medical emergencies - umbsod2017 · pdf file4/01/2015 · beth stirling, d.d.s.,...
TRANSCRIPT
Beth Stirling, D.D.S., M.D. Resident in OMFS University of Maryland
Medical Emergencies in the
Dental Office
Overview Emergencies do occur
“IT WILL HAPPEN IN YOUR OFFICE”
Failure to plan is planning for failure Management
Prevention Recocgnition Treatment
Emergency Number Emergency Number
Syncope 15,407 Cardiac arrest 331
Mild allergic reaction 2583 Anaphylaxis 304
Angina 2552 Myocardial infarction 289
Postural hypotension 2475 LA overdose 204
Seizure 1595 Heart failure 141
Asthma 1392 Diabetic coma 109
Hyperventillation 1326 CVA 68
Epinephrine reaction 913 Adrenal insufficiency 25
Hypoglycemia 890 Thyroid storm 4
N=4309 over 10 years Fast TB, Martin MD & Ellis TM, 1986
7.5 emergencies per dentist over 10 years
Most common emergencies
Stress related: Syncope & hyperventillation
Medical conditions exacerbated by stress:
Cardiovascular, bronchospasm (asthma) & seizures
Drug related Overdose & allergy
Timing of the emergency Time % of total
Waiting room 1.5
Local anesthesia* 55
During treatment 22
After treatment 16
After leaving the office 5.5
Matsuura H, 1990
U.S. Aging Population
35 million people (12%) 65 years or older
Life expectancy was 40 years in 1900 & 77 years in 2002.
Number will increase by nearly 75% by year 2030
Increasing risk
Aging population Medical advances Surgical procedures Longer appointments Increased drug use
PREVENTION & PREPARATION
Prevention Know your patient Clinical judgment Medical consult Optimize treatment
Preparation Know your patient Train your staff
BLS, ACLS, PALS Prepare your office
equipment Practice
Team roles
Preparation AED (Automated External Defibrillator)
Survival rate <5% if defibrillation after 10 mins*
Chance of successful resuscitation decreases 10% per minute that defibrillation is delayed after cardiac arrest.
Emergency drugs
Injectable: sympathomimetic - epinephrine (1 mg/ml) antihistamine - diphenhydramine (50
mg/ml) anticonvulsant - midazolam (5 mg/ml) corticosteroid – hydrocortisone (50mg/ml) 50% dextrose antihypoglycemic - glucagon (1 mg/ml) analgesic morphine (10 mg/ml) Anticholinergic – atropine (0.5mg/ml)
Non-injectable: Oxygen vasodilator nitroglycerin (sublingual
tablets or spray) bronchodilator - Ventolin aromatic ammonia source of sugar glucose - gel, table
sugar antiplatelet - ASA (325 mg tablets)
Emergency equipment
oxygen delivery system (Ambu bag, nasal prongs)
large bore suction tips needles and syringes oropharyngeal & nasopharyngeal airways Chemstrips
Obtain Adequate Medical History
Medications Allergies Cardiovascular System Respiratory System Endocrine System Renal System Gastrointestinal System Nervous System
MEDICAL CONSULTATION
IDENTIFY PATIENT PROPOSED
TREATMENT SPECIFIC
QUESTION
STRESS REDUCTION PROTOCOL
Recognition Morning & short appointments Minimize waiting time Premedication Psychosedation Intra and postoperative pain control
Case # 1
19 year old female
Attends your office for a root canal on tooth #8 which. As you are talking to her at the start of her appointment she tells you that she feels ”weird”, you ask her to sit down but as she is sitting on the chair she slumps and becomes unresponsive.
PMH - None, but extremely anxious about
dental treatment.
She appears pale and diaphoretic. Breathing is shallow & pupils are dilated. Some convulsive movements of hands and
feet that subside in 10 seconds Pulse = 48 (Difficult to palpate) BP = 75/30
19 year old female
UNCONSCIOUSNESS
Syncope Drug administration/ingestion Orthostatic hypotension Epilepsy Hypoglycemia Adrenal insufficiency, AMI, CVA
VASODEPRESSOR SYNCOPE Management:
position patient supine with head lower that heart
establish airway, oxygen Monitor vital signs ammonia inhalant atropine for profound bradycardia If delayed recovery >15 min suspect alternate
diagnosis & EMS
Case # 2
17 year old female
Presents to your office for an extraction. Her mother tells you she has asthma.
What questions do you ask?
Questions to ask an asthmatic
How often How severe (medication, hospitalization,
intubation) Getting worse or better over time Initiating factors Treatment Currently symptomatic Compliant with meds / take meds today Have medication with you
ASTHMA
Increased reactivity of bronchioles to a variety of stimuli resulting in widespread, but reversible narrowing of the airways due to bronchoconstriction, edema, and secretions
Types Extrinsic Intrinsic Exercise induced
Drug induced
ASTHMA
Extrinsic Allergen induced (IgE, mast cells, histamine,
prostaglandins) Children & often regresses at puberty
Intrinsic Upper respiratory irritants or infection Adults
Exercise induced Drug induced
NSAIDs, Aspirin (association with nasal polyps)
Asthma
Definitive treatment: position patient upright calm patient ABC’s oxygen Bronchodilator – inhaler (spacer) Vital signs
Severe bronchospasm Definitive treatment: position patient upright calm patient ABC’s oxygen Bronchodilator – inhaler (spacer) Parenteral bronchodilator (epinephrine)
0.3ml of 1:1000 or 3ml of 1:10,000 BLS
Case # 3
69 year old male
Presents to your office for extraction of 4 teeth. No PMH except “pressure meds”
but he has run out of meds.
3 BP readings were 215/110, 208/103 & 210/108
Blood Pressure SYSTOLIC DIASTOLIC
Normal < 120 < 80
Prehypertension 120-139 80-89
Stage 1 - Hypertension 140-159 90-99
Stage 2 - Hypertension 160-179 100-109
Stage 3 - Hypertension 180-209 110-119
Stage 4 - Hypertension >210 >120
A blood pressure of 130/80 mmHg or higher is considered high blood pressure in people with diabetes and chronic kidney disease.
Affects 50 million Americans – only 59% are treated
HTN underlies most cardiovascular disease
HTN
Prognosis: Relationship between BP and life expectancy is
linear Risk of cardiovascular disease doubles for
every increment of 20mmHg SBP or 10mmHg DBP (JNC-7)
Sustained HTN results in: Renal failure, CVA, Coronary insufficiency, LVH/CHF, MI, Aneurysms, Blindness
HTN
Diastolic HTN: increased peripheral resistance, classically a greater risk.
Systolic HTN: increased cardiac output and/or large vessel stiffness. More important risk factor in patients older than 50.
Target BP <140/90 (Diabetics 130/80)
Treatment of HTN
Target BP <140/90 (Diabetics 130/80)
Reduces risk of: CVA by 35-40% MI by 20-25% Heart failure by >50%
Malignant Hypertension
1% of hypertensive patients *Severe elevation in BP resulting in
end organ damage: Papilledema Acute left heart failure Acute renal failure Cerebral hemorrhage & encephalopathy
IMMEDIATE, AGGRESSIVE MEDICAL ATTENTION
Dental management
DO NOT TREAT OUR PATIENT & SEND HIM TO ER or PHYSICIANS OFFICE (Call ahead)
Recommendation: SBP >180 or DBP >110 is used as cut off
for most dentists – JNC-7*
Dental management
Identification Monitoring Stress reduction protocols Avoid orthostatic hypotension Limit vasopressors (topical & injectable)
Exogenous - 0.04mg epinephrine = 2.2 carpules 1:100,000
Endogenous – potentially a bigger problem (adrenal stress response – 0.28mg of epi / min)
Drug interactions & effects (MAOI, beta blockers)
Case # 4
55 year old male
Presents to your office for RCT & crown preparation.
PMH: MI 5 months ago Angioplasty with stent 4.5 months ago HTN Mitral valve prolapse with regurgitation
Would you treat him? Any special measures?
Treatment following an MI
ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery – exec summary.
Circulation 2002; 105: 1257-1267 “It appears reasonable to wait 4 to 6 weeks after an MI to
perform elective surgery”
AHA 2007 Guidelines on SBE prophylaxis
Prophylactic antibiotics, the authors state, should not be given based on a lifetime risk for infective endocarditis but are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients, according to the guidelines, include those with the following:
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous IE Congenital heart disease (CHD)*
Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the first 6 months after the procedure†
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy
CONSIDER antiplatelet therapies, b-blockers, antihypertensive regimen
Given CAD history, risk for repeat infarction
Correspondence with cardiologist- risk stratification for minor procedure under local anesthestic with vasocontrictor
O2, reduce stress, manage pain and anxiety, cardiac monitors, nitrates PRN
Case # 5
59 year old male In your office for restoration tooth # 30. PMH:
Angina HTN High cholesterol Type II diabetes
During treatment he complains of substernal chest pain, and on questioning he reports pain down his left arm, nausea and dyspnea. You notice that he appears diaphoretic.
Causes of Chest Pain Chest pain may originate in the chest
wall (muscle, bone, skin), or intrathoracic viscera (heart, lungs, esophagus)
Causes of Chest Pain
Myocardial infarction Angina pectoris Pericarditis Pleuritic/Pulmonary chest pain Gastrointestinal (GERD, Hiatal hernia, PUD) Musculoskeletal/aneurysm Aortic dissection
Management of Angina & AMI Terminate treatment Position patient
45 degrees or Trendelenberg if SBP <100 ABC’s Oxygen 100% (Facemask @10 L/min) Sublingual nitroglygcerin 0.4mg
Should relieve pain in 3-5 mins Repeat at 5 min intervals as needed Failure to relieve pain – suspect MI
Aspirin 325mg Morphine 2-5mg every 10 min PRN
Monitor vital signs
Case # 6
33 year old female In your office for routine hygiene
appointment. But her chart is missing. You decide to proceed with your scaling and polishing
During treatment she complains of itching, and you notice a rash developing on the face, neck and arm. Very quickly she tells you that her throat is swelling and that she forgot to remind you of her severe latex allergy, before starting to wheeze.
Anaphylactic reaction
Type I hypersensitivity reaction (IgE)* Life threatening emergency
Anaphylactic reaction management
Terminate treatment & remove latex Position in Trendelenberg ABC’s Oxygen Epinehphrine 0.3ml of 1:1000 IM every 10 mins Diphenhydramine 50mg IM
(Chlorpheniramine is less sedative)
IV access & fluids ? Hydrocortisone 250mg IV
Case # 7
26 year old male Undergoing a root canal on a traumatized
tooth #8 PMH: Epilepsy (poorly controlled) Dental phobia During treatment he becomes unresponsive and
soon after his eyes roll upwards and he becomes rigid for about 20 seconds and then begins to have violent muscle contractions, and becomes cyanotic. He is incontinent of urine and is hypersalivating.
SEIZURES
A paroxysmal disorder of cerebral function characterized by a change in the state of consciousness, motor activity, and sensory phenomena
SEIZURES Generalized seizures:
Affect both hemispheres with altered consciousness Absence (petit mal)
Lapse of attention and staring in children Short duration (10 seconds)
Tonic-clonic (grand mal) Adults – prodrome, preictal, tonic, clonic and postictal
phases 2-15 minute duration Status epilepticus = >5 minutes or multiple back to back
(mortality of 10%)
SEIZURES
Partial seizures: Affect one hemisphere but may become
generalized Simple = no loss of consciousness Complex = with loss of consciousness Short duration – 2-3 mins End spontaneously
Dental management
Medication regimen, compliance, degree of seizure control – communicate with PCP, consider pre-procedure bloodwork and EKG
Consider medication interactions and adverse drug effects Stress reduction in the office – consider adjunctive anxiolysis or sedation Be prepared to manage a seizure
Management of Seizure
Terminate dental procedure Position patient & prevent injury Seizure stops - reassure patient, allow patient
to recover and then discharge patient with an escort, recommend follow up with PCP
Seizure continues – Activate EMS (911) Airway monitoring/ maintenance, administer
O2, monitor VS, 3- lead EKG, pulse check >5 min administer anticonvulsant drug I.V.
diazepam 5 mg/min (children 0.3mg/kg) and 50 ml 50% dextrose IV
SUMMARY 1. Know your patient:
history and physical
2. Have a plan & practice
3. Maintain emergency kit 4. BLS, ACLS & PALS training
5. Consider AED in the office