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Medical Risk Assessment for DentistsMedical Emergencies in the Dental
Office
Matthew J. Dennis, D.D.S.
University of Florida College of Dentistry
Department of Oral and Maxillofacial Surgery and Diagnostic Sciences
Medical History for Dental Patients
WHY DO YOU DO IT???
WHY DO YOU CARE???
Medical Risk Assessment
Dentists take medical histories on their dental patients to perform medical risk assessment.
What is that???
Medical Risk Assessment
Allows you to predict how well a patient will tolerate a proposed treatment
Allows you to predict and prepare for medical emergencies
Allows you to prepare a treatment plan appropriate to the medical status of the patient and suggests modifications to planned treatment necessitated by the patient’s medical status
Allows you to predict complications and prepare strategies to avoid them
Medical Risk Assessment
Universally employed in medicine, surgery and anesthesiology
ASA Physical Status Classification
ASA I: no systemic disease; healthy ASA II: mild systemic disease ASA III: severe systemic disease that limits
activity; not incapacitating ASA IV: Incapacitating disease; constant
threat to life ASA V: Moribund; <24 hrs to live “E” prefix denotes emergency surgery
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Dental Treatment
Creates some level of physiologic and psychological response to the intervention that you deliver to the patient
Creates stress, both physiologic and psychological
Dental Treatment Stress Curves
Stress Tolerance
Young and healthy: good stress tolerance
Aging population, increased survival of patients with multiple medical problems, increased use of immunosuppressive therapy: poorer stress tolerance
Stress
What is it???
Stress
Complex state of physiologic reactions
Reflex withdrawal
Central stimulation (amygdala, hypothalamus, pituitary)
ACTH, thyroid stimulating hormone
Cortisol release
Autonomic nervous system activation
Stress
Catecholamine production- alpha (increased peripheral resistance) and beta effects (increased HR and force of contraction)
Increased BP and cardiac work (and oxygen consumption)
Blood flow shunting to facilitate fight or flight A form of exercise that may present a
significant physiologic challenge to some pts.
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Hypothalamic-Pituitary-Adrenal Axis Stress and Dental Treatment
Will your dental treatment produce any of the previous features of the stress response?
If so, how will the patient tolerate and respond to it?
Taking the Medical History
Every item in the history should have significance for you
Every “yes” requires a consideration of the consequences of proceeding with treatment
Red flags
“Yes” answers on the medical history are like raised red flags
The overriding question you must answer before proceeding with treatment on a patient with a raised red flag is:
“IS IT SAFE?”
Is it safe to work on a patient with the raised red flag?
If the flag indicates a condition that is medically treated and controlled and won’t significantly affect treatment, then you can dismiss the item in your mind and proceed.
If the flag indicates a poorly controlled condition or one that presents risk….
You must weigh the risk and justify why you are proceeding with treatment despite the red flag.
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Safe
Controlled hypertension, medically monitored
BP normal today
Pt taking meds
Proceed, keeping in mind potential risk of postural hypotension and drug interactions
Unsafe
“Heart disease” checked on med history form History of unstable angina No current medical monitoring Poorly compliant with medications Dental plan: multiple extractions
Do not proceed until medically worked up and cleared!
Your Responsibilities as a Dentist:
Know enough about the common medical problems patients present with to determine if it is safe to perform dental treatment on that patient
Get advice or help from medical or dental colleagues if you are unable to make reasonable risk assessments yourself
The Good News
There is a finite number of medical conditions you need to know
The material can be easily mastered by the general dentist
You don’t have to be an internist to do dentistry!
Once mastered, it takes seconds to process the information in your mind
Can we stick our head in the sand and make it all go away?
No! Patients are getting older, sicker, on more meds The dental-systemic connection is here to stay Patients expect a high level of medical expertise
from their dentist! Dentists have responsibility for the medical effects of
dental care The first two years of dental school had to be for
something!
HEART DISEASE
5 major categories:
Ischemic heart disease
CHF
Arrhythmias
S/P MI
Valves, murmurs, malformations
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Ischemia-Angina
Angina=Chest pain caused by cardiac ischemia Blood supply can’t meet metabolic demand Is angina stable or unstable? Stability relates to changes in the pattern, intensity,
conditions when it occurs, number of NTG to achieve relief. Unstable refer immediately.
Don’t let hypertension or tachycardia occur. Tachycardia bad because work is increased, cardiac filling occurs during diastole which is shortened by rapid heart rate
ANGINA PECTORIS
1. Stable or unstable? 2. Have Nitroglycerin available. Consider premed
with NTG 3. Consider supplemental O2 4. Ensure profound local anesthesia 5. Consider use of N2O sedation 6. Monitor vital signs closely. Avoid tachycardia 7. Limit epinephrine to 0.04mg (4cc of 1:100,000) 8. Maintain verbal contact with patient 9. Consider physician consult
Angina Attack in Office-Stable Angina
Treatment:– Oxygen 4L mask or cannula
– Vital signs
– NTG SL if systolic BP>90
– Repeat NTG in 5 min if no relief; Summon help; nonenteric ASA 325 mg chew
Angina Attack In Office-New Onset
Rapid assessment critical; Treat as possible MI; Activate EMS
Oxygen 4L mask or cannula Vital signs NTG SL if systolic BP>90 Morphine or other narcotic analgesic ASA 325 nonenteric chew (MONA)
Epinephrine
Epinephrine 10ug/cc, 18ug/carpule, 36ug/2carpules.
Endogenous epinephrine: Could be 200 ug from adrenal glands directly into vascular system.
Congestive Heart Failure-CHF
“Pump” failure. Pulmonary and/or venous congestion.
Usually indicates serious, chronic cardiovascular disease
Orthopnea, PND, ankle edema
Positioning
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CONGESTIVE HEART FAILURE
Confirm patient is feeling good for appt.
Defer treatment until medically improved, if possible
Consider supplemental O2
Avoid supine position
Keep appointments short, if possible
Congestive Heart Failure
Treatment:
a. Must treat underlying cause
b. Stress control, oxygen
c. Seat patient in upright position
d. Transport asap
Arrythmias
Normal rhythm determined by SA node conducting through atria to AV node, down bundle of His, to right and left bundle branches and into Purkinje fibers and ventricular muscle.
Rates of intrinsic pacemakers: SA: 70, AV: 40-60, ventricular: 30.
Arrhythmias
Fibrillation-chaotic electrical activity with no effective pumping action
Ventricular-must defibrillate. Depolarizes all cells at once so dominant pacemaker takes over.
Patients with implantable defibrillators have probably had life-threatening arrhythmias
Atrial Fibrillation
Loss of atrial output “atrial kick”
May be asymptomatic until stressed
Anticoagulation common (warfarin) due to blood pooling in atria
Pulses “irregularly irregular” -can be diagnosed by taking a pulse
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Arrhythmias
A ventricular impulse may cause a PVC, a common finding
Epinephrine may sensitize myocardium to form PVC’s
Arrhythmias may be generated near areas of scarring in myocardium
Arrhythmias
Can be fast (tachycardia)
Or slow (bradycardia)
Or normal rate with abnormal rhythm (block)
S/P MI
At greatest risk for repeat MI within 2 months of MI
Repeat MI still risky up to 6 months S/P MI
Avoid elective tx, consult cardiologist if emergency
MYOCARDIAL INFARCTION
1. Consider physician consult 2. Defer elective surgery until six months after infarction 3. Check for anticoagulation (including aspirin) 4. Have NTG available. Consider prophylactic use. 5. Consider supplemental O2 6. Provide profound local anesthesia 7. Consider N2O sedation 8. Monitor vital signs. Avoid tachycardia and HTN 9. Limit epinephrine use to 0.04mg (4cc of 1:100,000) 10. Maintain verbal contact with patient
Myocardial Infarction
Severe cardiac ischemia resulting in cellular death
Signs/Symptoms:a. Severe chest pain; assume new onset
angina is MI; unstable angina may evolve into MI
b. Sweatingc. Severe anxiety, unconsciousness
Cardiovascular
Myocardial Infarction Treatment
a. Summon help, stay calmb. Supplemental oxygen, NTG,
ASA, analgesia(MONA)
c. Monitor vital signsd. CPR
No elective dental treatment for six months
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Murmurs, valves, malformations
Prophylaxis
Determine associated cardiac problems
Watch for anticoagulants
HYPERTENSION
1. Refer for treatment. To ER stat if severe. 2. Defer treatment if possible until controlled.
Weigh emergency dental needs against risk of treatment.
3. Avoid postural hypotension 4. Monitor vitals especially blood pressure. 5. Monitor carefully if epinephrine exceeds
0.04mg (4cc of 1:100,000)
Stroke-CVA
Cerebral Vascular Accident – Focal neurologic disorder due to a disturbance in cerebral circulation from intracerebral hemorrhage or cerebral infarction
1. No elective treatment within six months
2. Check blood pressure each appointment
3. Minimize stress. Avoid hypertension.
4. May be on anticoagulants
Stroke-CVA
Acute symptoms– Mental status changes. Disorientation
– Slurred speech, facial droop
– Sudden weakness, specially unilaterally
Treatment:– Oxygen. EMS. Monitor vitals. Blood sugar
(variations may mimic stroke). Transport ASAP
Diabetes: Complications
Hyperglycemia
Damage to mediumand large blood vessels
Damage to small blood vessels
Macrovascular Disease Microvascular Disease
Coronary Artery Disease
CerebrovascularDisease
Peripheral vascular disease Retinopathy Nephropathy Neuropathy
www.merckmedicus.com
DIABETES MELLITUS
Type I IDDM: Controlled or brittle. What is most recent sugar? Can assess control by looking at dose of insulin. One dose of
long acting insulin usually better controlled than split dose of long acting w/regular
Did pt take insulin and eat breakfast? Risk of hypoglycemia (first signs may be inappropriate
comments, confusion, combativeness) much more likely than hyperglycemia (DKA) which takes longer to develop. Give oral glucose.
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INSULIN DEPENDENT DIABETES MELLITUS
1. Defer elective surgery if possible until well controlled
2. Early morning appointments. Short appointments. 3. Monitor vitals before, during, and after surgery 4. Confirm that patient took their AM insulin and had
a normal caloric intake for breakfast 5. Advise patient that they must consume a normal
calorie load for the remainder of the day, even if they must blenderize food. Otherwise they will need to modify their NPH insulin.
INSULIN DEPENDENT DIABETES MELLITUS
6. Consult physician for modifications to insulin regimen 7. When in doubt, check blood sugar levels with portable testing
unit 8. Watch for signs of hypoglycemia 9. Determine how well controlled patient is preoperatively. This
will indicate which patients are more prone to problems. Know their dosing regimen preop
10. Treat infections aggressively. 11. Maintain verbal contact with patient during surgery
Diabetes Mellitus
Acute hypoglycemia (Insulin Shock)
Symptoms - Anxiety, irritability, tachycardia, disorientation, unconsciousness
Treatment:
a. Oral sugar; candy, orange juice, coke
b. I.V. dextrose
c. Glucagon
Diabetic Ketoacidosis (DKA,Hyperglycemia) unlikely
Diabetes Mellitus
Type II DM:
Usually tolerate well.
Confirm compliance
NONINSULIN DEPENDENT DIABETES MELLITUS
1. Morning appointment is best 2. Monitor vital signs 3. Maintain verbal contact with patient during surgery 4. Make sure patient consumes a normal calorie load
postoperatively, even if they must blenderize food. 5. Confirm that patient has taken their oral hypoglycemic agent
and eaten a normal breakfast prior to surgery. 6. Watch for signs of hypoglycemia 7. Treat infections aggressively.
ADRENAL INSUFFICIENCY
Medulla= epi and norepi
Cortex = mineralocorticoid (aldosterone), glucocorticoid (cortisol) and androgens
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ADRENAL INSUFFICIENCY
Cortisol released in a diurnal pattern (greater in AM) regulated by ACTH from pituitary.
Related to stress (modulates inflammatory mediators, immune response, cell membrane integrity, blood pressure, mobilizes energy stores)
ADRENAL INSUFFICIENCY
Exogenous steroids chronically suppress ACTH- pt can’t mount a stress response
Mediated by cortisol.
Steroid prep necessary if major surgery is contemplated.
Acute insufficiency results in hypotension. Check BP’s
ADRENAL SUPPRESSION
1. For major oral surgery, for patients currently on corticosteroids, double dose day before, day of, and day after surgery. Return to normal dose on second postoperative day
2. For major oral surgery, for patients not currently on steroids, but who have taken at least 20 mg of hydrocortisone or equivalent for more than two weeks within the past year, give 60mg hydrocortisone or equivalent the day before surgery, the morning of surgery, 40mg for the first two postop days and 20mg for three days thereafter.
3. Steroid prep not necessary for minor oral surgery under local anesthesia.
4. Monitor vitals especially blood pressure, before, during, and after surgery
5. AM appointments best 6. Reduce stress
PREGNANCY
Second trimester best for tx.
Major organogenesis during first trimester
Positioning (pressure inferior vena cava) and premature labor 3rd trimester
Pregnancy risk categories in drug references A,B,C,D,X, determined by research performed not necessarily clinical practice.
Surgery can cause premature labor
High risk pregnancy call OB GYN
PREGNANCY
1. Defer surgery until delivery, if possible. 2. Consult obstetrician if surgery cannot be delayed 3. Avoid radiographs if possible. Use shielding when absolutely
necessary 4. Avoid drugs with teratogenic potential. Consult Pregnancy
Risk Catagories 5. Avoid supine position to prevent vena cava compression 6. Expect frequent trips to rest room. 7. Monitor blood pressure 8. Middle trimester best time for surgery
LIVER DISEASE
Clotting status
Communicable diseases
Drug metabolism
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HEPATIC INSUFFICIENCY
1. Identify cause; possible Hepatitis B or C. Ascertain current status of liver-recent labs
2. Avoid drugs requiring hepatic metabolism or excretion or modify their dose
3. Screen for bleeding disorders: PT, PTT, platelet count, platelet function testing
4. Avoid situations where patient might swallow large amounts of blood (impaired nitrogen metabolism may cause encephalopathy).
ANTICOAGULANTS-Clotting Factors
Blood clots by clotting factors, platelets and vascular action End product of clotting factors is fibrin Coumadin affects vit K dependant clotting factors, mainly
extrinsic pathway. Test coumadin with PT reported as INR. Must be 3.0 or less INR of 1.0 is normal Heparin also affects clotting factors. PTT tests (mainly intrinsic)
or assay for heparin Some physicians will switch coumadin to heparin (reversible,
shorter acting)
COUMADIN THERAPY
1. Consult patient’s physician regarding safety of modifying coumadin levels.
2. Safe surgery is 1.5 times control or INR less than 3.0
3. Obtain the baseline PT. Must have PT within two days of surgery
4. To reduce level, stop coumadin two days before surgery. Draw INR morning of surgery, proceed with surgery if criteria met. Restart coumadin day after surgery.
COUMADIN THERAPY
5. Augment clotting with gelfoam, surgicel, sutures, pressure packs.
6. Carefully instruct patient in bleeding management
7. If patient is not cleared for going off anticoagulation, may need heparinization. Consult patient’s physician regarding orders for this.
8. Coumadin not readily reversible. Vit K (slow) or plasma transfusion
Pradaxa® (dabigatran)
Direct thrombin inhibitor: for nonvalvularatrial fibrillation embolic stroke prevention
No p450 metabolism; Elimination half life 12-17 hrs; plasma levels ↓ 70% w/in 4-6 hrs; but no reliable reversal agent (hemodialysis)!
Few interactions; predictable anticoagulation; no lab monitoring (INR).
BID dosing
ANTICOAGULANTS- Platelets
Platelets affected by ASA, NSAIDS, Plavix, Ticlid, Persantine
Irreversibly acetylates cyclooxygenase necessary for adhesion
Platelet can’t repair-effect is for life of platelet-7-14 days
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ASPIRIN OR OTHER PLATELET INHIBITING DRUGS
1. Consult patient’s physician regarding safety of stopping anticoagulant drugs for surgery
2. Consider deferring surgery until platelet inhibiting drugs have been stopped for 5 days to two weeks, depending on the drug.
3. Augment clotting with gelfoam, surgicel, sutures, pressure packs.
4. Carefully instruct patient in bleeding management 5. Restart drug day after surgery if no bleeding is
present
COAGULOPATHY
1. Consult hematologist prior to surgery 2. Obtain baseline coagulation studies: PT, PTT,
platelet count, platelet function test (bleeding time). 3. Schedule patient to coincide with corrective
measures which may be prescribed by hematologist, i.e., platelet transfusion, factor replacement, chemical therapy (EACA Amicar, tranexamic acid antifibrinolytic), or hormonal therapy (DDAVP desmopressin, increases factor VIII, von Willebrand factor and platelet function)
COAGULOPATHY
4. Augment clotting with gelfoam, surgicel, sutures, well placed pressure packs
5. Monitor the wound for clotting post operatively before discharge
6. Carefully instruct the patient in bleeding management
7. Avoid NSAIDs and aspirin 8. Hepatitis precautions 9. Consider hospitalization for major procedures
UNCONTROLLED BLEEDING
Pressure (stasis)>gelfoam(gelatin), surgicel(cellulose), avitene(microfibrillar collagen), topical thrombin, electrocautery
Review medical history and medications
Check for hypertension
ASTHMA
Chronic disease of abnormal responsiveness of airways, leading to constriction, mucous production, inflammation. Usually involves triggers (allergen, exercise, stress).
Clinical signs: Wheezing, SOB, coughing
Treatment: Bronchodilators; anti-inflammatories, immune blockers
Asthma
Affects 5% of U.S. population
Increasing in incidence
Morbidity and mortality increasing in incidence
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Asthma
Extrinsic– Primarily children and young adults
– Inherited allergic disposition
– Dust, pollen, exercise, chemicals, drugs, air pollution, occupational exposures, dander, smoke
– Usually improves with age (~ 50% become asymptomatic by adulthood
Asthma
Intrinsic (nonallergic)– Usually older patients (>35)
– Infection most common cause
– Allergy tests – negative
– Cold, humidity changes
ASTHMA
1. Defer elective treatment until well controlled and no respiratory tract infection
2. Auscultate chest before major procedure or sedation 3. Anxiety control; Consider N2O sedation 4. Keep bronchodilator-inhaler easily accessable 5. Avoid NSAIDS and ASA 6. Consider steroid prep if on corticosteroids 7. Question patient regarding severity and precipitating factors.
History of ER visits good indicator.
Asthma Attack
Terminate procedure
Patient’s inhaler. Albuterol inhaler
Severe: Oxygen 4L nasal cannula
Epinephrine 0.3mg subcutaneous or IM
Lung Disease
Obstructive: Difficulty exhaling air from lungs
Narrow, obstructed airways. (COPD, asthma, cystic fibrosis, bronchiectasis (dilated inflamed bronchi from infection)
Restrictive: Cannot fully inhale. Lungs stiff due to interstitial fibrosis; sarcoidosis, obesity scoliosis, ALS or other muscular dystrophy
COPD
Chronic bronchitis: long term cough w mucous
Emphysema: destruction of lung tissue
Main cause: Smoking! Also environmental/toxic pollutants
Sx: Cough w or w/o mucous, fatigue, resp. infections, SOB, wheezing
Tx: Bronchodilators and antiinflammatories
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Respiratory Drive
Hypoxia, hypercarbia
Pickwickian syndrome : Chronic high CO2 relies on hypoxia to drive ventilation. Given higher O2 concentrations, hypoxic drive is reduced and ventilation may stop.
As ventilation stops, hypoxia reoccurs and ventilation continues.
COPD
1. If pt is on O2, continue at prescribed flow rate 2. If pt is not on O2, consult physician before
administering O2 3. Consider steroid prep if pt on corticosteroids 4. Avoid supine position unless patient can tolerate it 5. Have bronchodilator-inhaler readily available 6. Monitor vital signs and note respiratory rate and
depth preop 7. Afternoon appointments better tolerated because
of clearance of secretions
Airway Obstruction
Foreign body: in airway→distress. In esophagus→no distress
Look, listen, feel for the signs of respiration Have effective sweep suction immediately
available (Yankaur suction) Heimlich maneuver Abdominal thrust Cricothyrotomy
Airway Obstruction-Sedation
Tongue falling back on airway is most common reason for obstruction in sedated or unconscious patient
Must pull mandible forward to pull tongue forward. Head tilt jaw thrust. Bilateral jaw angle thrust
Opening mouth does not open airway
Tongue Obstruction Head Tilt –Jaw Thrust to Open Airway
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Renal Insufficiency: Hemodialysis
Blood is pumped through a semipermeable membrane, cleaned then returned to body
Heparinized
Reversal agent: protamine sulfate
Three times /week
Surgery: day after dialysis
Peritoneal Dialysis
Peritoneal membrane acts as semipermeable membrane
Hyperosmotic solution injected through port into peritoneum
Gradient moves from vascular to peritoneum
Peritoneum is drained of wastes
4-5 times/day or overnight
RENAL INSUFFICIENCY
1. Avoid drugs that depend on renal metabolism or excretion 2. Avoid nephrotoxic drugs, such as NSAIDS 3. Defer dental care until the day after dialysis 4. Consult nephrologist concerning the use of prophylactic
antibiotics, i.e., shunts 5. Monitor blood pressure (HTN prevalent) and heart rate (don’t
use arm with shunt for BP) 6. Look for signs of hyperparathyroidism (bone changes) 7. High incidence of Hepatitis B in these patients
RENAL TRANSPLANT
Clear with transplant physician. Avoid nephrotoxic drugs. Consider supplemental corticosteroids. Monitor blood pressure. Check for cyclosporin A induced gingival hyperplasia. Consider prophylactic antibiotics-on immunosuppressives.
Hyperthyroidism
Hypermetabolism
Elevated levels of free thyroid hormones
Tachycardia, fatigue, weight loss, nervousness, tremor
Graves Disease: autoantibody to TSH receptor resulting in excess T4 and T3. Goiter, exophthalmus, dermopathy due to infiltrates
Hypothyroidism
Hashimoto’s autoimmune fibroses thyroid decreasing output of thyroid hormone
Iodine deficiency: cretinism
Acquired: lithium, amiodorone, radiation
Reduction in TSH from pituitary
Cold intolerance, personality changes, weight gain, forgetfulness, paresthesias, carpel tunnel, amenorrhea, slow speech, facial puffiness, dry skin
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HYPERTHYROIDISM
1. Defer surgery until controlled
2. Monitor pulse and blood pressure before, during, and after surgery
3. Limit amount of epinephrine used
SEIZURE DISORDER
Seizure Disorder – Sudden alteration in cerebral function leading to abnormal motor, sensory or psychic activity.
Seizure Disorders
A. Types1. Acquired Epileptic (recurring)2. Non-epileptic
a. Hypoglycemiab. Toxic local anesthesiac. Drug overdosed. Etc.
Seizure Disorders
Auras (sensory or psychic manifestations preceding seizure)
Generalized (grand mal, absence or petite mal)
Partial (Jacksonian or focal motor)
Postictal state (deep sleep, confusion, headache, muscle aches)
SEIZURE DISORDER
1. Defer surgery until controlled if possible. AM best. 2. Confirm patient compliance with anti-seizure
medicines. Consider drawing serum levels if in doubt.
3. Avoid hypoglycemia and fatigue. Manage stress. 4. Have a plan for managing a seizure if it should
occur. Discuss with staff type of seizure to expect and what to do if it occurs.
5. Consider sedation
Seizure Disorders
B. Treatment1. Patient supine2. Prevent injury3. Maintain airway, oxygen4. Monitor vital signs5. Persists (>5 minutes, status epilepticus)
a. Summon helpb. Valium I.V.c. CPR if necessary
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Seizure Disorders
C. Post-Seizure Management
1. Permit patient to recover
2. Discharge from office
a . Escort
b. Consult physician
Cancer Therapy
Chemotherapy: “Nadir” WBC’s, platelets– Uncontrolled bleeding, post op infections, healing
Radiation: osteoradionecrosis
Bisphosphenates: osteonecrosis
VASOPRESSOR SYNCOPE
Vasopressor Syncope – Sudden transient loss of consciousness as a result of physical or emotional stress.A. Recline patientB. OxygenC. Monitor vital signsD. Stress controlE. May see seizure activity
HYPERVENTILATION SYNDROME
Hyperventilation secondary to anxiety. Symptoms secondary to respiratory alkalosis.
A. Symptoms: Tachypnea, tingling, lightheadedness.
B. Treatment: Calm patient, ask patient to hold breath or breathe slowly, breathe into paper bag or closed anesthesia circuit, I.V. of Valium
Allergy vs Adverse Drug Reaction
Not every unusual rxn to a drug is “allergy”
Abnormal response to a drug not caused by the immune system: toxicity, intolerance, idiosyncrasy, psychological reactions
True drug allergy: Latent interval between exposure and sensitization, rxn does not resemble effect of drug, rxn not dose dependent (⇩drug=⇧rxn), cross-reactivity with similar drugs
Allergic Reactions
Allergic reactions to local anesthesia rare (more common with ester type)
Consider rxn to topical benzocaine (ester)
Differentiate between allergy and overdose
Epinephrine reaction vs allergy
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Allergy-Latex
Emerging problem due to universal precautions
Latex is trigger in 10% of anaphylaxis under anesthesia
Urticaria, asthma>anaphylaxis Spina bifida: 30-70% chance of latex allergy Food crossreactivity: avocado, kiwi, banana
Acute Allergic Reactions
The most important element in predicting the seriousness of rxn is the interval between administration of allergen and appearance of reaction. A short interval indicates higher probability of serious systemic complications.
Allergic Reactions Seen in Dental Office
Cutaneous – Urticaria (rash, welt), exanthematous (eruption),
eczematoid (dry, flaky), itching
Angioedema– Lips, eyelids, face, mouth or throat
Respiratory– Rhinitis, sneezing, tight chest, dyspnea,
wheezing, bronchospasm
Ocular– Watery eyes, conjuctivitis
Allergic Reactions Seen in Dental Office
Anaphylaxis– Massive release of chemical mediators
– Cardiovascular collapse
– Usually drugs but consider latex
– Refractory capillary permeability, sm muscle spasm, pulmonary edema
– May develop airway edema
Anaphylaxis- Symptoms
Skin: warm, flushed, itching, urticaria, angioedema
Respiratory: Sneezing, runny nose, cough, wheeze, bronchospasm, tightness in chest, upper resp. obstruction
GI: nausea, vomiting, cramps, diarrhea CV: pallor, syncope, palpitations,
tachycardia, hypotension, arrythmias, convulsions, LOC, cardiac arrest
May occur in sequence or individually
Allergy Treatment
Seriousness related to interval between administration and reaction
Mild reactions:– Diphenhydramine (Benadryl®) 50-100mg PO, IV,
IM, then PO q6h
– Chlorpheniramine maleate 4-12 mg PO, IV,IM, then PO q6h
– Observe patient 1-2 hours
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Allergy-Treatment of Severe Reactions (Anaphylaxis)
Stop the antigen ABC’s (airway, ventilation (O2), IV volume loading) Epinephrine
– IV: 0.2(2ml)-0.5mg(5ml) of 1:10,000 in 10cc– IM or SC: 0.3-0.5mg of 1:1000 (1mg/ml)– ET tube: 2x dose
Benadryl– IV or IM: 50 mg
Corticosteroids:(slow acting)– Dexamethasone (Decadron®) 4-12 mg IV, IM– Hydrocortisone (Solu-Cortef®) 100mg
Allergy-Treatment of Severe Reactions (Anaphylaxis)
Trendelenburg if shocky
Observe for dyspnea, wheezing. Bronchodilators; cricothyrotomy for laryngeal obstruction
Treat hypotension (volume, pressors)
Observe for seizures (valium, versed)
Hospitalize 24 hrs and observe for recurrence
Distribution of Dental Emergencies
A. Syncope 4160B. Allergic Reactions 2583C. Postural Hypotension 2475 D. Hyperventilation 1326E. Hypoglycemia 709F. Seizure 644G. Angina Pectoris 584H. Bronchial Asthma 385
From Malamed, SF Medical Emergencies in
Dental Office N=13,775; 2704 dentists
Distribution of Dental Emergencies
I: Local Anesthetic Overdose 204
J: MI 187
K: Anaphylaxis 169
L: Cardiac Arrest 148
M: Acute Heart Failure 104
N: Stroke 68
O: Acute Adrenal Insufficiency 25
P: Thyroid Storm 4
PREVENTION
Prevention – THE MOST IMPORTANT phase of medical emergency management and the most often neglectedA. Past Medical HistoryB. Physical EvaluationC. Precautionary Measures
Past Medical History
Every item in the PMH alerts you to a modification of treatment that may be necessary or to a possible predictablemedical emergency that may occur.
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Physical Evaluation
Simple observation– Is patient in distress, dehydrated, airway
problems, psychiatric problems, obesity, skin tone
Vital signs– Respiratory rate, BP, heart rate and rhythm
GENERAL PREPARATION
A. Emergency contact numbers near telephone
B. Equipment accessible
C. Drugs Current - Oxygen
D. Emergency practice
E. Certified in CPR
PROTOCOLS
Have a listing of common medical emergencies and how to treat
The best protocols are made up by you. Not only a good review, but assures your understanding.
Brief bullet point form with specific info on dose, route of administration. MAKE IT SIMPLE!
Oxygen
Xylocaine® Package Insert
xylocaine (lidocaine Hydrochloride) injectionxylocaine with epinephrine (lidocaine Hydrochloride and epinephrine bitartrate) injection[DENTSPLY Pharmaceutical]
Injections for Local Anesthesia in Dentistry
“consists of immediate attention to the maintenance of a patent airway and assisted or controlled ventilation with oxygen and a delivery system capable of permitting immediate positive airway pressure by mask. “
Bag Valve Mask
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Epinephrine Aspirin
Blood Glucose Meter
diabetes.niddk.nih.gov
Optional
Valium I.V.
Morphine I.V.
Decadron I.V.
I.V. setup
Airway Adjuncts Yankauer Suction
Yankauer Suction
Airway Adjunct
Paper bag