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Medical Emergencies Simplified

Iowa Dental Association2009 Annual Session

James Q. Swift DDS

Professor and DirectorDivision of Oral & Maxillofacial Surgery

University of Minnesota

Update on Medical Emergencies-What has changed?

• Universal presence of AEDs, LMAs• Use of simulation clinic training to manage medical

emergencies• Use of phentolamine to reverse effects of local

anesthetics• Changes in CPR protocol• Administration of aspirin for acute chest pain

Personal Experience-Recent Report of Event• Anaphylaxis

– Dermatologist Southern CA– Vein procedure– Local without VC– Throat swelling– No epi, no 911– Without oxygen/anoxic for 16-19 minutes– Anoxic encephalopathy– Life support withdrawn

Objectives

• Identify the most frequent medical emergencies

• Know the most important drugs needed to treat medical emergencies occurring in the dental office

• Identify the situations most likely to lead to a medical emergency

Objectives

• Recognize the occurrence and the treatment of the most common medical emergencies

• Interactive problem based learning

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What do you need to treat medical emergencies in the dental environment in 2009?

• Knowledge of – Basic life support and CPR– Basic information on medical emergency management

• How to contact EMS and average arrival times• Team training and practice

University of Minnesota Emergency Response• Review of past experiences• New medical emergency protocol• SOD First Response

– Responsibilities– Medical emergency kits

• Most common medical emergencies and management

Past Experiences…..

• In the past 19 years at the University of Minnesota School of Dentistry, there has not been a death of a dental patient undergoing treatment in our clinics

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Past Experiences….

• Calling both 4-6133 and 911• Running up or down the back stairs to get help• The attending faculty disappearing act• “Could you send someone to check out our

patient….”• Telling the patient to go to the Emergency

Department

Past Experiences….

• A person walks inside the Delaware Street entrance to the School of Dentistry, tells bystanders that he has chest pain

• A dental patient complains of double vision and dizziness

• An asymptomatic dental patient has a blood pressure of 212/70

Past Experiences…..

• Chest pain• Insulin reaction-hypoglycemia-blood sugar 30 gm/dl• Trouble breathing, short of breath• Syncope-diminished consciousness, loss of consciousness• Stress reaction- “patient upset about bill”

Keys to Manage Medical Emergencies

• Accurate and complete medical history• Treatment modification

– Consultation with medical provider– Morning appointments

• Prevention– Managing stress/ anxiety– Extra measure of caution

Keys to Manage Medical Emergencies

• Recognition– Identify that there is a problem– Diagnosis may not be important

• Management– Primary management is basic life support– Application of emergency medications

• Follow up

Basic Life Support-2 Steps

• Primary ABCD Survey– A-Airway management with non invasive

technique– B-Breathing with positive pressure ventilation– C-Circulation-perform CPR until an AED is

brought to the scene– D-Defibrillation

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Basic Life Support-2 Steps

• Secondary ABCD Survey– A-Advanced airway with tracheal tube or LMA– B-Breathing-check tube placement-PPV through tube– C-Circulation

• Peripheral IV• ECG leads• Rhythm based medications

– D-Differential Diagnosis-search for, find and treat reversible causes

CPR BLS

• 100 compressions per minute• 30 compressions/ 2 breaths• Lay vs. health care worker

Potential for Disaster-Drug Administration in Dentistry• Local anesthetic

– Amide solution-overdose/toxicity vs. allergy– Vasoconstrictor-Cardiac effects

• Antibiotic– Penicillin like drugs-allergy

• Analgesic– ASA, NSAIDs-allergy

Potential for Disaster

• Latex allergy• Stressing a medically compromised patient

An Office Plan for Management of Medical Emergencies• Definitive procedure listed in office manual

– Role assignments-everyone involved!– Responsibilities

• CPR-monitor• Preparation of emergency medications• Notification of emergency medical system• Chart notations

– Immediate– Delayed-full account of event

Airway Management Objectives

• Airway issues and concerns– Is the patient able to breathe or move air– Is the patient attempting to breathe or move air

• Support of Airway– Patent airway

• Support of Ventilation– Respiratory effort– Positive pressure ventilation

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Oxygen- E cylinderSystematic Approach to Airway Management

• Recognize airway obstruction• Look• Listen • Feel

• Clear the airway• Reposition the patient• Mask Ventilation• Temporary, definitive, and surgical airway placement

Airway Examination-Mallampati Classification

Supraglottic Obstruction

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Systematic Approach to Airway Management• Reposition of the Patient

Mask Ventilation

• Can deliver high FI O2

• Avoids intubation trauma• Does not protect against

aspiration • May result in gastric

distension • Laryngospasm can occur • Requires use of both hands

Temporary Airway- Laryngeal Mask Airway (LMA)

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Rationale for AEDs in the Dental Office

Scope of the Problem

• 350,000 deaths due to cardiac arrest yearly– 1000 lives lost per day– 220,000 die before reaching the hospital

• Survival rates for performing basic CPR reported to be between 0% and 6%

Ventricular Fibrillation

• Electrical activity of the heart becomes “disordered”

• Ventricles contract in a rapid unsynchronized manner

• Heart no longer effective pump• Can be converted with a defibrillator

Early Defibrillation

• Survival rate increases to 31%• May save up to 300 lives per day• Estimated 2000 lives saved by early

defibrillation• First inflight AED save 1998• Prior treatment protocol “precordial thump”

AED Efficacy Data

• Quantas Airlines– 1991-all international terminals and 55

international routes– 64 months-46 cardiac arrests

• 27 on aircraft – 6 witnessed, 5 defibrillated (38 seconds avg. time)

• 19 in terminals• Success with VF in 16 of 17 cases in terminals

“Airlines must install defibrillators”USA Today, 4-13-01

• Federal Aviation Administration Ruling, to be completed in 3 years

• Only on aircraft carrying at least one flight attendant and with payload capacities of more that 7,500 lbs

• Includes oral antihistamines and an intravenous administration kit

• AA installed in 1996, estimates 12 lives saved

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Medical Emergency Kits/Drugs

Medical Emergency KitEssential Components• Medications

– Oxygen– Epinephrine 1 mg– Nitroglycerine 0.4 mg– ß-2 Agonist inhaler– Sugar source– Aspirin 325 mg– Antihistamine

• Equipment– Airway support

• Ambu bag and mask• Pocket mask• O2 triggered device• Laryngeal mask airway

– Blood pressure cuff– Stethoscope

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Other Drug Options

• Diphenhydramine (Benadryl) 50 mg• Hydrocortisone 100 mg• Naloxone 0.4 mg vial

Other Ancillary Equipment

• AED• IV catheters, fluids• Syringes and needles• A notepad• Oral airways, nasal airways• PPV

Optional Components- Emergency Kit

• Diazepam (10 mg injectable)• Diphenhydramine (Benadryl 50 mg

injectable)• Morphine (4 mg injectable)• Dextrose (injectable)• Aminophylline (injectable)

Most Common Medical Emergencies

Syncope

• A loss of consciousness secondary to extreme stress and anxiety

• Primarily an autonomic nervous system response– Not voluntary or conscious control– Patient or doctor cannot reverse but can halt or

treat

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Syncope-Autonomic Response to Stress

• Primarily sympathetic• Increased heart rate• Increased cardiac

output • Dilation of pupils

• Dilation of bronchi• Peripheral

vasoconstriction• Purposeful action• Fight or flight• Takes 30 seconds to

develop

Vasovagal Syncope

• Most common related to injections in younger individuals• Parasympathetic response often followed by sympathetic

response secondary to anxiety• Warm feeling, pale, diaphoresis, “feeling faint or sick,”

nausea, bradycardia, hypotension, tachycardia, LOC

Syncope-Parasympathetic Response• Inhibition of heart rate by vagus nerve• Decreased cardiac output• Response complete in 1 second

Syncope-Treatment

• Identify• Oxygen• Aromatic spirits• Consider nitrous oxide/oxygen• Avoid

– Alcohol– Head between the legs

Syncope-Treatment

• Always assume that sudden unconsciousness represents cardiac arrest until proven otherwise

• Supine position• Airway patency maneuver-basic life support

if unconscious• Emesis maneuver

Management: Vasovagal Presyncope/ Syncope

Trendelenburg Position

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Maladaptive Stress Response

• Overwhelming stress without hope• Adaptive stress response becomes

maladaptive• Possible death• When seen in older higher medical risk

patients, may proceed to life threatening emergency sooner or more frequently

Hyperventilation

• “Behavioral breathlessness”• “Psychogenic dyspnea”• Affects 6% of US population• Decrease of CO2 in blood, results in

respiratory alkalosis (increase in pH)• Hypocalcemia

Hyperventilation

• Anxiety• Hyperpnea• Lightheadedness• Paresthesias

• Circumoral numbness• Tingling extremities• Tetany• Unconsciousness (very

uncommon)

Hyperventilation-Treatment

• Reassurance• Slow breathing• Model breathing• Bag breathing• Pursed lips• Breathe through one nostril• Manage unconsciousness with basic life support

Seizures

• Seizures are very frightening• Death from seizure is exceedingly rare• Highest incidence of unexpected event is in patients with

diagnosed seizure disorder• Do not occlude the airway• Do not put yourself at risk

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Seizure

• Aura-prodrome• Ictal phase

– Rigidity– Cyanosis– Cheek or tongue biting– Urinary/fecal incontinence– Loss of consciousness

Seizure

• Post ictal– Disorientation, confusion, amnesia– Somnolence– Guilt

Seizure-Management

• Patient positioning so as to not injure self or others

• Airway maintenance for patency• Vital signs• “Ride it out”

Seizure-Management

• Benzodiazepine-Diazepam 5-10 mg IV or IM• Start IV• Manage post ictal phase with basic life

support• Check in with patient’s physician

Hypoglycemia

• Diminished cerebral function– Confused– Semi conscious

• Hunger with nausea• Sweating• Tachycardia• May progress to unconsciousness or seizure

Hypoglycemia-Treatment

• Oral carbohydrates• IV carbohydrates• Call for EMS if not resolving• Allow patient recovery

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Hypoglycemia-Management

• If unconscious– Perform BLS– Call for EMS– Administer carbohydrate

• IV-50% dextrose• IM-Glucagon/Epinephrine

Postural Hypotension

• Signs and Symptoms– Poor physical condition– Obesity– Medications– Prolonged spine position– Not precipitated by stress

Postural Hypotension-Management

• Position patient supine • Airway maintenance• Slowly elevate patient• Monitor• Can detect by dialogue history

Anaphylaxis

• Develops after re exposure to a sensitizing antigen within minutes

• Hypersensitivity reactions mediated by IgE and IgG4 subclass of antibodies

• Some may be mediated by complement (allergic reactions to blood products)

• Annual incidence unknown• Fatal incidence 154 per million hospitalized patients per

year

Anaphylactoid Reactions

• Look exactly the same as anaphylaxis• Not mediated by antigen-antibody reaction• Manifestations are so similar to anaphylaxis

that distinction is unimportant in relation to treatment of an acute attack

Etiology

• Insect stings• Drugs

– NSAIDs, ASA, PCN• Food

– Milk– Eggs– Fish– Shellfish– Peanut and tree nut

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Signs and Symptoms

• Chemical release of mediators from mast cells– Vasodilation– Increased capillary permeability– Airway constriction– Hypotension– Bronchospasm– Angioedema

Signs and Symptoms

• Upper airway (largyngeal) edema, lower airway edema (asthma) or both

• Cardiovascular collapse-absolute (intravascular volume loss) and relative (vasodilation) hypovolemia

• Urticaria, rhinitis, conjunctivitis, abdominal pain, vomiting, diarrhea, and sense of impending doom

• May be flushed or pale

Differential Diagnosis

• Common missed diagnoses– Vasovagal reaction, panic attack

• Angioedema/urticaria• Scombroid poisoning

– Develops within 30 minutes of eating spoiled tuna, mackerel or mahi-mahi-treated with antihistamines

Differential Diagnosis

• Hereditary angioedema– Severe abdominal pain, respiratory mucosal

edema, airway compromise• ACE inhibitors

– Reactive angioedema of the upper airway• Panic disorder

– Functional stridor

Anaphylaxis-Key Intervention

• Position-comfort• Oxygen• Epinephrine if there is clinical signs of shock,

airway swelling or definitive breathing difficulty• Administer IV epi if there is vascular access

available and the episode is profound and life threatening

Severe Allergic Reaction

epinephrine 1:1,000– 0.3 - 0.5 mg IM/ SC

repeat every 5-10 min if no improvement

– small child 0.1 - 0.2mg– older child 0.2 - 0.3mg

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Other interventions

• Antihistamines-IV or IM 25 mg diphenhydramine• H2 blockers (cimetidine 300 mg PO or IM or IV)• Isotonic solutions (NS) for hypotension• β-adrenergic agent if bronchospasm is present• Corticosteroids-high dose, effects delayed for 4-6

hours• Recurs within 1-8 hours in up to 20% of patients

Mild Allergic Reaction

• diphenhydramine (Benadryl) 50 -100mg IV/PO/IM

• repeat every six hours

Severe Allergic Reaction-Management

• Inject 0.3 mg epi submucosal, IV or IM

• Oxygen• Consider inhaler• Consider antihistamine

• Repeat epi as necessary

• Call for EMS if refractory to epi

• BLS if necessary

Acute Asthma

• Stress is most frequent cause of asthma attack

• Wheezing is presenting symptom• Patient at risk usually easily identified with

medical history

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Severe Asthma

• Cardiac arrest linked to severe bronchospasm and mucous plugging

• Cardiac dysrhythmias due to hypoxia• Most deaths occur outside of the hospital• Present to ED at night 10 greater than in

daytime

Preventing Arrest

• Oxygen• Nebulized β2 agonists• Intravenous corticosteroids (125 mg of

methylprednisolone)• Intravenous aminophylline

Acute Asthma-Management

• Inhaler-Beta 2 agonist• Repeat inhaler as necessary• Oxygen• Consider aminophylline 5 mg/kg slowly• Consider epinephrine 0.3 mg IM,

submucosal or IV

Chest Pain

• Angina pectoris• Myocardial infarction

Chest Pain

• When chest pain occurs, diagnosis is myocardial infarction (death of a portion of heart muscle) until proven otherwise

• Nitroglycerin is a diagnostic and therapeutic medication

• Any change in status of priorly occuring chest pain very significant

Chest Pain

• Oxygen at 4 L per minute• Nitroglycerin 0.4 mg spray• Aspirin 160-325 mg• BLS, vital signs• Stress reduction, reassurance• Repeat Nitroglycerin up to 3 doses• If pain unrelenting, diagnosis is MI• Morphine IV if pain not relieved by NTG

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Myocardial Infarction

• Basic life support• Oxygen, vital signs• Call for EMS as soon as possible• AED if available• Pain and anxiety relief• Transport

Stroke Treatment and Brain Oriented Intensive Care

• Cincinnati Prehospital Stroke Scale– Facial Droop– Arm Drift– Abnormal Speech

General Management of Acute Stroke Patient• IV Fluids Avoid D5W and load• Blood sugar Determine and treat• Thiamine 100mg if malnourish• Oxygen Pulse oximetry• Acetaminophen If febrile• NPO If at risk of aspiration

Conclusions

• The oral health care provider has an obligation to manage medical emergenciesin the dental environment

• As with anything else we do, constant attention to the potential of calamity willprovide us with more consistent and reliable outcomes