Medical EmergencyMedical EmergencyPrevention and Prevention and Preparedness in Preparedness in DentistryDentistry

Dr Neil PandeDr Neil Pande

BDS MFGDP(UK) MFDS RCS(Eng)BDS MFGDP(UK) MFDS RCS(Eng)

General Dental PractitionerGeneral Dental Practitioner

GuidanceGuidance

Medical emergencies can occur at Medical emergencies can occur at any timeany time. .

All members of All members of staffstaff need to know their need to know their rolerole in the event of a medical emergency. in the event of a medical emergency.

Members of staff need to be Members of staff need to be traintrained in dealing ed in dealing with such an emergency. with such an emergency.

Dental teams should practise together Dental teams should practise together regularly in regularly in simulatedsimulated emergency situations. emergency situations.

Unexpected EventsUnexpected Events

Accidental or willful bodily injury, Accidental or willful bodily injury,

Central nervous system stimulation and Central nervous system stimulation and depression, depression,

Respiratory and circulatory disturbances, Respiratory and circulatory disturbances,

Allergic reactions.Allergic reactions.

Medical Emergency PlanMedical Emergency Plan

PreventionPrevention

Action planAction plan

Diagnosis and ManagementDiagnosis and Management

Emergency drugs and equipmentEmergency drugs and equipment

PreventionPrevention

Medical History QuestionnaireMedical History Questionnaire

Verbal HistoryVerbal History

Medical History UpdateMedical History Update

Physical ExaminationPhysical Examination

Assessment of RiskAssessment of Risk

Stress ReductionStress Reduction

Pain ControlPain Control

Medical History Medical History QuestionnaireQuestionnaire

First thingFirst thing in dental practice in dental practice

Simple languageSimple language understandable to the understandable to the patientpatient

All All relevantrelevant questions asked questions asked

Signed and datedSigned and dated (Minor: Guardian/Parent) (Minor: Guardian/Parent)

Helped by the reception staff in case of Helped by the reception staff in case of difficulty (Training and understanding of the difficulty (Training and understanding of the staff)staff)

Verbal Medical HistoryVerbal Medical History

Re-enforces Medical History QuestionnaireRe-enforces Medical History Questionnaire

More information on conditionsMore information on conditions

Degree of severityDegree of severity

Gives out information that patient feels is Gives out information that patient feels is irrelevant to dentistryirrelevant to dentistry

Medical InteractionsMedical Interactions

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Medical History UpdateMedical History Update

Should be a part of every long interval dental Should be a part of every long interval dental visitsvisits

Noted in the record in every instanceNoted in the record in every instance

Physical ExaminationPhysical Examination

Visual InspectionVisual Inspection

Baseline Vital Signs: Baseline Vital Signs:

Pulse, BP, Breathing, TemperaturePulse, BP, Breathing, Temperature

Risk AssessmentRisk Assessment

ASA PS Classification SystemASA PS Classification System

PS 1PS 1: : NormalNormal Healthy Patient (-60) Healthy Patient (-60)

PS 2PS 2: : MildMild Systemic Disease (Anxiety, fear, Systemic Disease (Anxiety, fear, +60)+60)

PS 3PS 3: : SevereSevere Systemic Disease that limits Systemic Disease that limits activity but not incapacitatingactivity but not incapacitating

PS 4PS 4: : IncapacitatingIncapacitating Systemic Disease that Systemic Disease that is constant threat to lifeis constant threat to life

PS 5PS 5: Not expected to survive : Not expected to survive 24 hours24 hours

ASA 1ASA 1

Patients are considered to be Patients are considered to be normalnormal and and healthy. healthy.

Patients are able to walk up one flight of stairs Patients are able to walk up one flight of stairs or two level city blocks without distress. or two level city blocks without distress.

Little or no anxiety. Little or no anxiety.

Little or no risk. Little or no risk.

This classification represents a "green flag" This classification represents a "green flag" for treatment. for treatment.

ASA 2ASA 2Patients have Patients have mild to moderatemild to moderate systemic disease systemic disease or are healthy or are healthy ASA I with extreme anxiety ASA I with extreme anxiety and fearand fear

Patients are able to walk up one flight of stairs or two Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop after completion level city blocks, but will have to stop after completion of the exercise because of distress. of the exercise because of distress.

Minimal risk during treatment. Minimal risk during treatment.

Examples: History of well-controlled disease states Examples: History of well-controlled disease states including non-insulin dependent diabetes, including non-insulin dependent diabetes, prehypertension, epilepsy, asthma, or thyroid prehypertension, epilepsy, asthma, or thyroid conditions; ASA I with a respiratory condition, conditions; ASA I with a respiratory condition, pregnancy, and/or active allergies. May need medical pregnancy, and/or active allergies. May need medical consultation.consultation.

ASA 3ASA 3Patients have Patients have severe systemic diseasesevere systemic disease that limits that limits activity, but is not incapacitating. activity, but is not incapacitating.

Able to walk up one flight of stairs or two level city Able to walk up one flight of stairs or two level city blocks, but will have to stop enroute because of blocks, but will have to stop enroute because of distress. distress.

Stress reduction protocol and other treatment Stress reduction protocol and other treatment modifications are indicated. modifications are indicated.

Examples: History of angina pectoris, myocardial Examples: History of angina pectoris, myocardial infarction, or cerebrovascular accident, congestive infarction, or cerebrovascular accident, congestive heart failure over six months ago, slight chronic heart failure over six months ago, slight chronic obstructive pulmonary disease, and controlled insulin obstructive pulmonary disease, and controlled insulin dependent diabetes or hypertension. Will need dependent diabetes or hypertension. Will need medical consultation.medical consultation.

High Risk PatientsHigh Risk PatientsFrequent Exertional Frequent Exertional AnginaAngina and hospital admission and hospital admission

AsthmaAsthmatic under oral and inhalational therapy tic under oral and inhalational therapy /nebuliser / steroid / hospitalisation/nebuliser / steroid / hospitalisation

EpilepticEpileptic with recent change in medication/ with recent change in medication/ precipitating factor and time of last attack to be precipitating factor and time of last attack to be notednoted

Insulin treated Insulin treated diabeticsdiabetics more prone to more prone to hypoglycemia / Poorly controlled less aware hypoglycemia / Poorly controlled less aware diabetics!!!diabetics!!!

Previous Previous reactionsreactions to local anaesthetics, to local anaesthetics, antibiotics and latexantibiotics and latex

Preferred to be treated in medically supported Preferred to be treated in medically supported environmentenvironment

StressStress

Increased Increased catecholaminescatecholamines (epinephrine/norepinephrine)(epinephrine/norepinephrine)

Increase Increase load to the heartload to the heart

Increased Heart RateIncreased Heart Rate

Increased strength of Myocardial ContractionIncreased strength of Myocardial Contraction

Increased Oxygen RequirementIncreased Oxygen Requirement

PS1 can tolerate, but PS 2,3,4 less able to toleratePS1 can tolerate, but PS 2,3,4 less able to tolerate

MDASMDAS

StressStress

Patient withPatient with

AnginaAngina may develop into may develop into chest painchest pain and various and various dysrhythmiasdysrhythmias

Heart FailureHeart Failure may develop into may develop into pulmonary pulmonary edemaedema

AsthmaAsthma may develop into may develop into acute respiratory acute respiratory distressdistress

EpilepsyEpilepsy may develop may develop seizuresseizures

Hyperventilation and SyncopeHyperventilation and Syncope may develop in PS may develop in PS 11

Stress Reduction Stress Reduction ProtocolsProtocolsMinimize Stress before, during and after Minimize Stress before, during and after

treatmenttreatment

1.1. Communication / ConsultationCommunication / Consultation

2.2. Premedication Premedication Lorazepam 1mg night before Lorazepam 1mg night before & 90 mins. before treatment& 90 mins. before treatment

3.3. Appointment SchedulingAppointment Scheduling

4.4. Waiting Time ReductionWaiting Time Reduction

5.5. Vital Signs MonitoringVital Signs Monitoring

6.6. Sedation, Iatrosedation or HypnosisSedation, Iatrosedation or Hypnosis

Pain ControlPain Control

Treatment DurationTreatment Duration

slidesharslidesharee

Post -operative Pain Post -operative Pain ManagementManagement

Availability of dentist via telephone round the Availability of dentist via telephone round the clockclock

AnalgesicsAnalgesics

AntibioticsAntibiotics

Antianxiety drugsAntianxiety drugs

Muscle RelaxantsMuscle Relaxants

Action PlanAction Plan

Understandable by all the staff memberUnderstandable by all the staff member

Goal: Manage until full recovery or until Goal: Manage until full recovery or until help arriveshelp arrives

Sufficient Oxygenation to the brainSufficient Oxygenation to the brain

Patient PositionPatient Position

BLSBLS

Role of Each member of the TeamRole of Each member of the Team

Communication and hospital transferCommunication and hospital transfer

CPRCPR

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Common Medical Common Medical EmergenciesEmergencies

AsthmaAsthma

AnaphylaxisAnaphylaxis

AnginaAngina

Myocardial Myocardial infarctioninfarction

Cardiac ArrestCardiac Arrest

Epileptic SeizureEpileptic Seizure

HypoglycemiaHypoglycemia

•Intravascular Intravascular Injection Injection

•SyncopeSyncope

•Postural Postural HypotensionHypotension

•HyperventilationHyperventilation

•StrokeStroke

•Choking and Choking and AspirationAspiration

•Adrenal Adrenal InsufficiencyInsufficiency

•Mild AllergyMild Allergy

DR ABCDEDR ABCDE

DDangeranger

RResponseesponse

AAirwayirway

BBreathingreathing

CCirculationirculation

DDisabilityisability

EExposurexposure

International International Consensus on Consensus on

Cardiopulmonary Cardiopulmonary Resuscitation and Resuscitation and

Emergency Emergency Cardiovascular Care Cardiovascular Care

Science with Science with Treatment Treatment

Recommendations Recommendations (CoSTR)(CoSTR)

October 2010October 2010

Chain of SurvivalChain of Survival

Early recognition of a “sick” patient, a team Early recognition of a “sick” patient, a team effort...effort...

““Remember to breathe. Remember to breathe.

It is after all, the secret It is after all, the secret of life.”of life.”

Oxygen cylinderOxygen cylinder with with pressure reduction valvepressure reduction valve and and flowmeter/face maskflowmeter/face mask with with reservoirreservoir and and tubingtubing. .

Basic set of Basic set of oropharyngeal airwaysoropharyngeal airways (sizes 1,2,3 and (sizes 1,2,3 and 4). 4).

Pocket maskPocket mask with oxygen port. with oxygen port.

Self-inflating bagSelf-inflating bag and and mask apparatusmask apparatus with oxygen with oxygen reservoir and tubing reservoir and tubing / Child size also./ Child size also.

Portable suction Portable suction with appropriate suction catheters with appropriate suction catheters and tubingand tubing

Single use sterile Single use sterile syringes and needlessyringes and needles. .

‘‘Spacer’Spacer’ device for inhaled bronchodilators. device for inhaled bronchodilators.

Automated Automated blood glucose measurementblood glucose measurement device. device.

Automated External DefibrillatorAutomated External Defibrillator. .

Oropharyngeal AirwayOropharyngeal Airway

Team TrainingTeam Training

Monthly equipment Checks Monthly equipment Checks

Regular UpdatesRegular Updates

Mock TrialsMock Trials

AuditAudit

Ambulance SummoningAmbulance Summoning

Written telephone conversation guide:Written telephone conversation guide:

It is an emergency. A patient has collapsed, It is an emergency. A patient has collapsed, most likely, a _____________. I am calling from most likely, a _____________. I am calling from __________ Dental Clinic located at __________ Dental Clinic located at _________________________ _________________________ opposite____________beside_________. Please opposite____________beside_________. Please send us an ambulance. I will be waiting send us an ambulance. I will be waiting outside the _______________ wearing outside the _______________ wearing ______________ and a flag. My number is ______________ and a flag. My number is _________________._________________.

ReferencesReferences

Malamed SF. Knowing Your Patients. JADA 2010; Malamed SF. Knowing Your Patients. JADA 2010; vol. 141 no. suppl 1 3S-7Svol. 141 no. suppl 1 3S-7S

MEDICAL EMERGENCIES AND RESUSCITATION MEDICAL EMERGENCIES AND RESUSCITATION STANDARDS FOR CLINICAL PRACTICE AND STANDARDS FOR CLINICAL PRACTICE AND TRAINING FOR DENTAL PRACTITIONERS AND TRAINING FOR DENTAL PRACTITIONERS AND DENTAL CARE PROFESSIONALS IN GENERAL DENTAL CARE PROFESSIONALS IN GENERAL DENTAL PRACTICE A Statement from The DENTAL PRACTICE A Statement from The Resuscitation Council (UK) July 2006 Revised Resuscitation Council (UK) July 2006 Revised December 2012 Published by the Resuscitation December 2012 Published by the Resuscitation Council (UK) Council (UK)

ReferencesReferences

European Resuscitation Council Guidelines for European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life Resuscitation 2010 Section 2. Adult basic life support and use of automated external support and use of automated external defibrillators Rudolph W. Koster, Michael A. defibrillators Rudolph W. Koster, Michael A. Baubin, Leo L. Bossaert, Antonio Caballero, Baubin, Leo L. Bossaert, Antonio Caballero, Pascal Cassan, Maaret Castrén, Cristina Granja, Pascal Cassan, Maaret Castrén, Cristina Granja, Anthony J. Handley, Koenraad G. Monsieurs, Anthony J. Handley, Koenraad G. Monsieurs, Gavin D. Perkins, Violetta Raffay, Claudio Gavin D. Perkins, Violetta Raffay, Claudio Sandroni.Published online 19 October 2010, Sandroni.Published online 19 October 2010, pages 1277 - 1292pages 1277 - 1292