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

    Dental Office

  • 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

  • Increasing risk

    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

    equipment Practice

    Team roles

  • Preparation AED (Automated External Defibrillator)

    Survival rate

  • Emergency drugs

    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)

  • Emergency equipment

    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

  • MEDICAL CONSULTATION

    IDENTIFY PATIENT PROPOSED

    TREATMENT SPECIFIC

    QUESTION

  • 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

    dental treatment.

  • 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

  • UNCONSCIOUSNESS

    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?

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  • 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!

  • ASTHMA

    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

    Drug induced

  • ASTHMA

    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.

  • Asthma

    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

  • HTN

    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

  • HTN

    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.

    Target BP

  • 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