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Medical Emergencies Simplified 2009Iowa by bxk16778


									          Medical Emergencies
                                                                      James Q. Swift DDS
            Iowa Dental Association
              2009 Annual Session                                                    Professor and Director
                                                                            Division of Oral & Maxillofacial Surgery
                                                                                    University of Minnesota

Update on Medical Emergencies-                          Personal Experience-Recent
What has changed?                                       Report of Event
• Universal presence of AEDs, LMAs                      • Anaphylaxis
                                                          –   Dermatologist Southern CA
• Use of simulation clinic training to manage medical     –   Vein procedure
  emergencies                                             –   Local without VC
                                                          –   Throat swelling
• Use of phentolamine to reverse effects of local         –   No epi, no 911
  anesthetics                                             –   Without oxygen/anoxic for 16-19 minutes
• Changes in CPR protocol                                 –   Anoxic encephalopathy
                                                          –   Life support withdrawn
• Administration of aspirin for acute chest pain

Objectives                                              Objectives

• Identify the most frequent medical                    • Recognize the occurrence and the treatment
  emergencies                                             of the most common medical emergencies
• Know the most important drugs needed to               • Interactive problem based learning
  treat medical emergencies occurring in the
  dental office
• Identify the situations most likely to lead to a
  medical emergency
What do you need to treat medical emergencies in
the dental environment in 2009?

• Knowledge of
  – Basic life support and CPR
  – Basic information on medical emergency management
• How to contact EMS and average arrival times
• Team training and practice

University of Minnesota
                                                        Past Experiences…..
Emergency Response
• Review of past experiences                            • In the past 19 years at the University of
• New medical emergency protocol                          Minnesota School of Dentistry, there has not
• SOD First Response                                      been a death of a dental patient undergoing
  – Responsibilities
                                                          treatment in our clinics
  – Medical emergency kits
• Most common medical emergencies and
Past Experiences….                                            Past Experiences….
• Calling both 4-6133 and 911                                 • A person walks inside the Delaware Street
• Running up or down the back stairs to get help                entrance to the School of Dentistry, tells
• The attending faculty disappearing act                        bystanders that he has chest pain
• “Could you send someone to check out our                    • A dental patient complains of double vision
  patient….”                                                    and dizziness
• Telling the patient to go to the Emergency                  • An asymptomatic dental patient has a blood
                                                                pressure of 212/70

                                                              Keys to Manage Medical
Past Experiences…..
•   Chest pain                                                • Accurate and complete medical history
•   Insulin reaction-hypoglycemia-blood sugar 30 gm/dl
•   Trouble breathing, short of breath
                                                              • Treatment modification
•   Syncope-diminished consciousness, loss of consciousness     – Consultation with medical provider
•   Stress reaction- “patient upset about bill”                 – Morning appointments
                                                              • Prevention
                                                                – Managing stress/ anxiety
                                                                – Extra measure of caution

Keys to Manage Medical
                                                              Basic Life Support-2 Steps
• Recognition                                                 • Primary ABCD Survey
    – Identify that there is a problem                          – A-Airway management with non invasive
    – Diagnosis may not be important                              technique
• Management                                                    – B-Breathing with positive pressure ventilation
    – Primary management is basic life support                  – C-Circulation-perform CPR until an AED is
                                                                  brought to the scene
    – Application of emergency medications
                                                                – D-Defibrillation
• Follow up
Basic Life Support-2 Steps                                                   CPR BLS
• Secondary ABCD Survey                                                      • 100 compressions per minute
   – A-Advanced airway with tracheal tube or LMA
   – B-Breathing-check tube placement-PPV through tube                       • 30 compressions/ 2 breaths
   – C-Circulation
       • Peripheral IV                                                       • Lay vs. health care worker
       • ECG leads
       • Rhythm based medications
   – D-Differential Diagnosis-search for, find and treat reversible causes

Potential for Disaster-Drug
                                                                             Potential for Disaster
Administration in Dentistry
• Local anesthetic                                                           • Latex allergy
   – Amide solution-overdose/toxicity vs. allergy                            • Stressing a medically compromised patient
   – Vasoconstrictor-Cardiac effects
• Antibiotic
   – Penicillin like drugs-allergy
• Analgesic
   – ASA, NSAIDs-allergy

An Office Plan for Management of
                                                                             Airway Management Objectives
Medical Emergencies
• Definitive procedure listed in office manual                               • Airway issues and concerns
   – Role assignments-everyone involved!                                        – Is the patient able to breathe or move air
   – Responsibilities                                                           – Is the patient attempting to breathe or move air
       •   CPR-monitor                                                       • Support of Airway
       •   Preparation of emergency medications
                                                                                – Patent airway
       •   Notification of emergency medical system
       •   Chart notations                                                   • Support of Ventilation
             – Immediate                                                        – Respiratory effort
             – Delayed-full account of event                                    – Positive pressure ventilation
                           Systematic Approach to Airway
Oxygen- E cylinder         Management

                            • Recognize airway obstruction
                                    • Look
                                    • Listen
                                    • Feel
                            •   Clear the airway
                            •   Reposition the patient
                            •   Mask Ventilation
                            •   Temporary, definitive, and surgical airway placement

                            Airway Examination-Mallampati Classification

Supraglottic Obstruction
Systematic Approach to Airway   Mask Ventilation
• Reposition of the Patient
                                • Can deliver high FI O2
                                • Avoids intubation trauma
                                • Does not protect against
                                • May result in gastric
                                • Laryngospasm can occur
                                • Requires use of both hands

                                  Temporary Airway- Laryngeal Mask Airway (LMA)
                                                                Scope of the Problem

                                                                • 350,000 deaths due to cardiac arrest yearly
      Rationale for AEDs in the
                                                                   – 1000 lives lost per day
            Dental Office                                          – 220,000 die before reaching the hospital
                                                                • Survival rates for performing basic CPR
                                                                  reported to be between 0% and 6%

Ventricular Fibrillation                                        Early Defibrillation

• Electrical activity of the heart becomes                      • Survival rate increases to 31%
  “disordered”                                                  • May save up to 300 lives per day
• Ventricles contract in a rapid unsynchronized                 • Estimated 2000 lives saved by early
  manner                                                          defibrillation
• Heart no longer effective pump                                • First inflight AED save 1998
• Can be converted with a defibrillator                         • Prior treatment protocol “precordial thump”

                                                                “Airlines must install defibrillators”
AED Efficacy Data                                               USA Today, 4-13-01

• Quantas Airlines                                              • Federal Aviation Administration Ruling, to be completed in
                                                                  3 years
  – 1991-all international terminals and 55                     • Only on aircraft carrying at least one flight attendant and
    international routes                                          with payload capacities of more that 7,500 lbs
  – 64 months-46 cardiac arrests                                • Includes oral antihistamines and an intravenous
                                                                  administration kit
     • 27 on aircraft                                           • AA installed in 1996, estimates 12 lives saved
        – 6 witnessed, 5 defibrillated (38 seconds avg. time)
     • 19 in terminals
     • Success with VF in 16 of 17 cases in terminals
                                                               Medical Emergency

Medical Emergency Kit
Essential Components
• Medications                 • Equipment
  –   Oxygen                    – Airway support
  –   Epinephrine 1 mg             •   Ambu bag and mask
                                   •   Pocket mask
  –   Nitroglycerine 0.4 mg
                                   •   O2 triggered device
  –   ß-2 Agonist inhaler
                                   •   Laryngeal mask airway
  –   Sugar source              – Blood pressure cuff
  –   Aspirin 325 mg            – Stethoscope
  –   Antihistamine
Other Drug Options                   Other Ancillary Equipment

• Diphenhydramine (Benadryl) 50 mg   •   AED
• Hydrocortisone 100 mg              •   IV catheters, fluids
• Naloxone 0.4 mg vial               •   Syringes and needles
                                     •   A notepad
                                     •   Oral airways, nasal airways
                                     •   PPV

Optional Components- Emergency
• Diazepam (10 mg injectable)
• Diphenhydramine (Benadryl 50 mg
• Morphine (4 mg injectable)
• Dextrose (injectable)
• Aminophylline (injectable)


                                     • A loss of consciousness secondary to
       Most Common Medical             extreme stress and anxiety
           Emergencies               • Primarily an autonomic nervous system
                                         – Not voluntary or conscious control
                                         – Patient or doctor cannot reverse but can halt or
Syncope-Autonomic Response to Stress
                                                  Vasovagal Syncope

• Primarily sympathetic   • Dilation of bronchi   • Most common related to injections in younger individuals
• Increased heart rate    • Peripheral            • Parasympathetic response often followed by sympathetic
                                                    response secondary to anxiety
• Increased cardiac         vasoconstriction
                                                  • Warm feeling, pale, diaphoresis, “feeling faint or sick,”
  output                  • Purposeful action       nausea, bradycardia, hypotension, tachycardia, LOC
• Dilation of pupils      • Fight or flight
                          • Takes 30 seconds to

• Inhibition of heart rate by vagus nerve         •   Identify
• Decreased cardiac output                        •   Oxygen
• Response complete in 1 second                   •   Aromatic spirits
                                                  •   Consider nitrous oxide/oxygen
                                                  •   Avoid
                                                      – Alcohol
                                                      – Head between the legs

                                                  Management: Vasovagal
                                                  Presyncope/ Syncope
• Always assume that sudden
  unconsciousness represents cardiac
  arrest until proven otherwise
• Supine position
• Airway patency maneuver-basic life support
  if unconscious
• Emesis maneuver
                                                                       Trendelenburg Position
Maladaptive Stress Response                                 Hyperventilation

• Overwhelming stress without hope                          • “Behavioral breathlessness”
• Adaptive stress response becomes                          • “Psychogenic dyspnea”
  maladaptive                                               • Affects 6% of US population
• Possible death                                            • Decrease of CO2 in blood, results in
• When seen in older higher medical risk                      respiratory alkalosis (increase in pH)
  patients, may proceed to life threatening                 • Hypocalcemia
  emergency sooner or more frequently


•   Anxiety                     •   Circumoral numbness
•   Hyperpnea                   •   Tingling extremities
•   Lightheadedness             •   Tetany
•   Paresthesias                •   Unconsciousness (very

Hyperventilation-Treatment                                  Seizures
•   Reassurance                                             • Seizures are very frightening
•   Slow breathing                                          • Death from seizure is exceedingly rare
•   Model breathing                                         • Highest incidence of unexpected event is in patients with
•   Bag breathing                                             diagnosed seizure disorder
•   Pursed lips                                             • Do not occlude the airway
•   Breathe through one nostril                             • Do not put yourself at risk
•   Manage unconsciousness with basic life support
Seizure                                             Seizure

• Aura-prodrome                                     • Post ictal
• Ictal phase                                           – Disorientation, confusion, amnesia
    – Rigidity                                          – Somnolence
    – Cyanosis                                          – Guilt
    – Cheek or tongue biting
    – Urinary/fecal incontinence
    – Loss of consciousness

Seizure-Management                                  Seizure-Management

• Patient positioning so as to not injure self or   • Benzodiazepine-Diazepam 5-10 mg IV or IM
  others                                            • Start IV
• Airway maintenance for patency                    • Manage post ictal phase with basic life
• Vital signs                                         support
• “Ride it out”                                     • Check in with patient’s physician

Hypoglycemia                                        Hypoglycemia-Treatment

• Diminished cerebral function                      •   Oral carbohydrates
    – Confused                                      •   IV carbohydrates
    – Semi conscious
                                                    •   Call for EMS if not resolving
•   Hunger with nausea
                                                    •   Allow patient recovery
•   Sweating
•   Tachycardia
•   May progress to unconsciousness or seizure
Hypoglycemia-Management                            Postural Hypotension

• If unconscious                                   • Signs and Symptoms
    – Perform BLS                                     – Poor physical condition
    – Call for EMS                                    – Obesity
    – Administer carbohydrate                         – Medications
       • IV-50% dextrose                              – Prolonged spine position
       • IM-Glucagon/Epinephrine                      – Not precipitated by stress

Postural Hypotension-Management                    Anaphylaxis

•   Position patient supine                        • Develops after re exposure to a sensitizing antigen within
•   Airway maintenance                             • Hypersensitivity reactions mediated by IgE and IgG4
                                                     subclass of antibodies
•   Slowly elevate patient                         • Some may be mediated by complement (allergic reactions
•   Monitor                                          to blood products)
                                                   • Annual incidence unknown
•   Can detect by dialogue history                 • Fatal incidence 154 per million hospitalized patients per

Anaphylactoid Reactions                            Etiology

• Look exactly the same as anaphylaxis             • Insect stings
                                                   • Drugs
• Not mediated by antigen-antibody reaction           – NSAIDs, ASA, PCN
                                                   • Food
• Manifestations are so similar to anaphylaxis        –   Milk
  that distinction is unimportant in relation to      –   Eggs
  treatment of an acute attack                        –   Fish
                                                      –   Shellfish
                                                      –   Peanut and tree nut
Signs and Symptoms                                     Signs and Symptoms

• Chemical release of mediators from mast              • Upper airway (largyngeal) edema, lower airway edema
                                                         (asthma) or both
  cells                                                • Cardiovascular collapse-absolute (intravascular volume
   – Vasodilation                                        loss) and relative (vasodilation) hypovolemia
   – Increased capillary permeability                  • Urticaria, rhinitis, conjunctivitis, abdominal pain, vomiting,
                                                         diarrhea, and sense of impending doom
   – Airway constriction
                                                       • May be flushed or pale
   – Hypotension
   – Bronchospasm
   – Angioedema

Differential Diagnosis                                 Differential Diagnosis

• Common missed diagnoses                              • Hereditary angioedema
   – Vasovagal reaction, panic attack                     – Severe abdominal pain, respiratory mucosal
• Angioedema/urticaria                                      edema, airway compromise

• Scombroid poisoning                                  • ACE inhibitors
   – Develops within 30 minutes of eating spoiled         – Reactive angioedema of the upper airway
     tuna, mackerel or mahi-mahi-treated with          • Panic disorder
     antihistamines                                       – Functional stridor

Anaphylaxis-Key Intervention                           Severe Allergic Reaction
• Position-comfort
• Oxygen                                                                                 epinephrine 1:1,000
• Epinephrine if there is clinical signs of shock,                                           – 0.3 - 0.5 mg IM/ SC
  airway swelling or definitive breathing difficulty                                             repeat every 5-10 min if no
• Administer IV epi if there is vascular access                                                    improvement
  available and the episode is profound and life
  threatening                                                                                – small child 0.1 - 0.2mg
                                                                                             – older child 0.2 - 0.3mg
Other interventions
• Antihistamines-IV or IM 25 mg diphenhydramine
• H2 blockers (cimetidine 300 mg PO or IM or IV)
• Isotonic solutions (NS) for hypotension
• β-adrenergic agent if bronchospasm is present
• Corticosteroids-high dose, effects delayed for 4-6
• Recurs within 1-8 hours in up to 20% of patients

                                                       Mild Allergic Reaction

                                                                                   • diphenhydramine
                                                                                     (Benadryl) 50 -
                                                                                     100mg IV/PO/IM
                                                                                   • repeat every six

Severe Allergic Reaction-
                                                       Acute Asthma
• Inject 0.3 mg epi         • Repeat epi as            • Stress is most frequent cause of asthma
  submucosal, IV or IM        necessary                  attack
• Oxygen                    • Call for EMS if
                                                       • Wheezing is presenting symptom
• Consider inhaler            refractory to epi
                            • BLS if necessary         • Patient at risk usually easily identified with
• Consider antihistamine
                                                         medical history
Severe Asthma                                     Preventing Arrest

• Cardiac arrest linked to severe                 • Oxygen
  bronchospasm and mucous plugging                • Nebulized β2 agonists
• Cardiac dysrhythmias due to hypoxia             • Intravenous corticosteroids (125 mg of
• Most deaths occur outside of the hospital         methylprednisolone)
• Present to ED at night 10 greater than in       • Intravenous aminophylline

Acute Asthma-Management                           Chest Pain

•   Inhaler-Beta 2 agonist                        • Angina pectoris
•   Repeat inhaler as necessary                   • Myocardial infarction
•   Oxygen
•   Consider aminophylline 5 mg/kg slowly
•   Consider epinephrine 0.3 mg IM,
    submucosal or IV

Chest Pain                                        Chest Pain

• When chest pain occurs, diagnosis is            •   Oxygen at 4 L per minute
                                                  •   Nitroglycerin 0.4 mg spray
  myocardial infarction (death of a portion of    •   Aspirin 160-325 mg
  heart muscle) until proven otherwise            •   BLS, vital signs
• Nitroglycerin is a diagnostic and therapeutic   •   Stress reduction, reassurance
                                                  •   Repeat Nitroglycerin up to 3 doses
                                                  •   If pain unrelenting, diagnosis is MI
• Any change in status of priorly occuring        •   Morphine IV if pain not relieved by NTG
  chest pain very significant
                                                      Stroke Treatment and Brain Oriented
Myocardial Infarction
                                                      Intensive Care
•   Basic life support                                • Cincinnati Prehospital Stroke Scale
•   Oxygen, vital signs                                 – Facial Droop
•   Call for EMS as soon as possible                    – Arm Drift
                                                        – Abnormal Speech
•   AED if available
•   Pain and anxiety relief
•   Transport

General Management of Acute
Stroke Patient
•   IV Fluids              Avoid D5W and load         • The oral health care provider has an
•   Blood sugar            Determine and treat          obligation to manage medical emergencies
•   Thiamine               100mg if malnourish
                                                        in the dental environment
•   Oxygen                 Pulse oximetry
•   Acetaminophen If febrile                          • As with anything else we do, constant
•   NPO                    If at risk of aspiration     attention to the potential of calamity will
                                                        provide us with more consistent and reliable

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