Management of Medical Emergencies in Dental Office

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In this presentation, Dr. H. Ryan Kazemi, oral surgeon in Bethesda, MD, discussed management of common medical emergencies in dental office.

Transcript of Management of Medical Emergencies in Dental Office

  • 1. Management of! Medical Emergencies in! Dental Ofce
  • 2. Emergency Response Plan Receptionist: Recognition of incident; Notication of EMS; Crowd control Administrative: Documentation Team Leader: Dentist; Provides patient assessment and treatment Assistant: Airway management; Assist with patient monitoring; Vital signs
  • 3. Emergency Response Plan Preparation Every ofce should have a written emergency protocol utilizing a team approach Design policies to include: Written guidelines dening 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 certication- Health care provider course
  • 4. Prevention Complete Past Medical & Surgical History Careful Review of Current Medications Allergies Review of Systems Proper preoperative Management Pre-operative Consultation (not clearance) with Patients Physician
  • 5. 10 Core Questions 1.Are you now under a physicians care or have you been during the past5 years, including hospitalization and surgery? 2.Are you currently under a doctors 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?
  • 6. 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
  • 7. 10 Core Questions 7. Have you ever had any breathing difculty 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?
  • 8. 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?
  • 9. 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
  • 10. 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 ==>
  • 11. 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)
  • 12. 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
  • 13. Angioneurotic Edema !An 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.
  • 14. Asthma/Bronchospasm !A condition of acute narrowing, inammation, and swelling of the smaller airways." !Signs and Symptoms:" Wheezing, dyspnea, breathlessness" Cough" !Assessment:" Past Medical History" Patient examination: Auscultation of lungs
  • 15. 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.
  • 16. 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 dened in terms of diminished ow of air during forced expiration." !Signs and Symptoms: Shortness of breath; Cough
  • 17. 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.
  • 18. Hyperventilation !Signs:" Rapid breathing with a feeling that you cant 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
  • 19. Case #1 55 year old male, with history of heart murmur due to aortic valve insufciency, 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?
  • 20. !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
  • 21. Case #2 45 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?
  • 22. !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 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 10 and Oxygen saturation > 95% Respiratory rate