Medical Emergencies in Dental Practice

Medical Emergencies in Dental Practice
James G. Green, M.D., D.D.S., F.A.C.D. Dept. of Oral and Maxillofacial Surgery University of Florida College of Dentistry

Medical Emergencies When you prepare for emergencies, they cease to exist! Malamed

Medical Emergencies You have to have seen it to recognize it Green’s Rule

Medical Emergencies In case of an office emergency, the first procedure is to take your own pulse House of God Rule #3 (modified)

Medical Emergencies in the Dental Office
Hyperventilation 29% Seizures 20% Hypoglycemia 14% Vasodepressor syncope 11% Postural hypotension 7% Asthma % Angina % Allergy %

Medical Emergencies Office preparation Emergency procedure manual
Define each individual’s responsibilities Standardize equipment and train employees on location, set-up, function and use Establish a regular maintenance schedule and equipment checks

Medical Emergencies Office preparation Practice emergency procedures
Identify problems Demonstrates capabilities Set-up and use of equipment Improve performance Determine additional needs

Medical Emergencies Office preparation
Post emergency numbers on or around each telephone

Medical Emergencies Office preparation Determine equipment needs
Dependent upon: Training Skills Patient base Practice type Types of emergencies frequently seen

Medical Emergencies Emergency protocols
Develop treatment protocols for each common dental office emergency Post where easily retrieved Write in simple and easily followed step-by-step instructions

Airway Management It is essential that every practitioner be able to:
1. Maintain an airway 2. Manage an upper airway obstruction

Physical Evaluation Main purpose is to estimate the risk or probability of a patient having an emergency during treatment

Airway Evaluation Body habitus Status of dentition Retrognathia
Size of Neck Short, muscular neck Height and weight Status of dentition Full dentition vs. edentulous Protruding central incisors Retrognathia

Airway Evaluation High arched palate with long narrow mouth
Trismus or TMJ disease Cervical mobility Distance from chin to thyroid cartilage

Mallampati Airway Classification

Airway Angles

Airway Obstruction Most common cause Tongue
Treat by jaw thrust or chin lift - head tilt maneuver

Tongue Obstruction

Head Tilt - Open Airway

Airway Obstruction Other causes Foreign bodies
Treat by retrieving foreign body Finger sweep Heimlich maneuver Chest thrust

Darwin Award Nominee - 1998 Phillipsburg, NJ
An unidentified 29 year old man choked to death on a sequined pastie he orally removed from an exotic dancer. The dancer referred to only as “Ginger” said, “She didn’t know he was going to eat it.”

Airway Obstruction Other causes Laryngospasm Suction hypopharynx
Positive pressure ventilation Succinylcholine (if experienced) Cricothyroidotomy (if experienced)

Airway Obstruction If unable to clear obstruction by standard measures within 4-5 minutes: Emergent cricothyroidotomy

Neck - Topographical Anatomy

Anterior Neck Anatomy

Cricothyroid Membrane

Airway Adjuncts Oropharyngeal airways Nasopharyngeal airways
Mask-to-mouth airway Bag valve mask with reservoir

Airway Adjuncts Nasopharyngeal airways

Airway Management Nasopharyngeal airways
Length - nose to tragus of ear Size - little finger (guide) Insertion Lubrication Position

Surgilube

Nasopharyngeal Airway

Airway Adjuncts Oropharyngeal airways

Airway Management Oropharyngeal airways Unconscious patients only!!
Correct size Age Insertion Position

Oropharyngeal Airway

Mouth-to-Mask Airway

Bag Valve Mask

Bag Valve Mask Reservoir

Bag Valve Mask

Airway Management Ambu bag Experience Practice Volume
How many dentists does it take to use an Ambu bag?

Airway Adjuncts Oxygen
All patients with medical emergencies need oxygen No distress – 2 L/m via nasal cannula Mild distress – 5-6 L/m via face mask Moderate to severe distress – 10 L/m via face mask with reservoir Unconscious – 100% via intubation

Oxygen

Oxygen Masks Nasal cannula Face mask Face mask with reservoir
1-6 L/m % oxygen Face mask 8-10 L/m 40-60% oxygen Face mask with reservoir 10 L/m ~100% oxygen Venturi mask 24, 28, 35, 40% oxygen

Airway Management Nasal cannula Mask with reservoir
Readily accepted Mask with reservoir Poorer acceptance Mask-to-mouth device Separate provider from patient Oxygen inlet valve Clear mask Seal

Airway Adjunct Paper bag

Airway Adjuncts Yankauer Suction

Resuscitation ABCs Airway Breathing Circulation
Assess for airway obstruction Assess for respiratory arrest Circulation Assess for cardiac arrest

Resuscitation CPR BLS designed to maintain circulation of oxygenated blood to the heart and brain until definitive medical treatment can restore normal or sufficient heart and ventilatory function Rapid EMS response with early ACLS required for best chances of survival

Resuscitation Most cardiac arrest victims have ventricular fibrillation Supports early use of automated external defibrillators (AEDs) or manual defibrillators

Resuscitation Ventricular fibrillation
Only treatment is defibrillation 90% of patients with V-fib survive neurologically intact if treated with defibrillation within 1-2 minutes Success of resuscitation decreases linearly with each minute (50% minutes, <10% - 9 minutes) Converts to asystole in minutes

Resuscitation Survival of other cardiac arrest rhythms poor (~ 85 % die)

Case Scenario An 14 year old female presents for routine restorative dentistry. She has never had a cavity diagnosed until today. She is in your office and will need two simple Class I restorations.

Case Scenario Past Medical History Medications: None Allergies: None
PSH: None ROS: Noncontributory

Case Scenario Prior to the injections you note she is sighing frequently. During the injections, she yells that it hurts and starts crying. She becomes panicky and inconsolable. Two minutes later she starts complaining of midsternal chest pain.

Case Scenario What is your diagnosis?

Case Scenario Five minutes after the injections, she becomes unconscious.

Hyperventilation

Causes of Hyperventilation
Anxiety Most common Metabolic conditions Pain Metabolic acidosis Drug intoxication Hypercapnia CNS disorders

Predisposing Factors Anxiety Age
Most common Age years of age No sex difference May develop with other medical conditions

Case Scenario What is the pathophysiology of this “minor” emergency?

Pathophysiology Increased respiratory rate causes:
Acute decrease in PaCO2 and rise in blood pH Cerebral vessels constrict Unconscious Decreased PaCO2 depresses Apnea respiratory drive When PaCO2 rises and pH decreases, the patient will begin breathing again May repeat cycle

Case Scenario What other physical signs and symptoms assist in making the diagnosis?

Hyperventilation Signs Symptoms Tachypnea Tachycardia Unconsciousness
Dizziness Lightheadedness Chest pain Palpitations Numbness Lips, extremities SOB Nausea / Pain

Case Scenario How do you treat it?

Management Terminate procedure Position patient Calm patient
Rebreathing bag Sedation

Case Scenario A 25 year old male construction worker presents for removal of his third molars. He has 4 erupted thirds which you feel you can remove without difficulty or sedation. He has come from a job site. The outside temperature today was 103 F. He passed up his usual beers after work with his buddies.

Case Scenario PMH: Meds: None Allergies: None Illnesses: None
PSH: ORIF of left femur fracture from a motorcycle accident ROS: Noncontributory

Case Scenario During administration of local anesthesia, he becomes jittery, pale and diaphoretic. He appears anxious and disoriented.

Case Scenario What is your differential diagnosis?
Be specific! What would you do first? What is your treatment?

Case Scenario Vital signs BP - 80/40 P – 80 regular R – 14

Case Scenario After your treatment, he recovers sufficiently to allow you to do the extractions. The case goes well and after the procedure, the assistant sits him up and he again becomes faint and dizzy. A half hour later, you need to go home. You put him in a wheelchair and your assistant takes him to his car.

Case Scenario His girlfriend who met him at your office will drive him home. When he stands up to get into the car, he passes out.

Case Scenario What is your differential diagnosis?
Be specific! How does treatment for this differ from your previous treatment? How can you differentiate clinically between these two types?

Syncope

Syncope Syncope and death are the same – except that in one you wake up Anonymous

Syncope The sudden transient loss of consciousness
Usually < 1 minute

Syncope Incidence Presyncope - Universal Syncope - 50% Syncope accounts for ~ 3% of all ER visits and may account for up to 6% of hospital admissions

Syncope Definitive diagnosis of syncope is made in only about 50% of case. ER physicians can make a definitive diagnosis in only ~ 25% of cases 25% of all patients referred to cardiologist for cardiac work-up have syncope and not cardiac disease

Pathophysiology of Syncope
Lack of oxygen and blood to the brain Nonspecific with multiple causes Lack of glucose to the brain Seizure activity

Causes of Syncope Cardiac Peripheral vascular Cerebrovascular
Hyperventilation Hypoglycemia Seizures

Seizures and Syncope Difficulty is determining whether the seizure caused the faint or the faint caused the seizure Generalized clonic jerks result from cerebral anoxia Can’t rely on tongue-biting and urination

Seizures and Syncope Evaluate by history
Abrupt loss of consciousness with simultaneous tonic-clonic seizure activity with a slow recovery phase Suggests seizure Syncope – rapid recovery

Cardiac Events and Seizures
Most remediable cause of seizures Most lethal cause of seizures 3 broad catagories: Rhythm disturbances Ventricular outflow obstruction Myocardial ischemia

Arrhythmias and Syncope
Often difficult to prove Usually requires a heart rate of >150 or <40 beats per minute

Ventricular Outflow and Syncope
Aortic stenosis Prevalvular Postvalvular Mitral stenosis Tumors (rare)

Vasovagal Syncope Most commonly observed potentially life-threatening emergency seen in the dental office

Vasovagal Syncope Synonyms Simple faint Swoon Vasodepressor syncope
Psychogenic syncope Neurogenic syncope

Precipitating Factors
Psychogenic Fright Anxiety Emotional stress Pain Site of Blood

Precipitating Factors
Nonpsychogenic Prolonged sitting or standing Hunger Exhaustion Poor physical condition Hot humid crowded environment

Early Signs Feeling of warmth Loss of color (pale) Sweating Nausea
Faint Tachycardia Normal BP

Late Signs Yawning Cold Dizziness Rapid breathing Pupillary dilation
Hypotension Bradycardia Loss of consciousness

Stages Presyncope Syncope Postsyncope

Presyncopal Management
Terminate treatment Protect patient from falling Trendelenberg position Oxygen if necessary

Syncopal Management Trendelenberg position Protect the airway
Monitor vital signs Oxygen

Postsyncopal Management
Discontinue treatment Determine cause of event Treat appropriately Arrange for patient to be taken home by relative or friend when stable or to hospital

Recurrent Syncope Look for other causes May need hospitalization
Orthostatic Seizures Cardiac TIA Hypoglycemia Hyperventilation May need hospitalization

Case Scenario A 55 year old female presents for dental implants with IV sedation.

Case Scenario PMH: Medications: None Allergies: None Illnesses: None
PSH: None

Case Scenario An IV is started and she is given Versed and Fentanyl initially. She receives 1 g of Kefsol IV as antibiotic prophylaxis and 2 minutes later complains of itchy skin, develops a diffuse patchy rash, watery eyes and a runny nose. She feels nauseated and complains of stomach cramps.

Case Scenario What is your diagnosis?

Allergy

Allergy Hypersensitivity state Requires exposure to antigen
Body develops antibodies to antigen Re-exposure to antigen elicits reaction

Allergy Variable reactions Dermatological (most common) Respiratory
Nasal / Pulmonary CNS CV Generalized anaphylaxis (rare)

Type I Reaction IgE-mediated Immediate response Affects 10% population
Inherited tendency

Type I - Antigens Drugs most commonly associated with allergic reactions PCN Sulfa derivatives Narcotics ASA NSAIDS

Case Scenario What are some of the common dermatological manifestations of allergic reactions?

Dermatological Reactions
Urticaria Wheal and flare Pruritis Angioedema Conjunctivitis Rhinitis Rarely life-threatening if sole reaction May be first indication of a more generalized reaction to follow

Case Scenario What are the available treatments for dermatological signs of allergic reactions?

Treatment Dermatological reactions Delayed (> 1 hour)
Benadryl 50 mg PO q 6 h for 3-4 days Immediate (< 1 hour) Epinephrine 0.3 mg IM or SC Benadryl 50 mg IM Transfer to ER

Case Scenario You give the patient Benadryl 50 mg IV and 20 minutes later she starts to wheeze and complain of shortness of breath. Her blood pressure is slowly decreasing. What should you do now?

Bronchospasm Treatment
Terminate therapy Position patient to comfort Oxygen 5-6 liters/minute via cannula or mask Epinephrine 0.3 mg IM or SC or Medihaler-epi q 5 minutes as required Benadryl 50 mg po q 6 h for 3-4 days Start an IV (if capable) and give NS Call 911

Respiratory Reactions
Bronchospasm Dyspnea, wheezing, flushing, cyanosis, diaphoresis, tachycardia, anxiety, accessory muscle use Laryngeal edema Stridor or crowing May be indication of a developing generalized reaction

Laryngeal Edema Tx Epinephrine 0.3 mg IM or SC q 5 minutes prn
Maintain airway Oxygen 5-6 liters/minute by face mask Start IV (if capable) with NS Benadryl 50 mg IM or IV Solucortef 100 mg IM or IV Cricothyroidotomy (if necessary)

Case Scenario You can’t find your emergency drug kit. The patient is now confused and uncooperative. His BP is 70/0 and his HR is What should you do?

Generalized Anaphylaxis
BLS Epinephrine 0.3 mg IM or IV q 5 minutes prn Oxygen Monitor VS q 5 minutes

Generalized Anaphylaxis
Usually rapid onset (5 to 30 minutes, occasionally delayed for hours) Respiratory and cardiovascular problems predominate and occur early in the reaction Death can occur in minutes

Local Anesthetics Esters >>> Amides Antigenic components
Overall incidence very, very low No esters available in dental cartridges Antigenic components Parabens - PABA, Methylparabens Metabisulfite Bisulfites

Local Anesthetics Allergy History
Must try to differentiate between true allergy, overdose, intravascular injection, vasoconstrictor reaction or idiosyncratic reaction Requires good dialogue history with patient If questionable history, refer to allergist

Penicillin 2.5 million people allergic
Allergic reaction reported in 5-10% of patients receiving penicillin Fatal reaction in 1 per 100,000 Most frequent cause of generalized anaphylaxis in dental practice

Chest Pain

Chest Pain Origin Cardiac Pulmonary Musculoskeletal
Neck, thorax, shoulder Upper abdominal viscera

Chest Pain Classification Recurrent Severe Mild to moderate intensity
Prolonged pain

Recurrent Chest Pain Angina pectoris Musculoskeletal
Most important but not the most frequent cause of recurrent chest pain Secondary to transcient myocardial ischemia (imbalance between oxygen supply and tissue oxygen demands) Musculoskeletal Responsible for the majority of recurrent chest pain

Recurrent Chest Pain Other causes Anxiety states
Reflux esophagitis +/- hiatal hernia Associated with large meals, alcohol, highly seasoned food, chocolates, coffee Nocturnal and associated with recumbancy Relieved by nitroglycerin Diffuse esophageal spasms Associated with meals

Musculoskeletal Pain Characteristics
Neck, shoulder and thorax most common locations Tends to occur at night Precipitated or intensified by fatigue, posture, movement, coughing, sneezing Long duration of pain (often hours) Pain dull, aching with sharp twinges Relief characterized by rest, heat, postural exercises and analgesics

Angina Pectoris Causes: Coronary artery atherosclerosis
Coronary artery spasm Coronary artery thrombosis Multiple other cardiac and pulmonary etiologies: Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection

Angina Pectoris May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X) Uncommon in males less than 40 Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia

Angina Pectoris Clinical characteristics Poorly localized pain
Usually retrosternal but may occur anywhere from lower jaw to umbilicus Brief duration 2-10 minutes Moderate intensity pain described as squeezing, oppressive, burning or heavy

Angina Pectoris Clinical characteristics Precipitated by:
Emotional distress Physical exertion Heavy meals Cold Walking up stairs or hills Exacerbated by: Recumbency

Angina Pectoris Clinical characteristics Excluded if:
Pain localized with one finger Lasts less than 30 seconds or longer than 30 minutes Pain described as sticking, jabbing, throbbing or constantly severe

Angina Pectoris Types of angina pectoris Stable Unstable
Pain pattern repeatable for frequency, intensity, duration, provocation and response to nitroglycerin and rest Unstable Pain pattern changed in one or more characteristics (frequency, intensity, duration, provocation, response to nitroglycerin or cessation of activity) May occur at night or rest

Angina Pectoris Unstable angina pectoris
Indicative of progressive coronary artery disease Indistinguishable from MI Requires admission to “rule out” MI Enzymes - CPK-MB, LDH, Troponin I and T Serial EKGs Clinical history

Angina Pectoris Dialogue history Determine: Angina description
Classical, atypical or equivalent angina Frequency Duration of pain Precipitating factors Activity level Stressors Treatment Medications

Angina Pectoris Dialogue history Risk factors Smoking Hyperlipidemia
Obesity Sedentary life style Alcohol consumption Hypertension Diabetes mellitus

Angina Pectoris Dialogue history Risk factors Sex Age Genetics Race
Male Postmenopausal female Age Genetics Family history Race Blacks > Caucasians

Angina Pectoris Treatment Stop procedure Position patient to comfort
Oxygen 2-3 L per NC or face mask Nitroglycerin 0.4 mg SL Repeat q 5 minutes x 3 total doses If no response, assume MI or unstable angina Activate EMS and transfer to ER

Angina Pectoris Diagnostic approach Nitroglycerin
Normally relieves pain in 3 minutes or less Failure to relieve pain after 10 minutes evidence against angina Failure to relieve pain indicates either unstable angina or myocardial infarction

Angina Pectoris Function of nitroglycerin
Dilates coronary arteries to increase blood flow and improve oxygen delivery to cardiac tissue Platelet disaggregation

Angina Pectoris Dental treatment Early AM appointments
Short appointments Consider oxygen and prophylactic nitroglycerin Stress reduction protocols Good local anesthesia Nitrous oxide PO or IV sedation

Myocardial Infarction

Cardiac ischemia which results in myocardial necrosis

Pain more intense and longer in duration than angina pectoris Pain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectoris Not relieved by SL nitroglycerin or cessation of activity

MI Signs and Symptoms Symptoms Signs Pain Nausea/Indigestion
Weakness/Fatigue Dizziness Palpitations Sense of impending doom SOB Lightheadedness Signs Restlessness Acute distress Vomiting Diaphoresis Cardiac arrhythmia Pallor Cyanosis Dyspnea Wheezing

Dialogue history History of angina pectoris Changes in angina pectoris Previous MI When, Treatment, Outcome, Current status Medications Risk factors

Management of Acute MI Recognition BLS
Airway Breathing Circulation Activate EMS Oxygen L by NC or face mask

Management of Acute MI Monitor VS Position to comfort Pain relief
Morphine sulfate 2-5 mg IM/IV q 5-15 minutes prn Controls pain and reduces anxiety Prepare to perform CPR or provide ACLS (if properly trained)

Management of Acute MI Transfer to ER