudomembranous colitis is a problem with use of antibiotics –they kill the good bacteria
          and then you get an overgrowth of bad stuff.
       Analgesics
          *Ibuprofen and Aspirin – rarely use aspirin; most pharmacist do not carry asprin with
          codeine.
       *If patient is allergic to aspirin, cannot give ibuprofen there is a cross over between the two.
          Narcotics
          *Tylenol #3 (Tylenol with codeine - 3 is a code, 30 mg of codeine, Tylenol 4 = 60 mg codeine.
          Tylenol 2 = 15 mg codeine).
          *if patient has allergy to codeine, ask what happens - rash? Upset stomach? Rash = true
          allergy; upset stomach = not an allergy = idiosyncratic;
          *what alternative drugs can you give the patient? Darvocet N100, ?Voltran?Ultrem?,
          Demerol, Ibuprofen
       Preservatives in anesthetics
          *sodium metabilsulfite; be careful with patients that have significant asthmatic condition –
          use inhaler several times not recommended to use lidocaine with preservative (no epi = no
          preservative)
       Venom of stinging insects *carry bee sting kit
S3.   Signs and Symptoms *progressive symptoms
       Pallor
       Rash
       Itching
       Hives
       Angio-edema *swelling of throat larynx
       Hypotension
       Dyspnea
       GI upset *nauseated
       Bronchospasm
       Laryngeal edema *swollen larynx
       Rhinorrhea *runny nose
       Circulatory collapse
       Dysrhythmias
       Cardiac arrest
S4.   Management
       Position patient supine *chair all the way back
       BCLS
       Oxygen
       Monitor vital
       Epinephrine: 1/10,000 3.0 cc IV or
       Epinephrine: 1/1,000 0.3 cc IM *in deltoid or floor of mouth – if patient is clenching can go
          behind mandible
       Benadryl: 50 mg IV or IM
       Obtain medical assistance and transport to hospital
S5.   Prevention
       Medical history
       Large label on allergic patient’s chart
       Do not use chemically similar drugs
       Use oral administration instead of IM or IV
       Skin tests – questionable *rarely done
S6.   Allergic Reaction: Delayed *seen most often in dentistry.
       Onset greater than one hour *usually a rash
       Usually non-life threatening
       Antibiotics
       Analgesics
       Narcotics
       Preservatives in anesthetics
S7.   Signs and Symptoms
       Rash
       Pruritus (itching)
       Urticaria (hives)
       Edema
       Rarely – hypotension, dyspnea, coma
      *patient calls about rash ask if they are having any problems breathing?”
      If yes emergency room – normally give the patient benadryl
S8.   Management
       Terminate procedure
       Position patient based upon comfort
       BCLS if indicated (usually not)
       Benadryl 50 mg PO or IM q 4 h depending upon severity of symptoms
       Continue Benadryl for 24 hours after symptoms disappear
      *Stop penicillin get Benadryl take 2 of those switch from penicillin to Keflex or Clindamycin. Not
      sure on allergy go with clindamycin
S9.   Prevention
       Medical history *good medical history
       Large label on allergic patient’s chart
       Do not use chemically similar drugs
       Skin tests are questionable
Lecture XIV: Chest Pain, Angina, Myocardial Infarction, Basic Life Support
Assignment: Ch. 26, 27, 28, 30; pgs 437-514
Quiz:
    1. The effects of nitroglycerin occur in how many minutes? 2-4 minutes
    2. What do dentists have in their office to treat the pain of angina and/or MI? Nitrous oxide
        sedation
    3. Having a patient chew on 325 mg of aspirin is for treatment of what? MI
    4. If a patient has episodes of angina 2-3 times per week, what ASA are they? ASA III
    5. How can you tell if a patient is having an angina attack or an MI? Pain > 15 minutes indicates
        MI, pain relieved by nitro indicates angina

Objectives
   1. The student will be familiar with the predisposing factors in chest pain, atherosclerosis, angina,
        and myocardial infarction.
   2. The student will be familiar with the clinical manifestations of angina pectoris.
   3. The student will be able to discuss the management of angina pectoris
   4. The student will be familiar with the clinical manifestations of acute myocardial infarction
        patients and management

S1.     Cardiovascular Disease *always assume any emergency will be a heart attack until proven
        otherwise.
S2.     Chest Pain (Causes)
         Angina pectoris – most common *many patients have history of this
         Hyperventilation – common *complain chest hurts, fingers numb = tip off this is probably
            not a heartattack – bilateral symptom (=hyperventilation) vs. unilateral (=MI)
         Acute M I – least common *very rare, must be prepared for this.
S3.     Leading Causes of Death
        United States – 1984-85
         Cardiovascular disease *most common cause of death in elderly
            - MI
            - CVA *most deadly is hemmorhagic
            - HBP *high blood pressure causes MI and CVA
         Cancer
         Accidents *most common cause of death in young people
S4.     Risk factors for Heart Disease – Factors that cannot be changed
         Heredity *you are what you are born e.g., preponderance for high cholesterol
         Sex
         Race
         Age
S5.     Risk factors for Heart Disease – Factors that can be changed
         Smoking *decline in number of people smoking - far fewer people smoke now, in the 40s
            everyone smoked, now that has changed
         Hypertension *so many drugs, 40-50 years ago no drugs to control this, now medications
            control this
         High cholesterol *people are more conscious of this - grocery shopping, eating healthier,
            medications to control
          Diabetes *drugs for control of this – leading cause of circulatory problems, problems of
           circulation to the heart
S6.    Decline in Cardiovascular Deaths
        Improved detection and treatment of HBP *more regular check-ups
        Decreased cigarette use by 35+ y/o men *women are smoking more
        Improvements in medical and surgical care *stents, transplants, …
S7.    Angina Pectoris
S8.    Symptoms
        Sensation of pressure, tightness, fullness, pain
        Located behind sternum or throughout front of chest
        May radiate to shoulders, arms neck, back of chest
        Caused by ischemia to cardiac muscle due to loss of oxygen to the heart * heart is oxygen
           gourmet not enough causes damage to the vessels of the heart
S9.    Location and Intensity of Pain of Angina Pectoris
S10.   Diagram of Asymptomatic Coronary Heart Disease
        Sudden Cardiac Death, Angina Pectoris, Myocardial Infarction all part of Asymptomatic
           Coronary Heart Disease
S11.   Myocardial Infarction – cross section of a diseased artery
S12.   Participating factors
        Physical activity
        Hot, humid environment *more common in clinic in summer – so hot and stress from
           procedure = chest pain
        Large meals *blood to the stomach to digest food shunted away from the coronary arteries
           and triggers angina attack and cardiac arrest
        Emotional stress
        Caffeine ingestion
        Fever
        Cigarette smoke
        High altitudes *skiing higher elevation in Colorado, 1st day or two takes a while to get
           adapted to low O2 content in the air there compared to air here – some people get severe
           headaches or nauseated first day or so, get out of breath more quickly.
S13.   Frequency of Angina
        ASA 2 – 1 /month
        ASA 2 – 2-4 /month
        ASA 3 – 2-3 / week
        ASA 4 – daily
        Average patient is ASA 3
S14.   Management
        Position comfortably – usually semi-supine *unless totally unconscious then supine – most
           airway are semi-supine
        Administer 100% oxygen *6 L/minute
        Administer nitroglycerin (spray or tablets) *spray probably better thing to keep in office
           compared to tablets, last a couple of years. The patients does not work, try yours if it is
           angina pain goes away, otherwise
        BCLS if indicated
        Monitor vital signs
        Medical assistance if indicated
          Modify future treatment with stress reduction protocol *terminate procedure, reschedule
           for another day; patient should see physician in meantime.
        Nitrous oxide modification to treatment on recall. Gives them O2
S15.   Nitroglycerin
        Exerts action in 2-4 minutes
        Duration of action 30 minutes
        Side effects include the following
           - Pounding in head
           - Flushing
           - Tachycardia
           - Possible hypotension
           - *patient in chair contraindication for using nitroglycerin is systolic BP that is 90 or lower
S16.   Prevention
        Medical history ***most important***
        Stress reduction protocol
        Consider giving nitroglycerin five minutes before starting procedure
        Effective local anesthesia
           *max epi 0.2 mg in health and 0.04mg to patient with cardiac history (2 carps lido with epi
           1/100,000 then give plain lido no epi)
           *epi is usually metabolized by 15 -30 minutes; could give another carpule.
        Epi prolongs effect of anesthesia – prolongs duration
S17.   Acute Myocardial Infarction
       Myocardial Infarction
        Death of cardiac muscle due to inadequate blood oxygen supply
        Single leading cause of death in U.S.
        1.5 million Americans have MI each year
        36% of these patients will die
        60% will die within 2 hours of onset of signs and symptoms
S18.   Signs and Symptoms
        Severe chest pain > 15 minutes
        Pain not relieved by nitroglycerin
        Pain radiates to left arm, neck, jaw
        Nausea and vomiting
        Weakness
        Cold perspiration
        Sense of impending doom *if patient says “he feels like he might die” believe him
           *no previous angina history the patient is more likely to be having MI than patient with
           previous angina experience.
S19.   Causes
        Stress
        Coronary atherosclerosis
        Coronary vasospasm
        Coronary thrombosis
S20.   Management
        Position comfortably, usually semi-supine
        Administer 100% oxygen *6L
          Administer nitroglycerin
          If pain is not relieved in 1-3 minutes, administer
           - 5 mg of morphine OR *pneumonic what to give patient with MI in office MONA –
                morphine, oxygen, nitroglycerin, aspirin
           - Demorol 50 mg IV or IM *most dentists will not have this
                50% N20 can also be used *excellent
        BCLS
        Transport to emergency care facility
           After MI on cardiac electrogram (EKG) will see ventricular fibrillation
S21.   Prevention
        Medical history – MI < 6 months = ASA IV
        Stress reduction protocol
        Position semi-supine
        Effective local anesthesia with aspiration
        Observe cardiac dose of epinephrine – 0.04 mg
        Avoid 1/50,000 epinephrine
        Supplemental oxygen
        No elective treatment < 6 months after MI
S22.   Heartsaver AED – For the Lay Rescuer and First Responder
S23.   Extent of the Problem
        1.1 million heart attacks
        480,000 deaths due to coronary heart disease
        250,000 prehospital cardiac arrests
S24.   Chain of Survival
S25.   Recognize emergency and Call 911
        Airway obstruction
           Universal distress signal, blue skin
        Respiratory arrest
           Not breathing but has pulse
        Cardiac arrest
           Not breathing and no pulse
S26.   Activate EMS
        Know your local EMS number
        Give the location of call
        Telephone number
        The nature of the emergency
        Advise that AED is on the scene
        Don’t hang up until dispatcher advises
S27.   Signs of Cardiac Arrest
        Unresponsive
        Not breathing
        No pulse
S28.   AEDs and Ventricular Fibrillation
        VF is the most frequent initial rhythm in sudden cardiac arrest
        VF is a useless quivering of the heart that results in no blood flow
        Defibrillation is the only effective treatment for VF
        Successful electrical defibrillation diminishes rapidly over time
S29.   Time and AEDs
        Approximately 50% survival after 5 minutes
        Survival reduced by 7-10% each minute
        Rapid defibrillation is key
        CPR helps extend survival time
S30.   Priorities and the AED
       A – Airway
       B – Breathing
       C – Circulation
       D – Defibrillation
S31.   AEDs and Personnel
        One rescuer
           - Unresponsiveness – Call 911 – Get the AED
           - Assess Breathing/Pulse
           - Attach AED
        Two Rescuers
           - #1 – Call 911/Perform CPR
           - #2 – Attach AED
        More than two rescuers
           - #1 – call 911
           - #2 – Attach AED
           - #3 – Perform CPR
S32.   Special Considerations
        Is the victim lying in water? *must move victim,
        Is the victim less than 8 years old? cannot use AED on anyone younger than 8 years
        Is victim wearing a transdermal medication patch on his or her chest? Transdermal patch?
           E.g., nicotine patch – remove the patch
        Does victim have a pacemaker or implanted defibrillator?
S33.   Operation of AED
        POWER ON the AED
        ATTACH pads
        ANALYZE rhythm
        SHOCK (if advised)
S34.   Electrode Pad Placement
        Right electrode pad
           - To the right of the breastbone
           - Below the collarbone above the right nipple
        Left electrode pad
           - Outside the left nipple, upper edge of the pad several inches below the left armpit
S35.   Effective Adherence of Pads
        Sweaty chest
           - Dry with a towel
           - DO NOT use alcohol
        Hairy chest
           - Shaving may be needed
S36.   AED Safety
          No patient contact during analysis and shock
          Warn bystanders:
           - “I’m clear”
           - “You’re clear”
           - “Everybody’s clear”
          Perform a visual inspection
          Press to shock


Additional facts to know:
 With Aspirin use, check the patients Bleeding Time
 Narcon = Narcotic antagonist
 0.3 mg epinephrine dose for anaphylaxis
 Vasoxyl = vasopressor
 Maxicon = valium antagonist
 Presyncope = warmth, sweating, feels bad, nausea, bp at baseline, tachycardia
 Late syncope = cold hands and feet, dizziness, loss of consciousness, hypotension and bradycardia
 Syncope 1st thing you do is position patient horizontal
 With syncope you give atropine to raise their blood pressure
 With possible adrenal suppression, you give a loading dose (double their daily dose), or if over 40
   mg, no supplement for minor surgery
 Adrenal insufficiency symptoms include mental confusion
 Vasodepressor syndrome = pale, cold and clammy, nausea, low bp and pulse, loss of consciousness
 Hyperventilation: Respiratory alkalosis, decreased level of ionized calcium, blood pH increases for
   severe cases treat w/Valium 5mg IM or IV
 Extrinsic Asthma seen in children
 Intrinsic Asthma develops in adults over age 35
 Asthma: Avoid use of barbiturates and narcotics, Avoid aspirin and NSAIDs, Avoid penicillin and
   bisulfites
 Administer epinephrine 1/1000 0.3mg IM
 Hypoglycemia: pale, moist skin, blood glucose values <50mg/100 ml, administer Glucagon 1m IM or
   IV
 Hyperglycemia: dry, warm skin; Kussmaul’s respirations, fruity breath odor
 IV time = 20 seconds to work
 Hypothyroidism = Myxedema in adults
 Hyperthyroid = Weight loss, tachycardia, weakness, and warm, moist skin
 Cerebral hemorrhage more severe than cerebral infarction; 80% mortality rate
 Cerebrovascular accident = sudden, violent headache, nausea and vomiting, pupils unequal in size
 Anesthetic Overdose, Genetics = Atypical cholinesterase – don’t metabolize esters
 Anesthetic overdose, Know all the maximum recommended doses
 Epinephrine contraindications: SCVD/Hypertension, cardiac arrhythmia, and active hyperthyroid
 MOA inhibitor – can’t give epi. THIS IS WRONG
 Narcan .4mg IV or IM for Narcotic OD
 Mazicon .6mg IV or IM for Valium OD
 Atropine .4 mg IV or IM picks up pulse and bp (treats bradycardia)
 Epinephrine 1/1,000 0.3cc IM for emergency mgmt of allergic reactions
   If allergic to Pen VK don’t give Amoxicillin, go w/Clindamycin oral administration
   Frequency of Angina 2-3/week = ASA 3
   Mgmt of Angina Pectoris: Position comfortably – usu. Semi-supine, administer 100% oxygen,
    administer nitroglycerin
   Nitroglycerin – exerts action in 2-4 minutes, duration of action is 30 min.
   What do you avoid giving a pregnant female? epinephrine

              Know the drugs used and dosages for the different emergencies that occur.

              Bradycardia

              Hypoglycema

              Angina will have pain in left arm just like a cardiac arrest patient.

              Allergies

           

				
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