Medical Emergencies - umbsod2017 · PDF file4/01/2015 · Beth Stirling, D.D.S.,...
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Transcript of Medical Emergencies - umbsod2017 · PDF file4/01/2015 · Beth Stirling, D.D.S.,...
Beth Stirling, D.D.S., M.D. Resident in OMFS University of Maryland
Medical Emergencies in the
Overview Emergencies do occur
IT WILL HAPPEN IN YOUR OFFICE
Failure to plan is planning for failure Management
Prevention Recocgnition Treatment
Emergency Number Emergency Number
Syncope 15,407 Cardiac arrest 331
Mild allergic reaction 2583 Anaphylaxis 304
Angina 2552 Myocardial infarction 289
Postural hypotension 2475 LA overdose 204
Seizure 1595 Heart failure 141
Asthma 1392 Diabetic coma 109
Hyperventillation 1326 CVA 68
Epinephrine reaction 913 Adrenal insufficiency 25
Hypoglycemia 890 Thyroid storm 4
N=4309 over 10 years Fast TB, Martin MD & Ellis TM, 1986
7.5 emergencies per dentist over 10 years
Most common emergencies
Stress related: Syncope & hyperventillation
Medical conditions exacerbated by stress:
Cardiovascular, bronchospasm (asthma) & seizures
Drug related Overdose & allergy
Timing of the emergency Time % of total
Waiting room 1.5
Local anesthesia* 55
During treatment 22
After treatment 16
After leaving the office 5.5
Matsuura H, 1990
U.S. Aging Population
35 million people (12%) 65 years or older
Life expectancy was 40 years in 1900 & 77 years in 2002.
Number will increase by nearly 75% by year 2030
Aging population Medical advances Surgical procedures Longer appointments Increased drug use
PREVENTION & PREPARATION
Prevention Know your patient Clinical judgment Medical consult Optimize treatment
Preparation Know your patient Train your staff
BLS, ACLS, PALS Prepare your office
Preparation AED (Automated External Defibrillator)
Injectable: sympathomimetic - epinephrine (1 mg/ml) antihistamine - diphenhydramine (50
mg/ml) anticonvulsant - midazolam (5 mg/ml) corticosteroid hydrocortisone (50mg/ml) 50% dextrose antihypoglycemic - glucagon (1 mg/ml) analgesic morphine (10 mg/ml) Anticholinergic atropine (0.5mg/ml)
Non-injectable: Oxygen vasodilator nitroglycerin (sublingual
tablets or spray) bronchodilator - Ventolin aromatic ammonia source of sugar glucose - gel, table
sugar antiplatelet - ASA (325 mg tablets)
oxygen delivery system (Ambu bag, nasal prongs)
large bore suction tips needles and syringes oropharyngeal & nasopharyngeal airways Chemstrips
Obtain Adequate Medical History
Medications Allergies Cardiovascular System Respiratory System Endocrine System Renal System Gastrointestinal System Nervous System
IDENTIFY PATIENT PROPOSED
STRESS REDUCTION PROTOCOL
Recognition Morning & short appointments Minimize waiting time Premedication Psychosedation Intra and postoperative pain control
Case # 1
19 year old female
Attends your office for a root canal on tooth #8 which. As you are talking to her at the start of her appointment she tells you that she feels weird, you ask her to sit down but as she is sitting on the chair she slumps and becomes unresponsive.
PMH - None, but extremely anxious about
She appears pale and diaphoretic. Breathing is shallow & pupils are dilated. Some convulsive movements of hands and
feet that subside in 10 seconds Pulse = 48 (Difficult to palpate) BP = 75/30
19 year old female
Syncope Drug administration/ingestion Orthostatic hypotension Epilepsy Hypoglycemia Adrenal insufficiency, AMI, CVA
PresenterPresentation NotesTRENDELENBURG PT, O2 nasal cannula, place cardiac monitors 3 lead ekg for rhythm analysis, continuous pulse ox, and BP cuff autocycle, protect pt (hold head) and support airway (head tilt/chin lift), fingerstick!! Obtain additional hx from family regarding meds, possible drugs, last meal , consider IV access and isotonic fluid bolus for low BP +/- atropine to increase HRIf need to treat hypoglycemia in an unconscious pt without IV access -> IM glucagon
VASODEPRESSOR SYNCOPE Management:
position patient supine with head lower that heart
establish airway, oxygen Monitor vital signs ammonia inhalant atropine for profound bradycardia If delayed recovery >15 min suspect alternate
diagnosis & EMS
PresenterPresentation NotesDistinguishing neurocardiogenic syncope from seizure in pt with convulsions and LOC the postictal phase!
Case # 2
17 year old female
Presents to your office for an extraction. Her mother tells you she has asthma.
What questions do you ask?
Questions to ask an asthmatic
How often How severe (medication, hospitalization,
intubation) Getting worse or better over time Initiating factors Treatment Currently symptomatic Compliant with meds / take meds today Have medication with you
PresenterPresentation NotesMedication compliance, recent or frequent changes to medications. What are current symptoms nocturnal cough, frequency of symptoms- weekly versus daily! on the regimen they are on classify as intermittent or persistent, mild moderate severe. BRING RESCUE inhaler day of treatment!
PresenterPresentation NotesYOU DO NOT need to memorize this table! It wont be on the test!
Increased reactivity of bronchioles to a variety of stimuli resulting in widespread, but reversible narrowing of the airways due to bronchoconstriction, edema, and secretions
Types Extrinsic Intrinsic Exercise induced
Extrinsic Allergen induced (IgE, mast cells, histamine,
prostaglandins) Children & often regresses at puberty
Intrinsic Upper respiratory irritants or infection Adults
Exercise induced Drug induced
NSAIDs, Aspirin (association with nasal polyps)
PresenterPresentation NotesNSAIDs, ASA can increase leukotrienes which predispose some pts to asthmatic attacks better to avoid.
Definitive treatment: position patient upright calm patient ABCs oxygen Bronchodilator inhaler (spacer) Vital signs
PresenterPresentation NotesCALM patient- increased agitation/ anxiety increases turbulence of airflow and results in ineffective ventilation! PULSE OX! Give O2 nasal cannula. As long as pt is conscious, sitting up pt (head elevation) will allow pt to manage their own airway and improve air flows. GIVE BRONCHODILATOR b2 agonist first. AUSCULTATE and monitor pulse ox. If not effective and severe bronchospasm, with poor air mvmt on auscultation and SpO2 < 94% on supplemental O2, with evidence poor tissue perfusion or low BP, IM epinephrine, activate EMS (911), consider advanced airway, consider IV access, steroid admin, if loses consciousness > BLS and get AED. Place 3-lead EKG (monitor rhythm and rate). Resp arrest leads to cardiac arrest.
Severe bronchospasm Definitive treatment: position patient upright calm patient ABCs oxygen Bronchodilator inhaler (spacer) Parenteral bronchodilator (epinephrine)
0.3ml of 1:1000 or 3ml of 1:10,000 BLS
Case # 3
69 year old male
Presents to your office for extraction of 4 teeth. No PMH except pressure meds
but he has run out of meds.
3 BP readings were 215/110, 208/103 & 210/108
Blood Pressure SYSTOLIC DIASTOLIC
Normal < 120 < 80
Prehypertension 120-139 80-89
Stage 1 - Hypertension 140-159 90-99
Stage 2 - Hypertension 160-179 100-109
Stage 3 - Hypertension 180-209 110-119
Stage 4 - Hypertension >210 >120
A blood pressure of 130/80 mmHg or higher is considered high blood pressure in people with diabetes and chronic kidney disease.
Affects 50 million Americans only 59% are treated
HTN underlies most cardiovascular disease
Prognosis: Relationship between BP and life expectancy is
linear Risk of cardiovascular disease doubles for
every increment of 20mmHg SBP or 10mmHg DBP (JNC-7)
Sustained HTN results in: Renal failure, CVA, Coronary insufficiency, LVH/CHF, MI, Aneurysms, Blindness
Diastolic HTN: increased peripheral resistance, classically a greater risk.
Systolic HTN: increased cardiac output and/or large vessel stiffness. More important risk factor in patients older than 50.
Treatment of HTN
Target BP 50%
PresenterPresentation NotesANY changes in vision, headache, neurological findings slurred speech, facial droop, numbness, weakness, decreased urination, chest pain, SOB pt to ER for urgent management (hypertensive emergency). Call ER to provide history and discuss transport may need ambulance. Hypertensive u