Locale Anaesthetics Medical Emergencies

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Locale Anaesthetics Medical Emergencies Powered By Docstoc
					Medical Emergencies.

1. Locale Anaesthetics
2. Acute respiratory Obstruction

3. Emergency surgery equipment
4. Emergency drugs

5. Action of LA drugs

6. Chemical names of LA and constituents

7. Acute hypoglycaemia
8. Acute Allergic Reaction

9. Acute angina attack Medical emergencies

10. Myocardial infarction
11. Medical emergencies Acute Asthma attack
12. Vasovagal syncope

Ecosinoids 148




Indications for the use of lidocaine include:

      Topical,
      infiltration,



                                                1
      nerve block,
       ophthalmic,
      epidural and
      intrathecal anaesthesia,
      IV regional anaesthesia (IVRA)
      Treatment of serious ventricular arrhythmias (IV preparations),
       including VF (Ventricular Fibrillation) associated with cardiac arrest
      Neuropathic pain, including postherpetic neuralgia

Acidosis such as caused by wound infection

  1. Partly reduces the action of local anesthetics.
  2. This is partly because most of the anaesthetic is ionised and
  3. therefore unable to cross the cell membrane.




  Most ADRs associated with lidocaine for anesthesia relate to

      administration technique
      (resulting in systemic exposure) or
      pharmacological effects of anesthesia,
      however allergic reactions can rarely occur.




What are the names of commonly used LA solutions ?

 1.   Lidocaine
 2.   Prilocane
 3.   Mepivacaine
 4.   Articane
 5.   Bupivacaine



Q: What is the maximum safe dose of local anaesthetics?

 1. 2% lidocaine -4.4mg /kg body weight
 2. 3% prilocaine – 6 mg /kg body weight



                                                                                2
 3. 2% mepivacaine 4.4 mg bodyweight
 4. 4% Articaine -7mg /kg

Q: What are the signs and symptoms of LA over dose?
Signs
 1. restleness
 2. Agitation
 3. Pallor
 4. Sweating
 5. Respiratory distress
 6. Circulatory collapse
 7. Seizure
 8. Cynosis (In prilocaine methhaemoglobinaemia )

Symptoms
 1. Twitching of muscles
 2. Lightheadedness
 3. Palpitation
 4. Trembling
 5. Anxiety
 6. Headache

How will you treat LA overdose?
Administer oxygen
Sit upright to minimuse cerebral hypertension if head
Call emergency services
Monitor vital signs
BLS required

Q: What are the most common cause of failure of GA?

 1.   Inaccurate deposition of LA solution especially inferior alveolar nerve
 2.   Inject too deeply
 3.   Inadequate dose of anaesthesia = low concentration or volume
 4.   Buccl and lingual infiltration also use
 5.   Local infection

Q: What are the Contraindications of LA?



                                                                                3
1.  No LA in an abscess
2.  Inflammation
3.  Extremely nervous patient
4.  Ischemic heart disease –to avoid stress and pain effective LA is required
    Lidocaine with
5. Liver disease—cause excessive bleeding
6. severe liver disease – reduce dose of LA
7. Hypertension
8. Coagulation defects? ---
9. Diabetes –lidocaine with epinephrine is safe
10. Psychiatric –patients having tricyclic antidepressants could have an
    episode of hypertension if LA contains Epinephrine

What LA is good in pregnancy?

Pregnancy == lidocaine with epinephrine is drug of choice

 Q: what precaution is required for Ischemic heart disease patient?

 to avoid stress and pain effective LA is required
 Lidocaine with epinephrine is drug of choice and
 use aspirating syringe to avoid intravascular inj .
 alternative to lidocaine is citanest

Q: What precautions are required for Coagulation defects?

 1.   patient need hospital management
 2.   No block injection, as not safe
 3.   local infiltration inj is safe
 4.   intraliginemtary injection is method of choice



Q; How will you prevent LA over dose?

2.2ml cartridge of LA contains-- 44mg of drug Lidocaine
1. Therefore 1/10th of a cartridge contains-- 4.4mg lidocaine
  This means 1 cartridge-- per 10 kg body weight



                                                                            4
2. 2% lidocaine (2.2ml)
    70kg adult = 7 cartridges
    20 kg 5 year old child = 2 cartridges.

3. 2% mepivacaine 2.2ml
   70 kg adult = 7 cartridges
   20 kg child = 2 cartridges

4. 3% prilocaine 2.2ml
    70 kg adult = 6 cartridges
    20 kg child = 1.8 cartridges

5. Mepivacaine % 2.2ml plain
    70 kg adult 4.5 cartridges
    20kg 5year old = 1.3 cartridges

5. Action of LA drugs

1. Lidocaine 2% plain – poor and brief anaesthesia
2. Lidocaine 2% + adrenaline 1 in 80, 000 --- effective analgesia for >90
   min
3. Prilocaine 4% plain ---poor and brief analgesia
4. Prilocaine 3% plus felypressin 0.03IU (International Unit ) = effective
   analgesia for 90 min (Methhaemoglobinaemia.)
5. Bupivacaine 0.25% plain used for prolong nerve block – action is for 8
   hours



6. Chemical names of LA and constituents

   1. Lidocaine hydrochloride 2% with 1:80, 000 Epinephrine trade name is
      Xylocaine

   2. Prilocaine hydrochloride 3% with 0.03 IU felypressin Or 4% plain
      Trade name is citanest .

   3. Mepivacaine hydrochloride trade name is scandanest



                                                                            5
  4. Articaine 4% with epinephrine 1 :100,000 or 1: 200,000



Q: which is the most commonly used LA in UK?

 1. Lidocaine hydrochloride 2% with 1:80, 000 epinephrine
 2. Cytanest 3% with octapressin
 3. Mepivacaine less commonly used




Q: what are local anesthetics?

 1.   local anaesthetics are weak bases
 2.   combined with strong acids
 3.   to give soluble salts
 4.   salts dissolve to give ionic solution of cations and anions
 5.   LA solution is acidic
 6.   But on injection is buffered by tissue alkali

Q: How does LA work?

 1.   LA stabilizes nerve membrane
 2.   Prevent entry of Na ions into nerve fiber
 3.   Prevent depolarization of nerve fiber
 4.   And fail conduction

Q: Why is Epinephrine added?

 1. Epinephrine is a vasoconstrictor
 2. Cause local vasoconstriction
 3. Reduce absorption of LA solution and hence prolong action

What are the contents of a LA cartridge?

 1. LA agent = Lidocaine , prilocaine , mepivacaine are most commonly used
    agents



                                                                         6
 2. Vasoconstrictor = Epinephrine = prolongs anaesthesia , can cause cardio
    stimulation

 3.   Reducing agent = sodium metabisulphite is atabilizer for Epinephrine
 4.   Preservative no longer used
 5.   Buffering agent = sodium hydroxide = adjusts acidity
 6.   Sodium chloride = adjusts osmolarity
 7.   Sterile water = is carrier medium



How is LA metabolized?

LA is metabolized in liver

Q; what are the systemic effects of LA?

 1.   Drowsiness
 2.   Dizziness
 3.   Nausea
 4.   Headache
 5.   Restlessness
 6.   Small muscle twitching
 7.   CNS depression
 8.   Very high levels of LA lead to Convulsions and Death



2. Acute respiratory Obstruction

Q: What are the Causes of ARO ?

   1.   Foreign body
   2.   Food , liquid , solid object
   3.   Tongue , infection
   4.   Trauma




                                                                             7
Q: What are the signs and symptoms of acute respiratory
obstruction ?
Signs

  1.   Unable to talk
  2.   Unable to breath
  3.   Holding or pointing to throat
  4.   Flushing and changing to cynosis

Symptoms

  1.   Unable to talk
  2.   Inhale or exhale
  3.   Pain
  4.   Spasm in chest wall

How will you treat acute respiratory obstruction?

  1. Bend the person forward
  2. Or lie across knee if child series of backslaps between
     shoulders
  3. Or do abdominal thrush manoeuvre
  4. No blind sweeping of finger


Asthma

1) Patient has asthmatic attack in surgery, how will you manage?
Not relieved and progressing, what will you do then?
What medical emergency can it lead to? (status asthamaticus)
2) COPD, Asthma
3) Hypersensivity




                                                                   8
3. Emergency surgery equipment

  1. Oropharyngeal airway s No .00.1 ,2 ,3 ,4
  2. Oxygen
  3. Facemask or nasal cannula

  4.   Portable suction
  5.   Positive pressure ventilating device with 5mm oxygen tubing
  6.   (Ambu-bag+ mask + valve +bag)
  7.   Oxygen cylinder with pressure reducing valve , flow meter
       (D-size -340 litres , E-size -680 litres



4. Emergency drugs

  1. Adrenaline 1: 1000 1mg
  2. Glycerol trinitrate tab 500mcg or spray 400mcg
  3. Salbutamol inhaler = 100mcg
  4. Chlorphenamine maleate = 10mg
  5. Glucose, tabs or drink, or hypostop
  6. Hydrocortisone 100mg
  7. Chewable aspirin = 300 mg
  8. Glucagone = 1mg
  9. H2O ampules for injection
  10.      Drug information and expiry sheet
  11. 1ml & 5ml syringes
  12.      Needles 23g and 25g
  13.      Tape and plasters
  14.      Sphygmomanometer
  15.      Stethoscope
  16.      Optional= midazolam 10mg
  17.      23g and 21g cannula

                                                                 9
  18.       tourniquet



7. Acute hypoglycaemia



What are the causes of acute hypoglycaemia Causes ?

 1.   Type I an dII diabetes mellituds
 2.   Fasting
 3.   High intake of alcohol.
 4.   Hypoglycaemic drugs
 5.   Prolonge exercise
 6.   Pancreatic trauma or insulinoma
 7.   Acute hypopituitism or hypoadrenocorticism

What are the Signs of AH?
 1. Disorientation
 2. Confusion
 3. Irritability
 4. Aggressiveness
 5. Drowsiness
 6. Tremor
 7. Shaking
 8. Ketoacidotic breath

Q; What are the symptome of AH?
 1. Thirsty
 2. Sweary
 3. Clammy parasthesia
 4. Visual disturbance
 5. Tremor
 6. Pulse = bounding

                                                      10
 7. Headache

Treatment of conscious patient/
 1. Patient may have own emergency treatment regime
 2. Assist and support patient
 3. 10-25 g oral glucose
 4. Check blood glucose levels
 5. GMP followup

How much sugar should be given to a diabetic patient?
2-4 heaped tea spoon full in water
Ot 2 4 sugar cubes
1 sachet of hypostop

Q: How will you treat an unconscious patient ?

Call emergency services
Give glucagon IM, or IV




Q What is dose of Glucagon ?

Adult > 12 years = 1.0mg = 1 unit
Child < 12 years = 0.5 mg = 0.5 unit

What will you asoon as patient regains consciousness ness?

Give glucose 10 -20 g glucose

Q: What will you do if patient is not recovered?




                                                             11
Failure to regain consciousness within 10 -15 minutes require IV
dextrose 20 % - 50 %
Give oxygen
Monitor breathing, BP and pulse .




8. Acute Allergic Reaction

Q: What is the cause of AAR?
 1. Immunologic response to an agent to which the person has
    developed sensitivity
 2. During a previous exposure
 3. Mast cell de granulation and Histamine release
 4. Main symptoms are due to local and systemic effects of
    histamine .

What are the signs of acute allergic reaction ?

 1.   Urticaria
 2.   Flushing
 3.   Redness
 4.   Puffiness
 5.   Swelling
 6.   Wheeze
 7.   Stridor
 8.   Rhinitis ( swelling of the nasal mucosa.

Q: what are the Symptoms of AAR?

 1. Pruritis (itiching )
 2. Watering eyes & nose
 3. Shortness of breath

                                                                   12
Q: How will you treat a mild reaction ?

Remove allergen from patient
Give antihistamine for 24 to 48 hrs
Inform GP
Highlight in patients notes

Q: what drugs are given in AAR?

 1. Antihistamine
 2. Chlorphenamine

Q: What is the dose of chlorphenamine (Piriton ) ?

 1.   Less then 1 year --- not indicated
 2.   1-2 years 1mg bd –daily --- maximum 2mg
 3.   2-5 years 1mg qds daily maximum dose = 6 mg
 4.   6-12 years –2mg qds—daily maximum dose = 12 mg.
 5.   Over 12 years –4mg qds –daily maximum dose = 24 mg

Q: What is Anaphylaxis?

Anaphylaxis is extreme life threatening acute allergic reaction .

Q: What i causes of anaphylaxis ?

 1. Allergens e.g. nuts , sea food ,eggs , milk E numbers ,7
    addatives , some fruits, poisons ,
 2. insect bites ,
 3. industrial chemicals materials ,

                                                                    13
 4.   drugs , immunizations ,
 5.   antibiotics radiological contrast media ,
 6.   anaesthetic agents , NSAIDs, Aspirin
 7.   Plaster and dressings , latex, clothing , nickel , and plastics

Q: Signs of anaphylaxis?
 1. Same as acute allergic reaction but increased severetyand
    speed of onset
 2. Pulse = rapid and weak
 3. Tachycardia
 4. Rapidly falling BP= hypotension
 5. Initial flushing leading to pallor and cynosis.
 6. Breathing and speech difficulties.

 7. Laryngeal oedema and bronchospasm
 8. Apnoea
 9. Rapid loss of consciousness.

Q: How will you treat anaphylaxix?
Lie patient flat
Raise legs
Give oxygen
Give epinephrine 1 :1000 IM
<6months 0.05 mg
>6months - 6 years 0.125 mg
6 -12 years 0.25mg
Patients on beta blockers and TCA’s 0.25mg

Q: How often the dose repeated ?
Repeat only only once after 5 minutes if no clinical improvement



Q: How many drugs are given in anaphylaxis?

                                                                        14
Three drugs are given in anaphylaxis.
 1. Epinephrine
 2. Chlorphenamine
 3. Hydrocortisone

Q: What is the Dose of Chlorphenamine and hydrocortisone?



1. Chlorphenamine is given IM or IV
< 1 year not indicated –hospital management only
1-5 years 2.5 to 5 mg
6-12 years 5-10 mg
> 12 years 10-20 mg

2. Hydrocortisone IM or IV
<1 year 25mg
1 to 5 year 50mg
6-12 year 100
> 12 year 100- 500 mg

3. Salbutamol is given if there are respiratory symptoms

Q: What will you do next?
Monitor
Give BLS if signs of no pulse or breathing and circulation., pulse ,
Blood pressure

Air way, breathing, Circulation (ABC)

Q; Child dose of adrenaline?

0micrograms per kg body weight 1

                                                                   15
Or 0.1 ml of dilute 1 in 10,000 adrenaline injection per kg

Q; Adrenaline route of choice ?

Intramuscular is the first route of choice for the management of
anaphylactic shock

Intra venous route is used in case of wextreme emergency when
there inadequate circulation .

Q; When is epinephrine given intra venously ?

Epinephrine is only given IV when there are signs of inadequate
circulation or circulatory failure

Q; Strength of epinephrine given IV

  1. 5ml of dilute 1in 10,000 adrenaline = 500 micrograms,
  2. given 100 microgram per minute
  3. stopping when a response is achieved .

q; Adrenaline dose ?

  1.   1 in 1000 epinephrine intramuscularly
  2.   Under 1 year = 0.05ml
  3.   1 year = 0.1 ml
  4.   2 year = 0.2 ml
  5.   3-4 years = 0.3 ml
  6.   5 year = 0.4 ml
  7.   6 -12 year = 0.5 ml
  8.   Adults = 0.5 to 1 ml

Q; q; Indications of epinephrine?

                                                                  16
  1. Acute anaphylaxis
  2. Angioedema
  3. Cardiopulmonary resuscitation

Q; Cautions for the use of epinephrine or conditions where
caution is need for the administration of adrenaline?

  1.   Hyperthyroidism
  2.   Dibetes mellitus
  3.   Ischaemic heart diseases
  4.   Hypertension
  5.   Elderly

Q; Adrenaline interactions ?

  1. Patients on beta blockers may not respond to adrenaline
     injection so IV salbutamol is needed
  2. In patients taking tricyclic antidepressants cardiac
     arrhythmias can occur so reduced dose of adrenaline is
     needed.

Q; Side effects of epinephrine?

  1.   Anxiety
  2.   Tremors
  3.   Tachycardia
  4.   Arrhythmias
  5.   Dry mouth
  6.   Cold extremities

Q: Type one hypersensitivity reactions?



                                                               17
  1.   Anaphylaxis
  2.   Angiooedema
  3.   Asthma
  4.   Hay fever

Q: Type I hypersensitivity reaction mechanism ?

Free antigens ( Ag )bind to the Ig E fixed on mast cells and baso
phils causing release of histamine .



Q: Cytotoxic reactions?

Free Ig G or M antibodies bind to antigen ( Ag) on cell membrane
to cause complement activation , call damage or phagocytosis

Q: Examples of cytotoxic reactions?

  1. Pemphigus vulgaris
  2. Mucous membrane pepphigoid
  3. Idiopathic thrombocytopenic purpura.

Q: immune complexes?

Presence of Ag /Ab complexes lead to activation of complement
activation inflammation and tissue damage, which results in
arthritis and vasculitis

Q; Examples of immune complexes ?

Rheumatoid arthritis
Serum sickness
SLE = systemic lupus erthmatosis

                                                                18
Q; what is cell medicated hypersensitivity?

Is when Ag activate sensitised T-cells to become cytotoxic and
release lymphokinase, that stimulate other lucocytes .

Q; Examples of cell mediated hypersensitivity ?

  1. Contact dermatitis
  2. Graft rejection
  3. Latex allergy

Q: Anaphylaxis signs caused by chemical mediators ?

  1. Edema
  2. Acute hypotension

Q: Most common type of allergic reaction ?

  1.   Hay fever
  2.   Asthma ,
  3.   urticaria
  4.   Atopic diseases

Q; What is the genetic basis of allergies ?

Strong genetic basis = 10% of population

Q; Common allergens ?

Pollen , dust mites , mould , pet hair

Q: Common cause of hay fever ?

                                                                 19
Allergic rhinitis and asthma

Q: Immuneo pathogenesis of allergic reactions ?

  1. Allergens are attached to the dendritic cells which result in
      release of T-lymphocytes
  2. B-lymphocytes
  3. Mast cells
  4. T- lymphocytes cause release of
  5. eosinophils,
  6. mast cells
  7. which release substances
  8. neurotropins,
  9. histamines,
  10.      cytokinesand
  11. leukoterines
  12.      which are medictors of allergic reaction

Q: Immunologically mediated diseases ?

Are diseases involving immunocytes and their products.

Q: Important immunologically mediated diseases?

Immunologically mediated diseases are classified either by
mechanism or by the system they effect.

Q; Immunolocically mediated diseases classified by
mechanism?

Involve diseases whih show reaction to foreign antigens e.g.
allergic reaction s, asthma , eczema , urticaria , angioedema ,

                                                                  20
drug food allergies , latex allergy , anaphylaxis, contect
dermatitis .



Q: what are Granulomatous reactions ?

  1.   TB,
  2.   Leprosy
  3.   Syphilis,
  4.   cat scrateh,
  5.   sarcoidosis,
  6.   orofacial granulomatosis and
  7.   Crohn’s disease.

Q; What are autoimmune diseases ?

  1.   Are reaction to self antigens
  2.   Systemic lupus erythmatosus
  3.   Rheumatois arthritis
  4.   Sjogren’s syndromese
  5.   Systemic sclerosis
  6.   polymyosistis

What are immune comples diseases ?
Bechcet’s disease
Polyartritis nodosa.



VIVA QUESTIONS

34. Anaphylaxis

Q: How is allergy tested ?

                                                             21
  1. By skin testing by pricking the allergens in to the skin
     intradermally or
  2. prick testing , or
  3. patch testing

Q: 2 drugs which interfere allergy test ?
  1. Antihistamine and
  2. antidepressants

Q: laboratory test for IG E ?

  1. serum Ig E levels =
  2. PRIST test = paper radio immuno sorbent essay
  3. RAST = radio allegro sorbent test

Q: complications of skin testing ?

can induce sensitivity to the teste compound and anaphylactic
reaction can occur
Mechanism of hypersensitivity ?
First time a person is exposed to an allergen --- large amounts of
Ig E antibodies are produced
These IgE attach to basophils and mast calls
Which are plentiful in lungs , skin , tongue , lining of nose and
respiratory tract and GIT--- basophils are present in the
circulation
Mast cells are in the lining of mucous membrane
When specific allergens are encountered again
The IgE antibodies signal mast cells and basophils to release
histamine , prostaglandins , and leukoterines
Mast cells release histamine and heparine



                                                                 22
-Management of anaphylactic reactions

-Reasons for anaphylaxis, patient presentation,
Histamine released is a potent inflammatory mediator . changes
capillary permeability which results in accumulation of
exacerebated fluid in to the tissues spaces . whch results in
bronchospasm and swelling of mucous membrane .
clinical features, response of dentist and dental nurse (make sure
an ambulance is on the way!!
-Anaphylactic reaction (symptoms)
   1. wheezing
   2. sneezing
   3. runny nose
   4. runny eyes
   5. and itiching
-Hypersensitivity reaction (how many types and difference
between
type I and type II)

-Latex allergy & latex gloves?
 How common in dentistry? UK?
6% of health care workers are sensitive
-What type of allergic reaction is latex allergy?
Contact dermatitis
-How will you treat a patient comes with latex allergy?
-Treatment of anaphylactic shock
-Clinical signs of anaphylactic shock?
-How would you treat?
-How much adrenalin?
-Hydrocortisone? O2? Chlorpromine?
-On giving amoxycillin as part of the IE prophylaxis the patient
develops tingling around the mouth, rash, etc-what is happening?
(allergic reaction -hypersensitivity type 1)

                                                                23
-About hypersensitivity type 1
-what happens to the pressure due to the histamine release
(hypotension due peripheral pooling of blood)




9. Acute angina attack     Medical emergencies

What is acute angina attack ?

Restriction of bloos flow and local hypoxia of cardiac muscle

What are the causes of AMI ?

 1. Aetiology is atherosclerosis , thrombosis, respiratoryhypoxia
    , drug overdose , severe hypotension or hypovolomia
 2. Anaphylaxix or trauma

What are signs of acute angina ?

Reterosternal chest pain
Breathlessness
Nausea or faint
Pain radiating to left arem or lower jaw
Peripheral cyanosis
May be confused or anxious



What happens to pulse in aangina ?
Pulse rate increased
Pulse is weak and irregular

What are the symptoms of angina ?

                                                                24
 1.   Sweating
 2.   Thirsty
 3.   Anxious
 4.   Cold and clammy
 5.   Acute crushing chest pain
 6.   Feels faint
 7.   Nauseous
 8.   General feeling of unwell

How will you treat Traetment angina pectoris ?
Patient may have own drug regemine help and support
 1. Communication mayy be difficult
 2. Calm the patient down
 3. Good ventilation
 4. Do not lie the patient down
 5. Sit the patient on a chair
 6. Call emergency services
 7. Administer O2By mask
 8. If history of acute angina attack give sublingual spray of
     Nitro lingual spray GTN
 9. repeat 15 to 30 min
 10. Nitrous oxide given has relaxant affect will reduce the
     strain on heart
 11. Monitor pulse and respiration rate and consciousness
 12. Use Pulse oximetery

Q. What if the that angina pain persists for more than 3-5
min?
It is suggestive of myocardial infarction.

Q. What are the side effects of GTN?
Vasodilatation which results in headache and flushing.



                                                                 25
Q. What care for GTN tablets ?
GTN tablets are not photo stable.

10. Myocardial infarction

What is MI?
Myocardial infarction is occlusion of coronary arteries resulting
in cardiac ischemia

What causes MI?

 1.   Atherosclerosis,
 2.   thrombosis ,
 3.   respiratory hypoxia ,
 4.   drug overdose
 5.   severe hypotension
 6.   hypovolaemia
 7.   anaphylaxis
 8.   Trauma

Q: what are the Signs and symptoms of MI?



 1.   Acute chest pain
 2.   Breathlessness
 3.   Pain radiating to left arm or lower jaw
 4.   Rapid loss of consciousness ashen colour progressing to
      cyanosis



What happens to pulse in MI?
Pulse is irregular, weak and thready



                                                                    26
Q: How will you treat MI?
 1. Check for aspirin allergy
 2. Give dispersible aspirin 300mg once only ( check expiry date
    of tablets
 3. Monitor pulse and respiration
 4. Give O2
 5. Nitrous oxide can be helpful
 6. Prepare for CPR
 7. Call emergency services

11. Medical emergencies Acute Asthma attack

1. What is the cause of acute asthmatic attack?
 1. Allergy
 2. Infection
 3. Anxiety
 4. Stress
 5. Exercise

2. What are the signs of AA attack?

 1.   Rapid shallow breathing with > 25 breaths / min
 2.   Pulse rate > 110 /min
 3.   Peripheral cyanosis
 4.   Sweating
 5.   Noisy breathing
 6.   May be confused

3. What are the symptoms of AA?

 1. Cant breath
 2. Cant speak,
 3. Feels faint

                                                               27
 4. Tightness or pain in chest
 5. paraesthesia

4. How will you treat an asthmatic patient?

Treatment
 1. Patient may have own drug and emergency regime
 2. Assist and support
 3. Communication may be difficult
 4. Calm the patient down
 5. Well ventilated room
 6. Upright Sitting position,
 7. Use salbutamol actuator / inhaler
 8. Make DIY spacer by pushing the inhaler through the base of
    a paper cup
 9. Administer Oxygen by mask in-between medicine 10-15 times
    / min.
 10. Call emergency services if the attack does not subside with
    treatment = status asthmeticus.




5. What is Status asthmaticsus?

Patient has hypercapnia combined with tachycardia or becomes
cyanosed

6. How can we measure the oxygen levels?
By pulse oximetry if available

6. What medicine is given in acute asthmatic attack?

Hydrocortisone IM or IV

                                                               28
Salbutamol actuator

7. What is the dose of salbutamol actuator for children under
12.?

For children under 12, single dose (1 actuation) at 15 to 30
seconds intervals
Maximum 10 -20 actuations depending upon the size of patient.

8. What is the adult dose of salbutamol actuator?
 1. For adults dose is doubled 2 actuations 15 to 30 sec intervals,
 2. Up to maximum 20 actuations.
 3. Hydrocortisone IM or IV
 4. Stay with patients till emergency services arrive
 5. Prepare for BLS if signs of no breathing

Asthma
1) Patient has asthmatic attack in surgery, how will you manage?
Not relieved and progressing, what will you do then?
What medical emergency can it lead to?
(status asthamaticus)

2) COPD, Asthma

3) Hypersensivity

Q: What are “controllers”?

Controllers are medicines that prevent asthma attacks from
starting. There are two types of controller medicines –

   anti-inflammatory medicines and
   airway openers.



                                                                   29
Q; How glucocorticosteroids work in asthma?

glucocorticosteroids are Anti-inflammatory medicines work by
reducing the inflammation in the airways that occurs in asthma.

Q what is the most effective and commonly used anti-
inflammatory drugs?

Inhaled glucocorticosteroids, such as budesonide,
beclomethasone and fluticasone. These medicines help to prevent
periods of greater severity of asthma

Q: What If the inflammation is not controlled,

The airways become red, swollen, narrower and extra-sensitive.
Inflammation may lead an attack.

What Is Asthma?

 1. Asthma is a chronic lung condition.
 2. It is characterized by difficulty in breathing.
 3. People with asthma have extra sensitive or hyperresponsive
    airways.
 4. The airways react by narrowing or obstructing when they
    become irritated.
 5. This makes it difficult for the air to move in and out.

Q: What will this narrowing or obstruction cause?

one or a combination of the following symptoms:

     wheezing
     coughing
     shortness of breath
     chest tightness



                                                                  30
This narrowing or obstruction is caused by:

     Airway inflammation (meaning that the airways in the lungs
      become red, swollen and narrow)

Bronchoconstriction (meaning that the muscles that encircle the
airways tighten or go into spasm)

2. what are the Provoking Factors for asthma ?


Two factors provoke asthma:

  1. Inflammation Causes (or inducers) result in inflammation
     of the airways.
  2. Bronchoconstriction). Triggers result in tightening of the
     airways



Triggers

     Triggers irritate the airways and result in
      bronchoconstriction.
     Triggers do not cause inflammation and therefore do not
      cause asthma.
     Symptoms and bronchoconstriction caused by triggers tend
      to be immediate, short-lived, and rapidly reversible.
     Airways will react more quickly to triggers if inflammation is
      already present in the airways.
  


Q: What are the Common triggers of bronchoconstriction?

These include everyday stimuli such as:


                                                                  31
     Cold air
     Dust
     Strong fumes
     Exercise (For more information, please refer to Exercise
      and Asthma).
     Inhaled irritants
     Emotional upsets
     Smoke

     What are the Causes or Inducers of asthma?
      In contrast to triggers, inducers cause both airway
      inflammation and airway hyperresponsiveness and hence are
      recognized as causes of asthma.
     Inducers result in symptoms which may last longer, are
      delayed and less easily reversible than those caused by
      triggers.


The most common inducers are:

     Allergens
     Respiratory viral infections

Allergens

Inhalant allergens are the cause of inflammation and airway
hyperresponsiveness.

Probably 75-80% of young asthmatics are allergic.

What are The most common inhaled allergens?

inhaled allergens include:

     pollen (grasses, trees and weeds)


                                                                 32
      animal secretions (cats and horses tend to be to the most
       allergen causing)
      molds
      house dust mites

  Q: What will happen if somebody is Exposure to an allergen?

      1. It may cause immediate symptoms such as wheeze or
         cough. This occurs because airways are hyperresponsive
         and react by tightening.
      2. These symptoms can easily be relieved by a bronchodilator
         (such as Ventolin®).
      3. However, about 4 and 7-8 hours after exposure, a late
         response occurs which is caused by the inflammation.
      4. This inflammation develops over time. Because of the late
         response, it is often difficult for the patient and physician
         to identify what is actually causing the asthma

Q: What are the Respiratory Viral Infections

A respiratory viral infection is the most common causes of
asthma.

In some cases, the influenza vaccine is indicated.



Q: What are bronchodilators?

Bronchodilators are Airway openers, are medicines that help to
prevent attacks progressing by quickly opening up the narrowed
airways.




                                                                    33
Q: What are Asthma “relievers”?

Asthma Relievers – or airway openers – are medicines that
provide rapid relief from an asthma attack by quickly opening up
the narrowed airways (dilating the bronchi).

They do this by relaxing the muscles surrounding the airways,

Q: how will you treat a patient who have an Asthma attack
while at the dental surgery


 1. Most attacks will respond to 2 puffs of the patient’s short-
    acting beta2-adrenoceptor stimulant inhaler such as
    salbutamol
 2. 100 micrograms /puff (or terbutaline 250 micrograms/puff);
 3. further puffs are required if the patient does not respond
    rapidly.
 4. If the patient is unable to use the inhaler effectively further
    puffs should be given through a large-volume spacer device
    (or, if not available, through a plastic or paper cup with a hole
    in the bottom for the inhaler mouthpiece).
 5. If the response remains unsatisfactory, or if the patient
    develops tachycardia, then arrangements should be made to
    transfer the patient urgently to hospital.
 6. Whilst awaiting transfer, oxygen should be given with
    salbutamol 2.5–5 mg by nebuliser.
 7. If a nebuliser is unavailable, then 4–6 puffs of salbutamol
    inhaler or terbutaline inhaler should be given (preferably by a
    large-volume spacer device),
 8. and repeated every 10 minutes if necessary.
 9. Hydrocortisone (preferably as sodium succinate) 200 mg may
    be given by intravenous injection.


                                                                   34
 10. If asthma is part of a more generalised anaphylactic
     reaction, an intramuscular injection of adrenaline (as detailed
     under Anaphylaxis above) should be given.
 11. For a table describing the management of Acute Severe
     Asthma, see MANAGEMENT OF ACUTE SEVERE ASTHMA
     IN GENERAL PRACTICE




Q. what is the physiology of syncope? Syncope events

        1.   Pump fails
        2.   Decrease cardiac output
        3.   Decrease venous return
        4.   Increase arterial vaso dilatation
        5.   Increase carotid body reflex firing
        6.   Increase sympathetic outflow
        7.   Tachycardia
        8.   Increase blood pressure
        9.   Patient regains consciousness


1. What is Basic life support principles?

 1. BLS is treatment of all medical emergencies
 2. Use only those drugs which you are trained and competent.
 3. Ensure all surgery equipment and all drugs are safely stored
    and organised for easy access and use
 4. Regular training of all staff.
 5. Regular checkup of date of expiry of drugs.



                                                                   35
12. Vasovagal syncope

2. what is aetiology of Fainting ?

Fainting is called, vasovagal syncope
Causes are severe physical or emotional stress

3. Examples of vasovagal syncope?
Intravenous injection of Local Anaesthesia,
 1. fear,
 2. pain,
 3. starvation,
 4. dehydration ,
 5. mental illness.
 6. drug effects & interaction
 7. extremes of temperature



4. What are signs of Vasovagal S syncope?
 1. Pallor ( ashen colour )
 2. Skin Cold & moist, clammy or sweeting
 3. Pulse initially slow and week changing to rapid and full.
 4. Confusion

5. What are symptoms of VS?
 1. Premonitory dizziness,
 2. nausea
6. How will you treat vasovagal syncope?
 1. Get patient supine
 2. Preferably on floor
 3. Onside if patient is pregnant
 4. Raise legs
 5. Maintain airway

                                                                36
  6. Monitor pulse and breathing
  7. Monitor consciousness and vital signs
  8. Check for any other injury
  9. During fall
  10. If recovery is not rapid within few minutes reconsider
      diagnosis
  11. Supply oxygen
  12. Call emergency services
Syncope questions
1) Clinical signs?
2) Patient fainted in the clinic?
3) What is vasovagal attack?
4) Signs and symptoms
5) Physiological features of vasovagal syncope
Peripheral vasodilation and pooling of blood and reduced blood
supply to brain
6) Why the person should lie down?
To encourage cerebral circulation

7) Fill in the blanks on venous return.
Increase vasodilatation increases peripheral pooling of blood with
decreased blood to vital organs heart (as decreased venous
return ) and brain
8) Management.
Lie the patient flat raise legs , good ventilation

9) Which nerve is involved in bradycardia?
Vagus
10) A young patient that comes to your clinic suddenly loose
consciousness. Possible cause and your management.
Fear of needle results in extreme emotional stress and fainting




                                                                 37
Q: What will happen to his pulse, first its weak and slow
changing to full and rapid (due to increase production of cortisole
to cop with stress)

Q: What will happen to blood pressure?
Hypotension
Q: When will the patient return his consciousness?
After a few minute.

Q: What will happen to his pulse and pressure now?
Pulse and BP will come to normal.

11) In case of Shock what will happen to pulse and pressure?

12) What 3 conditions should be treated in emergency if the
patient collapses?
ABC= Airway , Breathing , circulation

13. Patient has chest pain in dental chair and not resolved with
GTN and patient collapses?
Myocardial infarction.

What are the six steps you will carry out immediately?



14) Patient collapses in your dental chair while doing treatment:
4 reasons?
Vasovagal syncope
Hypoglycaemia
Acute Adenocortical insufficiency.



4 drugs to manage the emergency?

                                                                    38
Oxygen
Glucagons or (Glucose solution hypostop)
Aspirin
1. Emergencies
1) Define shock:
(A) 2 causes of hypovolaemic shock other than hemorrhage
(B) 3 reflexes in shock. 10 marks
2) Simple faint – How does recovery occur?
3) Emergency drugs and dosages
4) Faint fit




Anaphylaxis
1) 2 early features
2) Heaf test… which type
3) Clinical signs of anaphylactic shock?
4) How would you treat?
5) How much adrenalin?
6) Hydrocortisone? O2? Chlorpropamide?
7) Clinical signs- heart rate and pulse volume?
8) Treatment of anaphylaxis (anaphylactic shock).
9) 2 examples of substances used in dental surgery, which can
cause anaphylaxis.
10) 2 accessory drugs that are used in treatment of anaphylaxis.
11) Hypersensitivity reactions. Descriptions of types of
hypersensitivity reactions were given. Match type 1 to type 4.
12) Compare facial features in anaphylaxis, fainting

Respiratory obstruction
1) Signs of foreign body aspiration.
2) To which main bronchi can objects from the mouth fall?
3) Methods to prevent it

                                                               39
4) Foreign body falls to back of throat –management-

Respiratory depression
-Management of midazolam overdose causing respiratory
depression?

Hyperventilation
1) What is physiology of hyperventilation? why does difference in
calcium ion concentration change?
2) What is physiology behind dizziness?

SIGNS AND SYMPTOMS
1) Xerostomia, everything about it
2) Headaches




The drugs referred to in this section include:

Adrenaline Injection (Epinephrine Injection), adrenaline 1 in 1000,
(adrenaline 1 mg/mL as acid tartrate), 1-mL amps

Aspirin Dispersible Tablets 300 mg

Chlorphenamine Injection (Chlorpheniramine Injection),
chlorphenamine maleate 10 mg/mL, 1-mL amps

Diazepam Injection, diazepam 5 mg/mL, 2-mL amps

Glucagon Injection, glucagon (as hydrochloride), 1-unit vial (with
solvent)

Glucose Powder

                                                                     40
Glucose Intravenous Infusion, glucose 20% (200 mg/mL), 500-mL
pack or glucose 50% (500 mg/mL), 50-mL prefilled syringe

Glyceryl Trinitrate Tablets and Sprays

Hydrocortisone Injection, hydrocortisone 100 mg (preferably as
sodium succinate vials with 2-mL solvent)

Oxygen

Salbutamol Aerosol Inhalation, salbutamol
100 micrograms/metered inhalation

Salbutamol Injection, salbutamol (as sulphate)
500 micrograms/mL, 1-mL amps



OFFICE EMERGENCIES

RUSSELL A. SPINAZZE DS



OFFICE MEDICAL EMERGENCIES

RUSSELL P. SPINAZZE DDS

AIRWAY OBSTRUCTION

     Correct position of tongue and mandible
     Assess for foreign bodies
     Suction oral-pharynx
     Trans-tracheal catheter ventilation, temporary measure
      until a permanent airway can be established
     If all methods are exhausted and the patient is


                                                               41
     deteriorating, proceed to cricothyrotomy and/or
     tracheostomy.

SURGICAL CRICOTHYROIDOTOMY

    Patient in supine position with the neck in neutral position.
    Palpate the thyroid notch, cricothyroid interval, and the
     sternal notch.
    Surgically prepare the site and anesthetize.
    Stabilize the thyroid cartilage with the left hand.
    Make transverse incision over the cricothyroid membrane.
    Incise through membrane.
    Insert scalpel handle into the incision and rotate 90
     degrees to open the airway.

SURGICAL CRICOTHYROIDOTOMY

    Insert an appropriate sized, cuffed endotracheal tube or
     tracheostomy tube into the cricothyroid membrane incision,
     directing the tube distally into the trachea.
    Inflate cuff and ventilate patient.
    Secure tube.

COMPLICATIONS OF SURGICAL CRICOTHYROIDOTOMY

    Asphyxia
    Aspiration
    Cellulitis
    Creation of a false passage into the tissues
    Subglottic stenosis or edema
    Laryngeal stenosis
    Hemorrhage or hematoma formation
    Laceration of the esophagus
    Laceration of the trachea


                                                                     42
    Mediastinal emphysema
    Vocal cord paralysis, hoarseness

LARYNGOSPASM

    Laryngospasm may be defined as a protective reflex that
     prevents foreign matter from getting into the larynx,
     trachea and lungs.
    The classic signs and symptoms of a laryngospasm have
     been described as increased ventilatory effort
     accompanied by an increasing difficulty in exchanging air.
    With a partial spasm, a "crowing" sound will be heard, but
     with complete spasm, no sound will be present.

LARYNGOSPASM

    Nasal mask with 100% oxygen.
    Suction the oral pharynx.
    Pack the surgical site.
    Draw tongue and mandible forward.
    Attempt to break the spasm by ventilation patient with full
     face mask and 100% oxygen.

LARYNGOSPASM
Treatment

    If mechanical ventilation is not successful, succinylcholine
     10 mg IV, if given early in the course of the spasm, will
     probably be adequate to stop it.
    In complete spasm or for heavy, barrel-chested patients, or
     patients with respiratory problems, larger doses of
     succinylcholine, 20 to 40 mg IV, should be given. Adequate
     hand ventilation will be required until the patient is able to
     spontaneously breathe.


                                                                  43
    Laryngospasm may also be broken in 1-2 minutes by the IM
     injection of succinylcholine of 4 mg/kg.
    A laryngospasm may be prevented by deepening the
     anesthesia at the first sign of symptom; however, once the
     spasm has actually occurred, it is usually better not to
     deepen the anesthesia.

LARYNGOSPASM
Treatment

    Succinylcholine, if administered for laryngospasm, can raise
     levels of potassium. Hyperkalemia can result in cardiac
     arrhythmias, such as severe bradycardia, leading to cardiac
     arrest.

    When administering succinylcholine, the heart rate must be
     carefully monitored.



    Pulmonary edema following laryngospasm, is a potential
     sequella and the post anesthetic monitoring may have to be
     extended, depending on clinical circumstances.

BRONCHOSPASM

    Bronchospasm may be defined as a generalized contraction
     of the smooth muscles of the bronchi and the bronchioles
     resulting in a restriction in the flow of pulmonary gases.
    This is usually accompanied by edema of the bronchial
     mucosa.
    Bronchospasm is an acute respiratory emergency demanding
     prompt treatment.
    Bronchospasm requires combined drug therapy and



                                                                44
      respiratory support.

BRONCHOSPASM

     With the onset of bronchospasm, there is an immediate
      impairment of respiratory exchange.
     Auscultation of the chest reveals an inspiratory and
      expiratory wheeze, often audible without a stethoscope.
     Positive-pressure ventilation treatment is not usually
      sufficient to increase oxygenation and is met with
      increased pulmonary resistance.
     The thoracic cage is fixed during the inspiratory effort and
      the patient usually becomes cyanotic.

BRONCHOSPASM
Treatment

     Bronchospasm demands immediate control of the airway
      with full face mask and positive pressure oxygen to
      minimize hypoxia and hypercarbia.
     Isoproterenol mist (Isuprel): 1-2 puffs (0.13mg/puff) with
      2-5 in between puffs
     Albuterol (Ventolin): 1-2 puffs (90 ug/puff)
     Epinephrine, 5 cc of 1:10,000 dilution IV
     Aminophylline, 50 mg/min IV
     Proceed with intubation if respiration is still impaired

How to Perform an Emergency Tracheotomy

This procedure, technically called a cricothyroidotomy, should be
undertaken only when a person with a throat obstruction is not
able to breathe at all-no gasping sounds, no coughing-and only
after you have attempted to perform the Heimlich maneuver
three times without dislodging the obstruction. If possible,


                                                                   45
someone should call for paramedics while you proceed.

What you will need

     A first aid kit, if available
     A razor blade or very sharp knife
     A straw (two would be better) or a ballpoint pen with the
     inside (ink-filled tube) removed. If neither a straw nor a
     pen is available, use stiff paper or cardboard rolled into a
     tube. Good first aid kits may contain "trache" tubes.

There will not be time for sterilization of your tools, so do not
bother; infection is the least of your worries at this point.




                                 Find the indentation
                                 between the Adam's
                                 apple and the Cricoid
                                 cartilage.




                                 Make a half-inch
                                 horizontal incision about
                                 one half inch deep.




                                                                    46
                                 Pinch the incision or
                                 insert your finger inside
                                 the slit to open it.




                                 Insert your tube into
                                 the incision, roughly
                                 one-half to one inch
                                 deep.



How to Proceed

  1. Find the person's Adam's apple (thyroid cartilage).
  2. Move your finger about one inch down the neck until you
     feel another bulge. This is the cricoid cartilage. The
     indentation between the two is the cricothyroid membrane,
     where the incision will be made.
  3. Take the razor blade or knife and make a half-inch
     horizontal incision. The cut should be about half an inch
     deep. There should not be too much blood.
  4. Pinch the incision open or place your finger inside the slit to
     open it.
  5. Insert your tube in the incision, roughly one-half to one
     inch deep.
  6. Breathe into the tube with two quick breaths. Pause five
     seconds, then give one breath every five seconds.
  7. You will see the chest rise and the person should regain
     consciousness if you have performed the procedure
     correctly. The person should be able to breathe on their

                                                                  47
own, albeit with some difficulty, until help arrives.




                                                        48

				
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