Medical Emergencies in Dental Practice Part I

Abtin Shahriari DMD, MPHOral & Maxillofacial SurgeonStaff Attending Northside HospitalStaff Attending Atlanta Medical Center

Medical Emergencies in Dental Office Objectives

◦Present various emergency situations Definition Causes Signs/Symptoms Treatment Prevention

Medical Emergencies in Dental Office Outline:

I. Loss of consciousness II. Respiratory distress III. Chest pain IV. Cardiac dysrythmias V. Allergy/Drug Reactions VI. Altered sensation VII. StrokeVIII. Blood Pressure Abnormalities IX. Emesis/Aspiration X. Malignant Hyperthermia

Be prepared

Most office emergencies are minor, but should be aggressively treated before they become major problems

P-R-A-YPreparedness- of the office and personnel

to treat the impending emergency in a timely and efficient manner.

Recognition- of predisposing signs and symptoms of an impending emergency

Action- Develop a plan to stabilize and support the emergency patient

Yell- To know when and where to obtain help in activating EMS when necessary

Loss of Consciousness (LOC)SyncopeHypoglycemiaCardiac arrest

LOC- SyncopeDefinition:

◦Sudden brief loss of consciousness caused by decreased blood flow to the CNS.

Usually the victim regains consciousness within a few minutes, but prolonged LOC leads to a seizure

LOC- SyncopeCauses:

◦Vasovagal◦Panic/Anxiety◦Hypoglycemia◦Heart Disease (arrhythmia/blocks)◦Seizures◦Diseases that interfere with CNS regulation

of BP (vasodepressor) & HR (cardioinhibitory) DM ETOH BP Medications

LOC- SyncopeSigns/Symptoms

◦Presyncope Nausea Sensation of warmth Light-headedness Diaphoresis Palor Tachycardia

◦Syncopal Stage (LOC) Hypotension Bradycardia Pupillary dilation

LOC- Syncope Treatment:

◦ Early Trendelenberg Assess level of consciousness ABCs Cause Checklist

Medication Hypoglycemia CVA Seizure Arryhthmias Anaphylaxis Anxiety attack

Head tilt 100% Oxygen Monitor BP/Pulse/Respirations Ammonia capsule Cold compresses to forehead & neck Reassure patient

LOC- SyncopeTreatment:

◦Advanced LOC>5 minutes or recovery > 20 minutes 911 Activate ACLS

ABC’s IV access

LOC- SyncopeBradycardia <60 bpm,

symptoms:◦Altered mental status◦Chest pain◦Hypotension◦SOB◦Seizures◦Syncope

LOC- SyncopePrevention (1 ounce= 1 pound of

cure)◦Sedation as needed◦Monitor carefully◦Supine position◦100% oxygen early◦Identify presyncopal stage

LOC- SyncopeSummary

◦Trendelenberg◦Airway◦100% oxygen◦Cold compress/ammonia◦Assess LOC◦Monitor vital signs

LOC- HypoglycemiaDefinition:

◦Reduction in blood glucose levels to below 50 mg/dl, resulting in glucose deprivation of the CNS

Causes:◦Excessive insulin/ oral hypoglycemic

therapy◦Missed/delayed meals◦Illness/infection◦Excessive exercise◦Alcohol ingestion

LOC- HypoglycemiaSigns/Symptoms

◦Mild- (<60-65 mg/dl) Cold clammy wet skin Extreme hunger Nausea Tachycardia Numbness/ tingling fingers Trembling

LOC- HypoglycemiaSigns/Symptoms

◦ Moderate- (<50 mg/dl) Extreme tiredness Irritability Anxiety Restlessness Fatigue/lethargy Headache Dizziness Slurred speech

◦ Severe (<10 mg/dl) LOC Seizures Hypothermia Coma

LOC- HypoglycemiaTreatment

◦Early- patient is conscious Stop treatment Supine position Maintain airway Monitor vitals Check blood glucose level Treat if less than 50 mg/dl,

Oral glucose Regular soft drink, fruit juice ½ cup

LOC- HypoglycemiaTreatment

◦Advanced (patient becomes unconscious) Basic life support (BLS) Activate Emergency Medical Service (EMS)

With IV access One ampoule glucose (50ml of 50% solution) Check blood glucose q10 min I.V. infusion of 5% to 20% dextrose solution

Without IV access One mg glucagon IM Check blood glucose q 10 min Repeat glucagon as needed

LOC- HypoglycemiaPREVENTION

◦H&P◦Maintain glycemic/insulin control,

avoid hyper- or hypo- glycemia.◦Short appointments/early AM◦Early identification and management

LOC- HypoglycemiaPreoperative-

◦Type I DM consider: ½ dose insulin if fasting Measure blood glucose on presentation IV D5W

◦Type II DM Avoid oral hypoglycemic medication on

the morning of surgery Metformin, Glyburide

Check blood glucose on presentation

LOC- HypoglycemiaSUMMARY

◦Stop treatment◦Supine position◦Airway◦Monitor vitals◦Check blood glucose levels◦Oral glucose

LOC- Cardiac arrestABCs of CPR

◦ Check responsiveness◦ If no response call 911◦ AED/ defibrillator◦ Start CPR

A- AIRWAY- Open airway with head tilt chin lift B- BREATHING- Look, listen, feel for breathing

If not breathing give 2 rescue breaths C- CIRCULATION- Check pulse, look for other signs of

circulation such as breathing, movement & coughing◦ If no pulse begin chest compressions between nipples◦ 30 compressions @ rate of 100/min

30 to 2 compressions to ventilation ratio◦ New guidelines: the compressions are more important

than ventilation

LOC- Cardiac arrestABCs of CPR Cont.

◦When to Shock- VF or pulse-less VT If shock does not work add pressors to

treatment. Epinephrine 1 mg Vasopressin 40 units 1 time

◦When not to Shock Pulseless electrical activity- PEA Asystole

Epinephrine, Vasopressin, Sodium bicarbonate, Magnesium

LOC- Cardiac arrestABCs of CPR Cont’

◦Think of the cause: 5Hs

Hypoxia Hypovolemia Hyperthermia Hyper/Hypokalemia Hyperglycemia

5Ts Toxins Tamponade Tension Pneumothorax Thrombosis Trauma

Respiratory Distress (RD)LaryngospasmAirway obstructionDyspneaBronchospasm/ Asthma

Respiratory Distress: LaryngospasmDefinition:

◦A protective reflex to prevent foreign matter from entering the larynx, trachea, or lungs.

Cause: Foreign material in the region of the vocal

cords. Light general anesthesia.

Respiratory Distress: LaryngospasmSigns/Symptoms

◦Increased respiratory effort◦“Crowing” sound- partial laryngospasm◦No air movement or sound- complete

laryngospasm◦Development of cardiac arrhythmias

secondary to: Hypoxia Hypercarbia Hyperkalemia

Respiratory Distress: LaryngospasmTreatment

◦Early: Rapid recognition and initiation of treatment

is essential Pack off surgical site 100% oxygen Immediate pharyngeal suction (yankhauer) Head-tilt position to establish and maintain

airway Pull tongue anterior (towel clip, Russian,

Suture) Observe/ listen for air exchange

Respiratory Distress: LaryngospasmTreatment

◦Advanced: Complete spasm: positive pressure 100% O2 Continuing spasm: Anectine 10-20 mg IV

Prepare for intubation. After Anectine you must breath for the patient

until they recover. Assist ventilation until and after respiration

returns as needed. Kids without IV give Anectine IM 3-4 mg/Kg or

One mg/kg sublingual

Respiratory Distress: LaryngospasmPREVENTION:

◦Throat pack◦Proper airway management◦Adequate suctioning◦Deepen anesthesia- with partial

laryngospasm

Respiratory Distress: LaryngospasmSummary:

◦Pack off surgical site◦100% oxygen◦Suction◦Tongue position anteriorly

Respiratory Distress: Airway ObstructionDefinition:

◦Obstruction caused by soft tissue in the head & neck, bronchoconstriction, secretions, or solids causing a decrease or absence of ventilatory movement.

Cause:◦Supraglotic- Tongue displaced posteriorly

due to loss of tone of pharyngeal muscles secondary to anesthesia or sedation.

◦Foreign body in larynx and pharynx- secretions or solids.

Respiratory Distress: Airway ObstructionSign/Symptoms

◦Choking◦Gagging◦Violent expiratory effort◦Substernal notch retraction◦Cyanosis◦Labored breathing◦Tachycardia, followed by bradycardia,◦Respiratory arrest◦Cardiac arrest

Respiratory Distress: Airway ObstructionAirway obstruction leads to

hypoxia which leads to cardiovascular complications.

Respiratory Distress: Airway ObstructionTreatment: Early

◦Position upright◦Pack off surgical site◦Suction oropharynx◦Tongue traction

Gauze Tongue forceps Hemostat Suture

Respiratory Distress: Airway ObstructionTreatment:

Advanced◦ Place patient supine◦ Chin-lift, jaw-thrust◦ Tilt head back and

continue to try to open airway

◦ Check for sounds of respiration and ventilate if possible

◦ Abdominal thrusts if unable to ventilate

Respiratory Distress: Airway ObstructionTreatment:

Advanced◦ Continued

obstruction Oral/Pharyngeal

airway Positive pressure

ventilation

Respiratory Distress: Airway ObstructionTreatment:

AdvancedContinued

obstruction LMA ET tube

Respiratory Distress: Airway ObstructionTreatment:

AdvancedContinued

obstruction Oxygen via

transtracheal catheter

Activate EMS

Respiratory Distress: Airway ObstructionTreatment:

AdvancedContinued

obstruction◦ Cricothyrotomy

Respiratory Distress: Airway ObstructionSigns of deterioration

◦Cyanosis◦LOC◦Cardiac or respiratory arrest

Re-establish airway before addressing circulatory issues

Re-evaluate diagnosis Maintain BLS

Signs of recovery◦Normal breathing returns◦Foreign body removed or swallowed

Respiratory Distress: Airway ObstructionSwallowed Objects:

◦ Cough to attempt to remove it

◦ Sit upright fast and coughing if conscious

◦ Complete airway obstructions Heimlich- Adult and kids

> 1year old◦ Partial obstruction

Heimlich NOT recommended

Coughing

Respiratory Distress: Airway ObstructionSwallowed Objects:

◦ Heimlich maneuver Stand behind patient Place a fist of one hand

slightly above navel Grasp fist with other

hand Quick upwards thrusts

to the abdomen Chest thrusts in

pregnant women Continue until object is

expelled or LOC occurs

Respiratory Distress: Airway ObstructionAn inhaled object

not coughed out:◦ X-ray chest and

upper GI ◦ Some GI and all

pulmonary objects must be removed.

Respiratory Distress: Airway ObstructionPrevention

◦Proper throat pack◦Removal of dentures, partials◦Adequate suctioning◦Adequate visualization of the

surgical field◦Maintain head position

Respiratory Distress: Airway ObstructionChocking and Looses Consciousness:

◦911◦Lower patient to ground ◦Place patient on their back◦Tongue-jaw lift and finger sweep◦Open airway and attempt ventilation◦If obstructed reposition and try again◦ If obstruction persists give 5 abdominal

thrusts using the heel of one hand above the navel

◦Repeat until obstruction is relieved◦Consider surgical airway

Respiratory Distress: Airway ObstructionSummary

◦Upright position◦Pack off surgical site◦Suction◦Determine if obstruction is indeed

occurring◦Heimlich maneuver

Respiratory Distress: DyspneaDefinition:

The sensation of labored, difficult, and uncomfortable breathing. It occurs when there is inadequate control of respiration, oxygenation and ventilation.

Cause:◦Heart disease◦COPD ( asthma, emphysema, chronic

bronchitis)◦Anxiety/hyperventilation◦Aspiration◦Lung infection◦Pulmonary embolism

Respiratory Distress: DyspneaSign/ Symptoms

◦Moderate Not enough air sensation Shallow slightly labored breathing SOB on mild exertion Cannot complete sentences due to SOB

◦Severe Chest tightness Severe wheezing Anxiety, fear, agitation and restlessness Drowsiness

Respiratory Distress: DyspneaTreatment:

◦Airway◦Assist ventilation as necessary◦100% O2◦Monitor

Pulse oximeter End tidal CO2 BP

◦Transport or Call EMS if unstable