CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Saleh AlbazieSaleh Albazie

CAGS OMFS, DSc OMFS, Dipl ABOMS.CAGS OMFS, DSc OMFS, Dipl ABOMS.

Oral and Maxillofacial Surgeon.Oral and Maxillofacial Surgeon.

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Patient is a 63 year old male who presents to your clinic for full mouth Patient is a 63 year old male who presents to your clinic for full mouth extractions and alveloplasty prior to planned placement of immediate extractions and alveloplasty prior to planned placement of immediate dentures. Past medical history is negative except that the patient used to dentures. Past medical history is negative except that the patient used to take a "pressure medicine" which he did not refill 2 months ago. take a "pressure medicine" which he did not refill 2 months ago. Pre‑operative blood pressure readings were 215/110. A second reading was Pre‑operative blood pressure readings were 215/110. A second reading was 208/103 208/103

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Classification of Hypertension in AdultsClassification of Hypertension in Adults

DiastolicDiastolic < 85 mm Hg< 85 mm Hg Normal BP Normal BP 85 ‑ 8985 ‑ 89 High normal BP High normal BP 90 ‑ 10490 ‑ 104 Mild hypertension Mild hypertension 105 ‑ 114105 ‑ 114 Moderate hypertension Moderate hypertension >115>115 Severe hypertension Severe hypertension

SystolicSystolic < 140 mm Hg< 140 mm Hg Normal BP Normal BP 140 ‑ 164140 ‑ 164 Borderline hypertension Borderline hypertension > 165> 165 Isolated systolic hypertension Isolated systolic hypertension

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Essential hypertensionEssential hypertension Secondary hypertensionSecondary hypertension

Malignant hypertensionMalignant hypertension

Treatment and the Importance of Diastolic pressuresTreatment and the Importance of Diastolic pressures Most diagnostic and treatment decisions are based on diastolic pressures Most diagnostic and treatment decisions are based on diastolic pressures

for two reasons Diastolic HTN = enhanced peripheral vascular resistance, for two reasons Diastolic HTN = enhanced peripheral vascular resistance, and Systolic HTN = increased cardiac output and/ or large vessel stiffness and Systolic HTN = increased cardiac output and/ or large vessel stiffness Treatment of diastolic HTN results in clinical benefit, treatment of systolic Treatment of diastolic HTN results in clinical benefit, treatment of systolic HTN is not clearly associated with reduction of cardiovascular HTN is not clearly associated with reduction of cardiovascular complicationscomplications

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Medical Treatment of HypertensionMedical Treatment of Hypertension DetectionDetection NonpharmacologicNonpharmacologic

‑ ‑ weight lossweight loss ‑ ‑ restriction of dietary sodiumrestriction of dietary sodium ‑ ‑ moderation of alcohol intakemoderation of alcohol intake ‑ ‑ reduction of dietary fats, cholesterolreduction of dietary fats, cholesterol ‑ ‑ smoking cessationsmoking cessation ‑ ‑ regular aerobic exerciseregular aerobic exercise ‑ ‑ stress reduction, relaxation therapystress reduction, relaxation therapy ‑ ‑ increased dietary calcium intakeincreased dietary calcium intake

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Medical Treatment of HypertensionMedical Treatment of Hypertension Pharmacologic (for DBP > 95 mm Hg) Pharmacologic (for DBP > 95 mm Hg) ‑ ‑ Step 1 = diuretic, beta blocker, ACE inhibitor, or calcium channel Step 1 = diuretic, beta blocker, ACE inhibitor, or calcium channel blockerblocker ‑ ‑ Step 2 = (1 to 3 mos.) increase the dose, add a different class of Step 2 = (1 to 3 mos.) increase the dose, add a different class of drug, or substitute another drug drug, or substitute another drug ‑ ‑ Step 3 = add a third drug, discontinue the second drug and Step 3 = add a third drug, discontinue the second drug and substitute another substitute another ‑ ‑ Step 4 = add a third or fourth drug Step 4 = add a third or fourth drug

Lack of compliance is the single greatest problem, therefore MONITOR Lack of compliance is the single greatest problem, therefore MONITOR PERIODICALLYPERIODICALLY

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

DENTAL MANAGEMENTDENTAL MANAGEMENT Identify patientIdentify patient ‑ ‑ Take relaxed BP (two if necessary)Take relaxed BP (two if necessary) ‑ ‑ Medical and medication historyMedical and medication history Stress and anxiety reductionStress and anxiety reduction ‑ ‑ doctor patient relationshipdoctor patient relationship ‑ ‑ pharmacologic (Valium, Nitrous oxide)pharmacologic (Valium, Nitrous oxide) ‑ ‑ short, morning appointmentsshort, morning appointments Avoid sudden changes in chair position, sit patient up slowly at the end of Avoid sudden changes in chair position, sit patient up slowly at the end of

the procedure (orthostatic hypotension)the procedure (orthostatic hypotension)

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

DENTAL MANAGEMENTDENTAL MANAGEMENT

Decrease exposure to epinephrineDecrease exposure to epinephrine

‑ ‑ Exogenous (limit to 0.04 mg = 2 carpules 1:100,000)Exogenous (limit to 0.04 mg = 2 carpules 1:100,000)

‑ ‑ EndogenousEndogenous

POTENTIALLY A MUCH BIGGER PROBLEMPOTENTIALLY A MUCH BIGGER PROBLEM

if individual is stressed, adrenal medulla can produce 0.28 mg of if individual is stressed, adrenal medulla can produce 0.28 mg of epinephrine/minuteepinephrine/minute

Avoid topical vasoconstrictorsAvoid topical vasoconstrictors

Adverse drug reactionsAdverse drug reactions

-epinephrine and beta blockers, peripheral adrenergic agonsists -epinephrine and beta blockers, peripheral adrenergic agonsists

(Reserpine), MAO inhibitors(Reserpine), MAO inhibitors

‑ ‑rarely a problem if small doses of epinephrine usedrarely a problem if small doses of epinephrine used

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

DENTAL MANAGEMENTDENTAL MANAGEMENT Avoid excessive stimulation of the gag reflex Avoid excessive stimulation of the gag reflex Surgical hemostasis, observe for post‑op bleedingSurgical hemostasis, observe for post‑op bleeding Antihypertensives ‑ dry mouthAntihypertensives ‑ dry mouth

NO ELECTIVE DENTAL PROCEDURES SHOULD BE PERFORMED NO ELECTIVE DENTAL PROCEDURES SHOULD BE PERFORMED ON A PATIENT WITH SEVERE UNCONTROLLED ON A PATIENT WITH SEVERE UNCONTROLLED HYPERTENSION!!HYPERTENSION!!

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Cardiovascular problemsCardiovascular problems

Coronary artery disease/ Ischemic heart disease ( Angina, MI, CHF)Coronary artery disease/ Ischemic heart disease ( Angina, MI, CHF)

Dysrhythmias and conduction disturbances ( SVT, VT,VF …..)Dysrhythmias and conduction disturbances ( SVT, VT,VF …..)

Valvular heart disease (Rheumatic heart disease, Infective endocarditis, Valvular heart disease (Rheumatic heart disease, Infective endocarditis, Mitral/aortic stenosis or regurgitation and prosthetic valve)Mitral/aortic stenosis or regurgitation and prosthetic valve)

Congenital heart disease( Teratolgy of fallot) Congenital heart disease( Teratolgy of fallot)

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Patient is a 59 year old male with a history of angina who was cleared for Patient is a 59 year old male with a history of angina who was cleared for surgery by anesthesia. In the recovery room s/p iliac crest graft to the surgery by anesthesia. In the recovery room s/p iliac crest graft to the mandible the patient complains of chest pain, dyspnea, nausea and is mandible the patient complains of chest pain, dyspnea, nausea and is diaphoretic with palpitations.diaphoretic with palpitations.

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

What clinical examination would you do?What clinical examination would you do?

Look at neck veins ‑ elevated jugular venous pulseLook at neck veins ‑ elevated jugular venous pulse

VS = BP =105/75, P=105, R = 26, Pulse Ox = 95VS = BP =105/75, P=105, R = 26, Pulse Ox = 95

Auscultate chest ‑ coarse rales and wheezes = pulmonary edema, NoAuscultate chest ‑ coarse rales and wheezes = pulmonary edema, No

Auscultate heart ‑ S3, or S4, or arrhythmia, NoAuscultate heart ‑ S3, or S4, or arrhythmia, No

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Terminate therapy and position patient Terminate therapy and position patient upright 45 deg. Trendellenburg if SBP < 100 mm Hg)upright 45 deg. Trendellenburg if SBP < 100 mm Hg) Calm patientCalm patient Sublingual Nitroglycerin 0.4 mgSublingual Nitroglycerin 0.4 mg should relieve pain in 3‑5 minsshould relieve pain in 3‑5 mins can repeat twice at 5 min. intervalscan repeat twice at 5 min. intervals failure to relieve pain‑ suspect MIfailure to relieve pain‑ suspect MI 100% O2100% O2 Assess vital signs every 3‑5 minsAssess vital signs every 3‑5 mins Transport to hospital prnTransport to hospital prn CPR prnCPR prn

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Lets say its not angina. What is a differential diagnosis?Lets say its not angina. What is a differential diagnosis? MIMI CHFCHF PEPE PneumothoraxPneumothorax CholecystitisCholecystitis PancreatitisPancreatitis PericarditisPericarditis Perforated peptic ulcerPerforated peptic ulcer Ruptured esophagusRuptured esophagus Aortic dissectionAortic dissection

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

How do you rule out MI?How do you rule out MI? 1. Clinical history and examination1. Clinical history and examination 2. Serial Enzymes2. Serial Enzymes ONSETONSET PEAK BASELINE PEAK BASELINE

CPK/MBCPK/MB q 8h (3 Iso.) q 8h (3 Iso.) 4‑6h 4‑6h 12‑20h 12‑20h 36‑48h36‑48h MM-MM- MuscleMuscle

MB ‑ MyocardiumMB ‑ MyocardiumBB ‑ BrainBB ‑ BrainBest enzymatic test, >3‑5% CK/MB evidence of a MIBest enzymatic test, >3‑5% CK/MB evidence of a MILow CK will not run MBLow CK will not run MB

LDH IsoenzymesLDH Isoenzymes q 12h (5 Iso.) 12h q 12h (5 Iso.) 12h 24‑48h 10‑14 days 24‑48h 10‑14 daysLDH 1/LDH 2>1 MILDH 1/LDH 2>1 MIGood for patients presenting > 24h after symptomsGood for patients presenting > 24h after symptoms

AST AST q12hq12h 3. Serial ECG's3. Serial ECG's 4. CXR4. CXR 5. ECHO5. ECHO cardiogram,cardiogram, 6. Thailium scan 6. Thailium scan 7. Tech‑99‑ scan 7. Tech‑99‑ scan

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

How would you treat this patient?How would you treat this patient? Treatment of MITreatment of MI 1. Oxygen (ABG's).1. Oxygen (ABG's). 2. Nitroglycerin, Morphine,2. Nitroglycerin, Morphine, 3. ECG (12 Lead)3. ECG (12 Lead) 4. CXR4. CXR 5. Beta‑blocker ‑ be careful5. Beta‑blocker ‑ be careful 6. Sedation6. Sedation 7. Lidocaine, Procainamide7. Lidocaine, Procainamide 8. CCU with invasive monitoring (enzymes)8. CCU with invasive monitoring (enzymes)

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Patient is a 72 year old female on Digitalis and Lasix referred to you for Patient is a 72 year old female on Digitalis and Lasix referred to you for bone grafting to the anterior maxilla.bone grafting to the anterior maxilla.

DigitalisDigitalis

Used to treat CHF, A‑flutter, A‑fib, and other SVT'sUsed to treat CHF, A‑flutter, A‑fib, and other SVT's

+ Ionotrope (increases force of contraction)+ Ionotrope (increases force of contraction)

‑ ‑ Chronotrope (slows heart)Chronotrope (slows heart)

Narrow therapeutic rangeNarrow therapeutic range

*Hypokalemia and hypoxia and renal insufficiency can exacerbate toxicity*Hypokalemia and hypoxia and renal insufficiency can exacerbate toxicity

*DO NOT cardiovert someone with Digitalis Toxicity *DO NOT cardiovert someone with Digitalis Toxicity (can precipitate a (can precipitate a fatal arrhythmia)fatal arrhythmia)

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

What are the signs and symptoms of Digitalis Toxicity?What are the signs and symptoms of Digitalis Toxicity? Dysrhythmias (all types)Dysrhythmias (all types) GI (Anorexia, nausea, vomiting, diarrhea)GI (Anorexia, nausea, vomiting, diarrhea) Mental status changes (agitation, lethargy, visual disturbances)Mental status changes (agitation, lethargy, visual disturbances)

How do you treat someone with Digitalis Toxicity?How do you treat someone with Digitalis Toxicity? Treatment of Digitalis toxicityTreatment of Digitalis toxicity

1. Stop Digitalis administration1. Stop Digitalis administration2. Monitor (type of dysrhythmia)2. Monitor (type of dysrhythmia)3. Correct precipitating factors (i.e. serum potassium to > 3.5)3. Correct precipitating factors (i.e. serum potassium to > 3.5)4. Atropine for bradycardia (avoid catechols)4. Atropine for bradycardia (avoid catechols)5. Lidocaine for dysrhythmias5. Lidocaine for dysrhythmias6. Digitalis specific antibodies = 6. Digitalis specific antibodies = Digibind Digibind (life threatening)(life threatening)

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

A 19 year old black female third molar patient presents to your office three weeks A 19 year old black female third molar patient presents to your office three weeks following surgery. She was feeling well until seven days ago. Since then she has a following surgery. She was feeling well until seven days ago. Since then she has a history of anorexia, malaise, myalgia, weight loss and low grade fever.history of anorexia, malaise, myalgia, weight loss and low grade fever.

Physical exam:Physical exam: PalePale Lungs clearLungs clear Abdomen soft, bowel sounds decreasedAbdomen soft, bowel sounds decreased Heart: NSR with grade II/VI late systolic murmur at left sternal borderHeart: NSR with grade II/VI late systolic murmur at left sternal border

Labs:Labs: CXR normalCXR normal U/A 1.018, 3+ protein, 4+ RBC's, Glucose = 0, WBC's = 0, Casts = 0U/A 1.018, 3+ protein, 4+ RBC's, Glucose = 0, WBC's = 0, Casts = 0 H/H = 10.2/31, MCV= 85 (84‑96), MCHC= 30 (30‑35)H/H = 10.2/31, MCV= 85 (84‑96), MCHC= 30 (30‑35) WBC = 11,000, P 65, L 20, M10, B3, E2WBC = 11,000, P 65, L 20, M10, B3, E2 Sed. rate = 85Sed. rate = 85 Chem. = WNL except BUN = 24Chem. = WNL except BUN = 24

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

Why is the sed. rate elevated?Why is the sed. rate elevated?Chronic inflammationChronic inflammationRheumatoid diseasesRheumatoid diseases

What are you going to do?What are you going to do? Physical Exam Physical Exam Blood culture ECHO Blood culture ECHO (look for vegetation, document murmur)(look for vegetation, document murmur) Blood culture = Alpha hemolytic Streptococcus (what if this was Staph. Blood culture = Alpha hemolytic Streptococcus (what if this was Staph.

Aureus) Aureus) IF CANDIDATE PUTS PATIENT ON ANTIBIOTICS IF CANDIDATE PUTS PATIENT ON ANTIBIOTICS BEFORE BLOOD CULTURE THEN CULTURES NEGATIVE BEFORE BLOOD CULTURE THEN CULTURES NEGATIVE

ECHO = Mitral vegetationECHO = Mitral vegetation

CARE OF THE MEDICALLY COMPROMISED PATIENTCARE OF THE MEDICALLY COMPROMISED PATIENT

What is your diagnosis?What is your diagnosis?

SBESBE

What are causes of SBE?What are causes of SBE?

Causes of SBECauses of SBE

Any flow disturbanceAny flow disturbance

Rheumatic heart diseaseRheumatic heart disease

Congenital heart diseaseCongenital heart disease

Mitral valve prolapseMitral valve prolapse

Degenerative heart diseaseDegenerative heart disease

IVDAIVDA