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Medical Emergencies in Dental Practice Part I

Medical Emergencies in Dental Practice Part I. Abtin Shahriari DMD, MPH Oral & Maxillofacial Surgeon Staff Attending Northside Hospital Staff Attending Atlanta Medical Center. Medical Emergencies in Dental Office . Objectives Present various emergency situations Definition Causes

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Medical Emergencies in Dental Practice Part I

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  1. Medical Emergencies in Dental Practice Part I Abtin Shahriari DMD, MPH Oral & Maxillofacial Surgeon Staff Attending Northside Hospital Staff Attending Atlanta Medical Center

  2. Medical Emergencies in Dental Office • Objectives • Present various emergency situations • Definition • Causes • Signs/Symptoms • Treatment • Prevention

  3. Medical Emergencies in Dental Office • Outline: I. Loss of consciousness II. Respiratory distress III. Chest pain IV. Cardiac dysrythmias V. Allergy/Drug Reactions VI. Altered sensation VII. Stroke VIII. Blood Pressure Abnormalities IX. Emesis/Aspiration X. Malignant Hyperthermia

  4. Be prepared

  5. Most office emergencies are minor, but should be aggressively treated before they become major problems

  6. P-R-A-Y • Preparedness- of the office and personnel to treat the impending emergency in a timely and efficient manner. • Recognition- of predisposing signs and symptoms of an impending emergency • Action- Develop a plan to stabilize and support the emergency patient • Yell- To know when and where to obtain help in activating EMS when necessary

  7. Loss of Consciousness (LOC) • Syncope • Hypoglycemia • Cardiac arrest

  8. LOC- Syncope • Definition: • Sudden brief loss of consciousness caused by decreased blood flow to the CNS. • Usually the victim regains consciousness within a few minutes, but prolonged LOC leads to a seizure

  9. LOC- Syncope • Causes: • Vasovagal • Panic/Anxiety • Hypoglycemia • Heart Disease (arrhythmia/blocks) • Seizures • Diseases that interfere with CNS regulation of BP (vasodepressor) & HR (cardioinhibitory) • DM • ETOH • BP Medications

  10. LOC- Syncope • Signs/Symptoms • Presyncope • Nausea • Sensation of warmth • Light-headedness • Diaphoresis • Palor • Tachycardia • Syncopal Stage (LOC) • Hypotension • Bradycardia • Pupillary dilation

  11. LOC- Syncope • Treatment: • Early • Trendelenberg • Assess level of consciousness • ABCs • Cause Checklist • Medication • Hypoglycemia • CVA • Seizure • Arryhthmias • Anaphylaxis • Anxiety attack • Head tilt • 100% Oxygen • Monitor BP/Pulse/Respirations • Ammonia capsule • Cold compresses to forehead & neck • Reassure patient

  12. LOC- Syncope • Treatment: • Advanced • LOC>5 minutes or recovery > 20 minutes • 911 • Activate ACLS • ABC’s • IV access

  13. LOC- Syncope • Bradycardia<60 bpm, symptoms: • Altered mental status • Chest pain • Hypotension • SOB • Seizures • Syncope

  14. LOC- Syncope • Prevention (1 ounce= 1 pound of cure) • Sedation as needed • Monitor carefully • Supine position • 100% oxygen early • Identify presyncopal stage

  15. LOC- Syncope • Summary • Trendelenberg • Airway • 100% oxygen • Cold compress/ammonia • Assess LOC • Monitor vital signs

  16. LOC- Hypoglycemia • Definition: • Reduction in blood glucose levels to below 50 mg/dl, resulting in glucose deprivation of the CNS • Causes: • Excessive insulin/ oral hypoglycemic therapy • Missed/delayed meals • Illness/infection • Excessive exercise • Alcohol ingestion

  17. LOC- Hypoglycemia • Signs/Symptoms • Mild- (<60-65 mg/dl) • Cold clammy wet skin • Extreme hunger • Nausea • Tachycardia • Numbness/ tingling fingers • Trembling

  18. LOC- Hypoglycemia • Signs/Symptoms • Moderate- (<50 mg/dl) • Extreme tiredness • Irritability • Anxiety • Restlessness • Fatigue/lethargy • Headache • Dizziness • Slurred speech • Severe (<10 mg/dl) • LOC • Seizures • Hypothermia • Coma

  19. LOC- Hypoglycemia • Treatment • Early- patient is conscious • Stop treatment • Supine position • Maintain airway • Monitor vitals • Check blood glucose level • Treat if less than 50 mg/dl, • Oral glucose • Regular soft drink, fruit juice ½ cup

  20. LOC- Hypoglycemia • Treatment • Advanced (patient becomes unconscious) • Basic life support (BLS) • ActivateEmergency Medical Service (EMS) • With IV access • One ampoule glucose (50ml of 50% solution) • Check blood glucose q10 min • I.V. infusion of 5% to 20% dextrose solution • Without IV access • One mg glucagon IM • Check blood glucose q 10 min • Repeat glucagon as needed

  21. LOC- Hypoglycemia • PREVENTION • H&P • Maintain glycemic/insulin control, avoid hyper- or hypo- glycemia. • Short appointments/early AM • Early identification and management

  22. LOC- Hypoglycemia • Preoperative- • Type I DMconsider: • ½ dose insulin if fasting • Measure blood glucose on presentation • IV D5W • Type II DM • Avoid oral hypoglycemic medication on the morning of surgery • Metformin, Glyburide • Check blood glucose on presentation

  23. LOC- Hypoglycemia • SUMMARY • Stop treatment • Supine position • Airway • Monitor vitals • Check blood glucose levels • Oral glucose

  24. LOC- Cardiac arrest • ABCs of CPR • Check responsiveness • If no response call 911 • AED/ defibrillator • Start CPR • A- AIRWAY- Open airway with head tilt chin lift • B- BREATHING- Look, listen, feel for breathing • If not breathing give 2 rescue breaths • C- CIRCULATION- Check pulse, look for other signs of circulation such as breathing, movement & coughing • If no pulse begin chest compressions between nipples • 30 compressions @ rate of 100/min • 30 to 2 compressions to ventilation ratio • New guidelines: the compressions are more important than ventilation

  25. LOC- Cardiac arrest • ABCs of CPR Cont. • When to Shock- VF or pulse-less VT • If shock does not workadd pressors to treatment. • Epinephrine 1 mg • Vasopressin 40 units 1 time • When not to Shock • Pulseless electrical activity- PEA • Asystole • Epinephrine, Vasopressin, Sodium bicarbonate, Magnesium

  26. LOC- Cardiac arrest • ABCs of CPR Cont’ • Think of the cause: • 5Hs • Hypoxia • Hypovolemia • Hyperthermia • Hyper/Hypokalemia • Hyperglycemia • 5Ts • Toxins • Tamponade • Tension Pneumothorax • Thrombosis • Trauma

  27. Respiratory Distress (RD) • Laryngospasm • Airway obstruction • Dyspnea • Bronchospasm/ Asthma

  28. Respiratory Distress: Laryngospasm • Definition: • A protective reflex to prevent foreign matter from entering the larynx, trachea, or lungs. • Cause: • Foreign material in the region of the vocal cords. • Light general anesthesia.

  29. Respiratory Distress: Laryngospasm • Signs/Symptoms • Increased respiratory effort • “Crowing” sound- partial laryngospasm • No air movement or sound- complete laryngospasm • Development of cardiac arrhythmias secondary to: • Hypoxia • Hypercarbia • Hyperkalemia

  30. Respiratory Distress: Laryngospasm • Treatment • Early: • Rapid recognition and initiation oftreatmentis essential • Pack off surgical site • 100% oxygen • Immediate pharyngeal suction (yankhauer) • Head-tilt position to establish and maintain airway • Pull tongue anterior (towel clip, Russian, Suture) • Observe/ listen for air exchange

  31. Respiratory Distress: Laryngospasm • Treatment • Advanced: • Complete spasm: positive pressure 100% O2 • Continuing spasm: Anectine 10-20 mg IV • Prepare for intubation. • After Anectine you must breath for the patient until they recover. • Assist ventilation until and after respiration returns as needed. • Kids without IV give Anectine IM 3-4 mg/Kg or One mg/kg sublingual

  32. Respiratory Distress: Laryngospasm • PREVENTION: • Throat pack • Proper airway management • Adequate suctioning • Deepen anesthesia- with partial laryngospasm

  33. Respiratory Distress: Laryngospasm • Summary: • Pack off surgical site • 100% oxygen • Suction • Tongue position anteriorly

  34. Respiratory Distress: Airway Obstruction • Definition: • Obstruction caused by soft tissue in the head & neck, bronchoconstriction, secretions, or solids causing a decrease or absence of ventilatory movement. • Cause: • Supraglotic- Tongue displaced posteriorly due to loss of tone of pharyngeal muscles secondary to anesthesia or sedation. • Foreign body in larynx and pharynx- secretions or solids.

  35. Respiratory Distress: Airway Obstruction • Sign/Symptoms • Choking • Gagging • Violent expiratory effort • Substernal notch retraction • Cyanosis • Labored breathing • Tachycardia, followed by bradycardia, • Respiratory arrest • Cardiac arrest

  36. Respiratory Distress: Airway Obstruction • Airway obstruction leads to hypoxia which leads to cardiovascular complications.

  37. Respiratory Distress: Airway Obstruction • Treatment: Early • Position upright • Pack off surgical site • Suction oropharynx • Tongue traction • Gauze • Tongue forceps • Hemostat • Suture

  38. Respiratory Distress: Airway Obstruction • Treatment: Advanced • Place patient supine • Chin-lift, jaw-thrust • Tilt head back and continue to try to open airway • Check for sounds of respiration and ventilate if possible • Abdominal thrusts if unable to ventilate

  39. Respiratory Distress: Airway Obstruction • Treatment: Advanced • Continued obstruction • Oral/Pharyngeal airway • Positive pressure ventilation

  40. Respiratory Distress: Airway Obstruction • Treatment: Advanced • Continued obstruction • LMA • ET tube

  41. Respiratory Distress: Airway Obstruction • Treatment: Advanced • Continued obstruction • Oxygen via transtracheal catheter • Activate EMS

  42. Respiratory Distress: Airway Obstruction • Treatment: Advanced • Continued obstruction • Cricothyrotomy

  43. Respiratory Distress: Airway Obstruction • Signs of deterioration • Cyanosis • LOC • Cardiac or respiratory arrest • Re-establish airway before addressing circulatory issues • Re-evaluate diagnosis • Maintain BLS • Signs of recovery • Normal breathing returns • Foreign body removed or swallowed

  44. Respiratory Distress: Airway Obstruction • Swallowed Objects: • Cough to attempt to remove it • Sit upright fast and coughing if conscious • Complete airway obstructions • Heimlich- Adult and kids > 1year old • Partial obstruction • Heimlich NOT recommended • Coughing

  45. Respiratory Distress: Airway Obstruction • Swallowed Objects: • Heimlich maneuver • Stand behind patient • Place a fist of one hand slightly above navel • Grasp fist with other hand • Quick upwards thrusts to the abdomen • Chest thrusts in pregnant women • Continue until object is expelled or LOC occurs

  46. Respiratory Distress: Airway Obstruction • An inhaled object not coughed out: • X-ray chest and upper GI • Some GI and all pulmonary objects must be removed.

  47. Respiratory Distress: Airway Obstruction • Prevention • Proper throat pack • Removal of dentures, partials • Adequate suctioning • Adequate visualization of the surgical field • Maintain head position

  48. Respiratory Distress: Airway Obstruction • Chocking and Looses Consciousness: • 911 • Lower patient to ground • Place patient on their back • Tongue-jaw lift and finger sweep • Open airway and attempt ventilation • If obstructed reposition and try again • If obstruction persists give 5 abdominal thrusts using the heel of onehand above the navel • Repeat until obstruction is relieved • Consider surgical airway

  49. Respiratory Distress: Airway Obstruction • Summary • Upright position • Pack off surgical site • Suction • Determine if obstruction is indeed occurring • Heimlich maneuver

  50. Respiratory Distress:Dyspnea • Definition: • The sensation of labored, difficult, and uncomfortable breathing. It occurs when there is inadequate control of respiration, oxygenation and ventilation. • Cause: • Heart disease • COPD ( asthma, emphysema, chronic bronchitis) • Anxiety/hyperventilation • Aspiration • Lung infection • Pulmonary embolism

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