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“Are You Prepared!”. Medical Emergencies in the Dental Office Presented by: Keith M. Schneider, MS, DMD Tuesday, July 16, 2013 Tuesday, July 23, 2013. Overview. Improve your ability to plan for, manage and handle office medical emergencies as part of the dental team. 

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are you prepared

“Are You Prepared!”

Medical Emergencies in the Dental Office

Presented by:

Keith M. Schneider, MS, DMD

Tuesday, July 16, 2013

Tuesday, July 23, 2013

  • Improve your ability to plan for, manage and handle office medical emergencies as part of the dental team. 
  • Discuss the importance of a thorough health history in dealing with medical emergencies
  • Cover background information on emergencies
  • Necessary office emergency equipment
  • Scenarios of medical emergency situations and how to handle them
in office emergencies
In Office Emergencies
  • Other emergencies can happen in the dental office
    • Not covered in this lecture
our 10 objectives
Our 10 Objectives
  • Describe emergency preventive procedures and preparedness in the dental office.
  • Explain the importance of obtaining a pretreatment health history from each patient.
  • Describe the procedure for obtaining a blood pressure, pulse, respirations, and temperature.
  • Demonstrate the initial sequence of patient assessment in an emergency.
  • Identify how stress and anxiety can lead to medical emergencies.
our 10 objectives1
Our 10 Objectives
  • Recognize the signs or symptoms of impending or developing emergencies.
  • List the general steps to be taken when a medical emergency arises in a dental office.
  • Identify the type of emergency when given a patient situation and describe the necessary emergency care.
  • Identify the contents of an emergency kit.
  • Describe the medicolegal implications of medical emergencies.
case scenerio
Case Scenerio
  • During root canal therapy, a 68-year-old male patient becomes pale, perspires profusely, and clutches his chest.  He appears confused, seizes briefly, and is now unresponsive to verbal stimuli.  He is not breathing and no pulse can be felt in the carotid artery. 
  • Do you know how to handle this situation?

Medical emergencies can occur at any time in the dental office. 

  • They can happen to anyone
    • the anxious patient in the reception room
    • the elderly diabetic who was told to skip breakfast prior to coming to her appointment
    • the receptionist with a seizure disorder
    • the dentist experiencing prolonged chest discomfort
  • In a survey of 4,000 dental offices, 75 percent said they had treated medical emergencies in the last ten years.
  • It is estimated that the average dentist will have to deal with one or two life-threatening medical emergencies in their office during their career.

Knowing how to handle medical emergencies will make the dental provider more confident in his or her ability to handle all aspects of the job.

  • The best way to handle an emergency is to be prepared in advance.
  • Whether the medical emergency occurs years in the future or this afternoon, preparation is the key. 
  • All health care providers should be prepared to recognize and handle medical emergencies in the office.

Staff should be trained and frequently updated in first aid and cardiopulmonary resuscitation procedures. 

  • A written emergency plan should be available, and all staff members should be thoroughly familiar with it and their responsibilities in an emergency.
    • This includes training of office personnel in handling emergencies, development and posting of office emergency guidelines, and maintenance of an emergency kit or “crash cart,” fully equipped and ready for immediate use.
  • Relatively rare
  • Most not life-threatening
  • Can become serious
  • Most are treated in office
  • Know when to refer for help
  • Increasing # of older patients
  • Therapeutic advances
  • Longer appointments
  • Surgery is more often stress provoking
  • Increasing variety of drugs administered
  • Preparation/Practice
    • Team
    • Patients
    • Action Plan
    • Supplies/Medication
  • Prevention
  • Recognition/Classification
    • History/signs/symptoms
  • Treatment
    • EMS – Activate when necessary
  • Doctor’s training – BLS, ACLS, CE
  • Auxiliary staff
  • Establish a system
  • Support
    • Staff – at least 2 in office at all times
    • 911
    • Fire department
    • Local Urgent Care
  • Practice
    • Annual BLS
    • Periodic Emergency Drills
    • Preassigned Responsibilities
avoiding emergencies
Avoiding Emergencies

Adequate preparation of the patient and staff.

The following are suggested guidelines:

  • Medical history – Update every 4-6 month
    • Obtain physician consultation when necessary.
  • Patients to take their normal medications on the day of their appointment. 
    • Review when confirming appointments
    • i.e. around meal times for diabetics; Angina patients bring nitroglycerin tabs; asthma patients bring inhaler.
avoiding emergencies1
Avoiding Emergencies
  • Staff member training
    • Monitor and interpret vital signs. 
      • Vitals at initial visit as a “baseline reading”
      • Subsequent visits for “high risk” patients
    • Basic first aid procedures and basic life support (CPR).
    • Each staff member should know and practice their particular function in an emergency
    • Emergency telephone numbers should be posted at each phone.
    • Should be aware of signs of stress and how to alleviate them
avoiding emergencies2
Avoiding Emergencies
  • Office personnel should be aware of the signs and symptoms indicating an emergency. 
    • An emergency kit readily available
    • each staff member should know where it is located.
  • All staff should be aware of their legal responsibilities when responding to an office emergency.
  • Remember—the “best handled” medical emergency will always be the one that never happened.
emergency manuals
Emergency manuals
  • Develop an emergency manual
  • Keep it simple
  • Commercial manuals are available
  • Staff designations
  • Phone numbers to EMS
  • Address and directions to office
  • Special instructions to EMS
emergency manuals1
Emergency manuals
  • Review protocol – twice a year
  • Practice using equipment
  • Use outdate drugs to practice
  • Practice airways
when to call 911
When to call – 911!
  • Condition is life-threatening
  • Patient not responding to Treatment
  • Patient’s response is not appropriate
  • When in doubt – SHOUT!
preparation equipment
Preparation Equipment
  • Dental Chair
  • Trendelenburg position
  • Operatory with adequate space
  • CPR board
preparation equipment1
Preparation Equipment
  • Respiratory assistance:
    • Oral / nasal airways
    • Tonsil suction
    • High-volume suction
    • Ambu bag (Air Mask Bag Unit)
    • Clear face masks
preparation equipment2
Preparation Equipment
  • BP Cuff and stethoscope
  • Oxygen Tank – (size E Portable with low flow regulator)
  • Syringes – IM (3cc), SubQ (TB syringe)
  • Automated External Defibrillator (AED)
oxygen and airway
Oxygen and Airway
  • Oxygen source – fixed / removable
  • Cannula
    • Readily accepted by patient – comfortable
    • Maximum delivery – 6L/M (higher is painful)
  • Non-rebreathing mask
    • Better than a rebreathing mask
    • Set O2 at 10L/M or maximum flow
      • Able to deliver 100% O2
oral pharyngeal airways
Oral-pharyngeal Airways
  • Prevent tongue from obstructing airway
  • Proper size – important
  • Measure corner of mouth to the earlobe
  • Insert upside down and rotate at soft palate
pocket mask
Pocket Mask
  • Always use with O/P airway if possible
  • Easy technique
  • Set O2 to maximum level
  • Rate – 12/minute (every 5 seconds)
bag valve mask
  • Gold standard
  • Use a O/P airway also
  • Delivers 100% O2
  • Difficult with small hands
  • Rate – 12/minute
  • Gently squeeze bag – assist patient breathing
preparation equipment3
Preparation Equipment
  • Administration of Medications:
    • Syringes – needles
    • Tourniquets
    • Intravenous solutions
    • Indwelling catheters
    • Intravenous tubing
preparation equipment4
Preparation Equipment
  • Commercial Emergency Kits
  • Self assembled: “Crash carts”
    • Choose agents likely to use
    • Organize in easy to use manner
    • Labeled – name and situation used
    • Checked frequently for completeness
    • Expiration of medications
preparation monitors
Preparation – Monitors
  • Stethoscope
  • Sphygmomanometers ( BP Cuff)
    • Detachable cuffs for varying sized arms
    • Proper size = 20% larger than the diameter of arm
    • Three sizes – standard, larger adult, pediatric
preparation supplies equipment
Preparation – Supplies & Equipment
  • Emergency Kits – commercial available/high price
  • Self assembled:
    • Choose agents likely to use
    • Organize - easy to use manner
    • Labeled – name and situation used
    • Checked frequently for completeness
    • Expiration of medications
emergency drugs oral preparations
Emergency Drugs Oral Preparations
  • Antihistamine:
    • Diphenhydramine (Benadryl)
  • Antihypoglycemic:
    • Candy, fruit, sugar,Glutose
  • Vasodilator:
    • Nitroglycerine
    • Nitrostat
emergency drugs inhaled preparations
Emergency Drugs Inhaled preparations
  • Oxygen
  • Brochodilator:
    • Allupent, Epinephrine bitartrate (Medihaler-Epi)
    • Albuteral (Proventil/Ventolin)
  • Respiratory stimulant – Aromatic Ammonia
emergency drugs parenteral preparations
Emergency Drugs Parenteral preparations
  • Analgesic
    • Morphine
  • Anticonvulsant – Diazepam
    • Valium
  • Antihistamine – Diphenhydramine
    • Benadryl
emergency drugs parenteral preparations1
Emergency Drugs Parenteral preparations
  • Antihypoglycemic – 50% dextrose in water
  • Corticosteroid:
    • Dexamethasone (Decadron)
    • Methyprednisolone (Solu-Medrol)
    • Hydrocortisone (Solu-Cortef)
emergency drugs parenteral preparations2
Emergency Drugs Parenteral preparations
  • Narcotic antagonist – Naloxone (Narcan)
  • Flumazenil (Romazicon)
  • Sympathomimetic – Epinephrine
  • Vagolytic - Atropine
  • Know who’s at risk
  • Medical history
    • Predict future problems
    • Prevent crisis in present
  • Physical exam – vital signs
  • Obtain consults - written
  • Alter treatment
  • Office Visit - thorough history and physical
    • Chief Complaint
    • Medical History
    • Surgical History
    • Family History
    • Social History
    • Medications
    • Allergies
    • Vital signs
  • Alter treatment
    • i.e. stress reduction protocols
medical history form
Medical History Form
  • Thorough
  • Easy to complete
  • Easily updated and dated
  • Easy to recall updated information
  • Patient’s signature – medical/legal
medical history form limitations
Medical History Form – Limitations
  • Unable to quickly recover information
  • Incorrect / inaccurate information
  • Patient mistakes re: medications
    • Daily maintenance medications are overlooked
    • Non-tablet form of medication
    • Alternative medications/vitamins
surgical history
Surgical History
  • Hospitalizations & operations
  • Supports the medical history
  • Cross check
  • Complications with procedures or anesthesia
family history
Family History
  • Genetic predispositions
    • Underlying health conditions that may surface as patient gets older
social history
Social History
  • Smoking
  • ETOH
  • Drug use
  • Dosage/indications
  • Prescription
  • Non-prescription (Vitamins/supplements)
  • Recreational
  • Pre-existing allergic conditions
  • Environmental allergies
  • Drug interactions

1. The most frequent medical emergency in the dental office is ____________________.

a. myocardial infarction

b. syncope

c. respiratory arrest

d. allergic reactions

2. The best office emergency kit is one ___________________________.

a. purchased from a dental supply house

b. set-up by a local physician

c. prepared by the dentist based on his/her needs

d. containing medications and equipment to handle any emergency

3. The ______________ artery is used when taking a patient’s blood pressure.

a. brachial

b. carotid

c. radial

d. femoral

4. In an emergency, the best place to check the pulse is the ________________________.

a. carotid artery

b. brachial artery

c. radial artery

d. femoral artery

  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
loss of consciousness

Loss of Consciousness



Cardiopulmonary Resuscitation

Acute Adrenal Insufficiency

Thyroid Storm

  • Definition:
    • “Fainting.”
    • Caused by a decrease in cerebral blood flow reversible.
    • Most common cause of transient LOC in OMS Office.
syncope pathophysiology
Syncope Pathophysiology
  • Stress-induced release of increased amounts of catecholamines
  • Decreases the peripheral vascular resistance
  • Vagal stimulation results in slowing of the heart rate / failure of maintaining BP
syncope predisposing factors
SyncopePredisposing Factors
  • Psychogenic
    • Anxiety/Fear
    • History of Fainting
    • Hyperventilation
    • Stress
  • Non-Psychogenic
    • Position - orthostasis
    • Hunger - Hypoglycemia
    • Exhaustion
    • Poor physical condition – Diabetes/ETOH
    • Hot and humid - dehydration
syncope signs symptoms
  • Generalized feeling of warmth
  • Lightheadedness - Dizziness
  • Diaphoresis (cold/clammy)
  • Pallor
  • Decreased BP (after transient increase)
  • Tachycardia - bradycardia
syncope signs and symptoms
SyncopeSigns and symptoms
  • Patient is talkative and then becomes quiet
  • Nausea
  • Loss of consciousness
  • Dilation of pupils
  • Seizures – if cerebral ischemia is severe enough
syncope diagnosis

Late Recognition


Possible Seizure

BP is low

Pulse – weak / thready

Syncope Diagnosis
  • Early Recognition
    • Nausea
    • Warm feeling
    • Diaphoretic
    • Pallor
    • Rapid pulse
    • BP almost normal
syncope prevention
  • Early recognition
  • 100% Oxygen
  • Patient position
    • Not upright
    • Especially during injection
  • Stress reduction
  • Oral premedication
syncope treatment
  • Stop procedure – monitor Vital signs
  • Assess consciousness
  • 100% oxygen – maintain airway
  • Trendelenburg - Head below legs (not between!)
syncope treatment1
  • Suction as necessary
  • Observe for a period of time
  • Drive home?
  • Reappoint
  • Faint version #2!
  • Expected Recovery
    • Awakens – VS stable
    • Maintain 100% Oxygen
    • Reassure patient
  • Deteriorating
    • Falling BP – Bradycardia
    • Not awake after 1 minute
    • Continued symptoms with BRADYCARDIA:
      • Atropine 0.5 – 1.0mg IV q 5 min x 3 doses
syncope differential diagnosis
SyncopeDifferential Diagnosis
  • Hypoglycemia
  • Seizure
  • Cardiac Arrest/Arrhythmias
  • Anaphylaxis
  • CVA
  • Hyperventilation

5. The best position in which to place a syncopal patient is _______________________.

a. seated with the patient’s head between their legs

b. supine with the legs elevated

c. on their side

d. in a seated position

6. ____________________ best illustrates the “normal” vitals for an adult.

a. Pulse 108, BP 160/90, respirations 22, temperature 101°F

b. Pulse 50, BP 88/40, respirations 28, temperature 98.6°F

c. Pulse 80, BP 118/70, respirations 16, temperature 98.6°F

d. Pulse 98, BP 208/110, respirations 18, temperature 97.2°F

7. Most emergencies occur ______________________.

a. in the reception room

b. after treatment is completed

c. while under nitrous oxide sedation

d. during or immediately following local anesthesia administration

8. A conscious patient is unable to breathe or talk. When you ask if they are choking, they nod their head. You should administer ________________________.

a. oxygen

b. four back blows

c. fifteen chest compressions

d. abdominal thrusts

diabetes mellitus
Diabetes Mellitus
  • Hypoglycemia – Rapid onset
    • More common emergency situation
    • Mismatch between insulin dose and serum glucose
  • Hyperglycemia – Slow onset
  • Definition
    • An abnormally low level of sugar in the blood
    • Causes:
      • Omission or delay of meals
      • Excessive exercise without meals
      • Overdose of Insulin
  • Causes of serum glucose levels to fall:
    • Increasing administered insulin
    • Poor glucose intake
      • Normal insulin – inadequate diet
      • NPO – Intentional / Unintentional
    • Increasing metabolic utilization
      • Exercise
      • Infection
      • Emotional stress
      • ETOH ingestion
hypoglycemia signs symptoms
Hypoglycemia Signs/Symptoms
  • Mild (60 – 65 mg.dL)
    • Sudden onset
    • Hunger/nausea
    • Pallor/sweating – cool and clammy!
    • Tremor
    • Tachycardia – full and bounding
    • Numbness – tingling lips and finger tips
hypoglycemia signs symptoms1
  • Moderate (<50 mg/dL)
    • Increased anxiety
    • Confusion
    • Restlessness
    • Dizziness
    • Headache
    • Lack of energy
    • Slurred speech
hypoglycemia signs symptoms2
  • Severe (<30mg/dL)
    • Lethargy
    • Decrease in cerebral function - headache
    • Seizures (not common)
    • Hypothermia
    • Loss of consciousness
    • Coma
hypoglycemia early treatment
HypoglycemiaEarly Treatment
  • Always treat as hypoglycemic until otherwise proven!
    • Conscious patient:
      • Supine position
      • Monitor BP/Pulse
      • Check blood glucose levels
    • Treat blood glucose < 50 mg/dL (even with no symptoms)
    • High sugar content substitute:
      • Orange juice
      • Soft drink
      • Candy / Cake frosting
hypoglycemia advanced treatment
HypoglycemiaAdvanced Treatment
  • Activate EMS
  • Unconscious patient:
    • 50% Dextrose IV solution – (50ml) over 2-3 minutes
  • IV solution – 5% - 20% dextrose solution
    • Without IV - Glucagon 1mg IM/IV
    • Recheck Blood Glucose in 15 minutes
    • Remain in office – 1 hour
    • Escorted home
hypoglycemia prevention
  • Careful medical history
  • Determine the severity of disease
    • Hospitalization
    • Frequency of hypoglycemic events
  • Patient control of diabetes/insulin control
  • Watch time of the day for surgery
hypoglycemia prevention1
  • Check patient’s blood sugar – AM serum
  • Reduce AM dose of insulin (MD consult?)
  • IV D5W infusion
  • NPO considerations
  • “Keep it sweet”
case scenerio1
Case Scenerio
  • During root canal therapy, a 68-year-old male patient becomes pale, perspires profusely, and clutches his chest.  He appears confused, seizes briefly, and is now unresponsive to verbal stimuli.  He is not breathing and no pulse can be felt in the carotid artery. 
  • Do you know how to handle this situation?
cpr c a b changed in 2010
CPR: (C-A-B) changed in 2010

Here is a step-by-step guide for the new CPR:

  • Call 911 or ask someone else to do so.
  • Try to get the person to respond; if he doesn’t, roll the person on his or her back.
  • Start chest compressions.  Place the heel of your hand on the center of the victim’s chest.  Put your other hand on top of the first with your fingers interlaced.
  • Press down so you compress the chest at least 2 inches in adults and children and 1.5 inches in infants. “One hundred times a minute or even a little faster is optimal,” Sayre says.  (That’s about the same rhythm as the beat of the Bee Gee’s song “Stayin’ Alive.”)
  • If you’ve been trained in CPR, you can now open the airway with a head tilt and chin lift.
  • Pinch closed the nose of the victim.  Take a normal breath, cover the victim’s mouth with yours to create an airtight seal, and then give two, one-second breaths as you watch for the chest to rise.
  • Continue compressions and breaths – 30 compressions, two breaths – until help arrives.
acute adrenal insufficiency1
Acute Adrenal Insufficiency
  • Definition
    • Rare, but life-threatening
    • When endogenous cortisol production is insufficient to cope with needs of the clinically-stressed patient
      • Cortisol is a hormone produced and released by the adrenal gland
acute adrenal insufficiency2
Acute Adrenal Insufficiency


  • Inadequate replacement therapy
  • Non-compliance or replacement therapy
  • Recent abrupt stop of corticosteroid
  • History of long-term use of corticosteroids
  • Fever
  • Dehydration
  • Surgery
  • Anesthesia
  • Injury
acute adrenal insufficiency3
Acute Adrenal Insufficiency


  • Hypotension
  • Abrupt mental changes
  • Weakness
  • Nausea and vomiting
  • Dehydration
  • Fever, chills, loss of appetite
  • Rapid respiratory rate
  • Abdominal pain
  • Joint pain/myalgias
acute adrenal insufficiency4
Acute Adrenal Insufficiency


  • Terminate procedure
  • Monitor vital signs
  • Trendelenburg position
  • Activate 911
  • IV access – 5% dextrose with NaCl
  • Administer steroid therapy
    • Dexamethasone or Hydrocortisone
  • Fluid replacement
  • Consider transfer to medical facility
acute adrenal insufficiency5
Acute Adrenal Insufficiency


  • If patient is already taking corticosteroids
    • Stress reduction protocols
    • Monitor vital signs
    • Consider stress dosing (double steroids day before, day of, and day after procedure
  • If patient not currently on, but has received 20 mg hydrocortisone for more than 2 weeks within 2 years (rule of 2’s)
    • Stress reduction protocols
    • Monitor vitals
    • Double daily dose
thyroid storm1
Thyroid Storm
  • Definition
    • When the thyroid gland releases large amounts of thyroid hormone in a short period of time
    • Stressful scenario or illness mixed with someone having hyperthyroidism (Graves disease/overactive nodules)
thyroid storm2
Thyroid Storm


  • Surgery
  • Trauma
  • Infection
  • Physiologic or emotional stress
  • Pregnancy
thyroid storm3
Thyroid Storm


  • Predisposing signs of hyperthyroidism
    • Weight loss
    • Intolerance to heat
    • Exophalmus
  • Acute signs
    • Tremor
    • Tachycardia
    • Hypertension
    • Irritability
    • Mental changes
    • Heart failure
thyroid storm4
Thyroid Storm


  • Terminate procedure
  • Activate 911
  • 100% Oxygen
  • Monitor vital signs
  • BLS
  • Cold packs – if hyperthermia arises
  • IV access
  • Fluid replacement – D5LR with steroid
  • Consider transport to medical facility
thyroid storm5
Thyroid Storm


  • Limit predisposing factors – if known
  • Primary physician consult
  • Control of thyroid hormone production
  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
respiratory distress

Respiratory Distress



Airway Obstruction (Foreign Body)

Dyspnea (SOB)

Bronchospasm/Asthma Attack

  • Definition
    • When the natural balance between O2 and CO2 are changed to be off balance with:
      • CO2 levels decreasing
      • O2 levels increasing.
    • Breathing to deeply or too rapidly, patient exhales too much carbon dioxide (CO2).
      • Decreased CO2 causes anxious feeling which leads to worsening hyperventilation


  • Acute anxiety – stress, fear
  • Ages 15-40
  • Females > males
  • Pain
  • Panic attacks


  • Neurologic
    • Dizzy, tingling
    • Syncope
  • Respiratory
    • Inc. RR & Depth
    • Feeling of SOB
    • Chest pain
    • Xerostomia


  • Cardiac
    • Palpitations
    • Tachycardia
  • Musculoskeletal
    • Myalgia
    • Muscle spasm - tetany
  • Psychological
    • Extreme anxiety

Signs/Symptoms - Initial

  • Tightness/Chest stiffness
  • Rapid breathing
  • Apprehensive/Confused
  • Vertigo
  • Vision changes
  • Tachycardia
  • Headache

Signs/Symptoms - Prolonged

  • Tingling/Parathesia of hands and feet
  • Carpalpedaltetany (cramping of hands or feet)
  • Loss of Consciousness

Treatment - Initial

  • Terminate stimulation – clear mouth!
  • Position – upright
  • Calm patient – instruct to hold breath
  • Paper bag – Recycles CO2

Treatment – Advanced

  • Medicate
    • Diazepam - 5mg IV
    • Midazolam - 2mg IM/IV
  • Monitor vital signs
  • Activate EMS if condition worsens
hyperventilation prevention
  • Careful preop history
    • Sedation before appointment
  • Recognition
  • Early management
  • Physical exam
  • Vital signs – respiration rate
  • Definition
    • Protective reflex to prevent foreign matter form entering the larynx, trachea, or lungs
  • Causes
    • Precipitated by foreign material in the region of the vocal cords
    • Light general anesthesia


  • Increased respiratory effort
  • Crowing or stirdor
  • No/Minimal air movement
  • Cardiac arrhythmias secondary to:
    • Hypoxia
    • Hypercarbia
    • Hyperkalemia
    • Bradycardia

Treatment - Early

  • Pack of surgical site
  • 100% oxygen
  • Clear airway of any debris
  • Position tongue anteriorly
  • Consider positive airway pressure with bag-mask

Treatment - Advanced

  • Complete Spasm - positive airway pressure with bag-mask and 100% oxygen
  • Continuing Spasm – Small vs Large dose of succinylcholine (10-20 mg vs 20-40 mg IV)
  • Prepare for intubation prn


  • Proper throat packs
  • Proper airway maintenance
  • Adquate suctioning
  • Prevention of foreign debris in the airway
  • Deep anesthesia
    • More likely to occur when patient is in light anesthetic plane
airway obstruction definition
Airway Obstruction Definition
  • Complete or partial
  • Mechanical Blockage of air exchange
    • Tongue
    • Foreign body
airway obstruction pathophysiology
Airway Obstruction Pathophysiology
  • Loss of object into oropharynx
    • Object is retrieved or…..
    • Enters esophagus and is swallowed or…
    • Blocks airway at vocal chords or….
    • Enter trachea - aspirated
airway obstruction risk factors
Airway Obstruction Risk factors
  • Supine patients
  • Sedated patients
  • Lack of airway protection
airway obstruction risk factors1
Airway Obstruction Risk Factors
  • Neuromuscular compromised patient
    • Stroke patient
    • Cerebral palsy
    • “Special patients”
airway obstruction signs symptoms
Airway Obstruction Signs/Symptoms
  • Foreign body in Larynx / pharynx
  • Gagging
  • Coughing
  • “Crowing” sounds
  • Universal choking sign
  • Inability to speak
airway obstruction signs symptoms1
Airway Obstruction Signs/Symptoms
  • Stridor
  • Wheezing
  • Labored breathing
  • Use of accessory breathing muscles
  • Decreased oxygen saturation – cyanosis
  • Tachycardia – Bradycardia
  • Respiratory arrest
  • Cardiac arrest
airway obstruction early treatment
Airway Obstruction Early Treatment
  • Position – upright / comfortable
  • Pack off surgical site
  • Suction oropharynx
  • Digital traction of Tongue
  • If object is lost in the oropharynx and no distress, transport for localization radiographs
airway obstruction advanced treatment
Airway Obstruction AdvancedTreatment
  • Re-establish airway
  • Finger sweeps – suction
  • BLS
  • Intubate
  • Cricothyrotomy / Tracheotomy
airway obstruction prevention
Airway Obstruction Prevention
  • Entirely preventable ??
  • Pre-op removal of potential foreign bodies
  • Adequate visualization of operative field
  • Good ventilation
airway obstruction prevention1
Airway Obstruction Prevention
  • Maintain head position
  • Suction
  • Adequate protection
    • Throat screen/pack
  • Ligature around small objects
asthma bronchospasm


asthma definition
Asthma Definition
  • Extreme airway sensitivity
  • Hyper-reactive smooth muscle of bronchioles
  • Resultant – bronchospasm
asthma precipitating factors
Asthma Precipitating Factors
  • Environmental – dogs, cats, foods
  • Exercise induced
  • Allergy induced
  • URI
  • Stress
asthma pathophysiology
Asthma Pathophysiology
  • Response to a stimulant
    • Bronchospasm
    • Increase secretions
    • Increase viscosity of secretions
  • Inflammation – constriction
asthma patients at risk
Asthma Patients at risk!
  • Frequency of attack
  • Medications – amount and usage
  • ER – Hospital
  • Steroids
  • Intubation
manifestations acute asthma attack
Manifestations Acute Asthma Attack
  • Mild to Moderate
    • Wheezing
    • Dypsnea
    • Tachycardia
    • Coughing
    • Anxiety
manifestations acute asthma attack1

Cyanosis of mucosa

Minimal breath sounds

Flushing of face




Manifestations Acute Asthma Attack
  • Severe:
    • Intense Dyspnea
    • Flaring of nostrils
    • Accessory breathing
bronchospasm definition

Generalized contraction of smooth muscles of bronchi and bronchioles in lungs resulting in restriction of air flow to and from the lungs. This results in the restriction of flow of inhalation and exhalation of air in the lungs.

bronchospasm treatment early
BronchospasmTreatment: Early
  • Terminate procedure
  • Patient in upright position
  • Full face mask with positive pressure
    • 100% oxygen
bronchospasm treatment advanced
BronchospasmTreatment : Advanced
  • Signs: Cyanosis, breathing slows, wheezing worsens
  • Activate EMS
  • Beta agonist inhaler – open bronchioles –
    • First line of defense
      • Albuterol (Ventolin®)
        • Metered-dose inhaler
        • 2-4 puffs initially –
        • repeat every 10-20 minutes
bronchospasm treatment advanced1
BronchospasmTreatment: Advanced
  • Epinephrine 0.3 - 0.5mg SubQ 1:1000
      • Repeat q 20 minutes
      • Maximum – 1mg
      • Especially if patient unable to use nebulizer
    • Intubation
bronchospasm prevention
  • Keep a dry field
  • Pre-operative inhaler puffs
  • Avoid histamine releasing drugs (Demerol®)
  • Careful usage of Brevital®
  • Stress reduction
  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
chest pain

Chest Pain

Angina Pectoris

Myocardial Infarction

angina pectoris definition
Angina PectorisDefinition


  • Angina Pectoris is chest pain or discomfort due to coronary heart disease, and is a symptom of Myocardial ischemia.
  • A primary symptom of coronary heart disease which occurs when myocardial oxygen demand exceeds supply.
    • Angina – comes from the Greek word – Anchein (to choke).
      • Anxiety and anguish come from the same word.
angina pectoris risk factors
Angina Pectoris Risk Factors
  • Smoking
  • Cholesterol
  • Hypertension
  • Coronary Artery disease
  • Diabetes
  • Genetics
acute onset of chest pain differential diagnosis


Intercostal muscle spasm



Acute Onset of Chest Pain Differential Diagnosis
  • Cardiovascular
    • Angina Pectoris
    • Myocardial infarction
  • GI Tract
    • Dyspepsia (heartburn)
    • Hiatal hernia
    • GERD
    • Gastric Ulcers
angina pectoris differential diagnosis
Angina PectorisDifferential Diagnosis
  • Indigestion!
    • Diaphoresis
    • Shortness of breath
    • Heaviness or squeezing sensation
    • Nausea
    • Pain not influenced by movement, breathing or coughing
    • Patient usually remains very still – relieved by rest
angina pectoris signs symptoms
Angina PectorisSigns/Symptoms
  • Symptoms may vary between patients
  • Pressure-like chest pain – duration 3-5 minutes
  • Radiation to arm, shoulder, neck, jaw, or teeth
  • Relieved by nitroglycerin
  • Patient usually has History of Angina
angina pectoris treatment early
Angina PectorisTreatment: Early
  • Terminate procedure
  • 100% oxygen – 10 L/minute – Face Mask
  • Place patient in comfortable position
  • Loosen clothing
angina pectoris treatment early1
Angina PectorisTreatment: Early
  • Monitor Vital signs
  • Nitroglycerine 0.4mg tablet or 1-2 sprays
    • Sublingual
    • Repeat q 5 minutes
    • Maximum – 3 times over 15 minutes
    • If not relieved – 911 / ER
  • Continue EKG monitoring
angina pectoris treatment advanced
Angina PectorisTreatment: Advanced
  • Same as early treatment plus…
  • Aspirin 325mg Orally
  • Transport to medical facility
angina pectoris prevention
Angina PectorisPrevention
  • Pre-op Nitroglycerin  tabs – (0.2-0.6 mg 5-10 minutes prior to procedure)
  • Oral premedication – stress reduction
  • IV sedation
  • 100% Oxygen during procedure
  • Profound local anesthesia – limit epinephrine!
myocardial infarction definition
Myocardial InfarctionDefinition

Necrosis or death of heart muscle precipitated by decreased oxygenation from partial or complete blockage of blood flow in the coronary arteries.

myocardial infarction signs and symptoms
Myocardial Infarction Signs and symptoms
  • Chest pain – pressure – most common
  • Elevated or reduced blood pressure
  • Pain NOT relieved by Nitroglycerin 
  • Arm, shoulder or jaw pain
  • Squeezing pain
myocardial infarction signs and symptoms1
Myocardial InfarctionSigns and symptoms
  • Sweating/pallor – diaphoresis
  • SOB
  • Nausea/Vomiting
  • Tachycardia – weak/thready pulse
myocardial infarction signs symptoms
Myocardial InfarctionSigns / symptoms
  • Feeling of impending doom
  • Different feeling than angina
  • Cyanosis
  • Hypotension
  • Cardiac dysrhythmias
myocardial infarction treatment early
Myocardial InfarctionTreatment: Early
  • Terminate procedure
  • 100% oxygen – 4-6 liters/minute
  • Comfortable position – upright
  • Loosen clothing
  • Activate EMS
myocardial infarction treatment advanced
Myocardial InfarctionTreatment : Advanced
  • Monitor vital signs – record on chart
  • ASA 160 – 325mg (chewed PO)
  • Reassure Patient
  • Establish IV
  • Set up AED
myocardial infarction treatment advanced1
Myocardial InfarctionTreatment: Advanced
  • MONA
      • Morphine
      • Oxygen
      • Nitroglycerine
      • Aspirin
myocardial infarction prevention
Myocardial InfarctionPrevention
  • Careful medical history taking
  • 100% oxygen throughout procedure
  • Oral premedication or sedation
    • 5-10mg Diazepam (Valium®) POHS
  • Profound local anesthesia
  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
cardiac dysrhythmias cardiac arrest
Cardiac Dysrhythmias

Cardiac Arrest

cardiac arrest definition
Cardiac ArrestDefinition
  • Temporary or permanent cessation of heart function
cardiac arrest pathophysiology
Cardiac ArrestPathophysiology
  • Alteration of electrical stimulation to myocardium:
    • Ventricular Tachycardia
    • Ventricular Fibrillation
  • Loss of electrical stimulation:
    • Asystole
    • Pulseless Electrical Activity
cardiac arrest risk factors
Cardiac Arrest Risk Factors
  • Hx of coronary artery disorder
  • Hypertension
  • Obesity
  • Hypercholesterolemia
  • Hx of Arrhythmia
  • Previous MI
cardiac arrest signs symptoms
Cardiac ArrestSigns/Symptoms
  • Absent pulse
  • Absent BP
  • Loss of consciousness – sudden collapse
  • Absent respiration
  • May be preceded by chest pain or SOB
cardiac arrest treatment
Cardiac ArrestTreatment
  • 911
  • BLS
  • Determine rhythm
  • ACLS
    • Establish IV access
    • Secure airway
cardiac arrest prevention
Cardiac ArrestPrevention
  • Consider the medical history
  • Measure the medical risk
  • Appropriate consultation
  • Appropriate anesthetic
  • Consider hospital treatment
  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
allergic drug reactions

Allergic/Drug Reactions

Urticaria or Pruritis

Anaphylactic Shock

Drug Overdose

Latex Allergy

urticaria or pruritis definition
Urticaria or PruritisDefinition
  • An allergic reaction, where an intensely pruritic (“itchy”) and red plaque occurs on the skin
    • Appears over minutes
    • May enlarge and coalesce
    • May take several hours to resolve
urticaria or pruritis causes
Urticaria or PruritisCauses
  • Medications
  • Latex
  • Environment
  • Food
urticaria or pruritis signs symptoms
Urticaria or PruritisSigns/Symptoms
  • Urticaria (wheal/flare)
    • Face/trunk/extremities
    • Blanching
    • Hives
  • Pruritis (mild to severe itching)
  • Angioedema
    • Edema
    • Lesions – painful/burning
    • Non-pruritic
  • Erythema(localized/generalized)
urticaria or pruritis treatment early
Urticaria or PruritisTreatment: Early
  • Upright patient position
  • 100% O2
  • Monitor vital signs
urticaria or pruritis treatment advanced
Urticaria or PruritisTreatment: Advanced
  • Activate EMS
  • Monitor vital signs – record
  • Assess precipitating factors
    • Withdraw agent
  • Benadryl
    • 25-50 mg orally q4-6 hrs, 300 mg daily max
  • Epinephrine 0.3-0.5 mg (1:1000 sol’n) Sub Q.
anaphylactic shock definition
Anaphylactic ShockDefinition
  • Sudden and severe allergic reaction
    • Characterized by cardiovascular collapse (severe hypotension) and respiratory compromise (bronchospasm)
anaphylactic shock causes
Anaphylactic ShockCauses
  • Medications
  • Latex
  • Environment – Bee stings
  • Food
anaphylactic shock signs symptoms
Anaphylactic ShockSigns/Symptoms
  • Onset
    • Injected drugs: 5-30 minutes
    • Oral ingestion: up to 2 hours
  • Skin
    • Flushed face
    • Rash
    • Urticaria (nose, hands)
    • Tingling (lips, axilla, groin, hands, feet)
    • Angioedema (tongue, oropharynx)
anaphylactic shock signs symptoms1
Anaphylactic ShockSigns/Symptoms
  • Respiratory
    • Dyspnea/Apnea
    • Dysphagia
    • Coughing
    • Inspiratory stridor
    • Wheezing
  • CNS
    • Diaphoretic
    • Feeling of impending doom
    • Altered consciousness
    • Seizure
    • Incontinence
anaphylactic shock treatment early
Anaphylactic ShockTreatment: Early
  • Activate EMS
  • Supine patient position
  • 100% O2
  • Monitor vital signs
  • Recheck patient medical history for factors
anaphylactic shock treatment advanced
Anaphylactic ShockTreatment: Advanced
  • Activate ACLS
  • Monitor vital signs – record
  • Assess precipitating factors
    • Withdraw agent
  • Epinephrine 0.3-0.5 mg (1:1000 sol’n) Sub Q.
  • Bronchospasm – admin Albuterol
  • Consider Decadron 4 mg IV
  • Benadryl
    • 25-50 mg orally q4-6 hrs, 300 mg daily max
  • Advanced airway may be required
  • Hospital transfer
local anesthetic toxicity definition
Local Anesthetic ToxicityDefinition
  • Harmful effects caused by overdose of agents used for local anesthesia.
    • Given in an amount or manner that produces an excessive serum concentration.
local anesthetic toxicity signs symptoms
Local Anesthetic ToxicitySigns/Symptoms
  • Excitement followed by depression
  • Restless nervousness
  • Tremors
  • Rapid pulse
  • Confusion
  • Rapid breathing
  • Seizures
local anesthetic toxicity treatment early
Local Anesthetic ToxicityTreatment: Early
  • Administer O2
  • Monitor vital signs
local anesthetic toxicity treatment advanced
Local Anesthetic ToxicityTreatment: Advanced
  • Active EMS
  • Supine patient position
  • Monitor/Maintain airway
  • BLS
  • Treat seizures (valium 5-10 mg IV)
    • Manage postictal state (lethargy after seizure)
local anesthetic toxicity prevention
Local Anesthetic ToxicityPrevention
  • Know safe doses!
    • Aspirate before injection
    • Use only what is necessary
epinephrine reaction signs symptoms
Epinephrine ReactionSigns/Symptoms
  • Rapid elevation of Blood Pressure
  • Increased heart rate
  • Anxiety
  • Tremor
epinephrine reaction treatment
Epinephrine ReactionTreatment
  • Terminate procedure
  • Position patient – not supine
  • Reassure patient
  • Vital signs
  • 100% Oxygen
  • Recovery
  • Activate EMS if not return to normal
  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
altered sensation

Altered Sensation

Stroke (CVA)

Seizure disorders


Stroke or cerebral vascular accident (CVA) is onset over minutes to hours of a focal neurologic deficit or abnormality that is caused by a decrease in blood flow to a specific area of the brain.

stroke causes risk factors



Cardiac dysrhythmias

Illegal drug use


Valvular heart disease

Stroke Causes/Risk Factors
  • Hypertension
  • CAD
  • Diabetes mellitus
  • Elevated cholesterol
  • Blood clotting disorders
  • Embolus
stroke signs symptoms

Severe headache – “worst ever”

Decreased LOC

Inability to walk

Difficulty breathing and/or swallowing

Stroke Signs/Symptoms
  • Localized weakness – facial muscles
  • Paralysis
  • Sensory deficits
  • Inability to speak
  • Memory loss
stroke treatment
  • Terminate procedure
  • Summon assistance
  • 100% Oxygen
  • Supine position with head slightly raised
  • Monitor VS / EKG
  • LOC – administer O2 and BLS


  • Advanced
    • ACLS as appropriate
    • Transport
stroke prevention
Stroke Prevention
  • 1-2 month rule
  • Confirm medications
  • Coumadin  /Plavix 
  • Stress reduction
  • Judicious use of epinephrine
seizures definition
  • Abnormal electrical activity of the brain
    • Vary in duration and length
    • Recurrent seziures = epilepsy
seizures causes
  • Syncope
  • Epilepsy
  • Brain tumor
  • Trauma to head
  • Stroke
  • Electrolyte inbalance
  • Hypoglycemia
  • Medications
  • Drug withdrawal
seizures signs symptoms
  • Generalized tonic-clonic seizure
  • Absence seizure
  • Simple partial seizure
  • Complex partial seizure
  • Jacksonian seizure
seizures treatment early
SeizuresTreatment: Early
  • Terminate procedure
  • Supine position
  • Loosen clothing
  • Ensure patient safety
  • Establish airway
  • Monitor vital signs
  • 100% oxygen
  • Observe in office for minimum 1 hour
seizures treatment advanced
SeizuresTreatment: Advanced
  • Initiate BLS
  • Establish IV access
  • IV benzodiazepines (Valium or Versed)
  • Cardiovascular support
  • If continued seizures – activate EMS
  • Treat arrhythmias as needed
seizures prevention
  • Check patient medication compliance
  • Limit amount of precipitating drugs
  • Avoid rapid local anesthetic injection
  • Calculate maximum local dosage
  • Avoid Brevital (general anesthetic agent)
  • Consider sedation for patient procedure – stress reduction protocol.
  • Loss of Consciousness
  • Respiratory Distress
  • Chest Pain
  • Cardiac Dysrhythmias
  • Allergic/Drug Reactions
  • Altered Sensation/Changes in Affect
  • Blood Pressure Abnormalities
blood pressure abnormalities

Blood Pressure Abnormalities



hypotension definition
  • Hypotension is the medical term for low BP. When BP drops suddenly and the vital organs are deprived of adequate blood supply and oxygenation.
  • Abnormally LOW arterial blood pressure
    • < 90/60
    • Similar to simple syncope – related to positioning
hypotension causes
  • Preoperative
    • Dehydration
    • Excessive premedication
    • Orthostatic hypotension (supine to upright)
  • Intraoperative
    • Hypoxia
    • Hypercarbia
    • Drug allergies
    • Anesthetic overdose
  • Systemic abnormalities
  • Sepsis
hypotension signs symptoms
Hypotension Signs/Symptoms
  • Palpitations
  • Generalized weakness
  • Dizziness
  • Orthostatic changes
  • Syncope
  • Nausea
  • Bradycardia (HR below 40)
  • Tachycardia (HR above 100) – late stage
hypotension treatment early
Hypotension Treatment: Early
  • Terminate surgery
  • Determine etiology:
    • Hypovolemia
    • Psychological
    • Postural
    • Premedication overdose
  • Trendelenburg position
  • 100% Oxygen – treat as syncope
  • Monitor vital signs
  • Support airway
hypotension treatment advanced
HypotensionTreatment: Advanced
  • IV fluids – Normal saline solution
  • Medicate with vasopressors
    • Ephedrine – 2.5 – 5mg IV then titrate until BP is stabilized
      • Gives both α & β effects to increase Heart Rate
      • Effects in 10 minutes
      • Peak at 20 minutes
      • Duration – 4 hours
hypotension prevention
  • Careful history taking
  • Recognize dehydration
  • Avoid stress
  • Avoid rapid positional changes
    • Elderly
    • After long procedures
hypertension definition
  • An elevation in BP that increases the risk for end-target organ damage.
  • Abnormally high arterial blood pressure
    • >140/90
    • Increased systolic BP – increased blood flow to brain
hypertension causes
Hypertension Causes
  • Inadequate/ light anesthesia
  • Hypoxia to stimulate Tachycardia/HTN
  • Anesthetic overdose
  • Hx of HTN - exacerbation
  • Stress – Pain
hypertension causes1
Hypertension Causes
  • Cessation of medication ( “rebound” hypertension)
  • Adrenal tumors
  • Renal failure
  • ASVD
hypertensive crisis signs and symptoms
Hypertensive CrisisSigns and symptoms
  • Sudden onset – Prodromal for CVA
  • Systolic pressure > 200mg Hg or diastolic > 100mm Hg
  • Headache
  • Dizziness
  • Tinnitus
  • Visual changes
  • Confusion
  • Chest pain
  • SOB
hypertensive crisis treatment early
Hypertensive Crisis Treatment: Early
  • Terminate procedure
  • Confirm patent airway
  • Place patient - upright
  • Loosen clothing
  • 100% oxygen
  • Monitor vital signs – q 5 min
  • Review medications
hypertensive crisis t reatment advanced
Hypertensive Crisis Treatment: Advanced
  • Consider EMS
  • Oral therapy for TMT of Urgencies
    • Give additional dose of patient’s meds
    • Clonidine (Catapres®) 0.2mg PO
hypertensive crisis treatment advanced
Hypertensive Crisis Treatment: Advanced
  • IV Therapy:
    • Beta-Blockers
      • Labetalol (Trandate®, Normodyne®)
        • 20mg IV over 2 minutes
        • May repeat q 10 minutes to maximum or 300mg
    • Narcotics for pain relief
hypertensive crisis prevention
Hypertensive Crisis Prevention
  • Thorough medical history
  • Medicine compliance
  • Profound local anesthesia
  • Limit epinephrine use
  • Consider sedation
  • Maintain anti-hypertensive medication
emesis and aspiration1
Emesis and Aspiration

Depressed or absent laryngeal reflexes which may allow the stomach contents to enter the lungs.

aspiration gastric contents
Aspiration – Gastric contents
  • Preparing to vomit!
    • Nausea
    • Frequent swallowing
    • Perspire
    • Feeling of warmth
    • Anxiety
    • Gagging
aspiration gastric contents1
Aspiration – Gastric contents
  • Leads to serious respiratory difficulty
  • High acidity of gastric juice
  • Necrotize pulmonary tissue
  • Obtunded gag reflex – at risk
    • Sedation
    • Loss of Consciousness
aspiration gastric contents prevention
Aspiration - Gastric contentsPrevention
  • Avoid levels of sedation that obtund gag reflex
  • NPO
aspiration gastric contents treatment
Aspiration – Gastric contentsTreatment
  • Head down – feet up
  • Right side*
  • High volume suction
  • 911 – supplement oxygen – VS monitored
aspiration foreign body acute manifestations
Aspiration – Foreign Body Acute manifestations
  • Large Foreign Body
    • Coughing
    • Choking sensation
    • Stridorous breathing (“Crowing sound”)
    • Severe dyspnea
    • Feeling of something caught in mouth
    • Inability to breath
    • Cyanosis
emesis and aspiration treatment early
Emesis and AspirationTreatment: Early
  • Tonsil suction
  • Trendelenburg position on right side
  • 100% Oxygen
emesis and aspiration prevention
Emesis and Aspiration Prevention
  • Careful preop screening
  • NPO
  • Clear liquids – no less than 2 hours before procedure
  • Anesthetic technique to maintain some level of laryngeal reflex

9. A 17-year-old anxious female suddenly develops shortness of breath, appears cyanotic around the mouth, and is audibly wheezing. Her problem is most likely __________________ and the treatment is ____________________.

a. allergic reaction; epinephrine SQ

b. angina; nitroglycerin sublingually

c. asthma; use of her inhaler

d. syncope; lying patient flat and elevating legs

10. Immediately upon recognizing cardiac arrest in the office you should ____________.

a. call 911

b. ventilate with a bag-valve-mask

c. begin chest compressions

d. administer oxygen

11. Mrs. Smith, a 57-year-old diabetic, is having extensive bridgework completed during her lunch break appointment. She begins acting strangely, her pulse is rapid, and her skin is pale, cool, and clammy. You suspect _________________ and treat it with _________________.

a. asthma; puff from her inhaler

b. hypoglycemia; oral sugar

c. angina; nitroglycerin

d. stroke; oxygen


12. While administering lidocaine anesthesia to a 21-year-old male, he becomes pale, pushes the dentist’s hand away and passes out. You suspect __________________.

a. lidocaine toxicity

b. allergic reaction

c. epinephrine reaction

d. syncope

13. A severe allergic reaction involving several body systems is called ______________.

a. convulsions

b. syncope

c. anaphylaxis

d. angina pectoris

14. An older patient becomes restless during treatment. He seems unable to move one arm and his speech is slurred. He may be having ____________________________.

a. cerebrovascular accident/transient ischemia attack

b. acute myocardial infarction

c. angina pectoris

d. epileptic seizure


15. During an episode of hyperventilation, the patient is losing too much _______________.

a. oxygen

b. nitrogen

c. hydrogen

d. carbon dioxide

16. ____________________________ may result in increased drug effects or hypersensitivity.

a. Rapid administration

b. Excessive dosing

c. Inadvertent IV administration

d. all of the above

17. The main cause of syncope is _____________________.

a. hypertension

b. stress

c. overexertion

d. hunger

18. Anxiety hyperventilation is best treated using _______________________.

a. a paper bag

b. high flow oxygen

c. coaching techniques to slow breathing

d. anti-anxiety agents


19. To reduce possible injury of the patient during a seizure, the provider should ____________________.

a. seat the patient upright in the chair

b. hold the patient absolutely still

c. loosen tight clothing and place a pad beneath their head while turning them to their side

d. place a bite block between their teeth to prevent damage to oral structures

20. The medication most often used to relieve anginal pain is ______________________.

a. nitroglycerin

b. Dilantin®

c. epinephrine

d. insulin

21. A patient is administered an oral antibiotic one hour before their appointment. They now complain of difficulty breathing, with rash and itching of their skin. Their blood pressure is 80/40 and the pulse is 120. The most likely problem is ________________ and the treatment would be ________________.

a. hyperventilation syndrome; rebreathing carbon dioxide

b. allergic/anaphylactic reaction; epinephrine SQ

c. diabetic ketoacidosis; insulin

d. pulmonary edema; oxygen


22. Nitroglycerin is administered _________________________.

a. intravenously

b. intramuscularly

c. sublingually

d. by inhalation

23. A heart rate greater than 100 is called _____________________.

a. tachycardia

b. arrhythmia

c. hypertension

d. bradycardia

24. Signs and symptoms of a heart attack include _______________________.

1. central chest pain

2. pain radiation to arms

3. nausea and vomiting

4. pale, clammy skin

a. 1 only

b. 1 and 2

c. all of the above

d. none of the above


25. A patient who complains of chest pain should be positioned ____________.

a. supine

b. seated with legs elevated

c. on their side

d. in a comfortable sitting position

26. During a post-emergency assessment, problems can be identified to improve the emergency plan. The goal of the evaluation is to avoid future crisis and provide appropriate patient care.

a. Both statements are true.

b. The first statement is true and the second statement is false.

c. The first statement is false and the second statement is true.

d. Both statements are false.

27. A patient health history should be taken ______________________________.

a. at the patient’s first visit and an update at each visit

b. in ink at the end of each treatment

c. only if surgery is required

d. at the patient’s first visit and again if the patient mentions a medical problem


28. Record the patient’s respirations ___________________________.

a. after explaining the procedure

b. when the patient is unaware of what the care provider is doing

c. with the stethoscope

d. during administration of anesthetic

29. Lawsuits can be avoided by ____________________________.

a. knowing your patient’s health history, contraindications and vital signs

b. being aware of the state’s Dental Practice Act

c. referring patients to medical professionals when necessary

d. all of the above

30. The first step in identifying the patient likely to develop a medical emergency is __________________.

a. obtaining a health history with a set of vital signs

b. one does not need to be concerned regarding medical emergencies since they rarely occur in a dental office

c. by identifying and thoroughly charting all existing oral conditions

d. by determining the patient’s age

cpr c a b changed in 20101
CPR: (C-A-B) changed in 2010

Here is a step-by-step guide for the new CPR:

  • Call 911 or ask someone else to do so.
  • Try to get the person to respond; if he doesn’t, roll the person on his or her back.
  • Start chest compressions.  Place the heel of your hand on the center of the victim’s chest.  Put your other hand on top of the first with your fingers interlaced.
  • Press down so you compress the chest at least 2 inches in adults and children and 1.5 inches in infants. “One hundred times a minute or even a little faster is optimal,” Sayre says.  (That’s about the same rhythm as the beat of the Bee Gee’s song “Stayin’ Alive.”)
  • If you’ve been trained in CPR, you can now open the airway with a head tilt and chin lift.
  • Pinch closed the nose of the victim.  Take a normal breath, cover the victim’s mouth with yours to create an airtight seal, and then give two, one-second breaths as you watch for the chest to rise.
  • Continue compressions and breaths – 30 compressions, two breaths – until help arrives.
emergency stabilization
Emergency Stabilization
  • Patient Position
    • Upright
    • Semi-recline
    • Supine
    • Trendelenburg
airway and breathing
Airway and Breathing
  • Patent Airway
  • Clear of obstruction
  • Spontaneous breathing
  • Supplemental Oxygen
  • Monitor – Pulse and Blood Pressure
  • CPR if necessary
continued stabilization
Continued Stabilization
  • Activate EMS – 911
  • Observe – recovery or deterioration
  • Assess: patient’s history/drugs/allergies
  • Determine cause of emergency
  • Continue care until EMS arrives
  • Medical evaluation – follow-up