Medical Emergencies in the Dental Office, Tomas ... - Dmcnet.org
Medical Emergencies in the Dental Office, Tomas ... - Dmcnet.org
Medical Emergencies in the Dental Office, Tomas ... - Dmcnet.org
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<strong>Medical</strong> <strong>Emergencies</strong> <strong>in</strong> <strong>the</strong><br />
<strong>Dental</strong> <strong>Office</strong><br />
<strong>Tomas</strong> J. Barrios DDS<br />
Associate Cl<strong>in</strong>ical Professor of<br />
Oral & Maxillofacial Surgery,<br />
St. Josephs Regional <strong>Medical</strong> Center,<br />
Jersey City <strong>Medical</strong> Center
• Prevention & Preparation<br />
• Syncope<br />
• Hypoglycemia<br />
• Epileptic episode<br />
• Ang<strong>in</strong>a<br />
• Myocardial <strong>in</strong>farct<br />
• Anes<strong>the</strong>tic overdose<br />
• Drug allergy anaphylaxis<br />
• Asthma
Prevention & Preparation<br />
• BLS Certification doctors and staff<br />
• ACLS certification : any type of sedation<br />
techniques<br />
• Emergency Kits<br />
• Staff drills
Emergency Kits<br />
• Contents Vary<br />
• Purchase from any<br />
manufacturer<br />
• Refill
Components of emergency kits
Emergency drills<br />
• Most important : Keep it<br />
simple !<br />
• Designate a specific task to<br />
each staff member<br />
1. Assistant : gets kit and assist<br />
Dr.<br />
2. Receptionist : calls 911 and<br />
make sure EMS arrives ,<br />
clears area for patients<br />
3. Additional staff : go between,<br />
records vitals,<br />
event tim<strong>in</strong>g
ABC of any emergency<br />
• Sup<strong>in</strong>e position<br />
• 100 % Oxygen<br />
• Evaluate Airway, breath<strong>in</strong>g , circulation<br />
• Vitals
Emergency management &<br />
resuscitation plan<br />
• Primary survey<br />
1. ABCDE<br />
2. Purpose : Identify &<br />
treat life threaten<strong>in</strong>g<br />
problems<br />
3. History<br />
4. Resuscitation measures<br />
are <strong>in</strong>stituted<br />
• Secondary survey<br />
1. Head to toe by region<br />
exam<br />
2. Purpose : Identify &<br />
treat life threaten<strong>in</strong>g<br />
problems<br />
3. History : data ga<strong>the</strong>r<strong>in</strong>g<br />
4. System specific test<br />
5. Re evaluation: repeat<br />
surveys untill cause is<br />
identified<br />
6. Def<strong>in</strong>itive care<br />
6.
Vitals, Cl<strong>in</strong>ical signs and<br />
symptoms of potential illness
Tenets of primary survey<br />
• Proceed rapidly<br />
• Err on <strong>the</strong> side of aggressiveness<br />
• When <strong>in</strong> doubt “do”<br />
• Stay <strong>in</strong> sequence<br />
• Know what to look for , recognize and treat<br />
• Look for likely, treatable problems<br />
• Make decisions based on direct exam<strong>in</strong>ation<br />
• Initiate only simple test and procedures
Generalized treatment protocol
Documentation<br />
• Brief history of <strong>the</strong> event<br />
• Positive f<strong>in</strong>d<strong>in</strong>gs of primary & secondary<br />
survey<br />
• Treatment provided<br />
• Time of important events<br />
• Disposition
<strong>Medical</strong> legal issues<br />
• What if its not a patient <strong>in</strong> <strong>the</strong> office <br />
• Death or Hospital transfer by EMS , is a<br />
reportable event to <strong>the</strong> State Board
Syncope
Types of syncope
Vasodepressor Syncope<br />
• Most common medical emergency <strong>in</strong><br />
dentistry<br />
• 30 % of adult population<br />
• Accounts for 3% of ER visits
Etiology<br />
• Decreased cerebral blood flow (CBF)
Differential diagnosis<br />
Anxiety attacks<br />
hyperventilation syndrome<br />
MI<br />
Hypoglycemia<br />
Epilepsy<br />
Hypotension
Cl<strong>in</strong>ical manifestation presyncopal<br />
• Early<br />
Nausea<br />
Warmth<br />
Perspiration<br />
loss of color<br />
Basel<strong>in</strong>e Blood press<br />
Tachycardia<br />
• Late<br />
Hypotension<br />
Bradycardia<br />
Hyperpnea<br />
Pupillary dilation<br />
Peripheral coldness<br />
Visual disturbance<br />
Loss of consciousness
Syncopal phase<br />
• All secondary to decreased CBF<br />
• Loss of consciousness<br />
• Loss of postural tone<br />
• Any syncope last<strong>in</strong>g > a few m<strong>in</strong>utes can<br />
<strong>in</strong>duce seizures and cerebral ischemia
Treatment<br />
• Trendelenburg position<br />
• Pregnant patient lateral decubitus<br />
• Asses consciousness<br />
• ABC<br />
• 100 % oxygen<br />
• Spirits of ammonia<br />
• Vitals ( Bradycardia < 60 adm<strong>in</strong>ister Atrop<strong>in</strong>e .5mg IV<br />
1mg IM every 5 m<strong>in</strong>utes until max dose of 3 mg<br />
• EMS if loss of consciousness is > 5 m<strong>in</strong> or if recovery is<br />
> 20 m<strong>in</strong>
Postsyncope<br />
• Evaluate discharge home with escort or<br />
EMS<br />
Dependent on recovery and Vitals<br />
Recovery > 20 m<strong>in</strong><br />
Underly<strong>in</strong>g medical conditions
Hypotension
Hypotension<br />
• Follow<strong>in</strong>g syncope it is <strong>the</strong> most common<br />
cause of loss of consciousness <strong>in</strong> <strong>the</strong><br />
dental office
What affects perfusion
Causes of hypotension
Orthostatic Hypotension<br />
• Most common cause of hypotension <strong>in</strong> <strong>the</strong><br />
dental office<br />
• It is Syncope when <strong>the</strong> patient is placed<br />
quickly from a sup<strong>in</strong>e to upright position<br />
( < CBF )
Why Most likely <strong>in</strong> elderly <br />
• Ag<strong>in</strong>g decreases baroreflex mechanism<br />
which impairs cardioacceleratory response<br />
to preload reduction dur<strong>in</strong>g upright<br />
posture<br />
• May be on medications<br />
• Most susceptible
Vasovagal Hypotension (syncope)<br />
• Initiated by stressful physical ,<br />
psychological or surgical stimuli ( cough<strong>in</strong>g<br />
pa<strong>in</strong>, gagg<strong>in</strong>g )<br />
• The impulses are transmitted directly to<br />
<strong>the</strong> medulla <strong>in</strong> area closely related to <strong>the</strong><br />
nuclei of <strong>the</strong> vagus nerve
Cl<strong>in</strong>ical sign and symptoms<br />
• Bradycardia results from Vagal stimulation<br />
and parasympa<strong>the</strong>tic tone<br />
• Vasodilation results from dim<strong>in</strong>ished<br />
sympa<strong>the</strong>tic tone
Treatment<br />
• Remov<strong>in</strong>g <strong>the</strong> <strong>in</strong>itiat<strong>in</strong>g stimuli<br />
• Trendelenburg position<br />
• Oxygen<br />
• Vitals
Rout<strong>in</strong>e treatment for a patient<br />
with hypotension and <strong>in</strong>adequate<br />
perfusion
Treatment<br />
• Place <strong>in</strong> Trendelenburg position<br />
• Oxygen<br />
• Vitals<br />
• ABC<br />
• Evaluate BP<br />
( if no BP monitor present , remember palpate<br />
pulse, correlated to a systolic of: Radial 80 mm<br />
Hg , Brachial 70 mm Hg , Carotid 60 m Hg )<br />
• Adm<strong>in</strong>ister: Phenylephr<strong>in</strong>e spray 0.25-0.5 0.5 mg IV<br />
2-3mg IM , Ephedr<strong>in</strong>e 10-25 mg IV
• What if patients are receiv<strong>in</strong>g B-Blockers B Blockers <br />
Isoproterenol 0.2mg IV slowly at 1 m<strong>in</strong><br />
<strong>in</strong>terval and monitor patients response
Hypoglycemia
Diabetes
Epidemiology<br />
• Incidence 15.7 million or 5.9% of<br />
population of U.S<br />
• Incidence of undiagnosed 5.4 million or<br />
34% of diabetic population
Why is glucose important <br />
• Primary energy<br />
substrate for all<br />
functions
Pathophysiology<br />
• Type 1 IDDM : little or no <strong>in</strong>sul<strong>in</strong> is secreted<br />
uptake of glucose or conversion <strong>in</strong>to glycogen <strong>in</strong><br />
<strong>the</strong> liver does not occur, <strong>the</strong>refore liver glucose<br />
production is elevated. Gluconeogenesis<br />
accelerates<br />
• Type 2 NIIDM : Insul<strong>in</strong> resistance causes <strong>the</strong><br />
liver to cont<strong>in</strong>ue glucose production and<br />
prohibits glucose uptake by muscles
Cl<strong>in</strong>ical factors of diabetes
Type II NIDDM Meds
Type I IDDM Meds<br />
• Need to know or quick reference
Monitor<strong>in</strong>g<br />
• Hemoglob<strong>in</strong> A1C<br />
• Fructosam<strong>in</strong>e<br />
• Home monitor<strong>in</strong>g
How are patients go<strong>in</strong>g to become<br />
hypoglycemic <br />
• Too much <strong>in</strong>sul<strong>in</strong><br />
• Alcohol consumption<br />
• Excessive exercise<br />
• Missed delayed meals<br />
• Reduced meals<br />
• Medication error<br />
• O<strong>the</strong>r illness
Symptoms<br />
• Autonomic<br />
1. Sweat<strong>in</strong>g<br />
2. Trembl<strong>in</strong>g<br />
3. Palpitations<br />
4. Anxiety<br />
5. Nausea<br />
5.<br />
• Neuroglycopenic<br />
1. Dizz<strong>in</strong>ess<br />
2. Confusion<br />
3. Difficulty speak<strong>in</strong>g<br />
4. Headache<br />
5. Inability to concentrate<br />
6. Weakness<br />
7. Blurred vision<br />
7.
Treatment
Alternative TX<br />
• Glucose tablets<br />
• 4 teaspoons of sugar <strong>in</strong> water<br />
• 5 oz of regular soft dr<strong>in</strong>k<br />
• Orange juice<br />
• Glucagon dosage : 0.5-1mg IM or IV
Seizures
Seizures<br />
• Manifestation of bra<strong>in</strong><br />
dysfunction<br />
• Excessive neuronal<br />
cortical discharge<br />
• Secondary to tox<strong>in</strong>s,<br />
drugs, cerebral<br />
hypoxia, or metabolic<br />
disturbances
Prevention & preparation<br />
• History<br />
1. What type of seizure disorder do you have <br />
2. Are you on any medications for <strong>the</strong> disorder <br />
3. Are you tak<strong>in</strong>g <strong>the</strong> medications as prescribed <br />
4. Have you had serum level of <strong>the</strong> medication done If<br />
so when <br />
5. When was your last seizure <br />
6. What provokes it <br />
7. Do you have an Aura <br />
8. Where you hospitalized <br />
9. How long was your seizure <br />
9.
Treatment protocol<br />
• Most seizures last < 2 m<strong>in</strong><br />
• EMS activated<br />
• Assure patient & staff safety<br />
• Adm<strong>in</strong>ister oxygen<br />
• Manage airway<br />
• Monitor vitals , pulse oxymetry<br />
• Suction available<br />
• If seizure is last<strong>in</strong>g > 2 m<strong>in</strong>utes , establish IV,<br />
adm<strong>in</strong>ister Meds
Benzodiazep<strong>in</strong>e<br />
• Diazepam<br />
Adult : 5 to 10 mg<br />
IV/IM<br />
Pediatric : 0.2 to 0.5<br />
mg/kg IV/IM<br />
• Midazolam<br />
0.05 to 0.1 mg/kg IV<br />
0.2 mg/kg IM ( Max<br />
10 mg)
Pharmacologic management<br />
• EMS not arrived > 5 m<strong>in</strong><br />
Adult : Dextrose 50 ml bolus of 50%<br />
glucose<br />
Pediatric : 2ml/kg 25% dextrose solution<br />
• Evaluate airway ma<strong>in</strong>tenance<br />
• Evaluate cardiac rhythm
Postictal<br />
• Lethargy<br />
• Disorientation<br />
• Apnea, obstructed airway<br />
• Cardiac arrhythmias<br />
• Evaluate patient <strong>in</strong>jury
Chest pa<strong>in</strong>
• Ang<strong>in</strong>a : Lat<strong>in</strong> for spasmodic , chok<strong>in</strong>g or<br />
suffocat<strong>in</strong>g pa<strong>in</strong><br />
• Pectoris :Lat<strong>in</strong> for chest
Differential Diagnosis<br />
• Ang<strong>in</strong>a<br />
• Myocardial <strong>in</strong>farction<br />
• Dyspepsia, GERD<br />
• Musculoskeletal<br />
• Pulmonary embolus<br />
• Spontaneous pneumothorax<br />
• Aortic dissection<br />
• Esophageal rupture<br />
• Panic disorder
Relevant factors<br />
• Onset : time, associated<br />
event<br />
• Location<br />
• Radiation absence or site<br />
• Type of pa<strong>in</strong>: deep<br />
visceral, superficial,<br />
pleuritic<br />
• Exacerbat<strong>in</strong>g or<br />
alleviat<strong>in</strong>g factors
What occurs <br />
• Increased Myocardial Demand<br />
1. Elevated heart rate<br />
2. Elevated BP<br />
3. Elevated endogenous catecholam<strong>in</strong>es<br />
3.<br />
• Decreased Myocardial Oxygen delivery<br />
1. Decreased diastolic fill<strong>in</strong>g<br />
2. Myocardial vessel occlusion<br />
3. Hypoxia<br />
4. anemia<br />
4.
Treatment<br />
• ABC<br />
• oxygen<br />
• Position patient comfort<br />
• Vitals<br />
• EMS<br />
• Nitroglycer<strong>in</strong> : spray or tab .4mg repeat three<br />
times every 5 m<strong>in</strong> ( systolic BP>90 mm Hg )<br />
• Aspir<strong>in</strong>
Myocardial <strong>in</strong>farct<br />
• If chest pa<strong>in</strong> > 20 m<strong>in</strong> consider MI<br />
• Cardiac monitor<br />
• Morph<strong>in</strong>e 2 – 4 mg IV<br />
• EMS transport
Adverse drug reactions with<br />
local anes<strong>the</strong>tics
Types of local anes<strong>the</strong>tic reactions<br />
• Local anes<strong>the</strong>tic toxicity<br />
• Drug <strong>in</strong>teractions<br />
• Vasoconstrictor <strong>in</strong>teractions<br />
• Me<strong>the</strong>moglob<strong>in</strong>emia
Dosages
How Anes<strong>the</strong>tic overdose can<br />
occur
Cl<strong>in</strong>ical Signs
Treatment<br />
• ABC<br />
• Oxygen<br />
• Vitals<br />
• EMS<br />
• Monitor seizures<br />
• Monitor respiration<br />
• Cardiac monitor
Drug <strong>in</strong>teractions
Vasoconstrictor <strong>in</strong>teractions
Treatment<br />
• ABC<br />
• Patient comfort<br />
• Vitals<br />
• EMS<br />
• Reassurance reaction will pass<br />
• If BP becomes >170 systolic consider<br />
nitroglycer<strong>in</strong>
Me<strong>the</strong>moglob<strong>in</strong>emia<br />
• Dose dependent reaction<br />
• Adm<strong>in</strong>istration of Nitrates, amide<br />
conta<strong>in</strong><strong>in</strong>g drugs ( priloca<strong>in</strong>e, Benzoca<strong>in</strong>e )<br />
• Pathophysiology : oxidation of <strong>the</strong> iron<br />
with<strong>in</strong> hemoglob<strong>in</strong> produc<strong>in</strong>g<br />
me<strong>the</strong>moglob<strong>in</strong>
Cl<strong>in</strong>ical signs<br />
• Cyanosis at me<strong>the</strong>moglob<strong>in</strong> levels of 10%<br />
to 20%<br />
• Dyspnea and tachycardia at metHb level<br />
of 35% to 40%
Treatment<br />
• ABC<br />
• Oxygen<br />
• EMS<br />
• Monitor patient vitals , Cardiac<br />
• Most healthy adults drugs and metabolites<br />
are elim<strong>in</strong>ated<br />
• Methylene blue 1-21<br />
2 mg/kg IV
Airway<br />
Allergy<br />
Obstruction<br />
Asthma<br />
Hyperventilation
Allergy and anaphylaxis
Drug allergy & Anaphylaxis<br />
• Adverse drug reactions occur <strong>in</strong> 1% to<br />
15% of drug regimens<br />
• Drug allergy < 2% overall except for some<br />
common agents : penicill<strong>in</strong> ,<br />
cephalospor<strong>in</strong>, and trimethoprim-<br />
sulfamethoxazole ( Sulfa )
Risks Factors<br />
• Multiple <strong>in</strong>termittent exposures<br />
• Parenteral vs oral<br />
• Children less chance of develop<strong>in</strong>g reactions to<br />
meds because of shorter exposure times<br />
• Women higher <strong>in</strong>cidence of cutaneous reactions<br />
secondary to <strong>the</strong>ir <strong>in</strong>creased exposure to<br />
cosmetics and latex gloves<br />
• Individuals with multiple illnesses ,<br />
polypharmacy<br />
• Allergies to foods
Gell & Coombs Classification<br />
• Type 1 ( IgE – Mediated Hypersensitivity)<br />
most life threaten<strong>in</strong>g<br />
few m<strong>in</strong>utes<br />
• Type 2 ( Cytotoxic / Cytolytic antibody<br />
mediated) IgM or IgG antibodies mediate<br />
• Type 3 ( Immnune complex mediated )<br />
1- 4 weeks, IgM – IgG soluble metabolite<br />
• Type 4 (delayed Hypersensitivity )<br />
sensitized T cell lymphocytes
Signs & Symptoms of m<strong>in</strong>or allergic<br />
reactions
Signs & Symptoms of Anaphylaxis
Treatment<br />
• ABC<br />
• Establish reaction type<br />
• Activate EMS<br />
• IV access
Medications for treatment
M<strong>in</strong>or reactions
Anaphylaxis
Management of allergic scenarios
Medications<br />
• Diphenhydram<strong>in</strong>e 50 mg IM , IV<br />
• Ep<strong>in</strong>ephr<strong>in</strong>e: .3ml 1/1000 ( 0.3mg )<br />
• Dexamethasone : 20 mg IM , IV
Obstructed airway
Etiology<br />
• Foreign body aspiration<br />
• Laryngeal edema
Basics treatment of obstructed<br />
airway
Cricothyrotomy
Asthma
Types of Asthma<br />
• Extr<strong>in</strong>sic : allergic asthma, younger<br />
patients , Type 1 hypersensitivity Rx<br />
• Intr<strong>in</strong>sic : older patients, nonallergic<br />
factors , cold temperatures, exercise,<br />
stress
Asthma medications
What is asthma <br />
• Basically it is slow<br />
progress<strong>in</strong>g<br />
Bronchospasm
Treatment<br />
• Term<strong>in</strong>ate <strong>the</strong>rapy<br />
• Position patient<br />
• Adm<strong>in</strong>ister B agonist spray Albuterol<br />
• Oxygen<br />
• EMS<br />
• Ep<strong>in</strong>ephr<strong>in</strong>e SC or IM 0.3ml ( 1/1000<br />
dilution) Epipen
Hyperventilation
• Usually a patient which suffers from:<br />
panic, phobias, psychiatric disorder<br />
• Identify patient early
Signs and symptoms<br />
• Sigh<strong>in</strong>g<br />
• Tachypnea<br />
• Shortness of breath<br />
• Pa<strong>in</strong> on respiration<br />
• Tachycardia<br />
• Nonradiat<strong>in</strong>g chest pa<strong>in</strong><br />
• Lungs clear to<br />
auscultation<br />
• Normal oxygen saturation<br />
• Dizz<strong>in</strong>ess<br />
• fa<strong>in</strong>tness<br />
• Altered consciousness<br />
• Muscle cramp<br />
• Tremor<br />
• Myalgia
Treatment<br />
• Reassurance<br />
• Slow down breath<strong>in</strong>g<br />
• Comfortable position<br />
• Remove any visual stimuli<br />
• Vitals<br />
• Full rebreath<strong>in</strong>g bag<br />
• Anxiolytic meds , Diazepam
Bibliography<br />
• Handbook of <strong>Medical</strong> <strong>Emergencies</strong> <strong>in</strong> <strong>the</strong><br />
<strong>Dental</strong> <strong>Office</strong>, Stanley F. Malamed<br />
• <strong>Medical</strong> <strong>Emergencies</strong> <strong>in</strong> Dentistry, Jeffrey<br />
D. Bennett , Morton B. Rosenberg<br />
• ACLS provider manual , American Heart<br />
Association
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