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Dental Office Medical Emergencies R B Templeton DMD

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Medical emergencies

Some medical emergencies are unavoidable but many are very much avoidable

Your actions and reactions can result in better control of the situation

The actions and reactions of the entire staff can also result in better control of the situation

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Prevent Medical EmergenciesKnow your patient!

New patient appointment Recall Consultation following an invasive procedureFollow-up for a colleagueEmergency

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Medical Clearance????Consultation with physicianDocument all communications Discuss proposed treatment and don’t assume consultant understands our dental procedures Lab value changesNoncompliant with current medication regimen Document conversations/recommendationsTreatment and clinical decisions are ours to makeYou are responsible for your decisions!

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The Absolute Best Strategy for Managing Medical Emergencies,be a AAA practice :

Always be Prepared

Advance Prevention

Advocate Practical Management of Medical Emergencies

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Keys to Manage Medical Emergencies :

Accurate and complete medical historyTreatment modification:

Consultation with medical providersPreventionManaging stress/anxietyExtra measure of caution

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Keys to Manage Medical Emergencies :

RecognitionIdentify the problemImmediate diagnosis may not be important

ManagementPrimary management is basic life support (BLS)Use of emergency medications

Follow-up

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An Office Plan for Management of Medical Emergencies

Definitive procedure listed in office manual

Role assignments: EVERYONE has a job to perform!

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Emergency Team:Member # 1

Remain with the patient

Activate staff response

BLS prn

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Emergency Team:Member # 2

Bring oxygen and emergency kitCHECK oxygen cylinder dailyCHECK emergency drugs weeklyFlashlightCheck AED on schedule

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Emergency Team:Member # 3

Assist with BLSMonitor vial signsPrepare DrugsActivate EMSAssist as neededMeet rescue team at entranceMaintain records

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What to do after (between) Medical Emergencies?

Evaluate actions taken“What went right?” “What went wrong?” “What could be changed?”

Make sure that new employees are “trained in”Check the emergency kit:

Quantity, drug expirations,...Anticipate potential medical emergencies for your medically compromised patients

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Temporal relationship of occurrence of systemic complications

Percentage %

Just before treatment 1.5%

During/following injection of local anesthetic 54.9%

During dental treatment 22.9%

In office following treatment 15.2%

At home after treatment 5.5%

Total: 100%

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76%• 76% of medical emergencies in the

dental office are related to stress and anxiety

» Fast, 1986

» Malamed, 1993

» Still True Today!

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Potentially Life Threatening Emergencies

Vasodepressor syncopeAnaphylaxisBronchospasmHyperventilationSeizures Angina pectoris Hypoglycemia Cerebrovascular Accident (stroke)Foreign Body Airway Obstruction

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Prior to Dental Treatment

Updated Medical History QuestionnaireDialogue HistoryThorough Physical Examination“Adequate use of these safeguards can accurately determine patient’s status and prevent up to 90% of all life threatening emergencies in dental practice...”

McCarthy

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Patient Evaluation Questions:Any pain or discomfort at this time?

Have you been hospitalized in the past 2 years?

Have you been under the care of a physician in the past 2 years?

Please list all medications and drugs taken in the past 2 years.

Nervous about dental treatment?

Bad experience in dental office?

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Patient EvaluationAny allergies? Example: local anesthetic, epinephrine, penicillin, codeine, aspirin, eggs...

Any history of excessive bleeding?If so, avoid techniques with higher incidence of positive aspirations and modify therapy

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Patient Evaluation

Heart Failure: American Society of Anesthesiologists (ASA) Patient Status (PS) 3, PS 4 patients will probably have some decreased liver perfusion leading to decreased metabolism of local anesthetic. Less functional reserve and stress reduction may be needed. Orthopnea is a concern in positioning.

http://www.asahq.org/clinical/physicalstatus.htmhttp://my.clevelandclinic.org/services/Anesthesia/hic_ASA_Physical_Classification_System.aspx

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Dialogue HistoryExample: Allergy W 7

What happened? Where did it happen?What medications were given, by whom?What was the chronology of events?What type of medication was given?Were you taking any other medications?Who treated you?

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Physical Examination

Vital Signs:Blood Pressure Visual Inspection:

Pulse: PostureRate & Rhythm Body WeightRespiratory Rate Height Temperature Skin, Hair

Speech Movements

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Risk AssessmentAmerican Society of Anesthesiologists Physical Status Classification System

ASA PS 1 - normal, healthy patientASA PS 2 - mild to moderate diseaseASA PS 3 - severe systemic disease, limits activity, not incapacitatingASA PS 4 - severe systemic disease that limits activity and is threat to lifeASA PS 5 - moribund patient not expected to survive without treatmentASA PS 6 - clinically dead (donor)

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Patient EvaluationMost Important Questions of the evaluation:

How are you feeling today?

Did you eat today?

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Emergency Kit : Essential ComponentsOxygenEpinephrine (1mg injectables, autoinjector)Anti-hypoglycemic (Sugar source)Histamine blockerVasodilator : Nitroglycerin tablets or spray (200 metered doses)

Bronchodilator/Beta agonist inhaler (Ventolin, Albuterol)Pocket mask or preferably Ambu BagAspirin (4 chewable 81 mg tablets or one 325 mg tablet) AED? Narcan

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Recognition of emergencies

Altered/loss of consciousnessSeizuresRespiratory distressDrug related emergenciesCardiovascular distressAllergies

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Independent assessment of risk factors:

HypertensionCholesterolCigarette smokingDiabetes mellitusFamily historyMen, but please do not forget atypical presentations Age

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Altered ConsciousnessConscious patent acting strangely

Hypoglycemia, seizures, unconsciousness

Changes in level of CNS activity

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Altered level of consciousnessPhysiologic PsychologicalAnxiety/Emotional Metabolic Medication relatedSubstance abuse Pathology/Comorbidities Traumatic

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Potential reasons for Unconsciousness

Drop in blood pressureLack of sugarPostural hypotensionSeizuresCerebrovascular accidentAnaphylaxisLocal anesthetic overdose

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Factors to consider with altered and or loss of consciousness: AgeEtiologyDifferential diagnosis Initial response Treatment GenderPast medical history Comorbidities Medication compliance

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Factors to consider with altered and or loss of consciousness:Unknown historyCurrent medical status Recent changes in medical historyRecent changes in medicationsRecent dietary changes Psychological / emotional status

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Pre-syncope

Lightheadedness, dizzinessHypotensionNauseaHypoxiaDiaphoresisPallorTachycardia

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Vasovagal Syncope One of the most common causes of fainting/sudden LOC

Body overreacts to certain triggers

Sudden drop in heart rate and blood pressure

Results and reduced blood flow to the brain resulting in LOC

Usually harmless requires only supportive therapy and observe for repeat episode

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SyncopeChildren who are generally healthy do not usually faint

Most common in adults at time of local anesthetic injection

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Syncope:Autonomic Response to Stress

Primarily sympatheticIncreased heart rateIncreased cardiac output Dilation of pupils

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Syncope:Parasympathetic Response

Inhibition of heart rate by Vagus nerve

Decreased cardiac output

Response complete in 1 second

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Management of Pre Syncope

Supine position

Oxygen

Aromatic ammonia ready

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SyncopeBradycardia : heart rate between 0 and 20

Blood pressure and cerebral blood flow diminish

Unconscious

Seizures

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Syncope Treatment

P supine with feet elevated 15 degreesBLS prnC assess and assist as neededA assess and maintainB assess and maintainD…

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Syncope

If not fully recovered in a few minutes:LOOK FOR OTHER CAUSESeg: hypoglycemia

C A B D…

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Additional management/assessment of syncopeIf not sure symptoms consistent with syncope - consider activating EMSAmmonia capsule under nose Review medical history Continue to monitor vital signs Reassure and comfort patient If patient condition is unstable or a delay in response - activate EMSRecord event and disposition of patient

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Postural Hypotension Rapid fall in BP when moving from supine to upright position

Prevention – position patient gradually

Identify predisposing factors :medicationshypovolemiapreexisting low BPage

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Hyperventilation

Increase in respiratory rate and depth beyond that required for normal metabolism“Hyperventilation syndrome”- most commonly seen in dental office

Related to anxiety/ panicAssociated with lightheadedness, dizziness, chest pain, dysphagia, nausea

Rule out more serious potential conditions including pulmonary (asthma, PE, cardiac (HF), endocrine (diabetic ketoacidosis)

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Hyperventilation

Reverse respiratory alkalosisBreath into bag or hands Verbal instructionBenzodiazepines prn

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Signs & Symptoms ofHypoglycemia

Diminished cerebral functionConfusedSemi conscious

Hunger with nauseaSweatingTachycardiaMay progress to unconsciousness or seizureSigns of Hyperglycemia are similar

Glu< 50 mg/dL When the blood glucose level is

unknown, always treat patient as if they are hypoglycemic

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HypoglycemiaCold, moist skin

Sweating, diaphoretic

Tremor, shaking

Mentally disoriented

May appear “ intoxicated “

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Diagnosis of HypoglycemiaWeaknessPaleMoist skinShallow respirationsHeadacheAltered level of consciousnessGlu< 50 mg/dL

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Hypoglycemia:Conscious

PositionAirway BreathingCirculationDefinitive management Trans-mucosal sugar

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Treatment of Hypoglycemia

Unresponsive semi-conscious patientRecognizeTerminate, position, BLS Call 911 Oral carbohydrates : Be CarefulIf patient unconscious:

Glucagon 1 mg50 ml of 50% dextrose IV over 2 minutes

Determine Blood Glucose

level

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Narcotic overdoseNarcotic level resulting in adverse reaction dosage varies :body weight, age genetic predisposition presence of pathology/synergistic medication route and rate of narcotic administration

Main adverse effect - direct depression and medullary respiratory center

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Narcotic overdose manifestationsOversedation BradypneaHypercarbia Hypoxia Hypotension Respiratory arrest Cardiac arrest

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Narcotic overdose preventionPMH of substance abuse History of adverse reactions, drug tolerance History of other central acting agentsHistory of other narcotic prescriptions (PDMP)Prescribe narcotics carefully Titrate narcotics carefully - monitor respiratory status

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Narcotic overdose management Position patient supine PABC Maintain airway and administer oxygen Monitor vital signsInitiate BLS as appropriate 911Administer naloxone .4 mg IV/IM/IN and continue to monitor vital signsObserve for re-sedation / narcotization Transport to ED / emergency facility.

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Seizures:Emergency ManagementAssess:

ResponsivenessCirculationAirwayBreathing

Call 911

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SeizuresPositionAirwayBreathingCirculationDefinitive treatment

Do not put anything in the mouth of a convulsing patient!

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Local Anesthetic Toxicity Early :Cerebral and Cortical stimulationExcitation , restlessness , apprehension Increased BP / HR / respirations Nausea and vomitingSeizures

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Local Anesthetic Toxicity Late:Cerebral , cortical and cardiovascular depressionRapid decease BPShallow respirationsRespiratory depressionApneaCardiac arrest

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Management of LA Toxicity Supine positionAssess ABCMaintain airway Administer OxygenMonitor VS BLS if appropriate Call 911

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AllergyDelayed : signs and symptoms develop slowly ( > 60 minutes)

Immediate : signs and symptoms develop within minutes

Reaction involves respiratory and cardiovascular systems

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AnaphylaxisPosition : make comfortable

If pt. feels faint, place pt. in supine position with feet elevatedCall 911

CirculationAirwayBreathingDrugs

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AnaphylaxisEpinephrine and Oxygen are the most important therapeutic agents administered in anaphylaxisEpinephrine is the drug of choice and should be administered promptly at the onset of anaphylaxis, it reverses two components of anaphylaxis that can be fatal:Bronchospasm and HypotensionIM injection takes about 2 minutes to work

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Severe AllergyAdminister Epinephrine IM or IV

Call 911

Administer Histamine blocker IM or IV

Administer corticosteroid IM or IV

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Asthma warning signs:

Recent attackMultiple asthma medications Non compliance with medications Active wheezing Upper respiratory track infection

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Asthma:

Patient will be short of breath with wheezingLeans forward to get comfortableRestlessCoughTightness in chestSuprasternal retraction

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Acute Asthma - ManagementTerminate procedureContinually monitor vital signs1-2 puffs Inhaler-Beta 2 agonist (Albuterol) Repeat inhaler as necessaryCall 911 if situation fails to improveOxygen --100%Consider epinephrine 0.3 mg IM or IV

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COPD:

Emphysema and Chronic BronchitisPossible to decompensate during dental appointment causing shortness of breathRecognize signs and symptomsMay not be able tolerate prolonged dental appointmentsDifficulty breathing while supineMay need supplemental oxygen 2-3 liters/minAlbuterol inhaler prn

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Foreign Body Airway Obstruction:

Use an oropharyngeal drape or screen if at all possibleTether small instruments with floss or sutureIf patient is supine have them stay thereTrendelenburg position on right sideIf upright, reposition as above if possibleIf object is sharp do not encourage coughingCall EMS

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FBAO:

If patient becomes unconscious call 911Do tongue - jaw lift and finger sweep to remove object if you can see itDo not perform blind finger sweepsOpen airway and attempt to ventilateIf obstruction persists, give 5 abdominal thrusts

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Patient Management:Cardiovascular Disease

History of Myocardial InfarctionDetermine date of MIMay defer major elective treatment until 6 months after MIDetermine if patient is being treated with anticoagulantsConsultation with primary physician is appropriate

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Patient Management:Cardiovascular Disease

Angina/Ischemic Heart DiseaseDetermine if stable or unstable anginaDefer elective treatment for unstable patient (consult primary physician)Anxiety reduction: N2O /O2 and profound Local AnesthesiaNitroglycerin availableSupplemental O2Limit epinephrine 0.04 mg

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Angina PectorisTransient chest pain brought on by exertion or emotion and relieved by rest and/or nitrate administration

For patients with a known history:Call the patient the day before and remind them to bring nitroglycerin

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Sudden Cardiac Arrest:Survivor Commonalities

Someone witnesses the event - responds & calls 911

CPR was initiated immediately

A defibrillator was used within minutes

Early advanced cardiac life support by EMS

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Myocardial Infarction (MI) :

Inadequate blood flow and oxygen flow (ischemia) to the heart muscle (myocardium)New onset chest painChest pain that lasts for at least 20 minutesEvidence of ischemia on ECGIncreased levels of cardiac enzymesChest pain- crushing/ squeezingPain continues at rest

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Myocardial Infarction:

Elevated or reduced BPPain not immediately relieved by nitroglycerin (NTG)Pain may originate under sternum and may radiate to arm, neck, and mandibleNausea/vomiting Diaphoresis/Dyspnea AnxietySense of “impending doom”

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Suspected Myocardial Infarction: Terminate procedureCall 911Conscious: semi recumbentUnconscious: supine on flat , firm surfaceBLS as needed 100% oxygenContinuously monitor vital signs and airway

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MI:

Aspirin 325mg chewedIf systolic BP >90 mmHg give 0.4 mg NTG sublingually for chest pain - repeat every 5 minutes up to three doses over 15 minutesConsider Nitrous Oxide/Oxygen for pain relief Continuously monitor vital signs Set up AEDBLS as needed

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StrokeCerebrovascular Accident (CVA)

Third leading cause of death in U.S.

Estimated annual medical cost $7.3 billion

Incidence is increasing

If you feel that your patient is having a Stroke, activate the EMS: CALL 911

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Kothari R, et al. Acad Em erg M ed 1997;4;986-990

Cincinnati Pre-hospital stroke scaleFacial Droop (have patient show teeth or smile)

Normal - both sides of face move equallyAbnormal - one side of face does not move as well as the other side

Arm Drift (patient closes eyes and holds arms straight out for 10 seconds)Normal - both arms move the same or both arms do not move at all (other findings, such as pronator grip,... may be helpful)

Abnormal - one arm does not move or one arm drifts down compared with the other

Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”)

Normal - patient uses correct words with no slurringAbnormal - patient slurs words, uses the wrong words or is unable to speak

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Those at risk for a stroke are:

Patients with:Previous stroke

20% recurrence rate in 5 yearsTransient Ischemic Attacks (TIA’s)

Transient episode of focal neurologic deficit (<24 hours)

HypertensionCardiac disorders: Atrial Fib/Flutter

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Emergency Principles to Remember:

Maintain the airwayTerminate the procedure : remove loose objects from the mouthReposition the patient : Supine on firm flat surface Cardiac or respiratory distress and conscious, make patient comfortableIf late stages of pregnancy and unconscious, supine for CPR – on left side if chest compressions not needed

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Principles:

Call 911 ( activate EMS ) as soon as possibleAssess and monitor Airway and BreathingAssess Circulation and take Vital Signs Administer Oxygen

HAVE A PLAN AND PRACTICE AS A TEAM

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