1. INTRODUCTION Prevention is the most important phase of treating medical emergencies. It must be remembered however that despite all efforts at prevention EMERGENCIES will happen. There are three 3 steps to prevention of medical emergencies in the dental office: 1.Medical History 2.Patient Evaluation 3.Staff Training and Preparation

2. TYPES OF EMERGENCY ALTERED CONCIOUSNESS CARDIOVASCULAR ALLERGY RESPIRATORY SEIZURES DIABETIES RELATED

3. Management Of Medical Emergencies Recognition Prevention Preparation Basic life support (BLS) Cardiopulmonary resuscitation (CPR) Specific medical emergencies

4. Specific medical emergencies Prevention / patient evaluation Medical History Physical Evaluation of the related organ system Vital Signs Dialogue History Determination of Medical Risk Stress Reduction

5. MEDICAL HISTORY General state of health Current medications Particular conditions like CHD, prosthetic valve Drug allergy (penicillin) Bleeding tendency HEMOPHILIA Immunodeficiency HIV

6. a) Are there any recent changes to health? b) Is the patient under the care of a physician? c) Has the patient had any serious illness / surgery d) Does the patient have any allergies? e) Is the patient taking any drugs or medications? f) Is the patient pregnant?

7. ASA Physical Status Classification DETERMINATION OF MEDICAL RISK/RECOGNTION Class1: Healthy patient with no systemic disease. Class 2: Mild Systemic disease with no limits on activity. Class 3: Severe systemic disease that limits activity. Class 4: Incapacitating systemic disease that is life threatening. Class 5: Moribund.

8. ASA I A patient without systemic disease A normal healthy patient Can tolerate stress involved in dental treatment No added risk of serious complications Treatment modification usually not necessary

9. ASA II A patient with mild systemic disease Example: -Well-controlled diabetic -Well-controlled asthma -ASA I with anxiety Represent minimal risk during dental treatment Routine dental treatment with minor modifications -Short early appointments -Antibiotic prophylaxis -Sedation

10. ASA III A patient with severe systemic disease that limits activity but is not incapacitating. Example: - a stable angina - 6 mos. Post - MI - 6 mos. Post - CVA - COPD Elective Dental Treatment is not Contraindicated Treatment Modification is Required - Reduce Stress - Sedation - Short Appointments

11. ASA IV A patient with incapacitating systemic disease that is a constant threat to life Example: - Unstable angina - M I within 6 months - CVA within 6 months - BP greater than 200/115 - Uncontrolled diabetic Elective dental care should be postponed Elective dental care should be postponed Emergency dental care only Emergency dental care only  Rx only to control pain and infection  Other treatment in hospital  (I&D, extraction)

12. ASA V A morbid patient not expected to survive Example: - End stage renal disease - End stage hepatic disease - Terminal cancer - End stage infectious disease Elective treatment definitely contraindicated Emergency care only to relieve pain

13. STRESS REDUCTION / PREVENTION Premedication Sedation Pain control (intra and post-op) Early appointments Short appointments Monitor vital signs

14. PREPERATION a) Training: Staff needs to have the knowledge to identify and correctly manage each emergency. b) Easily accessible emergency equipment & drugs c) Coordination of office personnel “team Effort” d) BLS for all office personnel e) CPR for all office personnel f) Emergency drills g) Emergency phone numbers (911) h) Emergency equipment

15. Basic Principle of Managing all Medical Emergencies 1. BLS: remember ABC’s 2. Place the patient supine. 3. Call for assistance. 4. Assure patient if conscious. 5. Maintain airway. 6. Place patient on Oxygen as indicated by nature of emergency. 7. Monitor vital signs. 8. Diagnose nature of event. 9. Initiate specific treatment. 10. Document.

16. PABCD P = Positioning A = Airway B = Breathing C = Circulation D = Definitive treatment

17. Emergency Equipment Tourniquets Syringes Suction Bag valve mask Oropharyngeal and nasopharyngeal airways laryngoscope and endotracheal tubes Normal saline 0.9%, 1000 cc bags 18-and 20-gauge angiocatheters Yankauer suction tip. Cricothyroidotomy sets Portable oxygen system-E cylinder size Stethoscope Sphygmomanometer-child and adult sizes Emergency back-up suction unit-venturi operated suction attached to oxygen system tape EKG/defibrillator Pulse oximeter Sterile water for injection

18. EMERGENCY DRUGS EPINEPHRINE -To treat cases of acute allergic reaction -Acute asthmatic attack DOSE = 0.3 mg of 1:1000 for adult 0.15mg of 1:1000 for children-IV -Management of cardiac arrest – DOSE = 1:10000-IV Chlorpheniramine (Histamine Blocker) M/o delayed-onset allergic reactions Diphenhydramine Definitive m/o acute allergic reaction As Local anesthetics when the patient has h/o allergy to LA

19. Nitroglycerine (vasodilator) Chest pain Definitive m/o angina pectoris Early m/o acute myocardial infarction M/o acute hypertensive episodes Albuterol (salbutamol) Bronchodilator To treat bronchospasm (acute asthmatic episodes) Allergic reactions with bronchospasm

20. Midazolam & Diazepam (Benzodiazepine) USES To treat prolonged seizures Local anesthetic induced seizures Hyperventilation Thyroid storm Flumazenil (benzodiazepine antagonist) Reduce the duration of anterograde amnesia associated with midazolam (from 121 min to 91 min) Use to reverse benzodiazepines anesthesia

21. Morphine sulphate (Opioid agonist) USES Intense, prolonged pain or anxiety. Acute myocardial infarction and Congestive heart failure Naloxone Acute morphine poisoning Use in opioid induced depression, including respiratory depression

22. Methoxamine (Vasopressor) To manage hypotension Syncope reactions A- phenylephrine (α receptor agonist) Drug overdose reactions Post seizure states Acute adrenal insufficiency Allergy

23. Esmolol (β1 adrenergic blocker) OR propranolol Acute hypertensive episodes Supra ventricular tachycardia Episodic atrial fibrillation Arrhythmia during anesthesia Hydrocortisone sodium succinate Definitive m/o acute allergy Rx of acute adrenal insufficiency, shock, status asthmatics

24. Atropine (Anticholinergic) To treat bradycardia Haemodynamically significant brady dysrhythmias Aromatic ammonia (respiratory stimulant) Used for Rx respiratory depression Nifedipine ca channel blocker Hypertension Acute anginal pain Dextrose, 50% Solution (Glucagon) hypogylcemia

25. Lidocaine (xylocaine) LA and anti-dysrhythmic Dopamine To treat haemodynamically significant hypotension in the absence of hypovolemia Aspirin (Antiplatelet) Used in patient with suspected myocardial infarction unstable angina