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Medical Risk Assessment for DentistsMedical Emergencies in the Dental

Office

Matthew J. Dennis, D.D.S.

University of Florida College of Dentistry

Department of Oral and Maxillofacial Surgery and Diagnostic Sciences

Medical History for Dental Patients

WHY DO YOU DO IT???

WHY DO YOU CARE???

Medical Risk Assessment

Dentists take medical histories on their dental patients to perform medical risk assessment.

What is that???

Medical Risk Assessment

Allows you to predict how well a patient will tolerate a proposed treatment

Allows you to predict and prepare for medical emergencies

Allows you to prepare a treatment plan appropriate to the medical status of the patient and suggests modifications to planned treatment necessitated by the patient’s medical status

Allows you to predict complications and prepare strategies to avoid them

Medical Risk Assessment

Universally employed in medicine, surgery and anesthesiology

ASA Physical Status Classification

ASA I: no systemic disease; healthy ASA II: mild systemic disease ASA III: severe systemic disease that limits

activity; not incapacitating ASA IV: Incapacitating disease; constant

threat to life ASA V: Moribund; <24 hrs to live “E” prefix denotes emergency surgery

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Dental Treatment

Creates some level of physiologic and psychological response to the intervention that you deliver to the patient

Creates stress, both physiologic and psychological

Dental Treatment Stress Curves

Stress Tolerance

Young and healthy: good stress tolerance

Aging population, increased survival of patients with multiple medical problems, increased use of immunosuppressive therapy: poorer stress tolerance

Stress

What is it???

Stress

Complex state of physiologic reactions

Reflex withdrawal

Central stimulation (amygdala, hypothalamus, pituitary)

ACTH, thyroid stimulating hormone

Cortisol release

Autonomic nervous system activation

Stress

Catecholamine production- alpha (increased peripheral resistance) and beta effects (increased HR and force of contraction)

Increased BP and cardiac work (and oxygen consumption)

Blood flow shunting to facilitate fight or flight A form of exercise that may present a

significant physiologic challenge to some pts.

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Hypothalamic-Pituitary-Adrenal Axis Stress and Dental Treatment

Will your dental treatment produce any of the previous features of the stress response?

If so, how will the patient tolerate and respond to it?

Taking the Medical History

Every item in the history should have significance for you

Every “yes” requires a consideration of the consequences of proceeding with treatment

Red flags

“Yes” answers on the medical history are like raised red flags

The overriding question you must answer before proceeding with treatment on a patient with a raised red flag is:

“IS IT SAFE?”

Is it safe to work on a patient with the raised red flag?

If the flag indicates a condition that is medically treated and controlled and won’t significantly affect treatment, then you can dismiss the item in your mind and proceed.

If the flag indicates a poorly controlled condition or one that presents risk….

You must weigh the risk and justify why you are proceeding with treatment despite the red flag.

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Safe

Controlled hypertension, medically monitored

BP normal today

Pt taking meds

Proceed, keeping in mind potential risk of postural hypotension and drug interactions

Unsafe

“Heart disease” checked on med history form History of unstable angina No current medical monitoring Poorly compliant with medications Dental plan: multiple extractions

Do not proceed until medically worked up and cleared!

Your Responsibilities as a Dentist:

Know enough about the common medical problems patients present with to determine if it is safe to perform dental treatment on that patient

Get advice or help from medical or dental colleagues if you are unable to make reasonable risk assessments yourself

The Good News

There is a finite number of medical conditions you need to know

The material can be easily mastered by the general dentist

You don’t have to be an internist to do dentistry!

Once mastered, it takes seconds to process the information in your mind

Can we stick our head in the sand and make it all go away?

No! Patients are getting older, sicker, on more meds The dental-systemic connection is here to stay Patients expect a high level of medical expertise

from their dentist! Dentists have responsibility for the medical effects of

dental care The first two years of dental school had to be for

something!

HEART DISEASE

5 major categories:

Ischemic heart disease

CHF

Arrhythmias

S/P MI

Valves, murmurs, malformations

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Ischemia-Angina

Angina=Chest pain caused by cardiac ischemia Blood supply can’t meet metabolic demand Is angina stable or unstable? Stability relates to changes in the pattern, intensity,

conditions when it occurs, number of NTG to achieve relief. Unstable refer immediately.

Don’t let hypertension or tachycardia occur. Tachycardia bad because work is increased, cardiac filling occurs during diastole which is shortened by rapid heart rate

ANGINA PECTORIS

1. Stable or unstable? 2. Have Nitroglycerin available. Consider premed

with NTG 3. Consider supplemental O2 4. Ensure profound local anesthesia 5. Consider use of N2O sedation 6. Monitor vital signs closely. Avoid tachycardia 7. Limit epinephrine to 0.04mg (4cc of 1:100,000) 8. Maintain verbal contact with patient 9. Consider physician consult

Angina Attack in Office-Stable Angina

Treatment:– Oxygen 4L mask or cannula

– Vital signs

– NTG SL if systolic BP>90

– Repeat NTG in 5 min if no relief; Summon help; nonenteric ASA 325 mg chew

Angina Attack In Office-New Onset

Rapid assessment critical; Treat as possible MI; Activate EMS

Oxygen 4L mask or cannula Vital signs NTG SL if systolic BP>90 Morphine or other narcotic analgesic ASA 325 nonenteric chew (MONA)

Epinephrine

Epinephrine 10ug/cc, 18ug/carpule, 36ug/2carpules.

Endogenous epinephrine: Could be 200 ug from adrenal glands directly into vascular system.

Congestive Heart Failure-CHF

“Pump” failure. Pulmonary and/or venous congestion.

Usually indicates serious, chronic cardiovascular disease

Orthopnea, PND, ankle edema

Positioning

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CONGESTIVE HEART FAILURE

Confirm patient is feeling good for appt.

Defer treatment until medically improved, if possible

Consider supplemental O2

Avoid supine position

Keep appointments short, if possible

Congestive Heart Failure

Treatment:

a. Must treat underlying cause

b. Stress control, oxygen

c. Seat patient in upright position

d. Transport asap

Arrythmias

Normal rhythm determined by SA node conducting through atria to AV node, down bundle of His, to right and left bundle branches and into Purkinje fibers and ventricular muscle.

Rates of intrinsic pacemakers: SA: 70, AV: 40-60, ventricular: 30.

Arrhythmias

Fibrillation-chaotic electrical activity with no effective pumping action

Ventricular-must defibrillate. Depolarizes all cells at once so dominant pacemaker takes over.

Patients with implantable defibrillators have probably had life-threatening arrhythmias

Atrial Fibrillation

Loss of atrial output “atrial kick”

May be asymptomatic until stressed

Anticoagulation common (warfarin) due to blood pooling in atria

Pulses “irregularly irregular” -can be diagnosed by taking a pulse

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Arrhythmias

A ventricular impulse may cause a PVC, a common finding

Epinephrine may sensitize myocardium to form PVC’s

Arrhythmias may be generated near areas of scarring in myocardium

Arrhythmias

Can be fast (tachycardia)

Or slow (bradycardia)

Or normal rate with abnormal rhythm (block)

S/P MI

At greatest risk for repeat MI within 2 months of MI

Repeat MI still risky up to 6 months S/P MI

Avoid elective tx, consult cardiologist if emergency

MYOCARDIAL INFARCTION

1. Consider physician consult 2. Defer elective surgery until six months after infarction 3. Check for anticoagulation (including aspirin) 4. Have NTG available. Consider prophylactic use. 5. Consider supplemental O2 6. Provide profound local anesthesia 7. Consider N2O sedation 8. Monitor vital signs. Avoid tachycardia and HTN 9. Limit epinephrine use to 0.04mg (4cc of 1:100,000) 10. Maintain verbal contact with patient

Myocardial Infarction

Severe cardiac ischemia resulting in cellular death

Signs/Symptoms:a. Severe chest pain; assume new onset

angina is MI; unstable angina may evolve into MI

b. Sweatingc. Severe anxiety, unconsciousness

Cardiovascular

Myocardial Infarction Treatment

a. Summon help, stay calmb. Supplemental oxygen, NTG,

ASA, analgesia(MONA)

c. Monitor vital signsd. CPR

No elective dental treatment for six months

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Murmurs, valves, malformations

Prophylaxis

Determine associated cardiac problems

Watch for anticoagulants

HYPERTENSION

1. Refer for treatment. To ER stat if severe. 2. Defer treatment if possible until controlled.

Weigh emergency dental needs against risk of treatment.

3. Avoid postural hypotension 4. Monitor vitals especially blood pressure. 5. Monitor carefully if epinephrine exceeds

0.04mg (4cc of 1:100,000)

Stroke-CVA

Cerebral Vascular Accident – Focal neurologic disorder due to a disturbance in cerebral circulation from intracerebral hemorrhage or cerebral infarction

1. No elective treatment within six months

2. Check blood pressure each appointment

3. Minimize stress. Avoid hypertension.

4. May be on anticoagulants

Stroke-CVA

Acute symptoms– Mental status changes. Disorientation

– Slurred speech, facial droop

– Sudden weakness, specially unilaterally

Treatment:– Oxygen. EMS. Monitor vitals. Blood sugar

(variations may mimic stroke). Transport ASAP

Diabetes: Complications

Hyperglycemia

Damage to mediumand large blood vessels

Damage to small blood vessels

Macrovascular Disease Microvascular Disease

Coronary Artery Disease

CerebrovascularDisease

Peripheral vascular disease Retinopathy Nephropathy Neuropathy

www.merckmedicus.com

DIABETES MELLITUS

Type I IDDM: Controlled or brittle. What is most recent sugar? Can assess control by looking at dose of insulin. One dose of

long acting insulin usually better controlled than split dose of long acting w/regular

Did pt take insulin and eat breakfast? Risk of hypoglycemia (first signs may be inappropriate

comments, confusion, combativeness) much more likely than hyperglycemia (DKA) which takes longer to develop. Give oral glucose.

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INSULIN DEPENDENT DIABETES MELLITUS

1. Defer elective surgery if possible until well controlled

2. Early morning appointments. Short appointments. 3. Monitor vitals before, during, and after surgery 4. Confirm that patient took their AM insulin and had

a normal caloric intake for breakfast 5. Advise patient that they must consume a normal

calorie load for the remainder of the day, even if they must blenderize food. Otherwise they will need to modify their NPH insulin.

INSULIN DEPENDENT DIABETES MELLITUS

6. Consult physician for modifications to insulin regimen 7. When in doubt, check blood sugar levels with portable testing

unit 8. Watch for signs of hypoglycemia 9. Determine how well controlled patient is preoperatively. This

will indicate which patients are more prone to problems. Know their dosing regimen preop

10. Treat infections aggressively. 11. Maintain verbal contact with patient during surgery

Diabetes Mellitus

Acute hypoglycemia (Insulin Shock)

Symptoms - Anxiety, irritability, tachycardia, disorientation, unconsciousness

Treatment:

a. Oral sugar; candy, orange juice, coke

b. I.V. dextrose

c. Glucagon

Diabetic Ketoacidosis (DKA,Hyperglycemia) unlikely

Diabetes Mellitus

Type II DM:

Usually tolerate well.

Confirm compliance

NONINSULIN DEPENDENT DIABETES MELLITUS

1. Morning appointment is best 2. Monitor vital signs 3. Maintain verbal contact with patient during surgery 4. Make sure patient consumes a normal calorie load

postoperatively, even if they must blenderize food. 5. Confirm that patient has taken their oral hypoglycemic agent

and eaten a normal breakfast prior to surgery. 6. Watch for signs of hypoglycemia 7. Treat infections aggressively.

ADRENAL INSUFFICIENCY

Medulla= epi and norepi

Cortex = mineralocorticoid (aldosterone), glucocorticoid (cortisol) and androgens

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ADRENAL INSUFFICIENCY

Cortisol released in a diurnal pattern (greater in AM) regulated by ACTH from pituitary.

Related to stress (modulates inflammatory mediators, immune response, cell membrane integrity, blood pressure, mobilizes energy stores)

ADRENAL INSUFFICIENCY

Exogenous steroids chronically suppress ACTH- pt can’t mount a stress response

Mediated by cortisol.

Steroid prep necessary if major surgery is contemplated.

Acute insufficiency results in hypotension. Check BP’s

ADRENAL SUPPRESSION

1. For major oral surgery, for patients currently on corticosteroids, double dose day before, day of, and day after surgery. Return to normal dose on second postoperative day

2. For major oral surgery, for patients not currently on steroids, but who have taken at least 20 mg of hydrocortisone or equivalent for more than two weeks within the past year, give 60mg hydrocortisone or equivalent the day before surgery, the morning of surgery, 40mg for the first two postop days and 20mg for three days thereafter.

3. Steroid prep not necessary for minor oral surgery under local anesthesia.

4. Monitor vitals especially blood pressure, before, during, and after surgery

5. AM appointments best 6. Reduce stress

PREGNANCY

Second trimester best for tx.

Major organogenesis during first trimester

Positioning (pressure inferior vena cava) and premature labor 3rd trimester

Pregnancy risk categories in drug references A,B,C,D,X, determined by research performed not necessarily clinical practice.

Surgery can cause premature labor

High risk pregnancy call OB GYN

PREGNANCY

1. Defer surgery until delivery, if possible. 2. Consult obstetrician if surgery cannot be delayed 3. Avoid radiographs if possible. Use shielding when absolutely

necessary 4. Avoid drugs with teratogenic potential. Consult Pregnancy

Risk Catagories 5. Avoid supine position to prevent vena cava compression 6. Expect frequent trips to rest room. 7. Monitor blood pressure 8. Middle trimester best time for surgery

LIVER DISEASE

Clotting status

Communicable diseases

Drug metabolism

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HEPATIC INSUFFICIENCY

1. Identify cause; possible Hepatitis B or C. Ascertain current status of liver-recent labs

2. Avoid drugs requiring hepatic metabolism or excretion or modify their dose

3. Screen for bleeding disorders: PT, PTT, platelet count, platelet function testing

4. Avoid situations where patient might swallow large amounts of blood (impaired nitrogen metabolism may cause encephalopathy).

ANTICOAGULANTS-Clotting Factors

Blood clots by clotting factors, platelets and vascular action End product of clotting factors is fibrin Coumadin affects vit K dependant clotting factors, mainly

extrinsic pathway. Test coumadin with PT reported as INR. Must be 3.0 or less INR of 1.0 is normal Heparin also affects clotting factors. PTT tests (mainly intrinsic)

or assay for heparin Some physicians will switch coumadin to heparin (reversible,

shorter acting)

COUMADIN THERAPY

1. Consult patient’s physician regarding safety of modifying coumadin levels.

2. Safe surgery is 1.5 times control or INR less than 3.0

3. Obtain the baseline PT. Must have PT within two days of surgery

4. To reduce level, stop coumadin two days before surgery. Draw INR morning of surgery, proceed with surgery if criteria met. Restart coumadin day after surgery.

COUMADIN THERAPY

5. Augment clotting with gelfoam, surgicel, sutures, pressure packs.

6. Carefully instruct patient in bleeding management

7. If patient is not cleared for going off anticoagulation, may need heparinization. Consult patient’s physician regarding orders for this.

8. Coumadin not readily reversible. Vit K (slow) or plasma transfusion

Pradaxa® (dabigatran)

Direct thrombin inhibitor: for nonvalvularatrial fibrillation embolic stroke prevention

No p450 metabolism; Elimination half life 12-17 hrs; plasma levels ↓ 70% w/in 4-6 hrs; but no reliable reversal agent (hemodialysis)!

Few interactions; predictable anticoagulation; no lab monitoring (INR).

BID dosing

ANTICOAGULANTS- Platelets

Platelets affected by ASA, NSAIDS, Plavix, Ticlid, Persantine

Irreversibly acetylates cyclooxygenase necessary for adhesion

Platelet can’t repair-effect is for life of platelet-7-14 days

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ASPIRIN OR OTHER PLATELET INHIBITING DRUGS

1. Consult patient’s physician regarding safety of stopping anticoagulant drugs for surgery

2. Consider deferring surgery until platelet inhibiting drugs have been stopped for 5 days to two weeks, depending on the drug.

3. Augment clotting with gelfoam, surgicel, sutures, pressure packs.

4. Carefully instruct patient in bleeding management 5. Restart drug day after surgery if no bleeding is

present

COAGULOPATHY

1. Consult hematologist prior to surgery 2. Obtain baseline coagulation studies: PT, PTT,

platelet count, platelet function test (bleeding time). 3. Schedule patient to coincide with corrective

measures which may be prescribed by hematologist, i.e., platelet transfusion, factor replacement, chemical therapy (EACA Amicar, tranexamic acid antifibrinolytic), or hormonal therapy (DDAVP desmopressin, increases factor VIII, von Willebrand factor and platelet function)

COAGULOPATHY

4. Augment clotting with gelfoam, surgicel, sutures, well placed pressure packs

5. Monitor the wound for clotting post operatively before discharge

6. Carefully instruct the patient in bleeding management

7. Avoid NSAIDs and aspirin 8. Hepatitis precautions 9. Consider hospitalization for major procedures

UNCONTROLLED BLEEDING

Pressure (stasis)>gelfoam(gelatin), surgicel(cellulose), avitene(microfibrillar collagen), topical thrombin, electrocautery

Review medical history and medications

Check for hypertension

ASTHMA

Chronic disease of abnormal responsiveness of airways, leading to constriction, mucous production, inflammation. Usually involves triggers (allergen, exercise, stress).

Clinical signs: Wheezing, SOB, coughing

Treatment: Bronchodilators; anti-inflammatories, immune blockers

Asthma

Affects 5% of U.S. population

Increasing in incidence

Morbidity and mortality increasing in incidence

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Asthma

Extrinsic– Primarily children and young adults

– Inherited allergic disposition

– Dust, pollen, exercise, chemicals, drugs, air pollution, occupational exposures, dander, smoke

– Usually improves with age (~ 50% become asymptomatic by adulthood

Asthma

Intrinsic (nonallergic)– Usually older patients (>35)

– Infection most common cause

– Allergy tests – negative

– Cold, humidity changes

ASTHMA

1. Defer elective treatment until well controlled and no respiratory tract infection

2. Auscultate chest before major procedure or sedation 3. Anxiety control; Consider N2O sedation 4. Keep bronchodilator-inhaler easily accessable 5. Avoid NSAIDS and ASA 6. Consider steroid prep if on corticosteroids 7. Question patient regarding severity and precipitating factors.

History of ER visits good indicator.

Asthma Attack

Terminate procedure

Patient’s inhaler. Albuterol inhaler

Severe: Oxygen 4L nasal cannula

Epinephrine 0.3mg subcutaneous or IM

Lung Disease

Obstructive: Difficulty exhaling air from lungs

Narrow, obstructed airways. (COPD, asthma, cystic fibrosis, bronchiectasis (dilated inflamed bronchi from infection)

Restrictive: Cannot fully inhale. Lungs stiff due to interstitial fibrosis; sarcoidosis, obesity scoliosis, ALS or other muscular dystrophy

COPD

Chronic bronchitis: long term cough w mucous

Emphysema: destruction of lung tissue

Main cause: Smoking! Also environmental/toxic pollutants

Sx: Cough w or w/o mucous, fatigue, resp. infections, SOB, wheezing

Tx: Bronchodilators and antiinflammatories

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Respiratory Drive

Hypoxia, hypercarbia

Pickwickian syndrome : Chronic high CO2 relies on hypoxia to drive ventilation. Given higher O2 concentrations, hypoxic drive is reduced and ventilation may stop.

As ventilation stops, hypoxia reoccurs and ventilation continues.

COPD

1. If pt is on O2, continue at prescribed flow rate 2. If pt is not on O2, consult physician before

administering O2 3. Consider steroid prep if pt on corticosteroids 4. Avoid supine position unless patient can tolerate it 5. Have bronchodilator-inhaler readily available 6. Monitor vital signs and note respiratory rate and

depth preop 7. Afternoon appointments better tolerated because

of clearance of secretions

Airway Obstruction

Foreign body: in airway→distress. In esophagus→no distress

Look, listen, feel for the signs of respiration Have effective sweep suction immediately

available (Yankaur suction) Heimlich maneuver Abdominal thrust Cricothyrotomy

Airway Obstruction-Sedation

Tongue falling back on airway is most common reason for obstruction in sedated or unconscious patient

Must pull mandible forward to pull tongue forward. Head tilt jaw thrust. Bilateral jaw angle thrust

Opening mouth does not open airway

Tongue Obstruction Head Tilt –Jaw Thrust to Open Airway

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Renal Insufficiency: Hemodialysis

Blood is pumped through a semipermeable membrane, cleaned then returned to body

Heparinized

Reversal agent: protamine sulfate

Three times /week

Surgery: day after dialysis

Peritoneal Dialysis

Peritoneal membrane acts as semipermeable membrane

Hyperosmotic solution injected through port into peritoneum

Gradient moves from vascular to peritoneum

Peritoneum is drained of wastes

4-5 times/day or overnight

RENAL INSUFFICIENCY

1. Avoid drugs that depend on renal metabolism or excretion 2. Avoid nephrotoxic drugs, such as NSAIDS 3. Defer dental care until the day after dialysis 4. Consult nephrologist concerning the use of prophylactic

antibiotics, i.e., shunts 5. Monitor blood pressure (HTN prevalent) and heart rate (don’t

use arm with shunt for BP) 6. Look for signs of hyperparathyroidism (bone changes) 7. High incidence of Hepatitis B in these patients

RENAL TRANSPLANT

Clear with transplant physician. Avoid nephrotoxic drugs. Consider supplemental corticosteroids. Monitor blood pressure. Check for cyclosporin A induced gingival hyperplasia. Consider prophylactic antibiotics-on immunosuppressives.

Hyperthyroidism

Hypermetabolism

Elevated levels of free thyroid hormones

Tachycardia, fatigue, weight loss, nervousness, tremor

Graves Disease: autoantibody to TSH receptor resulting in excess T4 and T3. Goiter, exophthalmus, dermopathy due to infiltrates

Hypothyroidism

Hashimoto’s autoimmune fibroses thyroid decreasing output of thyroid hormone

Iodine deficiency: cretinism

Acquired: lithium, amiodorone, radiation

Reduction in TSH from pituitary

Cold intolerance, personality changes, weight gain, forgetfulness, paresthesias, carpel tunnel, amenorrhea, slow speech, facial puffiness, dry skin

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HYPERTHYROIDISM

1. Defer surgery until controlled

2. Monitor pulse and blood pressure before, during, and after surgery

3. Limit amount of epinephrine used

SEIZURE DISORDER

Seizure Disorder – Sudden alteration in cerebral function leading to abnormal motor, sensory or psychic activity.

Seizure Disorders

A. Types1. Acquired Epileptic (recurring)2. Non-epileptic

a. Hypoglycemiab. Toxic local anesthesiac. Drug overdosed. Etc.

Seizure Disorders

Auras (sensory or psychic manifestations preceding seizure)

Generalized (grand mal, absence or petite mal)

Partial (Jacksonian or focal motor)

Postictal state (deep sleep, confusion, headache, muscle aches)

SEIZURE DISORDER

1. Defer surgery until controlled if possible. AM best. 2. Confirm patient compliance with anti-seizure

medicines. Consider drawing serum levels if in doubt.

3. Avoid hypoglycemia and fatigue. Manage stress. 4. Have a plan for managing a seizure if it should

occur. Discuss with staff type of seizure to expect and what to do if it occurs.

5. Consider sedation

Seizure Disorders

B. Treatment1. Patient supine2. Prevent injury3. Maintain airway, oxygen4. Monitor vital signs5. Persists (>5 minutes, status epilepticus)

a. Summon helpb. Valium I.V.c. CPR if necessary

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Seizure Disorders

C. Post-Seizure Management

1. Permit patient to recover

2. Discharge from office

a . Escort

b. Consult physician

Cancer Therapy

Chemotherapy: “Nadir” WBC’s, platelets– Uncontrolled bleeding, post op infections, healing

Radiation: osteoradionecrosis

Bisphosphenates: osteonecrosis

VASOPRESSOR SYNCOPE

Vasopressor Syncope – Sudden transient loss of consciousness as a result of physical or emotional stress.A. Recline patientB. OxygenC. Monitor vital signsD. Stress controlE. May see seizure activity

HYPERVENTILATION SYNDROME

Hyperventilation secondary to anxiety. Symptoms secondary to respiratory alkalosis.

A. Symptoms: Tachypnea, tingling, lightheadedness.

B. Treatment: Calm patient, ask patient to hold breath or breathe slowly, breathe into paper bag or closed anesthesia circuit, I.V. of Valium

Allergy vs Adverse Drug Reaction

Not every unusual rxn to a drug is “allergy”

Abnormal response to a drug not caused by the immune system: toxicity, intolerance, idiosyncrasy, psychological reactions

True drug allergy: Latent interval between exposure and sensitization, rxn does not resemble effect of drug, rxn not dose dependent (⇩drug=⇧rxn), cross-reactivity with similar drugs

Allergic Reactions

Allergic reactions to local anesthesia rare (more common with ester type)

Consider rxn to topical benzocaine (ester)

Differentiate between allergy and overdose

Epinephrine reaction vs allergy

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Allergy-Latex

Emerging problem due to universal precautions

Latex is trigger in 10% of anaphylaxis under anesthesia

Urticaria, asthma>anaphylaxis Spina bifida: 30-70% chance of latex allergy Food crossreactivity: avocado, kiwi, banana

Acute Allergic Reactions

The most important element in predicting the seriousness of rxn is the interval between administration of allergen and appearance of reaction. A short interval indicates higher probability of serious systemic complications.

Allergic Reactions Seen in Dental Office

Cutaneous – Urticaria (rash, welt), exanthematous (eruption),

eczematoid (dry, flaky), itching

Angioedema– Lips, eyelids, face, mouth or throat

Respiratory– Rhinitis, sneezing, tight chest, dyspnea,

wheezing, bronchospasm

Ocular– Watery eyes, conjuctivitis

Allergic Reactions Seen in Dental Office

Anaphylaxis– Massive release of chemical mediators

– Cardiovascular collapse

– Usually drugs but consider latex

– Refractory capillary permeability, sm muscle spasm, pulmonary edema

– May develop airway edema

Anaphylaxis- Symptoms

Skin: warm, flushed, itching, urticaria, angioedema

Respiratory: Sneezing, runny nose, cough, wheeze, bronchospasm, tightness in chest, upper resp. obstruction

GI: nausea, vomiting, cramps, diarrhea CV: pallor, syncope, palpitations,

tachycardia, hypotension, arrythmias, convulsions, LOC, cardiac arrest

May occur in sequence or individually

Allergy Treatment

Seriousness related to interval between administration and reaction

Mild reactions:– Diphenhydramine (Benadryl®) 50-100mg PO, IV,

IM, then PO q6h

– Chlorpheniramine maleate 4-12 mg PO, IV,IM, then PO q6h

– Observe patient 1-2 hours

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Allergy-Treatment of Severe Reactions (Anaphylaxis)

Stop the antigen ABC’s (airway, ventilation (O2), IV volume loading) Epinephrine

– IV: 0.2(2ml)-0.5mg(5ml) of 1:10,000 in 10cc– IM or SC: 0.3-0.5mg of 1:1000 (1mg/ml)– ET tube: 2x dose

Benadryl– IV or IM: 50 mg

Corticosteroids:(slow acting)– Dexamethasone (Decadron®) 4-12 mg IV, IM– Hydrocortisone (Solu-Cortef®) 100mg

Allergy-Treatment of Severe Reactions (Anaphylaxis)

Trendelenburg if shocky

Observe for dyspnea, wheezing. Bronchodilators; cricothyrotomy for laryngeal obstruction

Treat hypotension (volume, pressors)

Observe for seizures (valium, versed)

Hospitalize 24 hrs and observe for recurrence

Distribution of Dental Emergencies

A. Syncope 4160B. Allergic Reactions 2583C. Postural Hypotension 2475 D. Hyperventilation 1326E. Hypoglycemia 709F. Seizure 644G. Angina Pectoris 584H. Bronchial Asthma 385

From Malamed, SF Medical Emergencies in

Dental Office N=13,775; 2704 dentists

Distribution of Dental Emergencies

I: Local Anesthetic Overdose 204

J: MI 187

K: Anaphylaxis 169

L: Cardiac Arrest 148

M: Acute Heart Failure 104

N: Stroke 68

O: Acute Adrenal Insufficiency 25

P: Thyroid Storm 4

PREVENTION

Prevention – THE MOST IMPORTANT phase of medical emergency management and the most often neglectedA. Past Medical HistoryB. Physical EvaluationC. Precautionary Measures

Past Medical History

Every item in the PMH alerts you to a modification of treatment that may be necessary or to a possible predictablemedical emergency that may occur.

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Physical Evaluation

Simple observation– Is patient in distress, dehydrated, airway

problems, psychiatric problems, obesity, skin tone

Vital signs– Respiratory rate, BP, heart rate and rhythm

GENERAL PREPARATION

A. Emergency contact numbers near telephone

B. Equipment accessible

C. Drugs Current - Oxygen

D. Emergency practice

E. Certified in CPR

PROTOCOLS

Have a listing of common medical emergencies and how to treat

The best protocols are made up by you. Not only a good review, but assures your understanding.

Brief bullet point form with specific info on dose, route of administration. MAKE IT SIMPLE!

Oxygen

Xylocaine® Package Insert

xylocaine (lidocaine Hydrochloride) injectionxylocaine with epinephrine (lidocaine Hydrochloride and epinephrine bitartrate) injection[DENTSPLY Pharmaceutical]

Injections for Local Anesthesia in Dentistry

“consists of immediate attention to the maintenance of a patent airway and assisted or controlled ventilation with oxygen and a delivery system capable of permitting immediate positive airway pressure by mask. “

Bag Valve Mask

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Bag Valve Mask Bag Valve Mask

Insta-Glucose Ventolin Inhaler

Benadryl Nitroglycerin

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Epinephrine Aspirin

Blood Glucose Meter

diabetes.niddk.nih.gov

Optional

Valium I.V.

Morphine I.V.

Decadron I.V.

I.V. setup

Airway Adjuncts Yankauer Suction

Yankauer Suction

Airway Adjunct

Paper bag

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Automated External Defibrillator: AED

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