Management of!Medical Emergencies in!

Dental Office

Emergency Response PlanReceptionist: Recognition of incident; Notification of EMS; Crowd control

Administrative: Documentation

Team Leader: Dentist; Provides patient assessment and treatment

Assistant: Airway management; Assist with patient monitoring; Vital signs

Emergency Response Plan Preparation

Every office should have a written emergency protocol utilizing a team approach

Design policies to include:

Written guidelines defining those conditions that should be referred to local EMS.

Directions for accessing EMS.

Easily accessible Hospital telephone numbers and directions to ER

Staff training and role playing

CPR certification- Health care provider course

PreventionComplete Past Medical & Surgical History

Careful Review of Current Medications

Allergies

Review of Systems

Proper preoperative Management

Pre-operative Consultation (not clearance) with Patient’s Physician

10 Core Questions1.Are you now under a physician’s care or have you been during the past5 years, including hospitalization and surgery?

2.Are you currently under a doctor’s orders or taking any medications, including any BCP, OTC drugs, or homeopathic preparations?

3.Do you have any allergies or are you sensitive to any drugs or substances such as Penicillin, novocaine, aspirin, latex or codeine?

10 Core Questions

4. Have you ever bled excessively after a cut, wound, or surgery? Have you ever received a blood transfusion?

5. Are you subject to any fainting, dizziness, nervous disorders, seizures, or epilepsy?

6. Have you or your family ever had any anesthesia related problems

10 Core Questions

7. Have you ever had any breathing difficulty including asthma, emphysema, chronic cough, pneumonia, tuberculosis, or any other lung disorders Do you use any tobacco products?

8. Do you have heart disease or a history of chest pain or palpitations?

10 Core Questions

9.Is there anything you would like to discuss alone with the doctor?

10.Do you currently use or have a history of using recreational drugs?

Anaphylaxis Description: A Catastrophic and potentially fatal type of allergic reaction, which can

occur within minutes after administration of drugs of non-human proteins"

Key Signs & Symptoms:!

– Laryngeal Edema: Stridor, Throat tightening, Choking"

– Bronchospasm: Wheezing, Chest tightness"

– Vascular collapse: Confusion, Syncope, Seizures, Hypotension, Tachycardia"

Assessment Notations: !

– Generalized urticaria or edema"

– Sudden onset of symptoms"

– Onset of shortness of breath

Anaphylaxis Management

Position: comfortable, or lay down if hypotensive"

Airway: 100% O2 by non-rebreather mask"

Call Emergency Medical Services"

Epinephrine: 1:1000, 0.3 to 0.5 cc SQ."

Pediatric: 0.01 ml/kg to maximum of 0.3 cc."

Repeat in 5-10 minutes."

Dosage should 0.1 - 0.2 mg SQ."

If severe, vascular Collapse or marked airway embarrassment and no response to SQ epinephrine, then give Epinephrine ==>

Anaphylaxis Management

==> 1:10,000, 0.3 to 0.5mg IVP over 3-5 minutes. (Pediatrics 0.1 cc/kg) Repeat Epinephrine as needed every 5 minutes"

Without an IV, Epinephrine May be injected sublingually, 0.1 to 0.2 cc of 1:1000 concentration; (Pediatrics: Use 0.01 cc/kg)"

Obtain Vital Signs"

Diphenhydramine (Benadryl) may also be given: 25-50 mg IVP/IM. (Pediatrics: 20cc/kg IM)"

Solumedrol: 125mg IVP/IM (Pediatrics: 2mg/kg IVP/IM)

Drug-Induced Allergy Symptoms:"

– Uticaria: Red eruptions or hives & rashes"

– Pruritus: Itching"

Treatment:"

– Withdraw drug in question "

– Severe Reaction: Epinephrine 0.3 cc of 1:1000 I.M. or IV.; Oral antihistamines; "

– Mild-Moderate Reaction: Benadryl 50 mg orally or I.M. every 6-8 hours

Angioneurotic EdemaAn IgE-mediated allergic painless swelling of an entire anatomic

part such as lips, eyelids, cheeks, or pharynx"

– May be either drug or food induced"

– Not painful"

– Pruritus, Uticaria, hoarseness, stridor, cyanosis"

Treatment:"

– Antihistamines: Diphenhydramine 50mg P.O. or Hydroxyzine 25-100 mg QID."

– In severe cases: 0.3 cc of 1:1000 Epinephrine SQ.

Asthma/BronchospasmA condition of acute narrowing, inflammation, and swelling of the

smaller airways."

Signs and Symptoms:"

– Wheezing, dyspnea, breathlessness"

– Cough"

Assessment:"

– Past Medical History"

– Patient examination: Auscultation of lungs

Asthma/ Bronchospasm Management

Position patient is a comfortable sitting position."

Administer supplemental 100%O2 at 15 LPM."

– Assist ventilation with bag-valve-mask if patient becomes cyanotic or develops respiratory distress."

Administer nebulizer treatment of Albuterol (Proventil), 2 puffs; Repeat every 10-20 minutes if symptoms persist."

If symptoms are severe and no improvement after 2 treatments:"

– Epinephrine 1:1000, 0.3-0.5 ml, SQ. (Ped.: 0.01 cc/kg); or terbutaline 0.25 mg SQ."

If patient on steroids or remain symptomatic: Methylprednisolone, 125 mg IV push.

COPD COPD (Chronic Obstructive Pulmonary disease)

involves loss of normal elasticity of the airways. It may be the consequence of either chronic bronchitis or of parenchymal disease represented by emphysema."

Airway obstruction is defined in terms of diminished flow of air during forced expiration."

Signs and Symptoms: Shortness of breath; Cough

COPD Management

Call Emergency Medical Services"

Ascertain that the airway is open"

Begin O2 at 2 liters per minute by nasal cannula. If severely tachypneic and is cyanotic, place on 100% Oxygen 15 LPM via non-rebreather mask."

Albuterol (Proventil)- Two puffs"

Methylprednisolone, 125 mg IVP or Prednisone 40 mg P.O.

HyperventilationSigns:"

–Rapid breathing with a feeling that you can’t get enough air."

–Crying"

–Convulsions"

– Loss of consciousness"

Management:"

–Help patient breath in paper bag"

–Calm and reassure patient"

–Monitor BP and O2 saturation"

–Consider sedation with Valium

Case #155 year old male, with history of heart murmur due to aortic

valve insufficiency, is scheduled for periodontal surgery. Patient is given 2.0 g of Amoxicillin for prophylaxis against bacterial endocarditis. Ten minutes later patient begins to complain of SOB, and lightheadedness. He then reports throat tightening and exhibits increased wheezing. He also begins to show evidence of urticaria over his chest and extremities."

Diagnosis?"

Management?

Position: comfortable, or lay down if hypotensive Airway: 100% O2 by non-rebreather mask Call Emergency Medical Services Epinephrine: 1:1000, 0.3 to 0.5 cc SQ.

Pediatric: 0.01 ml/kg to maximum of 0.3 cc. Repeat in 5-10 minutes. Dosage should 0.1 - 0.2 mg SQ. If severe, vascular Collapse or marked airway embarrassment and no response to SQ. epi, then give Epinephrine 1:10,000, 0.3 to

0.5mg IVP over 3-5 h (Pediatrics 0.1 cc/kg) Repeat Epinephrine as needed every 5 minutes Without an IV, Epinephrine May be injected sublingually, 0.1 to 0.2 cc of 1:1000 concentration; (Pediatrics: Use 0.01 cc/kg) Obtain Vital Signs Diphenhydramine (Benadryl) may also be given: 25-50 mg IVP/IM. (Pediatrics: 20cc/kg IM) Solumedrol: 125mg IVP/IM (Pediatrics: 2mg/kg IVP/IM)

Anaphylaxis

Case #245 year old obese male with history of coronary artery disease

and heavy smoking is undergoing general restorative procedures. Patient is given 4 carpules of 2% lidocaine with epinephrine for bilateral mandibular blocks. During the procedure, patient begins to complain of chest tightness and SOB. He also reports pain radiating to his left side of jaw and arm. "

Diagnosis?"

Management?"

Prevention?

Place patient in a comfortable semi-inclining position. Ascertain that the airway is open & breathing is unlabored. Administer 100% Oxygen at 4 liters via nasal cannula. Monitor vital signs: Blood pressure, pulse, & respiration. Administer Nitroglycerin, 1/150 sublingually (0.4 mg). Repeat Nitroglycerin every 5 minutes, until pain resolves or blood pressure becomes <90, or a maximum of 3 doses.

IF PAIN DOES NOT RESOLVE, SUSPECT MYOCARDIAL INFARCTION Administer Morphine Sulfate, 2-5mg IV. if pain persists after 3 doses of NTG. Transfer to Hospital

Angina Pectoris

Case #2 (Continued)

Patient is now on 100% oxygen and has been given 3 doses of Nitroglycerin in 5 minute intervals. At this time, patient loses consciousness and becomes unresponsive."

Diagnosis?"

Management?

ABC now changed to CAB sequence Chain of Survival”:

Immediate recognition of cardiac arrest and activation of emergency response system Early CPR with emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post-cardiac arrest care

Call First, Call Fast, Call 911 Position patient comfortably (Semi-sitting) Start chest compressions Open Airway Rescue breaths (100% O2 via mask; IV started) Compression / breaths in 30:2 ratio for 100 compressions per minute Vital signs: EKG, Oximeter, and BP Nitroglycerin- Sublingual 0.4 mg; repeat Q5min up to three doses; or spray inhaler, repeat every 5 minutes Morphine Sulfate 1 to 3 mg IV q5 to 30 min.

Myocardial Infarction

Case #325 year old female is undergoing impression of implant tooth #18.

During placement of the impression coping, the patient suddenly coughs, and the operator loses the screw driver toward the back of the throat. The patient sits up and begins to cough violently."

What action should the dentist take?"

Next the patient stops coughing and is no longer able to speak. While he is holding his neck, he becomes unconscious."

What action should the dentist take?"

Position: Conscious adult and child: Standing Conscious adult or child: Perform Heimlich maneuver Unconscious adult or child: Perform Abdominal thrusts; then visualize airway for obstruction. DO NOT PERFORM BLIND FINGER SWEEPS ON PEDIATRIC PATIENTS Attempt to ventilate patient, look for chest rise. If none, reposition head and try again; Repeat steps until successful. Circulation: Check for pulse. If none, refer to cardiac arrest protocol. If pulse is present, maintain airway and monitor patient

Airway FB Obstruction

Case #3 (Continued)While performing abdominal thrusts, a rush of air is

felt as the patient’s airway becomes open and the patient is now breathing. The oral cavity is then inspected, but the screwdriver can not be seen. Patient now begins to regain consciousness."

Diagnosis?"

Management?"

Prevention?

Direct patient to hospital ER for chest X-ray Need to rule out aspiration Use preventive measures: ‘throat pack’, floss around small components, high suction

FB Aspiration

Case #417 year old female is about to undergo removal of

impacted third molars under local anesthesia. The patient appears quite anxious, diaphoretic and pallor. As the dentist begins to administer local anesthesia, the patient becomes unconscious and unresponsive. Her pulse is 45 beats per minute."

Diagnosis?"

Management?"

Prevention?

Place patient in supine position with feet elevated. Administer 100% Oxygen via mask. Ascertain airway is open and breathing is unlabored. Assist ventilation with bag-valve-mask if patent is unresponsive to O2 therapy, has marked respiratory distress, altered LOC, or apnea. Monitor vital signs: If Hypotensive, give 300-500 cc Fluid Permit patient to inhale aromatic ammonia vaporole Determine etiologies: Hypoglycemia, Hypovolemia (hypotension), Arrhythmia, psychogenic, seizure Consider transfer to hospital with prolonged symptoms

Syncope

Case #540 year old male with history of COPD (Chronic

Obstructive Pulmonary Disease) is undergoing root canal treatment of tooth #3 under local anesthesia. During the procedure, patient begins to complain of heart palpations. His breathing becomes more labored at this time, with increased wheezing. "

Diagnosis?"

Management?

Call Emergency Medical Services Ascertain that the airway is open Begin O2 at 2 liters per minute by nasal cannula. If severely tachypneic and is cyanotic, place on 100% Oxygen 15 LPM via non-rebreather mask. Albuterol (Proventil)- Two puffs Methylprednisolone, 125 mg IVP or Prednisone 40 mg P.O.

Asthma

Clinical ConditionStep 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient.

Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Ammonia vaporole respiratory stimulant (optional). Supplemental oxygen with Non-rebreathing face mask 15 L/minute or Nasal cannula/Nasal hood 4 L/minute. Raise the legs.

Step 3 Reversal agent(s) if indicated.

Step 4 Respiratory deterioration. Raise the legs.

Clinical ConditionStep 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient.

Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Ammonia vaporole respiratory stimulant. Raise the legs.

Step 3 Reversal agent(s) if indicated.

Clinical ConditionStep 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient.

Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Verify not breathing. Check Pulse oximeter (BP >80 systolic) and/or Carotid pulse present (BP >60 systolic) which indicate chest compressions not needed.

Step 3 Raise the legs.

Step 4 Reversal agent(s) if indicated.

Ventilation Management - Apnea / Hypoventilation / Obstruction

Apnea without Carotid Pulse - see Adult Cardiac Management

Action

Action

Action

Respiratory rate 0

Apnea with Carotid Pulse

Ten Minutes Saves A Life! is a registered trademark of the ADSA Anesthesia Research Foundation / © 2013 EmergSim LLC / 10Min Resp Mgmt 131108 (1)

Step 6 Confirm supraglottic airway placement with chest rise.

Step 7 If no chest rise seen after advanced airway placement, continue with evaluation for larynospasm, foreign body, bronchospasm, or chest wall rigidity.

Step 5 Consider advanced supraglottic airway with gastric venting capacity if unable to ventilate with bag mask easily.

Step 1 Open the airway with head tilt, chin lift, and jaw thrust.

Step 2 Consider oral or nasal airway if apneic.

Step 3 Bag Mask ventilation - preferably two person. One breath every 6 seconds, breath volume 400-800 mL, pressure <20 cm H 2O, oxygen flow 15 L/minute.

Step 4 Confirm chest rise with each breath.

Adult Respiratory Distress - The Unresponsive PatientTen Minutes Saves A Life!®

Monitoring (blood pressure, heart rate, pulse oximetry, respiratory rate) ongoing throughout evaluation and management. All initial actions are performed simultaneously after verification of unresponsiveness by stimulating the patient including head tilt and jaw lift. Reversal agents (naloxone and flumazenil) may be administered at any time.

Respiratory rate >10 and Oxygen saturation > 95%

Respiratory rate <10 and/or Oxygen saturation <95%

Breathing Normally and Unresponsive

Respiratory Depression and Unresponsive

Ventilation Management (see below)

Ventilation Management (see below)

Ventilation Management (see below)

Ten Minutes Saves A Life

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