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Medical Emergencies in Dental Practice
James G. Green, M.D., D.D.S., F.A.C.D.
Dept. of Oral and Maxillofacial Surgery
University of Florida
College of Dentistry
Medical Emergencies
When you prepare for emergencies, they cease to exist!
Malamed
Medical Emergencies
You have to have seen it to recognize it.
Green’s Rule
Medical Emergencies
In case of an office emergency, the first procedure is to take your own pulse.
House of God Rule #3(modified)
Medical Emergencies in the Dental Office
Hyperventilation 29%
Seizures 20%
Hypoglycemia 14%
Vasodepressor syncope 11%
Postural hypotension 7%
Asthma 7%
Angina 5%
Allergy 5%
Medical Emergencies
Office preparation– Emergency procedure manual
• Define each individual’s responsibilities• Standardize equipment and train employees
on location, set-up, function and use• Establish a regular maintenance schedule
and equipment checks
Medical Emergencies
Office preparation– Practice emergency procedures
• Identify problems• Demonstrates capabilities• Set-up and use of equipment• Improve performance• Determine additional needs
Medical Emergencies
Office preparation– Post emergency numbers on or around
each telephone
Medical Emergencies
Office preparation – Determine equipment needs
• Dependent upon:– Training– Skills– Patient base– Practice type– Types of emergencies frequently seen
Medical Emergencies
Emergency protocols– Develop treatment protocols for each
common dental office emergency– Post where easily retrieved– Write in simple and easily followed step-
by-step instructions
Airway Management
It is essential that every practitioner be able to:
1. Maintain an airway
2. Manage an upper airway obstruction
Main purpose is to estimate the risk or probability of a patient having an emergency during treatment
Physical Evaluation
Airway Evaluation
Body habitus– Size of Neck
• Short, muscular neck– Height and weight
Status of dentition– Full dentition vs. edentulous– Protruding central incisors
Retrognathia
Airway Evaluation
High arched palate with long narrow mouth
Trismus or TMJ disease
Cervical mobility
Distance from chin to thyroid cartilage
Mallampati Airway Classification
Airway Angles
Airway Angles
Airway Angles
Airway Obstruction
Most common cause – Tongue
• Treat by jaw thrust or chin lift - head tilt maneuver
Tongue Obstruction
Head Tilt - Open Airway
Airway Obstruction
Other causes– Foreign bodies
• Treat by retrieving foreign body– Finger sweep– Heimlich maneuver– Chest thrust
Darwin Award Nominee - 1998
Phillipsburg, NJ
An unidentified 29 year old man choked to death on a sequined pastie he orally removed from an exotic dancer. The dancer referred to only as “Ginger” said, “She didn’t know he was going to eat it.”
Airway Obstruction
Other causes– Laryngospasm
• Suction hypopharynx• Positive pressure ventilation• Succinylcholine (if experienced)• Cricothyroidotomy (if experienced)
Airway Obstruction
If unable to clear obstruction by standard measures within 4-5 minutes:– Emergent cricothyroidotomy
Neck - Topographical Anatomy
Anterior Neck Anatomy
Anterior Neck Anatomy
Cricothyroid Membrane
Airway Adjuncts
Oropharyngeal airways
Nasopharyngeal airways
Mask-to-mouth airway
Bag valve mask with reservoir
Airway Adjuncts
Nasopharyngeal airways
Airway Management
Nasopharyngeal airways– Length - nose to tragus of ear– Size - little finger (guide)– Insertion
• Lubrication• Insertion• Position
Surgilube
Nasopharyngeal Airway
Airway Adjuncts
Oropharyngeal airways
Airway Management
Oropharyngeal airways– Unconscious patients only!!– Correct size
• Age
– Insertion– Position
Oropharyngeal Airway
Mouth-to-Mask Airway
Mouth-to-Mask Airway
Mouth-to-Mask Airway
Bag Valve Mask
Bag Valve Mask Reservoir
Bag Valve Mask
Bag Valve Mask
Airway Management
Ambu bag– Experience – Practice– Volume– How many dentists does it take to use
an Ambu bag?
Airway Adjuncts
Oxygen– All patients with medical
emergencies need oxygen• No distress – 2 L/m via nasal cannula• Mild distress – 5-6 L/m via face mask• Moderate to severe distress – 10 L/m via
face mask with reservoir• Unconscious – 100% via intubation
Oxygen
Oxygen Masks
Nasal cannula– 1-6 L/m 24-44% oxygen
Face mask– 8-10 L/m 40-60% oxygen
Face mask with reservoir– 10 L/m ~100% oxygen
Venturi mask– 24, 28, 35, 40% oxygen
Airway Management
Nasal cannula– Readily accepted
Mask with reservoir
–Poorer acceptance
Mask-to-mouth device–Separate provider from patient–Oxygen inlet valve–Clear mask–Seal
Airway Adjunct
Paper bag
Airway Adjuncts
Yankauer Suction
Resuscitation
ABCs– Airway– Breathing
• Assess for airway obstruction• Assess for respiratory arrest
– Circulation• Assess for cardiac arrest
Resuscitation
CPR– BLS designed to maintain circulation of
oxygenated blood to the heart and brain until definitive medical treatment can restore normal or sufficient heart and
ventilatory function– Rapid EMS response with early ACLS required
for best chances of survival
Resuscitation
Most cardiac arrest victims have ventricular fibrillation– Supports early use of automated external
defibrillators (AEDs) or manual defibrillators
Resuscitation
Ventricular fibrillation– Only treatment is defibrillation– 90% of patients with V-fib survive
neurologically intact if treated with defibrillation within 1-2 minutes
– Success of resuscitation decreases linearly with each minute (50% - 4-5 minutes, <10% - 9 minutes)
– Converts to asystole in minutes
Resuscitation
Survival of other cardiac arrest rhythms poor (~ 85 % die)
Case Scenario
An 14 year old female presents for routine restorative dentistry. She has never had a cavity diagnosed until today. She is in your office and will need two simple Class I restorations.
Case Scenario
Past Medical History– Medications: None
– Allergies: None
– PSH: None
– ROS: Noncontributory
Case Scenario
Prior to the injections you note she is sighing frequently.
During the injections, she yells that it hurts and starts crying. She becomes panicky and inconsolable.
Two minutes later she starts complaining of midsternal chest pain.
Case Scenario
What is your diagnosis?
Case Scenario
Five minutes after the injections, she becomes unconscious.
Hyperventilation
Causes of Hyperventilation
Anxiety– Most common
Metabolic conditions– Pain– Metabolic acidosis– Drug intoxication– Hypercapnia– CNS disorders
Predisposing Factors
Anxiety– Most common
Age– 15 - 40 years of age– No sex difference
May develop with other medical conditions
Case Scenario
What is the pathophysiology of this “minor” emergency?
Pathophysiology
Increased respiratory rate causes:– Acute decrease in PaCO2 and rise in blood pH
• Cerebral vessels constrict Unconscious• Decreased PaCO2 depresses Apnea respiratory
drive
– When PaCO2 rises and pH decreases, the patient will begin breathing again
• May repeat cycle
Case Scenario
What other physical signs and symptoms assist in making the diagnosis?
Hyperventilation
Signs– Tachypnea– Tachycardia– Unconsciousness
Symptoms– Dizziness– Lightheadedness– Chest pain– Palpitations– Numbness
• Lips, extremities
– SOB– Nausea / Pain
Case Scenario
How do you treat it?
Management
Terminate procedure
Position patient
Calm patient
Rebreathing bag
Sedation
Case Scenario
A 25 year old male construction worker presents for removal of his third molars. He has 4 erupted thirds which you feel you can remove without difficulty or sedation. He has come from a job site. The outside temperature today was 103 F. He passed up his usual beers after work with his buddies.
Case Scenario
PMH:– Meds: None– Allergies: None– Illnesses: None– PSH: ORIF of left femur fracture from a
motorcycle accident– ROS: Noncontributory
Case Scenario
During administration of local anesthesia, he becomes jittery, pale and diaphoretic. He appears anxious and disoriented.
Case Scenario
What is your differential diagnosis?– Be specific!
What would you do first?
What is your treatment?
Case Scenario
Vital signs– BP - 80/40– P – 80 regular– R – 14
Case Scenario
After your treatment, he recovers sufficiently to allow you to do the extractions. The case goes well and after the procedure, the assistant sits him up and he again becomes faint and dizzy. A half hour later, you need to go home. You put him in a wheelchair and your assistant takes him to his car.
Case Scenario
His girlfriend who met him at your office will drive him home. When he stands up to get into the car, he passes out.
Case Scenario
What is your differential diagnosis?– Be specific!
How does treatment for this differ from your previous treatment?
How can you differentiate clinically between these two types?
Syncope
Syncope
Syncope and death are the same – except that in one you wake up.
Anonymous
Syncope
The sudden transient loss of consciousness– Usually < 1 minute
Syncope
Incidence– Presyncope - Universal– Syncope - 50%
Syncope accounts for ~ 3% of all ER visits and may account for up to 6% of hospital admissions
Syncope
Definitive diagnosis of syncope is made in only about 50% of case.
ER physicians can make a definitive diagnosis in only ~ 25% of cases
25% of all patients referred to cardiologist for cardiac work-up have syncope and not cardiac disease
Pathophysiology of Syncope
Lack of oxygen and blood to the brain– Nonspecific with multiple causes
Lack of glucose to the brain
Seizure activity
Causes of Syncope
Cardiac
Peripheral vascular
Cerebrovascular
Hyperventilation
Hypoglycemia
Seizures
Seizures and Syncope
Difficulty is determining whether the seizure caused the faint or the faint caused the seizure– Generalized clonic jerks result from cerebral
anoxia– Can’t rely on tongue-biting and urination
Seizures and Syncope
– Evaluate by history• Abrupt loss of consciousness with simultaneous
tonic-clonic seizure activity with a slow recovery phase
– Suggests seizure
• Syncope – rapid recovery
Cardiac Events and Seizures
Most remediable cause of seizures
Most lethal cause of seizures
3 broad catagories:– Rhythm disturbances– Ventricular outflow obstruction– Myocardial ischemia
Arrhythmias and Syncope
Often difficult to prove
Usually requires a heart rate of >150 or <40 beats per minute
Ventricular Outflow and Syncope
Aortic stenosis– Prevalvular– Postvalvular
Mitral stenosis
Tumors (rare)
Vasovagal Syncope
Most commonly observed potentially life-threatening emergency seen in the dental office
Vasovagal Syncope
Synonyms– Simple faint– Swoon– Vasodepressor syncope– Psychogenic syncope– Neurogenic syncope
Precipitating Factors
Psychogenic– Fright– Anxiety– Emotional stress– Pain– Site of Blood
Precipitating Factors
Nonpsychogenic – Prolonged sitting or standing– Hunger – Exhaustion– Poor physical condition– Hot humid crowded environment
Early Signs
Feeling of warmthLoss of color (pale)SweatingNauseaFaintTachycardiaNormal BP
Late Signs
YawningColdDizzinessRapid breathing Pupillary dilationHypotensionBradycardiaLoss of consciousness
Stages
Presyncope
Syncope
Postsyncope
Presyncopal Management
Terminate treatment
Protect patient from falling
Trendelenberg position
Oxygen if necessary
Syncopal Management
Trendelenberg position
Protect the airway
Monitor vital signs
Oxygen
Postsyncopal Management
Discontinue treatment
Determine cause of event– Treat appropriately
Arrange for patient to be taken home by relative or friend when stable or to hospital
Recurrent Syncope
Look for other causes– Orthostatic – Seizures– Cardiac– TIA– Hypoglycemia– Hyperventilation
May need hospitalization
Case Scenario
A 55 year old female presents for
dental implants with IV sedation.
Case Scenario
PMH:– Medications: None– Allergies: None– Illnesses: None– PSH: None
Case Scenario
An IV is started and she is given Versed and Fentanyl initially. She receives 1 g of Kefsol IV as antibiotic prophylaxis and 2 minutes later complains of itchy skin, develops a diffuse patchy rash, watery eyes and a runny nose. She feels nauseated and complains of stomach cramps.
Case Scenario
What is your diagnosis?
Allergy
Allergy
Hypersensitivity state– Requires exposure to antigen– Body develops antibodies to antigen– Re-exposure to antigen elicits reaction
Allergy
Variable reactions– Dermatological (most common)– Respiratory
• Nasal / Pulmonary
– CNS– CV– Generalized anaphylaxis (rare)
Type I Reaction
IgE-mediated
Immediate response
Affects 10% population
Inherited tendency
Type I - Antigens
Drugs most commonly associated with allergic reactions– PCN – Sulfa derivatives– Narcotics– ASA– NSAIDS
Case Scenario
What are some of the common dermatological manifestations of allergic reactions?
Dermatological Reactions
– Urticaria – Wheal and flare– Pruritis– Angioedema– Conjunctivitis– Rhinitis
• Rarely life-threatening if sole reaction• May be first indication of a more
generalized reaction to follow
Case Scenario
What are the available treatments for
dermatological signs of allergic
reactions?
Treatment
Dermatological reactions– Delayed (> 1 hour)
• Benadryl 50 mg PO q 6 h for 3-4 days
– Immediate (< 1 hour)• Epinephrine 0.3 mg IM or SC• Benadryl 50 mg IM• Transfer to ER• Benadryl 50 mg PO q 6 h for 3-4 days
Case Scenario
You give the patient Benadryl 50 mg
IV and 20 minutes later she starts to
wheeze and complain of shortness of
breath. Her blood pressure is slowly
decreasing. What should you do
now?
Bronchospasm Treatment
– Terminate therapy– Position patient to comfort– Oxygen 5-6 liters/minute via cannula or
mask– Epinephrine 0.3 mg IM or SC or
Medihaler-epi q 5 minutes as required– Benadryl 50 mg po q 6 h for 3-4 days– Start an IV (if capable) and give NS– Call 911
Respiratory Reactions
Bronchospasm• Dyspnea, wheezing, flushing, cyanosis,
diaphoresis, tachycardia, anxiety, accessory muscle use
Laryngeal edema• Stridor or crowing
– May be indication of a developing generalized reaction
Laryngeal Edema Tx
– Epinephrine 0.3 mg IM or SC q 5 minutes prn
– Maintain airway– Oxygen 5-6 liters/minute by face mask– Start IV (if capable) with NS– Benadryl 50 mg IM or IV– Solucortef 100 mg IM or IV– Cricothyroidotomy (if necessary)
Case Scenario
You can’t find your emergency drug kit. The patient is now confused and uncooperative. His BP is 70/0 and his HR is 140. What should you do?
Generalized Anaphylaxis
BLS
Epinephrine 0.3 mg IM or IV q 5
minutes prn
Oxygen
Monitor VS q 5 minutes
Generalized Anaphylaxis
Usually rapid onset (5 to 30
minutes, occasionally delayed for
hours)Respiratory and cardiovascular problems predominate and occur early in the reactionDeath can occur in minutes
Local Anesthetics
Esters >>> Amides– Overall incidence very, very low– No esters available in dental cartridges
Antigenic components– Parabens - PABA, Methylparabens– Metabisulfite– Bisulfites
Local Anesthetics
Allergy History– Must try to differentiate between true
allergy, overdose, intravascular injection, vasoconstrictor reaction or idiosyncratic reaction
• Requires good dialogue history with patient
– If questionable history, refer to allergist
Penicillin
2.5 million people allergic
Allergic reaction reported in 5-10% of patients receiving penicillin
Fatal reaction in 1 per 100,000
Most frequent cause of generalized anaphylaxis in dental practice
Chest Pain
Chest Pain
Origin – Cardiac– Pulmonary– Musculoskeletal
• Neck, thorax, shoulder
– Upper abdominal viscera
Chest Pain
Classification– Recurrent
• Mild to moderate intensity
– Severe• Prolonged pain
Recurrent Chest Pain
Angina pectoris– Most important but not the most frequent cause
of recurrent chest pain– Secondary to transcient myocardial ischemia
(imbalance between oxygen supply and tissue oxygen demands)
Musculoskeletal– Responsible for the majority of recurrent chest
pain
Recurrent Chest Pain
Other causes– Anxiety states– Reflux esophagitis +/- hiatal hernia
• Associated with large meals, alcohol, highly seasoned food, chocolates, coffee
• Nocturnal and associated with recumbancy• Relieved by nitroglycerin
– Diffuse esophageal spasms• Associated with meals• Relieved by nitroglycerin
Musculoskeletal Pain
Characteristics– Neck, shoulder and thorax most common locations– Tends to occur at night– Precipitated or intensified by fatigue, posture, movement,
coughing, sneezing– Long duration of pain (often hours)– Pain dull, aching with sharp twinges– Relief characterized by rest, heat, postural exercises and
analgesics
Angina Pectoris
Causes:– Coronary artery atherosclerosis– Coronary artery spasm– Coronary artery thrombosis– Multiple other cardiac and pulmonary etiologies:
• Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection
Angina Pectoris
May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X)
Uncommon in males less than 40
Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia
Angina Pectoris
Clinical characteristics– Poorly localized pain
• Usually retrosternal but may occur anywhere from lower jaw to umbilicus
– Brief duration• 2-10 minutes
– Moderate intensity pain described as squeezing, oppressive, burning or heavy
Angina Pectoris
Clinical characteristics– Precipitated by:
• Emotional distress • Physical exertion• Heavy meals• Cold• Walking up stairs or hills
– Exacerbated by:• Recumbency
Angina Pectoris
Clinical characteristics– Excluded if:
• Pain localized with one finger• Lasts less than 30 seconds or longer than 30 minutes• Pain described as sticking, jabbing, throbbing or
constantly severe
Angina Pectoris
Types of angina pectoris– Stable
• Pain pattern repeatable for frequency, intensity, duration, provocation and response to nitroglycerin and rest
– Unstable• Pain pattern changed in one or more characteristics
(frequency, intensity, duration, provocation, response to nitroglycerin or cessation of activity)
• May occur at night or rest
Angina Pectoris
Unstable angina pectoris– Indicative of progressive coronary artery disease– Indistinguishable from MI– Requires admission to “rule out” MI
• Enzymes - CPK-MB, LDH, Troponin I and T• Serial EKGs• Clinical history
Angina Pectoris
Dialogue history– Determine:
• Angina description– Classical, atypical or equivalent angina
• Frequency• Duration of pain• Precipitating factors
– Activity level– Stressors
• Treatment– Medications
Angina Pectoris
Dialogue history– Risk factors
• Smoking• Hyperlipidemia• Obesity• Sedentary life style• Alcohol consumption• Hypertension• Diabetes mellitus
Angina Pectoris
Dialogue history– Risk factors
• Sex– Male– Postmenopausal female
• Age• Genetics
– Family history• Race
– Blacks > Caucasians
Angina Pectoris
Treatment– Stop procedure– Position patient to comfort– Oxygen 2-3 L per NC or face mask – Nitroglycerin 0.4 mg SL
• Repeat q 5 minutes x 3 total doses• If no response, assume MI or unstable angina• Activate EMS and transfer to ER
Angina Pectoris
Diagnostic approach– Nitroglycerin
• Normally relieves pain in 3 minutes or less• Failure to relieve pain after 10 minutes evidence
against angina• Failure to relieve pain indicates either unstable
angina or myocardial infarction
Angina Pectoris
Function of nitroglycerin– Dilates coronary arteries to increase blood flow
and improve oxygen delivery to cardiac tissue– Platelet disaggregation
Angina Pectoris
Dental treatment– Early AM appointments– Short appointments– Consider oxygen and prophylactic nitroglycerin– Stress reduction protocols
• Good local anesthesia• Nitrous oxide• PO or IV sedation
Myocardial Infarction
Myocardial Infarction
Cardiac ischemia which results in myocardial necrosis
Myocardial Infarction
Pain more intense and longer in duration than angina pectorisPain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectorisNot relieved by SL nitroglycerin or cessation of activity
MI Signs and Symptoms
Symptoms– Pain– Nausea/Indigestion– Weakness/Fatigue– Dizziness– Palpitations– Sense of impending
doom– SOB– Lightheadedness
Signs– Restlessness– Acute distress– Vomiting– Diaphoresis– Cardiac arrhythmia– Pallor– Cyanosis– Dyspnea– Wheezing
Myocardial Infarction
Dialogue history– History of angina pectoris– Changes in angina pectoris– Previous MI
• When, Treatment, Outcome, Current status
– Medications– Risk factors
Management of Acute MI
Recognition
BLS– Airway– Breathing – Circulation– Activate EMS
Oxygen - 4-5 L by NC or face mask
Management of Acute MI
Monitor VS
Position to comfort
Pain relief– Morphine sulfate 2-5 mg IM/IV q 5-15 minutes prn
• Controls pain and reduces anxiety
Prepare to perform CPR or provide ACLS (if properly trained)
Management of Acute MI
Transfer to ER
Chest Pain
Chest Pain
Origin – Cardiac– Pulmonary– Musculoskeletal
• Neck, thorax, shoulder
– Upper abdominal viscera
Chest Pain
Classification– Recurrent
• Mild to moderate intensity
– Severe• Prolonged pain
Recurrent Chest Pain
Angina pectoris– Most important but not the most frequent cause
of recurrent chest pain– Secondary to transcient myocardial ischemia
(imbalance between oxygen supply and tissue oxygen demands)
Musculoskeletal– Responsible for the majority of recurrent chest
pain
Recurrent Chest Pain
Other causes– Anxiety states– Reflux esophagitis +/- hiatal hernia
• Associated with large meals, alcohol, highly seasoned food, chocolates, coffee
• Nocturnal and associated with recumbancy• Relieved by nitroglycerin
– Diffuse esophageal spasms• Associated with meals• Relieved by nitroglycerin
Musculoskeletal Pain
Characteristics– Neck, shoulder and thorax most common locations– Tends to occur at night– Precipitated or intensified by fatigue, posture, movement,
coughing, sneezing– Long duration of pain (often hours)– Pain dull, aching with sharp twinges– Relief characterized by rest, heat, postural exercises and
analgesics
Angina Pectoris
Causes:– Coronary artery atherosclerosis– Coronary artery spasm– Coronary artery thrombosis– Multiple other cardiac and pulmonary etiologies:
• Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection
Angina Pectoris
May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X)
Uncommon in males less than 40
Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia
Angina Pectoris
Clinical characteristics– Poorly localized pain
• Usually retrosternal but may occur anywhere from lower jaw to umbilicus
– Brief duration• 2-10 minutes
– Moderate intensity pain described as squeezing, oppressive, burning or heavy
Angina Pectoris
Clinical characteristics– Precipitated by:
• Emotional distress • Physical exertion• Heavy meals• Cold• Walking up stairs or hills
– Exacerbated by:• Recumbency
Angina Pectoris
Clinical characteristics– Excluded if:
• Pain localized with one finger• Lasts less than 30 seconds or longer than 30 minutes• Pain described as sticking, jabbing, throbbing or
constantly severe
Angina Pectoris
Types of angina pectoris– Stable
• Pain pattern repeatable for frequency, intensity, duration, provocation and response to nitroglycerin and rest
– Unstable• Pain pattern changed in one or more characteristics
(frequency, intensity, duration, provocation, response to nitroglycerin or cessation of activity)
• May occur at night or rest
Angina Pectoris
Unstable angina pectoris– Indicative of progressive coronary artery disease– Indistinguishable from MI– Requires admission to “rule out” MI
• Enzymes - CPK-MB, LDH, Troponin I and T• Serial EKGs• Clinical history
Angina Pectoris
Dialogue history– Determine:
• Angina description– Classical, atypical or equivalent angina
• Frequency• Duration of pain• Precipitating factors
– Activity level– Stressors
• Treatment– Medications
Angina Pectoris
Dialogue history– Risk factors
• Smoking• Hyperlipidemia• Obesity• Sedentary life style• Alcohol consumption• Hypertension• Diabetes mellitus
Angina Pectoris
Dialogue history– Risk factors
• Sex– Male– Postmenopausal female
• Age• Genetics
– Family history• Race
– Blacks > Caucasians
Angina Pectoris
Treatment– Stop procedure– Position patient to comfort– Oxygen 2-3 L per NC or face mask – Nitroglycerin 0.4 mg SL
• Repeat q 5 minutes x 3 total doses• If no response, assume MI or unstable angina• Activate EMS and transfer to ER
Angina Pectoris
Diagnostic approach– Nitroglycerin
• Normally relieves pain in 3 minutes or less• Failure to relieve pain after 10 minutes evidence
against angina• Failure to relieve pain indicates either unstable
angina or myocardial infarction
Angina Pectoris
Function of nitroglycerin– Dilates coronary arteries to increase blood flow
and improve oxygen delivery to cardiac tissue– Platelet disaggregation
Angina Pectoris
Dental treatment– Early AM appointments– Short appointments– Consider oxygen and prophylactic nitroglycerin– Stress reduction protocols
• Good local anesthesia• Nitrous oxide• PO or IV sedation
Myocardial Infarction
Myocardial Infarction
Cardiac ischemia which results in myocardial necrosis
Myocardial Infarction
Pain more intense and longer in duration than angina pectorisPain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectorisNot relieved by SL nitroglycerin or cessation of activity
MI Signs and Symptoms
Symptoms– Pain– Nausea/Indigestion– Weakness/Fatigue– Dizziness– Palpitations– Sense of impending
doom– SOB– Lightheadedness
Signs– Restlessness– Acute distress– Vomiting– Diaphoresis– Cardiac arrhythmia– Pallor– Cyanosis– Dyspnea– Wheezing
Myocardial Infarction
Dialogue history– History of angina pectoris– Changes in angina pectoris– Previous MI
• When, Treatment, Outcome, Current status
– Medications– Risk factors
Management of Acute MI
Recognition
BLS– Airway– Breathing – Circulation– Activate EMS
Oxygen - 4-5 L by NC or face mask
Management of Acute MI
Monitor VS
Position to comfort
Pain relief– Morphine sulfate 2-5 mg IM/IV q 5-15 minutes prn
• Controls pain and reduces anxiety
Prepare to perform CPR or provide ACLS (if properly trained)
Management of Acute MI
Transfer to ER
Case Scenario #10
Case Scenario
A 25 year old female presents for initial periodontal debridement with local anesthesia.
Case Scenario
PMH:– Medications: None– Allergies: Sulfa, PCN, Tetracycline,
Erythromycin– Illnesses: Asthma, Bladder
infections, Pneumonia x 2
– PSH: Bronchoscopies x 2, T&A
Case Scenario
Vital signs:– BP - 90/60– HR - 85– RR - 12– Temp - 37 F– Weight - 110 lb (50 kg)
Case Scenario
She receives 6 carpules of 2% Xylocaine with 1:100,000 epinephrine. Five minutes later, she tells the hygienist that she feels “really great”. She stutters as she says it and she now has twitching of her facial and extremity muscles. She begins to perspiring and c/o the room being hot.
Case Scenario
You are summoned back to the room. When you enter, she begins to seize in the chair.
Case Scenario
What do you suspect is happening?
How would you treat it?
What is the pathophysiology for this problem?
How can this occur and what are the differences?
Overdose
Overdose
Clinical signs and symptoms from high blood levels of a drug in various target organs and tissues
Most common adverse drug reaction
Overdose
Requirements– Access to the vascular system– Alteration of steady state
• Rapid absorption• Intravascular injection• Delayed redistribution• Delayed biotransformation• Delayed elimination• Excessive dosage
Mechanisms of Overdose
Rapid IV Overdose RapidAbsorption
SlowBiotransformation
SlowElimination
Occurrence Common Mostcommon
If no epi Uncommon Leastcommon
Onset Rapid 3-5minutes
3-5minutes
10-30 minutes 10 min /many hrs
Intensity Mostintense
Gradualonset
Gradualonset
Gradual onset,slow intensity
Gradualonset,slowintensity
Duration 2-3minutes
5-30minutes
5-30minutes
Longer (variable) Longer(variable)
Prevention Aspirate,1 minute
Minimaldose
Epi, Neo Adequate med hx Adequatemed hx
Drugs Amides /esters
Amides Amides Amides / esters Amides /esters
Overdose
Predisposing factors– Patient factors– Drug factors
Patient Factors
Age– Young and elderly
Weight– Lean vs. fat, overall weight
SexOther medicationsPresence of disease– Renal, liver
Genetics
Drug Factors
Vasoactivity
Concentration
Dose
Route of administration
Rate of injection
Vascularity at injection site
Vasoconstrictors
Local Anesthetic Overdose
Minimal - Moderate– Talkativeness– Apprehension– Excitability– Euphoria– Sweating– Disorientation– Increased BP, P, RR– Loss of reason
Moderate - High– Light headedness– Restlessness– Nervousness– Metallic taste
Visual, auditory disturbances– Seizures– CNS depression– CV collapse
Local Anesthetic Overdose
CNS precede CV symptoms
CNS symptoms– CNS depression or excitation – Seizures– Generalized CNS depression
Local Anesthetic Overdose Tx
– Oxygen– Monitor VS– BLS– IV line*
• Anticonvulsant (Valium) *
– Protect patient*– Transfer to ER*
• * If necessary
Drugs
Drugs
Just what drugs do you need?
Do I need a crash cart?
How extensive does your crash cart need to be?
What if I don’t have the training to use the equipment?
Crash Cart
Crash Cart
How much do you need?What is your training?– Match your training to the amount of drugs and
equipment you require • Do not overbuy via an emergency kit.
– Small tackle box may be all that is necessary vs, major crash cart
Must have certain necessary equipment to administer the drugs in your emergency kit or temporaily treat emergencies (needles, fluids, tubing, tourniquets, etc.)
Oxygen
All medical emergencies require oxygen initially!– What specific conditions require
oxygen?– What is the one exception?
Aspirin
Aspirin
81, 162 or 325 mg crush and swallowWho should be on it?Who gets it?What does it do?How does it supposedly work?
Epinephrine
Epinephrine
What concentrations does it come in?
Name 3 dental office emergencies where you would consider using it?
What is the normal dosage?
How often can it be repeated?– Why would you repeat it?
What adverse effects could occur?
Epinephrine
Pharmacology– Increases
• SVR• SBP/DBP• Myocardial electrical activity• Coronary and cerebral blood flow• Myocardial contraction• Automaticity
Nitroglycerin
Nitroglycerin
What forms does it come in?
When is it given?
How often is it given?
How do you know it is effective/active?
How does it work?
How is it stored?
What are the adverse side effects?
Atropine Sulfate
Atropine Sulfate
Indications?
How does it work?
How much do you give?
What adverse side effects can occur?
How often can you repeat it?
Benadryl
Benadryl
Name 3 dental emergencies in which this is used?
How is it administered?
What dosage is usually given?
How does it work?
What are the side effects?
Ventolin Inhaler
Ventolin Inhaler
Used to treat what conditions?
How much and how often can it be administered?
How should it be administered?
Side effects?
Insta-Glucose
Insta-Glucose
Used to treat what condition?
When should this not be used?
How is it administered?
Dextrose - 50
Dextrose - 50
Used to treat what condition?
How is it given?
Can it produce any problems if administered?
Succinylcholine
Succinylcholine
What is it and what is it used to treat what conditions?How is it administered and how much is given?How long does it take to be effective and how long does it last?How is it metabolized?What must you be able to do if you administer this medication?Are there any risks to administration of succinylcholine?
Narcan
Narcan
For what condition is this used?How is it administered?What special precautions must be utilized?What are the risks of giving this medication?If the patient doesn’t respond after repeated dosing, what is suggested?
Romazicon
Romazicon
For what condition is this used?
How is it administered?
What is the maximum dosage?
What risks are associated with giving this medication?
Valium
Valium
For what condition is this used?
How much and how is it given?
What is the biggest concern with giving this drug?