Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
my mantras EMERGENCIES WHAT IF?? Marvin Leventer DDS Dentist Anesthesiologist General Dentist University of Maryland Dental BASIC EMERGENCY DRUGS Oxygen Epinephrine Diphenhydramine Sugar Albuterol Nitroglycerin Aspirin Ammonia EMERGENCY EQUIPMENT Positive pressure oxygen Ambu bag Appropriate size masks Oral and nasal airway Syringes: 1cc, 3cc, 5cc Yankaur suction tips, tubing, connectors Magill intubation forceps AED Blood Pressure cuff/machine Pulse Oximeter (for sedation) OXYGEN THERAPY Used for All patients especially cardiopulmonary arrest acute chest pain suspected hypoxemia. Flow rate of 3-15L/min E-tank with regulator At least 1/2 full OXYGEN THERAPY Nasal cannula 2-4 L/min Nasal Hood 6-10 L/min Face mask 6-10 L/min Ambu-bag 10 L/min 1 NASAL CANNULA FACE MASK Attach tubing to Etank or Nitrous machine Attach to E-tank or Nitrous machine Can use Nasal Mask AMBU BAG Attach to E-tank or Nitrous machine Face masks of different sizes SYRINGES 1 CC 3 CC For benadryl or epinephrine SUCTION Battery backup Manual backup 2 SUCTION TIPS Yankaur- high volume, wide bore Tubing connector to vacuum MAGILL FORCEPS Intubation forceps Reach objects from back of mouth/throat Advanced airway Oral airway Nasal airway Measure sizes appropriately 3 Epinephrine Catecholamine, Vasopressor, Inotrope Indications: Anaphylaxis, asthma, symptomatic bradycardia, croup, pulseless arrest, hypotensive shock, beta blocker overdose, ca channel blocker overdose Epinephrine Stimulates B2-adrenergic receptors Bronchodilation Vasodilation of arterioles, decreases diastolic BP, primarily in skeletal muscle. Epinephrine Actions: Stimulates alpha receptors Increases SVR Stimulates B1-adrenergic receptors Inc. heart rate (SA node) Inc. contractility, automaticity, conduction velocity Epinephrine Adverse effects: Tremors, anxiety, headache, intracranial hemmorhage Dyspnea Arrhythmias (SVT, VT), palpitations, hypertension, poss. MI? Nausea, vomiting Hyperglycemia 4 Epinephrine Onset IM : 5-10 min Peak IM: ? Peak IV/IO: 1 min Half life 2-4 min EPINEPHRINE Pre-filled for use with IV line Ampules to be admns with 1cc syringe Epinephrine Forms: Injection 1:1000 (1mg/ml) Glass ampul Injection 1:10,000 (.1mg/ml) ANAPHYLAXIS ADULT 1:1000 epipen .3mg deep IM/thigh 1:1000 ampul .3-.5mg in 1cc syringe deep IM 1:10,000 prefilled 10cc syringe: titrate .1mg increments IV or 3-5mls IM. Prefilled 10cc syringe Epipen Adult .3 mg (.3ml 1:1000 soln) Epipen Child (10-30 kgs), .15 mg (.3mls 1:2000 soln) Racemic solution 2.25% ANAPHYLAXIS CHILD Best in thigh IM: .01mg/kg (1:1000) in thigh Q 15min PRN, max dose .5mg IM auto injector: .3mg >30kgs, or .15mg <30kgs. IV/IO: .01mg/kg, 1:10,000, .1mg at a time, q 3-5 min, max dose 1mg IV/IO infusion: .1-1 ug/kg/min for resistant hypotension 5 BRONCHOSPASM/ EPI Dose is .3 to .5 mg SQ/IM 1:1000 epi-pen Single or double dose Adult or pediatric (.15mg) 1:1000 ampul 1cc syringe .3-.5 mls 1/10,000 solution (pre-filled 10cc syringe) 3-5ml IM??, (intraoral or deltoid), or titrate .1mg increments IV. Epinephrine Asthma: SQ: .01mg/kg (.01ml/kg 1:1000), Q15min, max dose .5mg Bradycardia: IV/IO: .01mg/kg (.1ml/kg 1:10,000), q 3-5 min, max dose 1mg Croup: Nebulizer: .25ml racemic soln (2.25%) in 3 mls saline, up to .5 mls in 3mls saline older kids. CARDIAC ARREST/ EPI 1mg IV (ACLS protocol) every 3-5 minutes. Ventricular fibrillation Ventricular tachycardia no pulse Pulseless electrical activity Asystole Diphenhydramine Side effects: Dizziness, drowsiness, anxiety, dystonic Blurred vision, pupil dilation, dry mouth Hypotension, tachycardia DIPHENHYDRAMINE H1 blocker Antihistamine Antinausea Drying sedating Oral liquid IV/IM solution 50mg/ml ANAPHYLACTOID (MILD)/ BENADRYL Delayed type allergic reaction Hives, rash, itching 25-50mg 1/2 - 1 ml: IV/IM Liquid Benadryl 12.5mg/5ml 6 Diphenhydramine Anaphylactic shock (after epinephrine) 1-2 mg/kg IV/IM/IO q4-6 hrs, max 50mg Liquid dose: 2x IM dose, max 50mg Onset: 30 min. IM Peak: 1-4 hrs. IM Duration: 4-8 hrs. IM Half Life: 2-8 hrs. IM ANAPHYLAXIS/ BENADRYL 50mg IV/IM Following epinephrine ALBUTEROL Beta 2 agonist, minimal beta 1 Bronchodilator Asthma Aspiration with hypoxia Metered Dose Inhaler Albuterol Onset: 5-15min Peak: 1-1.5 hrs. Duration: 4-6 hrs. Half life: 3-8 hrs. 2-10 puffs 7 Albuterol Adverse effects: Tremors, anxiety,insomnia, dizziness Dry nose & throat, Palpitations, tachycardia Flushing, sweating Albuterol Mild/Mod asthma, anaphylaxis MDI: 4-8 puffs q 20min. Nebulizer: Albuterol Forms: Nebulized solution .5% Prediluted nebulized soln. .083% MDI, metered dose inhaler 90 ug/puff Albuterol Asthma anaphylaxis severe Nebulizer: .5mg/kg/hr, max 20mg/hr MDI: 4-8 puffs Q20 min (if intubated) <20kg 2.5mg/dose q20min >20kg, 5mg/dose q 20min SUGAR Glucose paste or orange juice 25-50gms What if unconscious 8 Dextrose/ Glucose Carbohydrate Indication: Hypoglycemia Needed for cellular respiration and ATP formation. IV / Oral Dose: .5-1 g/kg IV/IO D5W: 10-20 ml/kg D50: 1-2 ml/kg NITROGLYCERIN Tabs or spray .4mg/dose Dilates coronary arteries Decreases myocardial work 3 doses and call 911 Oral: >2yrs old: 10-20g as single dose NITROGLYCERIN Dilates systemic veins Lowers blood pressure 1/2 tab for uncontrolled HTN? 1/2 tab to aid in diagnosis of MI Nitroglycerin Dose: Angina, AMI: .4mg X 3 over 15 min 1-2 sprays under tongue, X3 over 15 min. Nitroglycerin Forms: Injection: .5, 5, 10 mg/ml. Tabs: .4mg Spray: .4mg/spray Nitroglycerin Onset: 1-2 min Duration: 3-5 min Half Life: 1-4 min Side Effects: Headache, dizziness, postural hypotension, flushing 9 ASPIRIN Antiplatelet Acute Myocardial Infarction (if not contraindicated) Regular aspirin or 2 chewable x (162mg) = 325mg First check for bleeding disorders, ulcers, blood thinners FLUMAZENIL/ ROMAZICON Reversal for BDZ overdose Concentration .1mg/ml Necessary with oral sedation? Route of administration? IV, IM, SL FLUMAZENIL/ROMAZICON What is nature of emergency Delayed drowsiness but safe Unable to maintain own airway but chin lift works Unable to maintain airway even with chin lift, but still breathing some Apnea/complete obstruction 10 FLUMAZENIL/ ROMAZICON Unable to maintain saturation >92% even with chin lift, jaw thrust, 100% O2 .2mg initially IV, .1mg/min up to 1mg .5mg IM right arm +.5mg IM left arm Prepare for resedation in 20-40 min FLUMAZENIL/ ROMAZICON Child dose IV: .01mg/kg up to .5mg Flumazenil Monitor for re-sedation, repeat doses at 20 min intervals Max 3mg/hr. Mechanism: Antagonizes effect of BDZ at GABA receptor Does not antagonize non BDZ GABA agonists, I.e., ethanol, barbiturates. Naloxone Classification: Opoid receptor antagonist Use: Narcotic reversal Form: injection .4mg/ml Dose: 1-5ug/kg IV/IM/IO/SQ titrate to effect, max .01mg/kg Peds dosing .1mg/kg?? 11 Naloxone Onset: IV/IO 1 min Duration: 20-60 min Half Life: 1 hour Adverse effects: Seizures, pulmonary edema, hypertension, tachycardia NOTE Drugs are not necessary for the proper management of most emergencies. Primary Management of all emergency situations is BLS. When in doubt, do not medicate. Consider repeat dosing LARYNGOSPASM Reflex closure of vocal cords to protect lungs from foreign matter. Must be in DEEP SEDATION to occur COMPLETE LARYNGOSPASM No breathing at all O2 sat is falling below 90% Airway maneuvers as previously Flumazenil?? Call for help PARTIAL LARYNGOSPASM Still making some breathing noises but unable to maintain >92% O2 sat with or without airway maneuvers Suction Chin lift, jaw thrust 100%O2 Positive pressure with BVM (bag valve mask) do NOT inflate stomach Flumazenil?? FOREIGN BODY AIRWAY OBSTRUCTION Where is the obstruction BLS protocol, Heimlich 12 EMESIS Can cause airway obstruction If awake with airway reflexes: low risk If sedated, YANKAUR suction, turn to right, trendelenburg position. Prevention? ASPIRATION Must have lost airway reflexes Deep sedation Elderly, infirm If aspiration of low pH stomach contents: leads to pneumonia, deterioration of lung tissue, hypoxia. >25mls of pH <2.5 Prevention? ISCHEMIC HEART DISEASE PTS W/ CHEST PAIN Monitor and vital signs Nitroglycerin sub lingual q5min x3 100% Oxygen nasal hood or face mask Aspirin 160-325mg chewed unless contraindicated If no relief, call 911 and transport to ER ASPIRATION What is O2 saturation? Listen to lungs If wheezing: Albuterol 100% O2 911 UNCONSCIOUS MI CARDIAC ARREST Ventricular fibrillation Ventricular tachycardia Immediate CPR and AED defibrillator 13 CONDITIONS REQUIRING ADVANCED CARDIAC LIFE SUPPORT Need an experienced trained team to provide ACLS Need IV EKG monitor required for proper diagnosis Necessary for oral sedation? 911 BRADYCARDIA Below 60 bpm Symptomatic Altered consciousness, low blood pressure, chest pain 100% O2 via nasal or face mask Associated with fainting ammonia BRADYCARDIA Increased parasympathetic tone due to intense pain Decrease painful stimulus Healthy heart No treatment MI 911 Atropine TACHYCARDIA Over 100 bpm What is blood pressure? Predisposition to tachycardia? Etiology: endogenous/exogenous epinephrine Wait (epi has short 1/2 life) Inform patient transient feeling Pain, anxiety More local, or Nitrous oxide TACHYCARDIA Hypovolemia NPO and blood loss Trendelenberg position, fluids Drug interactions 14 SUPRA VENTRICULAR TACHYCARDIA Sudden onset above 150 Predisposition Symptomatic Dizziness, lightheaded, hypotension TX: carotid massage, valsalva, cold water on face Consider 911 HYPOTENSION TREATMENT: Oxygen Supine /trendelenberg Fluids HYPOTENSION >20% Below baseline OR <80/40 Symptomatic? Dehydration, NPO status, vasodilation Sedation and/or local anesthesia overdose Drug interactions Capillary refill > 3sec. Vagal Myocardial ischemia HYPERTENSION Systolic > 160 or Diastolic>95 Increases bleeding, risk of CVA Leads to cardiac arrhythmias Increases myocardial oxygen consumption HYPERTENSION TREATMENT Fluid overload: empty bladder Pain: Increase analgesia Myocardial ischemia may require Nitrates 15 SEIZURE/STATUS EPILEPTICUS Repeated seizures over a short time without a recovery period. Drug toxicity, disease, injuries Pt may become hypoxic with acidosis Diazepam 5MG IV, 10MG IM Midazolam 2-5MG IV, 5MG IM 911 OVERDOSE/ EXESSIVE SEDATION Benzodiazepines Local anesthetics Poly-pharmacy/ synergism Antihistamines Narcotics Nitrous oxide Self medication/ all other prescription meds OVERDOSE/ EXCESSIVE SEDATION Airway: head tilt, chin lift, jaw thrust Breathing: Oxygen, assist with face mask Circulation: Vital signs: Spo2, BP, Pulse Position: supine Reduce level of sedation SYNCOPE Signs and Symptoms: Fainting, convulsions, bradycardia, sweating Inadequate O2 and Glucose to brain TX: supine, O2, ABC, sugar, ammonia OVERDOSE/ EXCESSIVE SEDATION Hypoventilation Rapid shallow breathing Disorientation Lack of cooperation Hysterical/ disinhibition LOCAL ANESTHETICS Additive with other CNS depressants Max dose may be less for adverse effects Use proper mg/kg dose Don’t administer all local at once Nitrous oxide- off Reverse BDZ? 16 LOCAL ANESTHETIC MAX DOSES drug mg/kg max dose mg Articaine 7.0 600 Lidocaine 4.4 (> w/ epi) 300 Mepivicaine 4.4 300 Prilocaine 6.0 600 Bupivicaine 2.0 90 Etidocaine 8.0 400 HYPERGLYCEMIA HYPOGLYCEMIA S/S:Hunger, weakness, trembling, tachycardia, pallor, sweating; incoherent, uncooperative, belligerent; unconsciousness Glucose <60mg/dl If conscious, give glucose or sugar by mouth Type 1: Diabetic Coma Hyperglycemia, ketoacidosis, hyperosmolar coma. >450 911 Drink or viscous If unconscious give 25g glucose or 50ml D50W IV push. Recheck glucose THANK YOU AIRWAY AIRWAY AIRWAY YOU CAN ALWAYS GIVE MORE BUT YOU CANT TAKE IT BACK WHAT IF LESS IS MORE HEAD TILT, JAW THRUST, TONGUE PULL 17 QUESTIONS [email protected] 410 706 2470 18