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MEDICAL EMERGENCIES
IN THE DENTAL OFFICE
Dr. Peter Nkansah
November 8, 2013
Winter Clinic 2013
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“Dentistry’s Perfect Storm”
In a “Viewpoint” article by Dr. L. Sangrik in Dentistry
Today (Sept. 2010), “4 factors are congerving that,
if left unaddressed, have the potential for disaster”
1. Dental patients are becoming increasingly ill
2. Baby-boomers are getting older
3. Obesity is epidemic
4. Seriously ill patients are increasingly able to enjoy a
good quality of life (includes receiving dental care)
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“Dentistry’s Perfect Storm”
“Six Links of Survival” are suggested for medical
emergency preparedness
1. Dentist training
2. Staff/team training
3. Routine practice drills
4. A written protocol
5. Proper medications
6. Proper equipment
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Medical Emergencies
Of greatest concern to us are the cardiovascular
and respiratory systems
Be prepared for a worst-case scenario
What is your responsibility?
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Ready?
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Scenario K
A 53-year-old woman presents for a hygiene
appointment
She is a long-standing patient of the office and,
while somewhat overweight, has a non-contributory
medical history
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Scenario K
Approximately 20 minutes into the appointment, she
begins to cough and excuses herself to the
bathroom
After 5 minutes, you search for the patient and find
her slumped on the floor
What do you do?
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Risky business?
How healthy are your patients?
How do you know?
What are you watching for?
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30,608 Emergencies
Syncope
Mild Allergy
Angina
Postural Hypotension
Seizure
Brochospasm (asthma)
15,407
2,583
2,552
2,475
1,595
1,392
Martin & Ellis, JADA 112:499-501 (1986) and Malamed, JADA 124:4-53 (1993)
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The Big 12
Syncope
Angina
Myocardial infarction
Hypertension
Hypotension
Asthma
COPD
Hyperventilation
Allergies
Diabetic imbalances
Epilepsy/seizure
disorders
Bleeding problems
Ref.: Sangrik, Dentistry Today, Sept. 2010
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Medical History &
Patient Evaluation
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Who Is At Risk?
Everyone, but not equally
90% of office emergencies are predictable in some
way
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Who Is At Risk?
Patient risk factors
Medical history
Age
Existing disease(s)
Medications
Allergies
Psychological
Especially fear & anxiety
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Who Is At Risk?
Medications:
Anti-anginals
Anti-hypertensives
Diabetic medications
Corticosteroids
Coumadin
Oxygen
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Who Is At Risk?
Psychological Factors
Ask the patient
Ask the rest of the team
Acknowledge and treat dental anxiety
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Time of Emergency (%)
Ref.: H Matsuura, Anesthesia Progress (36):223-225 (1989)
Immediately before treatment 1.5
During or after LA administration 54.9
During treatment 22.0
After treatment 15.2
After going home 5.5
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Treatment During Emergency (%)
Ref.: H Matsuura, Anesthesia Progress 36: 223-225 (1989)
Extraction 38.9
Pulp extirpation 26.9
Tooth preparation 7.3
Filling 2.3
Incision 1.7
Apicoectomy 0.7
Removal of fillings 0.7
Other tx & unknown 21.3
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Medical history
With a thorough medical history and examination, you can decide how to safely proceed with treatment
A good history will also prepare you for any foreseeable emergency
“An ounce of prevention…”
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Obstructive Sleep Apnea
This is a relative contraindication to outpatient
sedation/anaesthesia
OSA presents dangers peri- and postoperatively
Prevalence is 9% in women and 24% in men
Of those diagnosed, only 10-20% are optimized
Polysomnography is the diagnostic gold standard
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Obstructive Sleep Apnea
Associated with cardiovascular disease and
increased cardiovascular risk
Affects 50% of people with cardiovascular disease
Perioperative care depends on good assessment
and use of short-acting agents where possible
Postoperative complications include apnea,
bradypnea and desaturation
Hospital recommendation is to monitor for >60 min
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Obstructive Sleep Apnea
Assessment tools:
ASA checklist
STOP questionnaire
STOP-Bang questionnaire
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STOP-Bang Questionnaire
Snore
Tiredness during the day
Observed apnea
Blood pressure
BMI
Age
Neck circumference
Gender
High risk if 3 or more "yes" answers are given
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Medical History
Vital Signs
Blood pressure
Heart rate
Respiratory rate
Establish a baseline…in your office
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Sphygmomanometers
Mercury manometer
most accurate
Aneroid manometer
less accurate
prone to decalibration
Automatic System
accurate but different
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Precautions for Accuracy
Arms may differ 5-10 mmHg (left higher)
Tight sleeve forming tourniquet
Rest before measurement
Cuff too small = elevated readings
Cuff too big = decreased readings
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Asthma Algorithm
May finish appt.
Attack resolves
Call 9-1-1
Epinephrine injection0.3-0.5 mgIM, IL or IV
Salbutamol puffs
2x100 mcg
q 3 min.
Oxygen
Attack continues
ABCs
Position patientcomfortably
Asthma attack!
+/- antihistamines & corticosteroids
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Treating the Asthmatic Patient
1.
2.
3.
4.
5.
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Emergency Drugs & Equipment
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Emergency Drugs
The RCDSO (the dental licensing board in Ontario) mandates the following drugs for medical emergency kits:
Oxygen
Epinephrine
Nitroglycerin
Diphenhydramine
Salbutamol
ASA
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Oxygen
Indicated for all medical emergencies
Mechanism of action: C’mon!
Dose: Some is good, lots is better!
Guideline for supplementation: 1 L of O2 =+4% of
[O2]
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Oxygen
E cylinder
660 L - good portable O2 size
Provides >30 minutes* of supplemental O2
Can estimate remaining time using the following equation:
Time remaining =
Remaining pressure (psi)
200 x flow rate (L/min)
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Epinephrine
Indicated in SCA, asthma and allergy/anaphylaxis
Can be administered IL/IM/IV
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Epinephrine
Mechanism of action: 1 agonist (peripheral
vasoconstriction), 1 agonist (heart) and 2 agonist
(bronchodilation, vasodilation)
Adult dose: 0.3-1.0 mg IM/IL/IV
Children’s dose: 0.01 mg/kg IM/IV
Duration: 5-10 minutes
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Epinephrine = 9-1-1
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Nitroglycerin
Indicated in angina and MI
Mechanism of action: relaxes vascular smooth
muscle in arteries and veins
venous return to the heart ( preload)
myocardial O2 demand
BP
Dose: 0.3-0.4 mg sublingual
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Nitroglycerin
Light- and oxygen-sensitive
Store tablets in the dark, at room temp, tightly
closed
Opened bottle has shelf life of 3 months
Do not use if systolic 90 mmHg or…
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Sublingual Spray
Nitrolingual® pumpspray
1-2 metered-doses (0.4 mg)
Given q 3-5 min (x 3)
Sprayed onto or under the tongue
200 metered doses/bottle
Shelf life of 2-3 years
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Diphenhydramine HCl
Indicated to block histamine-mediated reactions (e.g. allergy, asthma)
Available in many formulations
Injectable form: 1 ml vial with 50 mg (25 mg for kids)
Capsules are 25 or 50 mg
Sedative and antiemetic actions are secondary
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Diphenhydramine HCl
Mechanism: H1-receptor site competition
Dose: 50 mg po/IM/IV
Children’s dose = 1 mg/kg
Duration: 4-6 hours
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Salbutamol (Albuterol)
Indicated in acute asthma attacks
An inhaled bronchodilator
Addresses 1 key element of asthma attacks
Trade name = Ventolin®
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Salbutamol (Albuterol)
Mechanism: Direct action to relax bronchial smooth
muscle (-2 agonist)
Dose: 200 µg (2 puffs) q 3-5 min prn
Children’s dose = 100 µg q 3-5 min
Puffer = metered dose inhaler (MDI)
Duration: 3-6 hours
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AeroChamber
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AeroChamber Max (for age < 3 years)
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ASA
Indicated in cases of suspected myocardial
infarction
Contraindicated in stroke
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ASA
Mechanism of action: inhibits platelet aggregation
(clot formation)
Prevents ischemia injury infarction
Decreases overall mortality from acute MI
Dose: 160-320 mg po*
CHEW, SWISH & SWALLOW
Duration: ~3 days
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ASA
Can be given up to 24 hrs after MI onset
Contraindications:
Allergy
History of significant gastric bleed
Asthma
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Other Emergency Equipment
Pen and paper
Glucometer
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Approaching Emergencies
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Basic Principles
Don’t hesitate to seek help
KISS
Once you are prepared for emergencies, there’s no
reason to panic (not that we need a reason)
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Overview
P-A-B-C-D4
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Change “A-B-C” to “C-A-B”
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Chest compressions and
early defibrillation.
Chest compressions
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Circulation
CHECK:
Shake and Shout (check responsiveness)
Check for a pulse & for breathing
THEN DO:
If no pulse, start CPR and prepare AED
(Push hard, push fast)
CPR → cerebral and coronary perfusion
(provides 25% of cardiac output)
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Airway & Breathing
CHECK:
Look, Listen & Feel
THEN DO:
If no response, head tilt & chin lift
If not breathing, give 2 breaths
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Four D’s
CHECK:
Differential Diagnosis
THEN DO:
Drugs or Defibrillation
Disposition
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Differential Diagnosis
How did we get here? Where is here?
Assess the patient
How sick are they?
How sick were they?
What is the medical history?
Baseline vital signs?
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Defibrillation
Surviving SCA outside hospital <8% (with CPR)
Survival 10% every minute defibrillation is delayed
Immediate shock: survival 49-85% with biphasic defibrillators
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Drugs
Choice is based on the situation
Know the 6 RCDSO-mandated drugs well
Know others as they pertain to your practice
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Disposition
“When in doubt, ship them out!”
Activate EMS if you are unsure or if symptoms persist
If the symptoms resolve and you’re unsure of what to do
Family MD?
Neighbouring MD’s near your office?
If discharging to home, make sure they can get there
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Disposition
As soon as possible after an emergency, meet with
your team to:
Debrief and review
Gather suggestions to better the team’s response for
the next time
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Simplified ACLS Algorithm
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Chest Pain Diagnosis
3 categories for chest pain:
1. Known angina, typical presentation
2. Known angina, more pronounced presentation
3. No previous angina (unstable)
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Cardiac Pain Presentation
Typically atypical
“Chest pain” with MI
Pressure = 50%
Burning = 25%
SOB = 10%
Epigastric = 10%
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“MONA greets all chest pain”
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Initial Management
PABC
Monitor, O2*, vital signs, ECG (12- or 15-lead), IV*
Brief history of incident
Patient signs and symptoms
D
MONA or POACH?
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Chest Pain Diagnosis
• Acute Coronary Syndrome/angina/MI
• Aortic Dissection
• Pulmonary Embolism
• Acute Pericarditis +/- tamponade
• Pneumothorax
• Esophageal Rupture
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Chest Pain Diagnosis
2-4% of AMI missed in the hospital
Common source of lawsuits vs. emergency departments
and MD’s
Have a low threshold to seeking help
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Acute Coronary Syndromes
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Chest Pain Risk Factors
History of HTN, angina, MI, stroke, diabetes, high
cholesterol
Age
Sex
Race
Family history*
Smoking
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Myocardial Infarction
Deficient coronary blood to heart tissue necrosis
90% of MIs are due to CAD
Little or no relief from nitroglycerin
⅓ die before reaching hospital
Know the risk factors
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The Impact of Cardiovascular Disease
The Heart and Stroke Foundation of Ontario
estimates 45,000 cardiac arrests in Canada each
year
The overall survival rate for out-of-hospital cardiac
arrest is ~5%
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“MONA greets all chest pain”
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“MONA”
Comfortable
position
⇊
ABC’s
⇊
D (monitor)
⇊
Oxygen
+
NTG
+
Morphine
(analgesic)
+
ASA
5-6 L/min
0.3-0.4 mg q 3 min
2-5 mg IM
325 mg
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Initial Treatment
Morphine
Used if pain persists despite NTG
Contraindications:
Hypotension
RV dysfunction
Not life-saving (symptom relief)
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Initial Treatment
Oxygen
Target Sp02 > 94%
Not life-saving (symptom relief)
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Initial Treatment
Nitroglycerin
0.4 mg SL q 5 min x 3 doses
Contraindications:
Hypotension
Inferior MI with RV dysfunction
Viagra/Adcirca or Levitra = 24 h
Cialis = 72 h
Not life-saving (symptom relief)
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Initial Treatment
asa (Aspirin)
160 mg* chew-swish-swallow
23% mortality reduction in AMI!
Contraindicated if allergy or active GI bleed
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“MONA” can be a bad girl
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“POACH”
MONA is sometimes bad
In right-sided MI, anything that lowers BP is harmful
Morphine and NTG?
Oxygen may not be necessary
Need a 12- or 15-lead ECG to determine the location
of the MI
MONA is out, POACH(?) is in
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“POACH”
P = phone hospital/cardiology
O = oxygen
A = asa
C = clopidogrel (Plavix)
H = heparin
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Assess ECG Findings
Classify patients with ACS within 10 minutes of arrival
• ST elevation or new or presumably new LBBB:
strongly suspicious for injury
• ST-elevation AMI
• ST depression or dynamic T-wave inversion:
strongly suspicious for ischemia
• High-risk unstable angina/ non–ST-elevation AMI
• Nondiagnostic ECG:
absence of changes in ST segment or T waves
• Intermediate/low-risk unstable angina
REPERFUSION
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ECG
ST-depression ST-elevation
ECG findings for infarction and ischemia
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Recognition of STEMI
ST elevation >1 mm
2 contiguous leads
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ST-Elevation MI (STEMI)
Most important from ACLS perspective
Indicates complete occlusion of coronary artery
Goals:
1. Early reperfusion to restore blood flow
Time = myocardium
2. Monitor for and treat arrhythmias
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Reperfusion: PCI
“Plumber”
Angioplasty + stenting
Time goal = 90 mins
Disadvantages:
Requires cath lab
Operator-dependent
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Pathophysiology of ACS
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Automated External Defibrillators
Early defibrillation is one of the keys to surviving
cardiac arrest in adults
Published survival rates of up to 85%
The common early dysrhythmia in adult SCA is
ventricular fibrillation
Lethal but treatable
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How AEDs Work
A computerized defibrillator that can:
Recognize ventricular fibrillation
“Matches” pre-programmed criteria for a shockable rhythm
Advise the user whether the rhythm should be shocked
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AEDs and the Law
The Good Samaritan Act (2001)
For health care professionals as defined by the
Regulated Health Professions Act, 1991
Protection from liability after the performance of CPR
or other first aid “unless…the damages were caused by
the gross negligence…”
Applies if you are outside of a hospital (or healthcare
facility) and your actions are voluntary
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AEDs and the Law
The Chase McEachern Act (2007)
The user and the owner of the defibrillator has
protection from civil liability (damages) if the actions
are in good faith and without reckless endangerment
The AED must be kept in good working order
Covers CPR also
Does not apply in healthcare facilities (like our offices)
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Anaphylaxis
Almost always occurs within minutes
“Faster is worser”
96% of fatalities within 1 hour
May occur or recur (5%) in 1-72 hours
Involves CV and/or respiratory system
Definition applies to multi-organ involvement and cardiovascular compromise
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Progression of Anaphylaxis
Skin (itching, rash, flushing)
⇓
Eyes, nose, GI tract (exocrine glands, cramps)
⇓
Respiratory system (bronchospasm)
⇓
Cardiovascular system (CV collapse, cardiac arrest)
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Allergy
Patient with allergy histories are more likely to have
allergic response to dental drugs
Penicillin allergy is most common medication allergy
Approx. 1 in 10,000 doses
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Histamine-release treatments
Itching
Hives
Rash
⇒
Benadryl
⇩ Bronchospasm
Vasodilation
⇒ Epinephrine
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Supine if unconscious
O2
Epinephrine
9-1-1
Antihistamine &
Corticosteroid
Anaphylaxis Algorithm
ABC’s
D
0.5 mg IL or IM 0.3 mg IV
0.01 mg/kg children
May need to
administer
epinephrine
earlier
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Stroke
A sudden loss of brain function
Caused by interruption of blood flow to the brain
(ischemic) or the rupture of blood vessels in the brain
(hemorrhagic)
80-85% of strokes are ischemic
Overall 15% die, 10% recover completely
Cerebrovascular accidents are the 3rd leading
cause of death in North America
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Stroke
Warning signs:
Weakness
Trouble speaking
Vision problems
Headache
Dizziness
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Stroke
Treatment in dental offices is palliative
Assess, activate EMS and support the victim
Fibrinolytic therapy is done in-hospital
tPA is used within 3 hours of symptoms
15% of stroke victims die, 10% recover completely
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Diabetes Mellitus
Hypo- and hyperglycaemia each present very real
and very different dangers
Hypoglycemia is fast-onset and fairly easy to treat
Hyperglycaemia is slow-onset and dangerous when
symptomatic
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Diabetes Mellitus
Definition
A disease caused by insulin deficiency
Affects 2-5% of the population
Characterized by hyperglycemia, polyphagia,
polyuria, and polydipsia
There is an overall excess of glucose extracellularly,
and a glucose deficiency intracellularly
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Blood Sugar Algorithm
Take BS
and treat appropriately
Glucometer present
Get best possible historyGive glucose
Conscious
Give glucose*and call 911
Unconscious
No glucometer
ABC's & oxygen
Patient distress
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Benzodiazepine Rescue
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Triazolam Titration
There are some groups who believe that oral
sedatives can be safely titrated to give moderate
conscious sedation
t½elim = 2.5 hours
The most recognizable group is DOCS Education
Founded by Drs. M. Silverman and A. Feck in 1999 in
Seattle
Claim to have instructed 17,000 dentists and served
2,000,000 patients
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Triazolam Sedation
Concerns:
Underestimating the potency of the suggested route of
administration
Maximum dose = 2 mg
Maximum dose allowed in Ontario = 0.5 mg
Very lengthy appointments are encouraged
Abuse of the dosing protocols
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Triazolam Sedation
A study by Jackson et al. examined the
pharmacokinetics and sedative effects of
incremental sublingual dosing
Gave 0.25 mg of triazolam sublingually
Additional 0.5 mg 60 minutes later
Additional 0.25 mg 90 minutes after the initial dose
Sedation, vital signs and blood levels were measured
every 30 minutes
J of Clin Psychopharmacology, vol. 26(1): 4-8, 2006
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Triazolam Sedation
Jackson’s findings included:
Increasing blood levels throughout measuring period
No maximum was found
Increasing sedation scores throughout
No maximum was found
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Triazolam Rescue?
If you don’t have an IV, the following routes of
administration have been suggested:
Intramuscular
Submucosal/Sublingual/Intralingual
Intranasal
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Triazolam Rescue?
Other suggested BZD reversal agents:
Gatorade
Yogourt
Caffeine
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The Office Plan
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The Office Plan
All office staff should be current in BLS training
A written, reviewed and practiced emergency
protocol should be in place
Reviews should include specific individual
responsibilities in a worst-case scenario
Who does what?
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Emergency Baggies plus O2
Allergy/Anaphylaxis
Asthma
Chest Pain/MI
Hypo/Hyperglycemia
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Emergency Baggies Allergy/Anaphylaxis
Antihistamine
Chlorpheniramine 10 mg
Diphenhydramine 50 mg
Children = 1 mg/kg
Corticosteroid
Hydrocortisone IV 100 mg (x1)
Epinephrine
1:1000 ampoule & syringe or Epi-Pen 0.3-0.5 mg (x2)
Children = 0.01 mg/kg
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Emergency Baggies Asthma
Salbutamol (x1)
plus AeroChamber
Children = 1 puff
Epinephrine
1:1000 ampoule & syringe or Epi-Pen 0.3-0.5 mg (x2)
Antihistamine
Diphenhydramine 50 mg (x2)
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Emergency Baggies Chest Pain/MI
Nitroglycerin spray (x1)
ASA 160-325 mg
Children’s tablets = 80 mg
Demerol 25-50 mg IM/IV
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Emergency Baggies Hypo/Hyperglycemia
Glucometer
Icing sugar and/or juice box
Glucagon 1 mg IM
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Emergency Drug Kit
DRUG USE ADULT
DOSE
CHILD
DOSE
Oxygen Most
emergencies
100% 100%
Epinephrine Anaphylaxis
Asthma
Cardiac Arrest
0.5 mg im
0.5 mg im
1 mg iv
0.01mg/kg
Nitroglycerin Angina
MI
0.3-0.6mg tablet
0.4 mg spray
N/A
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Emergency Drug Kit
DRUG USE ADULT
DOSE
CHILD
DOSE
Salbutamol Asthma 2 puffs
100μg/puff
1 puff
Diphenhydramine
Chlorpheniramine
Allergic
reaction
50 mg iv/im
10 mg iv/im
1 mg/kg
ASA MI
thrombolytic
160-325 mg N/A
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Other Kit Considerations
DRUG USE ADULT
DOSE
CHILD
DOSE
Morphine MI
Analgesia
2-5mg im/iv
q 5-15 min
N/A
Glucose Hypoglycemia Orange juice
Soda
Icing sugar
Orange juice
Soda
Icing sugar
Diazepam
Midazolam
Status epilepticus
5mg iv q 5 min
5mg im q min
0.3 mg/kg iv
?
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Emergency Kit Costs
Drug Cost Shelf Life
Epi ampoule $4.29 1 year
Epi-Pen® $102.55 1 year
Nitrostat® tabs $4.49/100 tablets 6 mos.*
Nitrolingual® spray
$24/200 dose bottle
2 years
Benadryl® vial $5.62/vial 2 years
Ventolin® inhaler $13.55 1 year
ASA $3.99/24 tablets 2 years
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The Office Plan
The books, Crisis Management in Anesthesia (David
Gaba et al.), Outliers (Malcolm Gladwell), Thinking
Fast and Slow (Daniel Kahneman), and The Checklist
Manifesto (Atul Gawande) all offer good
advice/insight for emergency situations:
Prevention is best
Algorithms work
Preparation is key
Very few disasters are because of a single factor
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