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Monitors and Records TSBDE Rules and Regulations 110.3 (f) Clinical Requirements Patient Evaluation Healthy or medically stable patient (ASA I, II) – Review of history, PE, medications Significant health disability (ASA III, IV) – Documentation of medical consult regarding potential procedure risks Pre-Procedure Preparation: Informed Consent The patient and/or guardian must be advised of the procedure associated with the delivery of the enteral conscious sedation (h) Monitoring and Documentation Pre-procedure: patients who have been administered enteral conscious sedation must be monitored during waiting periods prior to operative procedures – – – – Alertness Responsiveness Breathing Skin color Monitoring: During the Procedure Direct Supervision Oxygenation – Color of mucosa, skin or blood must be continuously evaluated. O2 saturation must be continuously evaluated by pulse oximetry Ventilation – Chest excursions – Precordial stethoscope Monitoring: During the Procedure Circulation – Initial blood pressure and pulse – There after as appropriate (10 minutes) Time oriented anesthetic record – – – – – – Vital signs Individual administering drugs Assistants in the room Name of drug Dosage administered Time of administration Pulse Oximetry Ventilation vs. Oxygenation Arterial vs. venous – SpO2—arterial oxygen saturation HbO2 vs. Hb; absorption of infra-red and red light – Ratio of oxygenated hemoglobin to total hemoglobin (%) Use of supplemental O2 Limits and alarms Recovery and Discharge Positive pressure O2 and suction immediately available Direct continuous supervision until O2 and circulation stable and patient appropriately responsive for DC Document O2 circulation, activity, skin color, and level of consciousness appropriate and stable for DC Written Postoperative Instructions: DC criteria CV function satisfactory Airway patency Patient easily arousable Protective reflexes intact Hydration adequate Patient can talk if applicable Patient can sit unaided if applicable Written Postoperative Instructions: DC criteria Patient can ambulate if applicable Very young and disabled—return to presedation baseline Responsible individual available Any unusual reactions documented and assisted Dentist must determine that the patient is appropriate for DC OFFICE EMERGENCIES Medical Emergencies… Goal is to recognize and treat minor emergencies to prevent a major lifethreatening emergency, and initiate treatment of the life-threatening emergencies awaiting transport to an acute care facility Prevention… Patient’s baseline – Vital signs – Psychological baseline Important to get vital signs at each appointment to establish a solid baseline Any variations in baseline before sedation need to be evaluated This established baseline gives an accurate record to base any intra-operative changes Prevention/Warning Signs… Physical Signs – – – – – Bradycardia Tachycardia Irregular pulse rate Irregular respiratory rate Abnormal temperature Prevention… Mentation Signs – Inappropriate alterations in cognitive function Sensation Signs – Inappropriate Psychological Signs – Acute changes – Apprehension – Agitation Emergency Equipment… Oxygen Suction – Back-up suction Airway management equipment Drugs AED ? Office Emergency Drug Kit… Commercial vs. “Home Made” Kits Primary or critical drugs – – – – – Vasopressor—Epinephrine Histamine blocker—Benadryl Bronchodilator—Albuterol Carbohydrate—Cake frosting Antiplatelet—ASA Office Emergency Drug Kit: Primary or Critical Drugs Anticonvulsant—Benzodiazepine Opioid antagonist—Naloxone Benzodiazepine antagonist—Flumazenil Ammonia capsules ???? Complications/Emergencies Recognition and Management Syncope: Transient Cerebral Hypoxia Signs and Symptoms: – – – – – – Clammy-sweaty, pale appearance C/O nausea/vomiting Rapid pulse Nervousness Loss of consciousness Dilated pupils Syncope: Management Supine position with feet elevated ABC’s Spirits of Ammonia? Cold compresses to neck and face Monitor vital signs: BP, HR, SpO2 Syncope: Outcome Signs and symptoms resolved Return of normal state of consciousness Return of vital signs to near baseline levels Orthostatic Hypotension… Cause: syncopal episode secondary to supinevertical position change Management: same as syncope, reposition pt slowly after stable Outcome: signs and symptoms resolve, pt returns to normal state of consciousness and return to baseline vitals Allergic Reactions… History, History, History Slow / delayed reactions (mild) Immediate / rapid onset(Anaphylaxis) Slow / Delayed Reaction… Signs and Symptoms: one hour or days after offending drug allergen administered – Urticaria – Pruritus Slow / Delayed Allergic Rxn Management… Identify and eliminate the cause Document vital signs (BP, HR, Resp) Treatment of skin lesions: – Systemic: diphenhydramine (Benadryl) 50mg IV, IM initially. If lesions persist may need po 5-7 days of Benadryl 25-50mg q 68o Slow / Delayed Allergic Rxn Management… Treatment of skin lesions – Topical: corticosteroid preparations (Lidex, Kenalog Synalar) Medical consultation with physician or allergist prior to any further treatment Immediate Rxn (Anaphylaxis) Identification of offending agent and management of signs and symptoms. Signs and symptoms – – – – – Urticaria, Pruritis, rhinitis Erythema Hypotension and bronchoconstriction Swelling of lips, eyelids, cheeks Constriction of pharynx or larynx with stridor/hoarseness Anaphylaxis Management… Head down position ABC’s with supplemental O2 Triad of Drugs: – Epinephrine-IV 1:1,000 Adults 0.3ml; Child, 0.01mg/kg – Antihistamine—diphenhydramine 50mg IM – Corticosteroid--Solu-Medrol 125mg IV or Decadron 8mg IV Anaphylaxis Management… Activate the EMS Must have stable vital signs for 1 hour prior to DC from acute care facility or office. Medical consultation recommended Rx diphenhydramine 50mg q 6-8 Severe Hypoglycemia (Insulin Shock) Normal B.S.: 80-120mg/dl – Acute hypoglycemia B.S. < 50mg/dl Signs and Symptoms – Adrenergic symptoms: sweating, nervousness, tremulousness, faintness, palpitations – CNS manifestations:Visual disturbances,stupor, coma, Sz Severe Hypoglycemia Management If possible, sugar by mouth If oral route not possible: – IV dextrose 50%(500mg/cc); 50cc infused over 2-3 minutes Activate EMS Seizures… The most dramatic finding in medicine Belief that trained assistance is necessary Partial seizures – Simple partial Sz—”spells” – Complex partial Grand Mal – Generalized tonic-clonic (90%) Seizures… Petit Mal – Brief lapse of consciousness 5-10 seconds No tonic clonic movement Cyclic blinking Seizure prevention – Therapeutic blood levels Seizures… Management – Prevention of injury – Maintenance of adequate ventilation – Usually self limiting and not requiring intervention – ABC’s Cerebrovascular Accident… “Brain Attack” Causes – Hemorrhagic – Occlusive Signs and symptoms – Variable—violent to HA, dizziness, vertigo, loss of consciousness Management – ABC’s – Transport to hospital Chest Pain… Angina Pectoris – History, History, History – Location of pain Substernalradiating pain Treatment – – – – – Termination of procedure Position—upright ABC’s Vasodilators and oxygen EMS Acute Myocardial Infarct… Mangement – – – – – ABC’s vs. ABCD Activate EMS Oxygen Nitroglycerin ASA AED Automatic External Defibrillation Relationship Between Survival and Defib Time With each passing minute, survival rate drops 10% Out of hospital survival rates without defibrillation < 2 minutes: 8% Survival rates with defibrillation < 2 min: 30-89% FEATURES OF AED’s Monophasic defibrillators deliver 200-360 Joules in ONE direction Biphasic defibrillators deliver 150 Joules of energy in TWO directions (Double pass through the heart) Biphasic defibrillators are smaller, lighter, less expensive, and less demanding of batteries, with fewer maintenance requirements FEATURES OF AED’S Biphasic waveform shocks combined with impedance adjustment or compensation provides equivalent defibrillation success at lower energy levels than those of monophasic shocks Laboratory studies have verified and clinical human studies are supporting RESTRICTIONS CONTRAINDICATION Not recommended in children under 8 years and/or 90 pounds Not used unless adult patient has NO pulse Not to be used in moving vehicle AED’s ON THE MARKET Heartstream Forerunner (Agilent Technologies) Physiolcontrol 500 (Medtronics) SurvivaLink Quickstart (SurvivaLink) Laerdal HeartStart 911 (Laerdal) Respiratory Distress… Apnea—absence of respiratory movement Hyperventilation – Tachypnea – Treatment Hypoventilation—PaCO2 > 45 torr Hypoxia—deficiency of O2 Airway Obstruction… Partial vs. complete obstruction – Partial—coughing, wheezing—should allow the coughing to continue – Partial with weak cough reflex—crowing sound, prolonged inspiration In the conscious patient there is a good chance that the object well be swallowed or coughed up Asthmatic… Mangaement – – – – – Termination of procedure Position—upright Calming of the patient ABC’s Definitive care—administration of bronchodilator Management of Airway Position—supine Head tilt-chin lift Jaw-thrust maneuver Artificial ventilation Airway Obstruction Most common cause: tongue and/or epiglottis Opening the Airway Jaw thrust Head tilt–chin lift The Oropharyngeal Airway Malposition of Oropharyngeal Airway Too short Nasopharyngeal Airway Insertion technique Bag-Mask Ventilation Key—ventilation volume: “enough to produce obvious chest rise” 1-Person: difficult, less effective 2-Person: easier, more effective Cricoid Pressure Thyroid Cartilage Cricoid Equipment for Intubation Laryngoscope with several blades Tracheal tubes Malleable stylet 10-mL syringe Magill forceps Water-soluble lubricant Suction unit, catheters, and tubing Aligning Axes of Upper Airway A Mouth A B B Pharynx C C Trachea Extend-the-head-on-neck (“look up”): aligns axis A relative to B Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C Visualization of Vocal Cords Anatomy Vallecula Tongue Epiglottis Vocal cord Glottic opening Arytenoid cartilage Esophageal-Tracheal Combitube A = esophageal obturator; ventilation into trachea through side openings = B E C = tracheal tube; ventilation through open end if proximal end inserted in trachea D = pharyngeal cuff; inflated through catheter = E Distal End F = esophageal cuff; inflated through catheter = G H = teeth marker; blindly insert Combitube until marker is at level of teeth A C H Proximal End D B F G Esophageal-Tracheal Combitube Inserted in Esophagus A H D A = esophageal obturator; ventilation into trachea through side openings = B D = pharyngeal cuff (inflated) F = inflated esophageal/tracheal cuff H = teeth markers; insert until marker lines at level of teeth D B F Laryngeal Mask Airway (LMA) The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end. LMA Introduced Through Mouth Into Pharynx Anatomic Detail Cricothyroid Membrane With Horizontal Cricothyrotomy Incision CNS Depressant Drug Overdose… Position—supine ABC,s Administration of O2 – Positive pressure Administration of antagonist – BZD—flumazenil 0.2 mg repeat q 5 minutes (adult) 0.1 mg or 3ug/kg (child) – Opioid—Naloxone 0.4 mg IM/IV (adult) 0.01 mg/kg IM/IV (child)
