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 <5% if defibrillation after 10 mins*

Chance of successful resuscitation decreases 10% per minute that defibrillation is delayed after cardiac arrest.

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

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

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

Presenter

Presentation Notes

YOU 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)

Asthma

Definitive treatment: position patient upright calm patient ABC’s oxygen Bronchodilator – inhaler (spacer) Vital signs

Severe bronchospasm Definitive treatment: position patient upright calm patient ABC’s 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 <140/90 (Diabetics 130/80)

Treatment of HTN

Target BP <140/90 (Diabetics 130/80)

Reduces risk of: CVA by 35-40% MI by 20-25% Heart failure by >50%

Presenter

Presentation Notes

ANY 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 urgency – elevated BP with high risk for end organ damage (consider history of CHF, TIA, CRI, etc).. Pt needs to see their PCP within 1 day – call PCP to provide history or send with letter. NO DENTAL TX! Pain, anxiety, vasoconstictive LA, NSAID, steroids, decongestants can worsen BP and precipitate a hypertensive emergency!!!

Malignant Hypertension

1% of hypertensive patients *Severe elevation in BP resulting in

end organ damage: Papilledema Acute left heart failure Acute renal failure Cerebral hemorrhage & encephalopathy

IMMEDIATE, AGGRESSIVE MEDICAL ATTENTION

Dental management

DO NOT TREAT OUR PATIENT & SEND HIM TO ER or PHYSICIANS OFFICE (Call ahead)

Recommendation: SBP >180 or DBP >110 is used as cut off

for most dentists – JNC-7*

Dental management

Identification Monitoring Stress reduction protocols Avoid orthostatic hypotension Limit vasopressors (topical & injectable)

Exogenous - 0.04mg epinephrine = 2.2 carpules 1:100,000

Endogenous – potentially a bigger problem (adrenal stress response – 0.28mg of epi / min)

Drug interactions & effects (MAOI, beta blockers)

Presenter

Presentation Notes

Causes of orthostatic hypotension

Case # 4

55 year old male

Presents to your office for RCT & crown preparation.

PMH: MI 5 months ago Angioplasty with stent 4.5 months ago HTN Mitral valve prolapse with regurgitation

Would you treat him? Any special measures?

Treatment following an MI

ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery – exec summary.

Circulation 2002; 105: 1257-1267 “It appears reasonable to wait 4 to 6 weeks after an MI to

perform elective surgery”

AHA 2007 Guidelines on SBE prophylaxis

Prophylactic antibiotics, the authors state, should not be given based on a lifetime risk for infective endocarditis but are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients, according to the guidelines, include those with the following:

Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous IE Congenital heart disease (CHD)*

Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device,

whether placed by surgery or by catheter intervention, during the first 6 months after the procedure†

Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients who develop cardiac valvulopathy

CONSIDER antiplatelet therapies, b-blockers, antihypertensive regimen

Given CAD history, risk for repeat infarction

Correspondence with cardiologist- risk stratification for minor procedure under local anesthestic with vasocontrictor

O2, reduce stress, manage pain and anxiety, cardiac monitors, nitrates PRN

Case # 5

59 year old male In your office for restoration tooth # 30. PMH:

Angina HTN High cholesterol Type II diabetes

During treatment he complains of substernal chest pain, and on questioning he reports pain down his left arm, nausea and dyspnea. You notice that he appears diaphoretic.

Causes of Chest Pain Chest pain may originate in the chest

wall (muscle, bone, skin), or intrathoracic viscera (heart, lungs, esophagus)

Causes of Chest Pain

Myocardial infarction Angina pectoris Pericarditis Pleuritic/Pulmonary chest pain Gastrointestinal (GERD, Hiatal hernia, PUD) Musculoskeletal/aneurysm Aortic dissection

Management of Angina & AMI Terminate treatment Position patient

45 degrees or Trendelenberg if SBP <100 ABC’s Oxygen 100% (Facemask @10 L/min) Sublingual nitroglygcerin 0.4mg

Should relieve pain in 3-5 mins Repeat at 5 min intervals as needed Failure to relieve pain – suspect MI

Aspirin 325mg Morphine 2-5mg every 10 min PRN

Monitor vital signs

Case # 6

33 year old female In your office for routine hygiene

appointment. But her chart is missing. You decide to proceed with your scaling and polishing

During treatment she complains of itching, and you notice a rash developing on the face, neck and arm. Very quickly she tells you that her throat is swelling and that she forgot to remind you of her severe latex allergy, before starting to wheeze.

Anaphylactic reaction

Type I hypersensitivity reaction (IgE)* Life threatening emergency

Anaphylactic reaction management

Terminate treatment & remove latex Position in Trendelenberg ABC’s Oxygen Epinehphrine 0.3ml of 1:1000 IM every 10 mins Diphenhydramine 50mg IM

(Chlorpheniramine is less sedative)

IV access & fluids ? Hydrocortisone 250mg IV

Case # 7

26 year old male Undergoing a root canal on a traumatized

tooth #8 PMH: Epilepsy (poorly controlled) Dental phobia During treatment he becomes unresponsive and

soon after his eyes roll upwards and he becomes rigid for about 20 seconds and then begins to have violent muscle contractions, and becomes cyanotic. He is incontinent of urine and is hypersalivating.

SEIZURES

A paroxysmal disorder of cerebral function characterized by a change in the state of consciousness, motor activity, and sensory phenomena

SEIZURES Generalized seizures:

Affect both hemispheres with altered consciousness Absence (petit mal)

Lapse of attention and staring in children Short duration (10 seconds)

Tonic-clonic (grand mal) Adults – prodrome, preictal, tonic, clonic and postictal

phases 2-15 minute duration Status epilepticus = >5 minutes or multiple back to back

(mortality of 10%)

SEIZURES

Partial seizures: Affect one hemisphere but may become

generalized Simple = no loss of consciousness Complex = with loss of consciousness Short duration – 2-3 mins End spontaneously

Dental management

Medication regimen, compliance, degree of seizure control – communicate with PCP, consider pre-procedure bloodwork and EKG

Consider medication interactions and adverse drug effects Stress reduction in the office – consider adjunctive anxiolysis or sedation Be prepared to manage a seizure

Management of Seizure

Terminate dental procedure Position patient & prevent injury Seizure stops - reassure patient, allow patient

to recover and then discharge patient with an escort, recommend follow up with PCP

Seizure continues – Activate EMS (911) Airway monitoring/ maintenance, administer

O2, monitor VS, 3- lead EKG, pulse check >5 min administer anticonvulsant drug I.V.

diazepam 5 mg/min (children 0.3mg/kg) and 50 ml 50% dextrose IV

SUMMARY 1. Know your patient:

history and physical

2. Have a plan & practice

3. Maintain emergency kit 4. BLS, ACLS & PALS training

5. Consider AED in the office