Drug Related emergencies

R. John Brewer NREMT-PDental Education Inc.

Drug Related emergencies The administration of drugs is

common in the practice of dentistry and oral surgery.

The majority of the drugs used in dentistry can be divided into four categories.

1. Local anesthetics2. Analgesics3. Antibiotics4. CNS Depressants

Local anesthetics

Important part of the dental treatment plan when potentially painful procedures are considered.

Analgesics

Prescribed for relief of preexisting pain or alleviation of potential post-operative pain.

antibiotics

Used in the management of infections

Central nervous system depressants Prescribed for all phases of the

dental treatment for the prevention and management of dentistry related fears.

Drug related emergencies Whenever a drug is administered, a

rational purpose should exist for its use.

Indiscriminate administration of drugs is one of the major reasons the number of incidents of serious or life threatening emergencies in the medical and dental office have increased.

Drug related emergencies It is estimated well over 100,000

patients have died in hospitals due to adverse drug reactions.

It is estimated that over 2 million patients have suffered serious but non fatal adverse drug reactions.

Drug related emergencies Toxicology is the study of the harmful

effects of chemicals on biological systems. These effects range from minor to serious, or even cause death.

Whenever a drug is administered, two types of reactions may be noted.

- Desirable drug reaction- undesirable drug reaction

Drug related emergencies General principles of toxicology

- No drug ever exerts a single action.

- No useful drug is entirely devoid of toxicity.

- The potential toxicity of the drug rests in the hand of the user.

Drug related emergencies Our goal is to give the correct drug

in the correct dose, via the correct route to the correct patient at the correct time for the correct reason.

It is very important you know about the drugs that you have in the office or prescribe to the patient.

Drug related emergencies Most Adverse drug reactions do not

pose a threat to the patients life.

There are three responses to drugs that are life threatening:

- Overdose reaction- Allergic reaction- Idiosyncrasy reaction

Overdose reaction

A condition that results from exposure to toxic amounts of a substance that does not cause adverse effects when given in smaller amounts .

Allergy

Defined as a hypersensitive response to an allergen to which the individual has been previously exposed, and now has developed antibodies.

Allergic reaction is possible with any drug or substance.

allergy

The drugs and substances most likely to cause allergic reactions.

- Aspirin- Penicillin- Bisulfites- Latex

Idiosyncrasy reactions

An individuals unique hypersensitivity to a particular drug, food, or other substance.

Management is to position the patient, ABC’S are vital.

Drug related emergencies The major cause of drug related

emergency situations in the dental office is the “administration” of local anesthetics.

Although true Adverse reactions occur ,most reactions are related to the injection(seeing the needle)

Drug related emergencies Syncope and hyperventilation are

the most common “drug related” emergencies.

These episodes usually result from emotional stress receiving the local, not from the drug itself.

Local anesthetics

Locals is the most widely used drugs , are the safest, and most effective drugs for the prevention, and management of pain.

It is important to stress again that most adverse drug reactions to locals are a result of the administration, not the drug.

Local anesthetics

The next most common adverse drug reaction is the toxic reaction. This is produced by a relative overdose secondary to accidental intravascular injection.

True documented allergic reactions to locals is extremely rare.

Antibiotics

Prescribed to treat established active infections

Should only be used when indicated due to resistant bacteria strains and allergies.

Analgesics

Pain relieving drugs make up a significant portion of scripts written by dentists.

analgesics

Two categories of analgesics

mild- non opioid strong opioid

analgesics

Mild- asa, ibuprofen, Tylenol

Strong- Opioid- codeine, demerol, diludid, vicodin oxycontin

analgesics

Adverse drug reactions to the mild analgesics are GI upset, nausea, constipation, itching

Adverse drug reactions to the opioids are nausea, vomiting, and orthostatic hypotension, respiratory depression, respiratory arrest.

analgesics

Aspirin, Tylenol and Codeine remain the most commonly prescribed drugs.

Antianxiety drugs

The use of these drugs for all phases of dental care has increased significantly over the years.

The most common drugs prescribed is the benzodiazepines.

Drug overdose Reactions

Local anesthetic overdose An overdose of a local is related to

the blood level of the local in the myocardium and Central nervous system.

There are several factors which influence the rate at which blood levels increase or for which blood levels remain elevated. These factors could be drug or patient related.

Patient factors of Local anesthetic overdose Normal distribution curve. This is where the majority of

patients responds appropriate with “normal dose”, However some are less responsive, and some become more responsive to the local.

Patient factors AgeDue to absorption, metabolism, and excretion

drug doses should be decreased for patients under 6 years and over 65 years.

- Weight > Lean body weight more of the drug the patient can tolerate.

***A lack of consideration of body weight is one of the major causes of overdose reactions.

Patient factors

Pathological processPresence of Pre-existing disease may

alter bodies ability to transform a drug into a biologically inactive substance.

Patients with CHF demonstrate blood levels of locals 2x those found in healthy patients receiving the same dose.

Pathologic factors

Patients with chronic lung disease are at increased risk for local overdose. CO2 retention results in the decrease of the seizure threshold for local anesthesia. If a patient has a PCO2 of 65-81 their seizure threshold is lowered by approx 53%.

Patient factors

GeneticsIt is been reported that there are

certain individuals that possess genetic deficiencies that alter their response to certain drugs.

Patient factors

AttitudeIt has been shown that the seizure

threshold for locals is lowered in patients who are overly stressed.

Drug Factors

VasoactivityLocals that are more lipid soluble and

more highly protein bound are retained longer, therefore having a slower absorption rate. This increases the margin of safety.

The greater the degree of vasodilatation, the more rapid the local is absorbed.

Drug factors

Dosage : The larger the dose the higher the

peak blood level.

Drug factors

Route of Administration:Inadvertent intravascular is the factor

that causes most overdoses.

Drug factors

Rate of InjectionThe rate of injection is vital in the

cause or prevention, of overdose reactions to all drugs.

Drug factors

Local Anesthetic overdose reactions can result from the combination of inadvertent intravascular injection, combined with too rapid a rate of ingestion.

Both 100% preventable

Vascularity of injection site The more vascular the area, the

faster the absorption rate will be.

Presence of vasoconstrictors The addition of a vasoconstrictor to a

local results in a decrease rate of systemic absorption of the drug.

Signs , Symptoms of a local anesthetic overdose Low to moderate overdose- Confusion- Talkativeness- Apprehension- Excitedness- Slurred speech- Generalized stutter- Muscular twitching, tremor to

face,and extremities

Signs, symptoms (cont)

Nystagmus Elevated blood pressure Elevated heart rate Elevated respiratory rate

Symptoms of local overdose headache Feeling lightheaded dizziness Blurred vision Ringing in ears Numbness of tongue Flushed or chilled feeling Drowsiness Disorientation and loss of consciousness

Management of Local Anesthetic overdose Management is based on its severity. -again most cases are mild in nature

requiring little or no treatment. Most local overdoses again are self limiting.

Rarely should you go beyond just administering a little 02.

Over treatment has the potential to become a problem.

Management of mild overdose with sudden onset It is imperative when administering a

local, that the patient remain under continual observation, during and after administration of the local.

Again mild local reactions, will begin in 5-10 minutes following injection.

Management of mild overdose Terminate procedure Position of comfort ABC’s 02 administration Vital signs Iv access Administration of anti-convulsant. EMS

Management of severe overdose with rapid onset If signs symptoms appear

immediately (seconds to 1 minute)intravascular injection is the most likely cause.

Clinical findings are going to be much more severe and rapid.

Patient may immediately become unconscious, and have seizures.

management

Position patient supine - remove syringe

911 ABC’s 02 administration Protect patient Vital signs IV therapy/ anticonvulsant Manage the postictal patient

Epinephrine Overdose reactionSigns and Symptoms

Anxiety after injectionTremors of limbsDiaphoresisHeadacheTachycardia/ BradycardiaElevated blood pressure

Management Terminate procedure Position – semi sitting ABC’s Reassurance of the patient Vital signs every 5 minutes 911 If hypertensive administer vasodilator(NTG) esmolol Transfer to hospital

Central Nervous System Depressant Overdose Reactions

Whenever CNS-depressant drugs are administered, the possibility exists that an exaggerated degree of CNS depression may develop.

There have been several deaths both Adult and Pediatric due to this.

Predisposing Factors

The clinical efficacy of a drug is dependent on its absorption into the cardiovascular system and its blood levels in different target organs.(Brain)

Only the inhalation and IV routes of drug administration permit titration of the drug to a precise clinical effect.

Drug absorption via oral or IM is erratic.

CNS Depressant overdose The use of a CNS depressant to

obtain deep sedation via a route of administration in which titration is not possible is an invitation to overdose and cannot be recommended.

Signs and symptoms of Sedative overdose Recent administration Decreased level of consciousness Unconscious Respiratory depression Loss of motor coordination Slurred speech

Management

Terminate dental procedure Place Supine ABC’s 911 Oxygen administration Vitals IV therapy Reversal agents

Opioid overdose

Over sedation and respiratory depression are the primary clinical findings. However they may have :

- Altered level of consciousness- Constricted pupils

Treatment

RECOGNIZE THE PROBLEM!!!!! Discontinue treatment Position ABC’s Oxygen Vitals IV therapy Reversal agent

Summary

A majority of the overdoses involve the administration of more than one drug.

Whenever more than one CNS depressant drug is administered, the doses of both drugs must be reduced to prevent exaggerated, undesirable effects.

A reminder that locals are CNS depressants themselves.

Summary

When administering locals in conjunction with CNS depressants, the dose of the local anesthetic should be minimized.

Ensuring a cooperative patient who maintains protective reflexes is the primary goal of sedation.

summary

Be prepared for emergencies Individualize drug dosages Recognize and expect adverse drug

effects

Common Factors to those offices that had deaths:

-Improper preoperative evaluation - lack of knowledge of drug

pharmacology - lack of adequate monitoring.

Summary

The monitoring process should include

-(CNS) direct verbal contact with patient

-Respiratory system (Capn0graphy)

Pulse OX Cardiovascular system continuous monitoring of vital signs. EKG

Cases

Case #1

Death of a 28 lb. pediatric patient. Patient was given 7.5cc of local.

Cases

Case #2Robert Pauley 73 y/o gentleman

undergoing IV sedation, at some point stops breathing, cardiac arrest.

No vitalsNo Pulse oxNo Reversal drugs givenWrong ACLS drugs givenSuite filed/ Plaintiff’s family

$1,135,000

Case #3

Dec. 2007 Georgetta Watson 46 y/o female

Root Canal

No history was taken prior to doing procedure

Patient monitored with pulse oximeter

Case #3

Pulse ox decreasing

Irregular breathing pattern noted.

Eventually EMS contacted

EMS arrives finds patient in cardiac arrest. Transported to hospital pronounced DEAD.

Case 3 Reports indicate a combination of 2

sedation drugs were given in excessive amounts.

No patient history is documented Patient was not placed on a monitor no

documentation of vital signs being recorded No CPR being performed Staff did not have BLS training. NO record of staff training MD’s license suspended 8/08

Aug. 13,2008 8.5 million dollar awarded to family in wrongful death lawsuit.

This patient went into cardiac arrest 40 minutes after given a combination of 2 sedation drugs.

The patient received the following: - 7mg versed iv push - 75mg Demerol iv push -.7mg atropine - 6mg decadron 1 carpule 2% lidocaine 1: 100,000 3 carpules 3% mepivacaine

Case 4

Oct. 15, 2007Henry Dillow age 25 has 4 wisdom

teeth removed. Dead x3 days after surgery from necrotizing fasciitis.

John Coleman was a 47 y/o male patient

Needed multiple extractions.

Given 2mg halcion.

Patient did not respond well to drug.

Staff restrained patient do DMD could finish procedure.

Following procedure patient given flumazenil. Apparently at that point patient went into cardiac arrest.

EMS transported patient to hospital, anoxic brain death, taken off ventilator the next day and pronounced dead.

Wife files suit against office stating the following:

Office not prepared to handle emergency

Patient was over sedated Delay in 911 call

In addition “DOCS” also being sued since they did the training.

This patient had a history of obesity, diabetic, and colon cancer.

A patient in Wheeling, was administered 17 tablets of 0.25 mg halcion, for total dose of 4.25mg. A reminder an overdose can occur at 2 mg.