Presentation is loading. Please wait.

Presentation is loading. Please wait.

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.

Similar presentations


Presentation on theme: "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."— Presentation transcript:

1 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

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

3 Medical Emergencies You have to have seen it to recognize it. Greens Rule

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

5 Medical Emergencies in the Dental Office Hyperventilation29% Seizures20% Hypoglycemia14% Vasodepressor syncope11% Postural hypotension 7% Asthma 7% Angina 5% Allergy 5%

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

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

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

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

10 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

11

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

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

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

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

16 Mallampati Airway Classification

17 Airway Angles

18

19

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

21 Tongue Obstruction

22 Head Tilt - Open Airway

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

24 Darwin Award Nominee 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 didnt know he was going to eat it.

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

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

27 Neck - Topographical Anatomy

28 Anterior Neck Anatomy

29

30 Cricothyroid Membrane

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

32 Airway Adjuncts Nasopharyngeal airways

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

34 Surgilube

35 Nasopharyngeal Airway

36 Airway Adjuncts Oropharyngeal airways

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

38 Oropharyngeal Airway

39 Mouth-to-Mask Airway

40

41

42 Bag Valve Mask

43 Bag Valve Mask Reservoir

44 Bag Valve Mask

45

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

47 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

48 Oxygen

49 Oxygen Masks Nasal cannula – 1-6 L/m24-44% oxygen Face mask – 8-10 L/m40-60% oxygen Face mask with reservoir – 10 L/m~100% oxygen Venturi mask – 24, 28, 35, 40% oxygen

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

51 Airway Adjunct Paper bag

52 Airway Adjuncts Yankauer Suction

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

54 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

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

56 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

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

58 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.

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

60 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.

61 Case Scenario What is your diagnosis?

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

63 Hyperventilation

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

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

66 Case Scenario What is the pathophysiology of this minor emergency?

67 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

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

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

70 Case Scenario How do you treat it?

71 Management Terminate procedure Position patient Calm patient Rebreathing bag Sedation

72 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.

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

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

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

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

77 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.

78 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.

79 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?

80 Syncope

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

82 Syncope The sudden transient loss of consciousness – Usually < 1 minute

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

84 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

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

86 Causes of Syncope Cardiac Peripheral vascular Cerebrovascular Hyperventilation Hypoglycemia Seizures

87 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 – Cant rely on tongue-biting and urination

88 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

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

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

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

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

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

94 Precipitating Factors Psychogenic – Fright – Anxiety – Emotional stress – Pain – Site of Blood

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

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

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

98 Stages Presyncope Syncope Postsyncope

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

100 Syncopal Management Trendelenberg position Protect the airway Monitor vital signs Oxygen

101 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

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

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

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

105 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.

106 Case Scenario What is your diagnosis?

107 Allergy

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

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

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

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

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

113 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

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

115 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 Benadryl 50 mg PO q 6 h for 3-4 days

116 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?

117 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

118 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

119 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)

120 Case Scenario You cant find your emergency drug kit. The patient is now confused and uncooperative. His BP is 70/0 and his HR is 140. What should you do?

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

122 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

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

124 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

125 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

126 Chest Pain

127 Origin – Cardiac – Pulmonary – Musculoskeletal Neck, thorax, shoulder – Upper abdominal viscera

128 Chest Pain Classification – Recurrent Mild to moderate intensity – Severe Prolonged pain

129 Recurrent Chest Pain Angina pectoris – 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

130 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 Relieved by nitroglycerin

131 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

132 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

133 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

134 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

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

136 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

137 Angina Pectoris Types of angina pectoris – Stable 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

138 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

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

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

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

142 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

143 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

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

145 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

146 Myocardial Infarction

147 Cardiac ischemia which results in myocardial necrosis

148 Myocardial Infarction 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

149 MI Signs and Symptoms Symptoms – 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

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

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

152 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)

153 Management of Acute MI Transfer to ER

154 Chest Pain

155 Origin – Cardiac – Pulmonary – Musculoskeletal Neck, thorax, shoulder – Upper abdominal viscera

156 Chest Pain Classification – Recurrent Mild to moderate intensity – Severe Prolonged pain

157 Recurrent Chest Pain Angina pectoris – 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

158 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 Relieved by nitroglycerin

159 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

160 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

161 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

162 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

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

164 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

165 Angina Pectoris Types of angina pectoris – Stable 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

166 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

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

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

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

170 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

171 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

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

173 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

174 Myocardial Infarction

175 Cardiac ischemia which results in myocardial necrosis

176 Myocardial Infarction 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

177 MI Signs and Symptoms Symptoms – 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

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

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

180 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)

181 Management of Acute MI Transfer to ER

182 Case Scenario #10

183 Case Scenario A 25 year old female presents for initial periodontal debridement with local anesthesia.

184 Case Scenario PMH: – Medications:None – Allergies:Sulfa, PCN, Tetracycline, Erythromycin – Illnesses:Asthma, Bladder infections, Pneumonia x 2 – PSH:Bronchoscopies x 2, T&A

185 Case Scenario Vital signs: – BP-90/60 – HR-85 – RR- 12 – Temp-37 F – Weight-110 lb (50 kg)

186 Case Scenario She receives 6 carpules of 2% Xylocaine with 1:100,000 epinephrine. Five minutes later, she tells the hygienist that she feels really great. She stutters as she says it and she now has twitching of her facial and extremity muscles. She begins to perspiring and c/o the room being hot.

187 Case Scenario You are summoned back to the room. When you enter, she begins to seize in the chair.

188 Case Scenario What do you suspect is happening? How would you treat it? What is the pathophysiology for this problem? How can this occur and what are the differences?

189 Overdose

190 Clinical signs and symptoms from high blood levels of a drug in various target organs and tissues Most common adverse drug reaction

191 Overdose Requirements – Access to the vascular system – Alteration of steady state Rapid absorption Intravascular injection Delayed redistribution Delayed biotransformation Delayed elimination Excessive dosage

192 Mechanisms of Overdose

193 Overdose Predisposing factors – Patient factors – Drug factors

194 Patient Factors Age – Young and elderly Weight – Lean vs. fat, overall weight Sex Other medications Presence of disease – Renal, liver Genetics

195 Drug Factors Vasoactivity Concentration Dose Route of administration Rate of injection Vascularity at injection site Vasoconstrictors

196 Local Anesthetic Overdose Minimal - Moderate – Talkativeness – Apprehension – Excitability – Euphoria – Sweating – Disorientation – Increased BP, P, RR – Loss of reason Moderate - High – Light headedness – Restlessness – Nervousness – Metallic taste Visual, auditory disturbances – Seizures – CNS depression – CV collapse

197 Local Anesthetic Overdose CNS precede CV symptoms CNS symptoms – CNS depression or excitation – Seizures – Generalized CNS depression

198 Local Anesthetic Overdose Tx – Oxygen – Monitor VS – BLS – IV line* Anticonvulsant (Valium) * – Protect patient* – Transfer to ER* * If necessary

199 Drugs

200 Just what drugs do you need? Do I need a crash cart? How extensive does your crash cart need to be? What if I dont have the training to use the equipment?

201 Crash Cart

202 How much do you need? What is your training? – Match your training to the amount of drugs and equipment you require Do not overbuy via an emergency kit. – Small tackle box may be all that is necessary vs, major crash cart Must have certain necessary equipment to administer the drugs in your emergency kit or temporaily treat emergencies (needles, fluids, tubing, tourniquets, etc.)

203 Oxygen All medical emergencies require oxygen initially! – What specific conditions require oxygen? – What is the one exception?

204 Aspirin

205 81, 162 or 325 mg crush and swallow Who should be on it? Who gets it? What does it do? How does it supposedly work?

206 Epinephrine

207 What concentrations does it come in? Name 3 dental office emergencies where you would consider using it? What is the normal dosage? How often can it be repeated? – Why would you repeat it? What adverse effects could occur?

208 Epinephrine Pharmacology – Increases SVR SBP/DBP Myocardial electrical activity Coronary and cerebral blood flow Myocardial contraction Automaticity

209 Nitroglycerin

210 What forms does it come in? When is it given? How often is it given? How do you know it is effective/active? How does it work? How is it stored? What are the adverse side effects?

211 Atropine Sulfate

212 Indications? How does it work? How much do you give? What adverse side effects can occur? How often can you repeat it?

213 Benadryl

214 Name 3 dental emergencies in which this is used? How is it administered? What dosage is usually given? How does it work? What are the side effects?

215 Ventolin Inhaler

216 Used to treat what conditions? How much and how often can it be administered? How should it be administered? Side effects?

217 Insta-Glucose

218 Used to treat what condition? When should this not be used? How is it administered?

219 Dextrose - 50

220 Used to treat what condition? How is it given? Can it produce any problems if administered?

221 Succinylcholine

222 What is it and what is it used to treat what conditions? How is it administered and how much is given? How long does it take to be effective and how long does it last? How is it metabolized? What must you be able to do if you administer this medication? Are there any risks to administration of succinylcholine?

223 Narcan

224 For what condition is this used? How is it administered? What special precautions must be utilized? What are the risks of giving this medication? If the patient doesnt respond after repeated dosing, what is suggested?

225 Romazicon

226 For what condition is this used? How is it administered? What is the maximum dosage? What risks are associated with giving this medication?

227 Valium

228 For what condition is this used? How much and how is it given? What is the biggest concern with giving this drug?


Download ppt "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."

Similar presentations


Ads by Google