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6/3/20141 Management Of Medical Emergencies In The Dental Office Fady Faddoul, DDS, MSD,FICD Professor and Vice-Chairman Department of Comprehensive Care.

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Presentation on theme: "6/3/20141 Management Of Medical Emergencies In The Dental Office Fady Faddoul, DDS, MSD,FICD Professor and Vice-Chairman Department of Comprehensive Care."— Presentation transcript:

1 6/3/20141 Management Of Medical Emergencies In The Dental Office Fady Faddoul, DDS, MSD,FICD Professor and Vice-Chairman Department of Comprehensive Care Director, Advanced Education in General Dentistry Case Western Reserve University School Dental Medicine

2 6/3/20142 Management of Medical Emergencies Medical emergencies can and do happen Advances in medicine Longer lifespan Multiple medications Medically compromised Longer appointments

3 6/3/20143 Incidence A survey done in the 90s showed that, over a 10 year period, 90% of dentists have encountered at least one medical emergencies. A survey done in the 90s showed that, over a 10 year period, 90% of dentists have encountered at least one medical emergencies.

4 6/3/20144 Types TYPE OF EMERGENCY NUMBERPERCENT Altered Consciousness 17,78259 Cardiovascular4,28014 Allergy2, Respiratory2,7189 Seizures1,5955 Diabetes-Related9993

5 Management of Medical Emergencies Basic Life Support Basic Life Support Advanced Life Support Advanced Life Support 6/3/20145

6 6 Management of Medical Emergencies Emergency situations Managed properly most emergencies are resolved satisfactorily Managed properly most emergencies are resolved satisfactorily Mismanaged even benign emergencies can turn disastrous Mismanaged even benign emergencies can turn disastrous Recognize Recognize Position Position Stabilize Stabilize Diagnose Diagnose Treat Treat Refer Refer

7 6/3/20147 Management Of Medical Emergencies 1. Recognition 2. Prevention 3. Preparation 4. Basic life support (BLS) 5. Cardiopulmonary resuscitation (CPR) 6. Specific medical emergencies

8 6/3/20148 Prevention IS THE BEST TREATMENT IS THE BEST TREATMENT Know your patient Never treat a STANGER

9 6/3/20149 Prevention 90% of life-threatening situations can be prevented 90% of life-threatening situations can be prevented 10% will occur in spite of all preventive efforts (sudden unexpected death) 10% will occur in spite of all preventive efforts (sudden unexpected death)

10 6/3/ Prevention Medical History Medical History Physical Evaluation Physical Evaluation Vital Signs Vital Signs Dialogue History Dialogue History Determination of Medical Risk Determination of Medical Risk Stress Reduction Stress Reduction

11 6/3/ Prevention MEDICAL HISTORY Review Review Update Update Medication Medication Medical consultation Medical consultation

12 6/3/ Prevention PHYSICAL EVALUATION Length of time since last evaluation Length of time since last evaluation Vital signs Vital signs Visual inspection of patients Visual inspection of patients Referral to physician Referral to physician

13 6/3/ Prevention VITAL SIGNS Blood pressure Blood pressure Pulse rate Pulse rate Respiratory rate Respiratory rate Temperature Height Weight

14 6/3/ Prevention DIALOGUEHISTORY Putting it all together Putting it all together Check accuracy of Check accuracy of medical history Recognize anxiety Recognize anxiety

15 6/3/ Prevention DETERMINATION OF MEDICAL RISK. Ability of patient to safely tolerate dental treatment. Ability of patient to safely tolerate dental treatment. Does patient represent increased medical risk? Does patient represent increased medical risk? Can patient be managed in the dental office? Can patient be managed in the dental office?

16 6/3/ Determination Of Medical Risk American Society of Anesthesiology Physical Status Classification System

17 6/3/ ASA I A patient without systemic disease A patient without systemic disease A normal healthy patient A normal healthy patient Can tolerate stress involved In dental treatment No added risk of serious Complications Treatment modification Usually not necessary

18 6/3/ 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

19 6/3/ ASA III A patient with severe systemic disease that limits activity but is not incapacitating Example: - a stable angina - a stable angina - 6 mos. Post - MI - 6 mos. Post - MI - 6 mos. Post - CVA - 6 mos. Post - CVA - COPD - COPD Elective Dental Treatment is not Contraindicated Treatment Modification is Required - Reduce Stress - Sedation - Short Appointments

20 6/3/ ASA IV A patient with incapacitating systemic disease that is a constant threat to life A patient with incapacitating systemic disease that is a constant threat to lifeExample: - Unstable angina - M I within 6 months - CVA within 6 months - BP greater than 200/115 - Uncontrolled diabetic Elective dental care should be postponed Emergency dental care only Rx only to control pain and infection Other treatment in hospital (I&D, extraction)

21 6/3/ 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

22 6/3/ Prevention STRESS REDUCTION Premedication Premedication Sedation Sedation Pain control (intra and post-op) Pain control (intra and post-op) Early appointments Early appointments Short appointments Short appointments

23 6/3/ Preparation Team Effort Team Effort BLS for all office personnel BLS for all office personnel CPR for all office personnel CPR for all office personnel Emergency drills Emergency drills Emergency phone numbers (911) Emergency phone numbers (911) Emergency equipment Emergency equipment

24 6/3/ BASIC LIFE SUPPORT (BLS) CARDIOPULMONARY RESUCITATION (CPR)

25 6/3/ SBE Prophylaxis In 2012, the guidelines were updated and now premedication is needed for fewer conditions. In 2012, the guidelines were updated and now premedication is needed for fewer conditions. The conditions for which premedication is necessary includes: The conditions for which premedication is necessary includes: artificial heart valves artificial heart valves a history of infective endocarditis a history of infective endocarditis a cardiac transplant that develops a heart valve problem a cardiac transplant that develops a heart valve problem the following congenital (present from birth) heart conditions: the following congenital (present from birth) heart conditions: *unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits *a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure *any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

26 6/3/ SBE Prophylaxis Patients who previously needed antibiotic prophylactic but no longer need them include: Patients who previously needed antibiotic prophylactic but no longer need them include: mitral valve prolapse mitral valve prolapse rheumatic heart disease rheumatic heart disease bicuspid valve disease bicuspid valve disease calcified aortic stenosis calcified aortic stenosis congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy

27 6/3/ SBE Prophylaxis Procedures needing prophylaxis: Procedures needing prophylaxis: All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. procedures that do not require prophylaxis are radiographs, placement of removable prosthesis, and placement orthodontic bracket. procedures that do not require prophylaxis are radiographs, placement of removable prosthesis, and placement orthodontic bracket.

28 6/3/201428

29 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures AMOXCICILIN Adults 2 grams Children 50 mg/kg (not to exceed adult dosage) Orally 1 hour before procedure No repeat dose

30 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Allergic to Penecillin AdultChildren AdultChildren Clindamycin 600 mg 20 mg/kg Cefalexin or Cfadroxil 2 gr. 50 mg/kg Azithromycin or Clanthromycin 500 mg 15mg/kg ORALLY 1 HOUR BEFORE PROCEDURE

31 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Unable to take Oral Medication Ampicillin Adults:2 gr IM or IV Children:50 mg/kg IM or IV Within 30 minutes of procedure

32 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Amoxicillin vs. Penecillin Amoxicillin vs. Penecillin Both equally effective against Streptococus viridan Both equally effective against Streptococus viridan Amoxicillin is better absorbed from the GI tract, and provides higher and more sustained serum level Amoxicillin is better absorbed from the GI tract, and provides higher and more sustained serum level 2 gr. Provides as effective coverage as 3 gr. With less GI adverse effects. 2 gr. Provides as effective coverage as 3 gr. With less GI adverse effects. 2 nd dosage not required due to prolonged serum level above the inhibitory period for most oral Streptococci. 2 nd dosage not required due to prolonged serum level above the inhibitory period for most oral Streptococci.

33 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis ERYTHROMYCIN ERYTHROMYCIN No longer recommended due to GI side effects. Practitioners who have used it successfully in the past, may continue to use it following the previously published regimen. 2 gr. 2 hours before procedure 1 gr. 6 hours later

34 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Patient already taking antibiotic used for prophylaxis: Patient already taking antibiotic used for prophylaxis: 1. Select an antibiotic from a different class, rather than increasing the dosage 2. Delay treatment if possible 9 to 14 days after completion of antibiotic to allow usual flora to reestablish Example: Amoxicillin, go to Clindamycin. No Cephalosporin due to cross resistance

35 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Prophylaxis for dental patients with TOTAL JOINT REPLACEMENT

36 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis The most crucial period is up to 2 years following a joint replacement The most crucial period is up to 2 years following a joint replacement Prophylaxis not recommended for dental patients with: Pins, Plates, and Screws. Prophylaxis not recommended for dental patients with: Pins, Plates, and Screws. Prophylaxis is not routinely indicated for most dental patients with total joint replacement Prophylaxis is not routinely indicated for most dental patients with total joint replacement

37 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Patients at potential increased risk of total joint infection Immunocompromized/Suppressed patients Immunocompromized/Suppressed patients Other Patients: Other Patients: Insulin Dependent diabetics Insulin Dependent diabetics 1 st 2 years following joint replacement 1 st 2 years following joint replacement Previous prosthetic joint infection Previous prosthetic joint infection Malnourishement Malnourishement Hemophilia Hemophilia

38 6/3/ Management of Medical Emergencies Antibiotic Prophylaxis Procedures and regimens are the same as discussed earlier for SBE prophylaxis. Procedures and regimens are the same as discussed earlier for SBE prophylaxis. A cephlosporin is preferable to Amoxicillin due to its affinity to cynovial fluids A cephlosporin is preferable to Amoxicillin due to its affinity to cynovial fluids


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