Key Points: 1. The Drug Enforcement Administration (DEA) has a manual that
specifically lays out the requirements of record keeping, storage, inventory for the prescribing and dispensing of a controlled substance.
2. To administer a controlled substance you must be registered with the DEA.
3. The oral sedation medications in the recommended protocols of this course are schedule IV substances.
4. An inventory record must be maintained for two years. Inventory Record Requirements:
List the name, address, and DEA registration number of the doctor.
Indicate the date and time the inventory is taken. Be signed by the person or persons responsible for taking the
inventory. Be maintained at the location appearing on the registration
certificate for at least two years. DOCS members - just use your DOCS drug logbook.
5. Keep all oral sedation medications and all other controlled substances in a locked cabinet.
6. When drugs are removed from the locked drug cabinet, care must be taken that they not be left out where others have access to them. Keys to the locked cabinet should be in a location known only to trusted personnel.
7. You must keep good records of the dispensing of all controlled substances. Chart Entries should include comprehensive chart notes including:
All procedures performed, Sedative medications dispensed, Dosages and times and routes of administration, Local anesthetics administered, Disposition of the patient upon arrival, as well as during the
appointment, and at dismissal. 8. The printout from Pulse Oximeter should be copied and made a
permanent part of the patient’s record. The ink from the original printout from the pulse oximeter will fade in a couple of years.
9. Three readings from the Pulse Oximeter should be recorded manually on a standard anesthesia form. The three readings are at time of arrival, when dentistry is begun, and at discharge.
10. The pressure of the emergency oxygen supply should be verified on a regular basis. A record of this weekly inspection should be kept by a designated individual in the office near the oxygen source.
DATE: ____________ PATIENT’S NAME: ___________________ AGE: ______________ MEDICAL STATUS: ASA I II III Mallapatti: I II III (CIRCLE ONE) ALLERGIES: WEIGHT LBS: _____ kg(LB/2.2): _____ VITAL SIGNS: PRE-OP AFTER SEDATION BEFORE DISCHARGE
BP P O2 BP P O2 BP P O2 MEDICATIONS: DRUG(S) DOSAGES TIMES DENTAL PROCEDURE: DISCHARGE DISPOSITION: DOCTOR’S NAME: ___________________________________ ASSISTANT’S NAME: ____________________________________
Dispensing Medications From The Office Medications that are dispensed from the office per the DOCS protocol such as diazepam, triazolam, or lorazepam should be carefully and accurately labeled in “child-proof” containers. There containers are inexpensive and can be obtained from several medical/pharmacy supply houses. One such supplier is
Clark Containers 1-800-477-8425 The labels on these containers should include the following:
Patient’s Name Medication Name (Generic or Brand) Prescribing Doctor’s Name & Contact Information Directions for Use Special Precautions Number of Authorized Refills Date of Prescription Date of Expiration (If Applicable)
* Your State may have additional requirements Disposal Of Expired Drugs The first step is to simply inform your regional DEA Field Division that you are in possession of expired Class IV drugs that you wish to dispose of and request a Form 41. You can find the number for your regional division in the blue pages of your phone book or by going to http://www.usdoj.gov/dea/agency/domestic.htm. The DEA representative will advise you how to complete and submit the form. You may be required to do this by either standard mail or facsimile, depending on their preference. Complete the Form 41 (Registrants Inventory of Drugs Surrendered), and return it in the communiqué to DEA in triplicate. Once the DEA has reviewed your completed Form 41, you will be contacted by an agent at your local DEA Field Division to inform you of the specific procedures you must follow while destroying the medication along with the permission to do so. You will be instructed to have at least two persons participate in the disposal of the medication. These must be persons who are licensed physicians, pharmacists, nurses, state or local law enforcement, or any combination thereof.
Once the drug has been destroyed, fill out the remainder of Form 41 and return it to the individual noted by your local DEA Field Division, also in triplicate. This will be used to certify that you have indeed taken the measures required by the DEA to correctly dispose of expired medications in your possession. Proper disposal of these drugs should also be noted in your drug log book in the inventory section. This is a good place to reference the location of the DEA documents in your office.
Legal Preventive Measures: • Always protect your patient and yourself with thorough and thoughtful
documentation. • Never leave a sedated patient unattended. • Never leave a male doctor in the room with a sedated female patient
alone. • Do not be afraid to turn down a patient for suspicion of any kind. • Have the consent form signed by the patient and witnessed before any
sedation is administered. • Emergency Drug Kit should only contain those drugs you will use in an
emergency. If you have advanced drugs and do not use them, you are liable.
• Having an AED and being trained to use one will give your office the finishing touches that will make you litigiously resistant.
• Risk exists when a sedated patient is escorted home. Be clear in writing that an escort must take a patient right home and call the office to confirm a safe trip.
• Maintain a current CPR certificate for all clinical team members. Informed Consent 1. Appropriate informed consent must be obtained prior to administration of
oral sedation dentistry (anxiolysis or conscious sedation). 2. Informed consent – short forms…see next two pages 3. Informed consent – long forms … see New Patient Packet 4. All of the following requirements for informed consent must be satisfied
and documented prior to administration of conscious sedation: a. The patient and/or guardian must be advised of the specific
procedure inducing oral conscious sedation. b. The patient and/or guardian must be advised of the risks
associated with the delivery of oral conscious sedation. c. The patient and/or guardian must be advised of the options to
the delivery of the oral conscious sedation. d. The patient or the guardian must be advised that unforeseen
circumstances do occur and the doctor and the support team need permission in advance to change the plan of treatment if it is deemed in their professional judgment to be in the best interest of the patient.
e. The patient and/or guardian must be afforded the opportunity to have concerns and questions addressed by qualified personnel.
f. The patient and/or guardian’s consent must be documented.
1. I understand that the purpose of anxiolysis is to more comfortably receive necessary care. Anxiolysis is
not required to provide the necessary dental care. I understand that anxiolysis has limitations and risks and absolute success cannot be guaranteed. (See #4 options.)
2. I understand that anxiolysis is a drug-induced state of reduced awareness and decreased ability to
respond. The purpose of anxiolysis is to reduce fear and anxiety. I will be able to respond during the procedure. My ability to respond normally returns when the effects of the sedative wear off.
3. I understand that anxiolysis will be achieved by the following route:
Oral Administration: I will take a pill approximately ______ minutes before my appointment. The sedation will last approximately ______ to ______ hours.
4. I understand that the alternatives to anxiolysis are:
a. No sedation: The necessary procedure is performed under local anesthetic with the patient fully
aware. b. Nitrous oxide sedation: Commonly called laughing gas, nitrous oxide provides relaxation but
the patient is still generally aware of surrounding activities. Its effects can be reversed in five minutes with oxygen.
c. Oral Conscious Sedation: Sedation via pill form that will put the patient in a minimally
depressed level of consciousness.
d. Intravenous (I V) Administration: The doctor will inject the sedative in a tube connected to a vein in my arm.
e. General Anesthetic: Commonly called deep sedation, a patient under general anesthetic has
no awareness and must have their breathing temporarily supported. General anesthesia is more appropriate for longer procedures lasting 3 or more hours.
5. I understand that there are risks or limitations to all procedures. For anxiolysis these include:
Inadequate initial dosage may require the patient to undergo the procedure without anxiolysis or delay the procedure for another time. Atypical reaction to drugs which may require emergency medical attention and/or hospitalization such as altered mental states, physical reactions, allergic reactions, and other sicknesses. Inability to discuss treatment options with the doctor should circumstance require a change in treatment plan.
6. If, during the procedure, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.
7. I have had the opportunity to discuss anxiolysis and have my questions answered by qualified personnel
including the doctor, if I so desire. I also understand that I must follow all the recommended treatments and instructions of my doctor.
8. I understand that I must notify the doctor if I am pregnant, or if I am lactating. I must notify the doctor if I
have sensitivity to any medication, of my present mental and physical condition, if I have recently consumed alcohol, and if I am presently on psychiatric mood altering drugs or other medications.
9. I will not be able to drive or operate machinery while taking oral sedatives for 24 hours after my procedure.
I understand I will need to have arrangements for someone to drive me to, if I take the pill beforehand, and from my dental appointment while taking medication.
10. I hereby consent to anxiolysis in conjunction with my dental care.
YOUR OFFICE NAME HERE Conscious Sedation Consent Form
The purpose of this document is to provide an opportunity for our patients to understand and give permission for conscious sedation when provided along with dental treatment. Each item should be checked off after the patient has the opportunity for discussion and questions.
1. I understand that the purpose of conscious sedation is to more comfortably receive necessary care. Conscious sedation is not required to provide the necessary dental care. I understand that conscious sedation has limitations and risks and absolute success cannot be guaranteed. (See #4 options.)
2. I understand that conscious sedation is a drug-induced state of reduced awareness and decreased ability to respond. Conscious sedation is not sleep. I will be able to respond during the procedure. My ability to respond normally returns when the effects of the sedative wear off.
3. I understand that my conscious sedation will be achieved by the following route:
Oral Administration: I will take a pill approximately ______ minutes before my appointment. The sedation will last approximately ______ to ______ hours.
4. I understand that the alternatives to conscious sedation are:
a. No sedation: The necessary procedure is performed under local anesthetic with the patient fully aware.
b. Anxiolysis: Taking a pill to reduce fear and anxiety.
c. Nitrous oxide sedation: Commonly called laughing gas, nitrous oxide provides relaxation but the patient is still
generally aware of surrounding activities. Its effects can be reversed in five minutes with oxygen.
d. Intravenous Administration: The doctor could inject the sedative in a tube connected to a vein in my arm.
e. General Anesthetic: Commonly called deep sedation, a patient under general anesthetic has no awareness and must have their breathing temporarily supported. General anesthesia is more appropriate for longer procedures lasting 3 or more hours.
5. I understand that there are risks or limitations to all procedures. For sedation these include:
(Oral Sedation) Inadequate sedation with initial dosage may require the patient to undergo the procedure without full sedation or delay the procedure for another time. Atypical reaction to sedative drugs which may require emergency medical attention and/or hospitalization such as altered mental states, physical reactions, allergic reactions, and other sicknesses. Inability to discuss treatment options with the doctor should circumstance require a change in treatment plan.
6. If, during the procedure, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.
7. I have had the opportunity to discuss conscious sedation and have my questions answered by qualified personnel including the doctor. I also understand that I must follow all the recommended treatments and instructions of my doctor.
8. I understand that I must notify the doctor if I am pregnant, or if I am lactating. I must notify the doctor if I have sensitivity to any medication, of my present mental and physical condition, if I have recently consumed alcohol, and if I am presently on psychiatric mood altering drugs or other medications.
9. I will not be able to drive or operate machinery while taking oral sedatives for 24 hours after my procedure. I understand I will need to have arrangements for someone to drive me to and from my dental appointment while taking oral sedatives.
10. I hereby consent to conscious sedation in conjunction with my dental care.
Patient / Guardian Date Witness Malpractice Insurance: • Determine the appropriate level (anxiolysis or conscious sedation) of
sedation that you will be providing based upon your state regulations and permitting process, as well as your education and comfort level.
• Notify your malpractice insurance carrier which of the two levels of oral sedation you will be providing (see sample letters at the end of this section).
• Your malpractice premiums in most situations will remain the same. In the state of Utah, a minor increase of $200/yr is assessed to your premium for providing oral sedation dentistry.
• There may be a few malpractice carriers that do not cover oral sedation dentistry. If you are insured with one of these companies (we are only aware of one company at this time - EDIC), you can contact the Academy of General Dentistry’s sponsored malpractice carrier.
Dentists Advantage 888-778-3981
Advertising Laws: • Do not use “Sleep Dentistry”! • Use “Sedation Dentistry” if you have the appropriate permits • FALSE, FRAUDULENT, MISLEADING, OR DECEPTIVE STATEMENT.
A statement or claim having one or more of the following characteristics: o One that contains a misrepresentation of fact. o One that is likely to mislead or deceive because in context it makes
only a partial disclosure of relevant facts. o One that is intended or is likely to create a false or unjustified
expectation of favorable results. o One that implies unusual superior dental ability. o One that contains other representations or implications that in
Regulatory Matters: Check all state laws regarding conscious sedation You will be surprised how varied it is in this country of ours.
Key to Oral Sedation Dentistry Map: Light Blue Permit and/or C.E., < 20hr./20exp. Required for Adult Oral Conscious Sedation. No permit for Anxiolysis. Yellow No present permit; new regulations proposed; expecting <18hr./20exp. No permit for Anxiolysis. Red IV permit (>60 hours/20pts) required for Adult Oral Conscious Sedation. No permit for Anxiolysis. Green No permit required for Adult Oral Conscious Sedation; no proposed changes; no committees formed. No permit for Anxiolysis. Orange Board proposal or committee recommendation of >20hr/20exp; DOCS and other organizations are advocating 18hr/20exp. No permit for Anxiolysis. Dark Blue AZ = 30 hours NY = New York University course MS = 50 hours (includes ACLS) TX = Baylor University course
Apply for the appropriate certificates. If required to take CE, make sure you include this course as part of your
requirements or other DOCS courses for your continuing education requirement.
Many states are considering new regulations. Keep up your CE. Maintain a current CPR certificate for all clinical team members. Choose Sedation or Anxiolysis protocols for permit purposes Having an AED and being trained to use one will give your office the
equipment required for one level higher in most states
Example of Letter (Anxiolysis) to be sent to Liability Insurance Carrier
Date Ins. Co. To Whom It May Concern, Please be advised that I will be providing for my patients premedication or anxiety relief (anxiolysis) with a class IV schedule DEA drug. These medications are in the benzodiazepine family, similar to Valium. Anxiolysis is defined as “a pharmacologically induced state of consciousness where an individual is awake but has decreased anxiety to facilitate coping skills, retaining interaction ability.” Thank you very much for your time and effort. Very truly yours,
Example of Letter (Conscious Sedation) to be sent to Liability Insurance Carrier
Date Ins. Co. To Whom It May Concern, Please be advised that I will be providing for my patients the safe and effective use of oral conscious sedation with a class IV schedule DEA drug. This medication is in the benzodiazepine family, similar to Valium. Oral conscious sedation is defined as a “minimally decreased state of consciousness in which the patient is able to maintain their own airway and responds to both physical and verbal stimuli”. Thank you very much for your time and effort. Very truly yours, Doctor
The session is designed to allow you to walk away at the end feeling a great deal more comfortable about management of the most common emergencies you are likely to encounter during your day- to- day practice. Unfortunately, medical emergencies are 5.8 times more likely to occur in a dental office than in a medical office. The dental office is actually a relatively controlled environment, has trained personnel, usually has an oxygen source, suction equipment and some of the necessary emergency equipment and drugs. The dental staff should be able to handle a great many of the emergencies that may arise, provided that they are adequately trained. The session will examine the most frequently encountered emergencies encountered in the dental office, address the medical issues surrounding each of the emergencies and examine the implications of these issues for the dental office The emphasis is to allow the team to anticipate trouble, to prevent trouble and to manage trouble. The session will emphasize the importance of Team Building to optimize emergency management. Simple algorithms will be developed to help management of the commonly encountered medical emergencies in the dental office.
1. What is your practice like with respect to emergency
preparedness? 2. Do you have a team approach to medical emergencies? 3. Do you have an emergency drug kit? 4. Do you know how to use all of the drugs in the drug kit? 5. Can you intubate a patient? 6. Can you start an IV? 7. Do you have an AED?
What Equipment Should You Have?
MONITORING EQUIPMENT Blood pressure monitoring Pulse oximeter EQUIPMENT FOR MANAGEMENT OF AIRWAY Ambu bag, mask and tubing
CO2 detector Positive pressure oxygen delivery system
Do You Need an Automatic External Defibrillator?
Electrical shocks applied to dogs within 30 seconds of induced VF produced a 98% rate of resuscitation. Electrical shocks applied to dogs after 2 minutes of VF had only a 27% rate of success. Early defibrillation of VT and VF can increase the survival from acute cardiopulmonary arrest. The latest renditions of automatic defibrillators are easy to operate. The machine automatically determines the cardiac rhythm and delivers a synchronized shock for patients with VT or
VF. These machines have high sensitivity (>80%) and very high degree of specificity (100%) Current literature suggests that use of AED in the field is associated with improved outcome in out-of-hospital arrest. Although AED is very easy to use, the dentist and the office staff need to be trained to use the machine. The machine needs to be checked periodically to ensure proper maintenance. There should be a physician oversight of the training. Vendors are usually extremely helpful in training the office staff.
Optional Equipment
Oral laryngeal airway such as the King LTD and IV or IO kits are optional equipment of the trained individuals.
EMERGENCY KIT
Do you have one?
Are you comfortable using what is in the kit?
The Only Six Drugs You Need to Learn to Use
The drugs one should have in the emergency kit can be as complicated or as simple as you wish. The dentist should consider the kind of practice he/she has and tailor the emergency kit to his/her needs. There are, however, 4 drugs that the dentist should have in the emergency kit. Familiarity with the use of these 4 drugs and an understanding of the side effects of these drugs would allow the dentist to handle many of the emergencies encountered. A. NITROGLYCERIN Nitroglycerin is used for patients with angina. It is a vasodilator for the coronary tree and can rapidly reverse cardiac ischemia.
It is important to be sure that the patient is having angina prior to giving nitroglycerin. (see section on Evaluation and Management of Patient with Chest Pain) Nitroglycerin should be given at 0.3 mg dose sublingually at the onset of angina. If the patient brought his/her own nitroglycerin, it is reasonable to allow the patient to use his/her medication. Relief of pain is usually seen within 1-5 minutes after the administration of nitroglycerin. If angina is not relieved within 5 minutes after the nitroglycerin, the patient should be given a second dose. Patient should be urgently transferred to the Emergency Room if pain is not relieved by two nitroglycerins. In patients with frequent angina, nitroglycerin can be used prophylactically and be given in anticipation of a stressful procedure. SIDE EFFECTS: Common side effects of nitroglycerin include hypotension and headaches.
MANAGEMENT OF PATIENTS WITH ANGINA
1. What is angina pectoris?
Angina pectoris is a form of symptomatic ischemic heart disease. When there is a transient myocardial oxygen demand in excess of the available oxygen delivery for the coronary arteries, the patient would exhibit a symptom complex with chest pain.
2. Why is angina an important issue for the dentist?
A stressful dental procedure can precipitate an acute attack of angina. This would require emergency
intervention. Prolonged angina can result in a life-threatening myocardial infarction. The presence of angina is indicative of significant coronary artery disease and should alert the dentist to judicious use of vasoconstrictors in local anesthetics.
3. What is the cause of angina pectoris?
In the majority of cases, atherosclerotic changes of the coronary vessels can result in lack of blood supply to the myocardium. Less frequently, angina can result from excess oxygen demand, limited oxygen-carrying capacity (e.g. anemia) or inadequate perfusion of the coronary arteries due to hypotension or coronary vessel spasm.
4. What is the clinical manifestation of angina pectoris?
A classic case of angina is precipitated by emotional stress or physical exertion and is relived by rest. Typically, the patient would complain of a compression of the chest in the retrosternal area. The pain is often described as a heavy sensation over the precordial area and can radiate to the left shoulder and arm or to the jaw. It is usually of brief duration, lasting 3 to 5 minutes if the precipitating factor is removed.
5. What are Red Flags in the management of patients with angina?
Patients with unstable angina should not undergo elective dentistry. Patients on 4 or more drugs for the management of angina should be considered high risk patients
8. What is unstable angina?
Occasionally, a patient may experience a change in the pattern of angina. With an increase of the frequency and severity of the pain or with the appearance of angina at rest, the patient is said to have unstable angina. A
significant fraction of patients with unstable angina progress to myocardial infarction within a short time. These patients are therefore treated aggressively.
7. What are the guidelines for use of local anesthetics with vasoconstrictors in the patient with angina?
If the dentist elects to use local anesthetic with epinephrine, he should limit the amount used to 2 carpules of local anesthetic containing 1:100,000 epinephrine (4 carpules of 1:200, 000). In the case of local anesthetic with levonordefrin, the dentist should limit the amount used to 2 carpules of local anesthetic with 1:20,000 levonordefrin (Mepivacaine with levonordefrin).
9. What should the dentist do if an episode of angina should occur in the dental chair?
a. Stop the dental procedure b. Place the patient in a supine position c. Administer sublingual nitroglycerin d. Administer oxygen e. Monitor serial blood pressure and heart rate f. If angina is not relieved after 5 minutes, give a second
sublingual nitroglycerin g. Have the patient chew a 325 mg of aspirin h. Transfer the patient to a medical facility if pain is
refractory. (Protracted bout of angina can result in life-threatening myocardial infarction).
10. What are the side effects of nitroglycerin? Nitroglycerin can cause headaches Nitroglycerin can cause hypotension
MYOCARDIAL INFARCTION 1. What is myocardial infarction?
Myocardial infarction is the result of prolonged ischemic injury to the heart. The most common reason for having a myocardial infarction is progressive coronary artery disease secondary to atherosclerosis.
2. What are the symptoms of myocardial infarction?
The patient usually presents with severe chest pain in the substernal or left precordial area. The pain can radiate to the left arm or the jaw and may be associated with shortness of breath, palpitations, nausea or vomiting. The pain is often similar to that of angina but is more protracted and prolonged.
3. What are the complications of myocardial infarction?
The complications include arrhythmias and congestive heart failure. Complications depend upon the extent of the myocardial infarction. Patients with a small infarct will usually recover with minimal morbidity. Patients with large areas of injury are more likely to suffer heart failure and life threatening arrhythmias.
4. What are the emergency procedures for managing a
patient with an evolving myocardial infarction?
a. Stop the dental procedure b. Activate EMS support c. Place the patient in a supine position d. Consider using nitrous oxide e. Administer oxygen f. Administer sublingual nitroglycerin g. Monitor serial blood pressure and heart rate h. If angina is not relieved after 5 minutes, give a second
sublingual nitroglycerin i. Have the patient chew a 325 mg of aspirin j. Transport patient to nearest ER
B. BENADRYL Benadryl is an anti-histamine that is commonly used for minor adverse drug reaction. The drug is available in oral and parenteral forms. In the majoring of instances, minor adverse drug reaction can be managed with oral Benadryl. Benadryl is available as 50 mg capsule and the usual dosage is 50 mg q8 hours for minor adverse drug reaction. When a patient complaints of itching or develops a maculopapular rash after the administration of drugs (local anesthetics, sedatives, antibiotics or analgesics), Benadryl 50 mg should be given to the patient orally. In instances when the cutaneous manifestation is progressing rapidly, Benadryl can be given intramuscularly. In instances where the drug reaction is more severe and the patient begins to complain of throat itching, Benadryl IM should be given and the patient should be given prescriptions for Benadryl 50 mg q8h for 3-6 doses and for Medrol pac #1 as directed. If there are signs of impending anaphylaxis, Epinephrine, in the form of EpiPen, should be given intramuscularly and the patient should be transported by ambulance to the nearest emergency room. ADVERSE DRUG REACTIONS
1. DRUG ERUPTION Drug allergy often manifests itself as generalized maculopapular rash involving the trunk and limbs, usually sparing palms and soles. The rash may be mild erythema, a maculopapular rash or frank hives (angioedema).
For minor drug eruption with itching, erythema and maculopapular rash, Benadryl 50 mg q8h should be given for 2 days For severe drug eruption such as hives (angioedema), Medrol pac can be used (Medrol pac #1 as directed) in addition to Benadryl. Topical steroids are often helpful with symptomatic management of the drug eruption.
2. BRONCHOSPASM
Allergic reaction to drugs may present with respiratory and upper airway symptoms. Early symptoms include itching in the throat. This progresses on to difficulty swallowing, wheezing and eventually stridor. Bronchospasm is a serious condition and is usually the prodrome to anaphylaxis. Patients with bronchospasm should have prompt medical attention. For patients with mild bronchospasm, Benadryl 50 mg or Medrol should be given. For patients with severe bronchospasm, IM Benadryl (50 mg) and IM epinephrine (1 ampoule) should be given. Patients with severe bronchospasm should be given oxygen by facemask and, if trained, IV access should be established. The patient should be transported to the ER urgently. Patients with bronchospasm can progress onto upper airway obstruction if it is not promptly reversed by medications.
3. ANAPHYLAXIS Anaphylaxis is the most dreaded of the adverse drug reaction. The patient would develop skin eruption initially, then proceed to laryngospasm and eventually to hemodynamic collapse.
Anaphylaxis is mediated through an IgE mediated reaction and is a Type 1 immediate reaction. The reaction occurs within seconds to minutes of administration of drug. IM Epinephrine (one ampoule) should be given at the first concern over anaphylaxis since the patient can rapidly decompensate. IM Benadryl is also helpful. EMS should be activated at the first hint of anaphylaxis since the patient will need ER support and management. Airway should be established and oxygen administered via facemask. If trained, intravenous access should be established and D5NS should be allowed to run wide open. The patient should be carefully monitored and transferred to ER by Emergency Medical Services as soon as possible.
C. EPINEPHRINE Epinephrine is a sympathomimetic drug that stimulates both the alpha and beta receptors. The drug is used in cardiopulmonary arrest to stimulate and restore cardiac rhythm. Epinephrine is also important for treatment of severe bronchospasm and stridor. Patients with severe drug reactions, hypotension and patients with anaphylaxis are candidates for epinephrine. In the emergency kit, one should have an ampoule of EpiPen. This can be given intramuscularly and should have its onset of action within minutes. SIDE EFFECTS: Common side effects include hypertension and tachycardia. Epinephrine can also precipitate angina and congestive heart failure in the susceptible patient.
D. GLUCOSE SOURCE: GLUCOGEL Glucose is used exclusively for treatment of hypoglycemia in the diabetic patient with either excessive insulin or excessive oral hypoglycemic agents. It is extremely important to make sure that dental management takes into consideration changes in management to minimize the likelihood of hypoglycemia. In the majority of patients with hypoglycemia, oral glucose solution should be adequate (Orange juice, Glucola, Gluco-stat). In the patient with somnolence or coma, Glucogel can be applied to the gums with reasonable absorption. D50W can be used in instances where intravenous access can be established. It is the most reliable way of resuscitating the comatose hypoglycemic patient. D50Wcomes in an ampoule containing 50 cc of 50% glucose (25 grams of glucose). This has to be infused very slowly since extravasation can result in significant tissue necrosis. SIDE EFFECT: Can cause hyperglycemia HYPOGLYCEMIA IN DIABETIC PATIENTS
Hypoglycemia is the most serious complication of therapy. Hypoglycemia usually occurs as a result of excessive insulin or hypoglycemic agents. Inadequate oral intake may aggravate the situation. In Type 1 diabetics, hypoglycemia occurs because of relative insulin excess. In Type 2 diabetic, hypoglycemia occurs because of excessive oral hypoglycemic agents. In both groups, inadequate oral intake can accentuate the problem.
The clinical signs and symptoms of hypoglycemia include weakness, nervousness, tremulousness, palpitations, and excessive sweating. The patient’s sensorium may progress from confusion and agitation to seizures and coma. The most important point is to be able to recognize the symptoms of hypoglycemia and to prevent the symptoms from progressing. Patients with early symptoms should be given orange juice or candy bar Patients who are severely compromised and cannot safely take oral intake should be given Gluco-Gel or Insta-Glucose. Alternatively, patients can be given 1 ampoule of glucagon. If trained, D50W can be given via a secure IV line. The patient will usually respond within 1-3 minutes of the administration of glucose. Patients should be managed with the understanding that it is better to have blood sugars that are running high than running low. Diabetic patients should be given early to mid-morning appointments. They should specifically instructed to take a normal breakfast. Sessions should be limited to three hours or less so as not to interfere with the patient’s normal dietary intake. In these instances, neither the insulin therapy nor the oral hypoglycemic therapy needs to be altered.
E. ALBUTEROL INHALER Albuterol medihaler should be used for patients with acute flares of bronchospasm or asthma. It is a non-selective bronchodilator and works quite promptly. The patient should be instructed to inhale 2 puffs of the medication. If symptoms do not resolve promptly, the patient should be transported immediately to the Emergency Room.
SIDE EFFECT: Albuterol can cause tachycardia and hypertension. It can induce arrhythmia, precipitate angina and congestive heart failure in the susceptible patient. MANAGEMENT OF PATIENTS WITH ASTHMA
1. What is asthma?
Asthma is a condition characterized by episodic reversible narrowing of the airways. This would result in acute episodes of shortness of breath and wheezing. The disease can begin at any age but about half of the patients develop asthma before the age of 10. Asthma affects about 2% of the population and is responsible for 50,000 deaths per year in the United States.
2. What causes asthma?
The most common cause of asthma is an inherited immunologic disorder that allows inhaled antigens (allergens) to trigger a hypersensitivity response mediated by immunoglobulin E (IgE) and thus produce reversible bronchial narrowing. Asthma can also be precipitated by cold or by exercise.
3. What would constitute a Red Flag in the evaluation of
the patient with asthma?
Patients who are not adequately controlled on multiple medications should raise a Red Flag. Patients with PEF of less than 50% should raise a Red Flag.
4. What are the crucial issues in the evaluation of the patient with asthma?
A detailed history is crucial in the evaluation of the patient with asthma. The age at which symptoms of asthma appear is of some prognostic value, because patients develop asthma in childhood often have amelioration of symptoms as adults. Many patients with severe asthma as children have minimal symptoms in later years. Patients developing asthma as adults tend to have less dramatic improvement with time. The circumstances leading to an episode should also be analyzed to identify possible precipitating factors. Some patients develop bronchospasm at time of emotional stress. These patients should be identified and managed with adjunctive sedation techniques for dental procedures. Another common precipitant is an upper respiratory infection. It is therefore important to avoid elective dental procedures in these patients at the time of an upper respiratory infection. Other precipitants of bronchospasm include exercise, cold air and air pollutants. The severity of the patient’s asthma should be noted. Patients with prior history of respiratory insufficiency are obviously problematic and should be cautiously. The frequency of asthmatic attacks is also important in the determination of the need for chronic therapy. Peak expiratory flow is a convenient marker of severity of disease. PEF of < 50% indicated severe asthma and should pose a Red Flag.
5. What are the dental implications in the management of the patient with asthma?
The major goal for the dentist in the management of a patient with asthma is to minimize the likelihood of precipitating an asthmatic attack. A detailed history of the severity of the asthma, the precipitating factors and the medications used would be very helpful in the management of these patients.
6. What are the general guidelines for the management of patients with asthma?
Patients with asthma can occasionally have an exacerbation of symptoms under stress and efforts should be made to identify patients whose bronchospasm are precipitated by emotional stress. A. Minimize stress: Wherever possible, lengthy procedures should be spread over several appointments. Adjunctive sedation techniques should be considered when appropriate for minimization of stress. B. Sedation techniques are often necessary C. Avoid antihistamine: Antihistamines such as
promethazine (Phenergan) or diphenhydramine (Benadryl) should be avoided, because they have a drying effect that can exacerbate the formation of tenacious mucus in an acute attack.
D. Minimize Epinephrine use: For patients using methylxanthine preparations (e.g. Theophylline), the dentist should minimize the use of epinephrine in order to avoid additive toxicity and arrhythmia. Local anesthesia up to 2 carpules of 2% lidocaine with 1:100,000 epinephrine or the equivalent.
E. Avoid Erythromycins and Clarithromycin: These drugs should be avoided in patients on methylxanthine preparations (e.g. Theophylline) in order to minimize the likelihood of arrhythmia
F. Be aware of history of aspirin sensitivity: There is a clinical triad of asthma, nasal polyp and aspirin sensitivity. It is important to be sure that the patient with asthma does not have this triad when aspirin containing preparations are prescribed
EMERGENCY MANAGEMENT OF ASTHMA
Stop procedure Allow patient to take own inhaler
Use Albuterol Medihaler from the Emergency Kit if the patient does not have his/her medication Place patient on oxygen
Use Epinephrine 3 cc of 1:1000 dilution for patients with refractory asthma Transport patient to ER if symptoms are refractory to inhalation therapy
F. FLUMAZENIL Flumazenil is an antagonist of benzodiazepines. Its use should be limited to patients with severe obtundation and/or hemodynamic compromise from severe over-sedation. By following the DOCS protocol, with continuous monitoring of the patient, over-sedation can be avoided. Flumazenil is available as 0.1 mg/ml in either 5 or 10 mg vials. The drug can most conveniently be given in the dental setting by sublingual injection. 0.2 mg (2 ml) should be given and titrated up to 1 mg as necessary. The effect of Flumazenil is quite prompt but its duration of action is considerably shorter than the duration of action of even the short-acting benzodiazepines. It is therefore important to continue to monitor the patient closely after reversal. SIDE EFFECTS: Flumazenil is a pure antagonist with no agonistic effect. It has few side effects. In patients who are chronically on benzodiazepines, flumazenil may unmask the underlying condition the benzodiazepines were originally prescribed for.
![ACKNOWLEDGMENT OF DUTY TO NOTIFY COURT OF …...DUTY TO NOTIFY COURT OF CHANGE OF RESIDENCE [SUP.R.66.08(E)] INSTRUCTIONS: Read the below statements. If you agree, sign on the Guardian’s](https://static.documents.pub/doc/80x56/5f196cc9a9e8205cb36cadc9/acknowledgment-of-duty-to-notify-court-of-duty-to-notify-court-of-change-of.jpg)
