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Dental Office Emergencies Lecture 1 CO U RS E D I R EC TO R M S . M A R I A N N E KOZ E RO, R D H , B S D H CO N CO R D E C A R E E R CO L L EG E L EC T U R E : F R I DAY 1 : 3 0 - 3 : 0 0 DH111 4-14 Objectives •Put together emergency kit & identify the basic supplies of an emergency kit. •Describe the use of basic emergency kit supplies. •Properly administer Oxygen for patient emergencies. •Discuss the emergency reference charts. •Recognize & respond to a medical emergency in the dental office. •Utilize the medical / dental history in planning for an emergency. •Explain the essential components of an emergency kit in the dental office. Objectives •Discuss adult & pediatric doses of essential emergency drugs. •Describe the signs of common life's threatening emergencies in adults. •Differentiate between hypertensive urgency & emergency. •Explain the various methods of oxygen administration. •Discuss the armamentarium associated with oxygen administration. •Explain the proper methodology for oxygen administration. Medical Emergencies • Do occur in the dental office • 1/3 of all emergencies are life threatening • Increasing age of population and healthcare will lead to an increase in medical emergencies • Our goal as a health care professional is to recognize the signs and symptoms of a medical emergency and manage it correctly to prevent it from becoming a life-threatening situation. 4-14 ASA Classification • Patients with higher ASA classifications have a greater risk of medical emergency • ASA: American Society of Anesthesiologists • Pg. 3 Table 1.1 4-14 ASA I • Normal, healthy patient • Can walk up two flights of stairs or walk two city blocks without shortness of breath 4-14 ASA II • Mild systemic disease, or risk factors for a systemic disease like tobacco use, alcohol abuse, mild obesity. • Can walk up one flight of stairs or walk two city blocks, but may have shortness of breath upon completion Adult onset diabetes-type II: controlled Controlled Epilepsy Controlled hypertension (Stage 1) Allergies Pregnancy Fearful dental patient 4-14 ASA III • Severe systemic disease that limits activity but is not incapacitating. • Can walk up one flight of stairs or walk one city block, but must stop during the walk due to shortness of breath Stable angina Renal Failure MI longer than 6 months ago – no signs or symptoms Well-controlled diabetes Type I Controlled CHF: Congestive Heart Failure BP > 160/100 (Stage 2) Morbid obesity 4-14 ASA IV • Systemic disease that is incapacitating • Constant threat to life • Unable to walk up a flight of stairs or one city block • 4-14 May have shortness of breath or distress at rest MI or CVA within past 6 months Unstable angina BP > 180/110 Heart Failure Uncontrolled diabetes Uncontrolled epilepsy Uncontrolled thyroid condition ASA V • Moribund patient not expected to survive 24 hours with or without operation. Multiorgan failure Poorly controlled coagulopathy Sepsis with hemodynamic instability Dental professionals will see ASA I, II, and III patients. ASA IV, and V will most likely be hospitalized or bedridden. 4-14 Most Common Dental Emergencies • Syncope: 50% • Mild allergic reaction: 8% • Angina pectoris: 8% • Orthostatic hypotension: 8% Most likely to occur after the administration of a local anesthetic, extractions, or endodontics 4-14 Prevention • Thorough and detailed medical history • ASK QUESTIONS!!!! • Vital signs • Preparing for a medical emergency • Knowing where the emergency kit is located in the dental office. 4-14 Medical History Patients may report a condition that can increase the risk of a medical emergency Conditions may include: Heart conditions Asthma CVA Epilepsy Thyroid problems Diabetes Corticosteroid use Allergic Reactions Bleeding disorder 4-14 Positive Response • Further dialogue with patient • Determine frequency, severity, triggers • May need to postpone or modify treatment • May need to talk to the patient’s doctor for further information and/or clearance to treat the patient. 4-14 Preparation for Medical Emergencies in the Dental Office • Well-equipped medical emergency kit with O2 tank and AED (Automated External Defibrillator) recommended • Current CPR (Cardiopulmonary resuscitation) training • Attendance at CE courses on medical emergencies • In-office simulated medical emergencies 4-14 Management of Medical Emergency : R.E.P.A.I.R. • R- Recognize signs and symptoms • E- Evaluate patients level of consciousness • P- Positioning patient • A- Activate ABC of CPR • I- Implement emergency protocol for specific emergency • R- Refer patient to healthcare professional 4-14 Emergency Team Structure • P1 – person in whose operatory emergency is occurring Stays with patient Performs emergency procedure: CPR P2 – next most available person Assists P1 Responsible for vital signs and administers O2 Records events and informs P1 of time elapsed since medication delivered 4-14 Emergency Team Structure • P3 – next available person Retrieves emergency kit Prepares emergency drugs for P1 • Office receptionist Makes all necessary phone calls Pg 5. Table 1.2 4-14 Conclusion • Taking and recording accurate medical history • Recording vitals: getting a baseline • Preparation in event of emergency with current CPR, emergency drills, continuing education • Skill in using the emergency dental kit including oxygen 4-14 Emergency Kit • Use drugs familiar with • Custom designed • Readily available for use • Mobile • Easily accessible O2 11-14 Emergency Kit Simple and includes only materials with which the dental team is familiar and will use Consider location ◦ Urban setting with quick EMS response time – less components ◦ Rural setting – full complement of products ◦ Are we in an urban or rural setting and why? 11-14 Essential Drugs Oxygen –Inhaled, used in respiratory distress, cardiac disease. Do not use in hyperventilation!! 11-14 Oxygen Administration • Needed when breathing is inadequate for keeping the blood saturated with oxygen • In dental office usually supplied by portable O2 tank Green in color Several parts • Cylinder • Regulator • Flow meter Parts of O2 Tank Regulator • Regulator ~Reducing valve and flow meter Flow meter joined ~Allows for safe release of O2 outlet pressurized O2 ~Must be turned on Reducing valve Parts of O2 Tank • Flow meter Dial that allows operator to determine amount of O2 delivered Measured in liters/minute Amount determined by condition being treated and oxygen delivery device Types of Delivery Devices in Dental Office • Bag mask ~Two rescuers recommended ~During ventilation should see chest rise – if not, reposition head to open airway and/or bag mask Nasal cannula Non-rebreathing face mask 4-14 Essential Drugs • Epinephrine Anaphylaxis: severe allergic reaction • Counteracts major physiological events in anaphylaxis • Reduces hypotension, bronchospasm, laryngeal edema, prevents additional release of histamine and other chemical mediators • Rapid onset and short duration; vasodilator • Adult dosage - .3 mg of 1:1,000 concentration for intramuscular and intralingual injections • Pediatric dosage - .15 mg of 1:1,000 concentration 11-14 Essential Drugs Epinephrine ◦ Severe asthma attack if albuterol doesn’t work ◦ Should not use with ischemic heart disease or severe hypertension 11-14 Essential Drugs Nitroglycerine ◦ Angina pectoris, MI or CHF ◦ Dilates coronary blood vessels ◦ Rapid onset ◦ Tablet and spray form ◦ Tablets become impotent or useless if exposed to light or air 11-14 Essential Drugs Nitroglycerine Administer sublingually Administer at 5 minute intervals – up to 3 doses Should not administer if systolic BP < 90 mmHg 11-14 Essential Drugs Diphenhydramine or Chlorpheneramine ◦ Mile, non-life threatening allergic reactions with respiratory symptoms ◦ Oral histamine blocker ◦ Chlorpheneramine – 10 mg or Diphenhydramine 25 – 50 mg for adults ◦ Pediatric dosage- 1 mg/kg of body weight and should not exceed the adult dosage. 11-14 Essential Drugs Diphenhydramine or Chlorpheneramine Intramuscular histamine blocker Diphenhydramine 25 – 50 mg or Chlorpheneramine 10 – 20 mg Pediatric dose is 1 mg/kg of body weight and should not exceed adult dose Chlorpheneramine does not cause as much drowsiness 11-14 Albuterol Asthma attack or bronchospasm Inhaler Dilation of bronchioles with minimal cardiovascular effects Quick onset – 30 to 60 minutes Long duration of action – 4 to 6 hours Adult dose 2 sprays Pediatric dose 1 spray Can repeat dose if necessary 11-14 Essential Drugs Figure 2.7 Albuterol inhaler Essential Drugs Aspirin ◦ Reduces overall mortality from (MI) ◦ Prevents progression of cardiac ischemia to cardiac injury or cardiac tissue death ◦ Recommended dose 162 mg – 325 mg: 2 - 4 baby aspirin (81 mg each) ◦ Check medical history for allergy 11-14 Essential Drugs Oral Carbohydrate- (Glucose) ◦ ◦ ◦ ◦ ◦ for conscious patients Hypoglycemia Not actually a drug, but inclusion necessary Paste or tablets do not require refrigeration ALWAYS ask diabetic patients if they ate before their visit and look for hypoglycemic signs 11-14 Supplemental Drugs • Glucagon Unconscious hypoglycemic patient Administered IM Adult dose – 1 mg Pediatric dose–0.5 mg Supplemental Drugs Atropine Hypotension Increases heart rate which may also increase BP Recommended dosage – 0.5 mg/ml IM 3 mg maximum 11-14 Supplemental Drugs Corticosteroid Prevention of recurrence of anaphylaxis Adrenal crisis 100 mg hydrocortisone drug of choice for dental office emergency kit Reduce histamine release Slow onset > 1 hour 11-14 Supplemental Drugs Injectable Benzodiazepine ◦ ◦ ◦ ◦ Prolonged seizures or hyperventilation Skeletal muscle relaxation – anticonvulsant Lorazepam drug of choice 4 mg IM 11-14 Additional Items BP cuff and stethoscope 11-14 Additional Items Thermometer with sleeves: to check for fever Perioretriever: a magnetized device for the removal of broken instrument tips. 11-14 Additional Items Pocket mask with one-way valve 11-14 Additional Items Syringes: to deliver IM drugs Bandaids and sterile gauze: for minor cuts and burns 11-14 Additional Items Ice pack: for burns or bruises 11-14 Additional Items AED : automated external defibrillator 11-14 Case Scenario 1 Your 1:00 p.m. oral prophylaxis patient is John Brown, a 79-year-old male retired service salesman for an automobile dealership. He is in fair health, having suffered from a previous myocardial infarction four years ago. You take his vital signs (pulse, respiration, and blood pressure) and find the following readings: Pulse: 102 beats per minute Respiration: 22 per minute and exaggerated Blood pressure: 150/98 mmHg What can you conclude from these vital signs? 11-14 Vital Signs Accurate taking and recording of vital signs is essential to comprehensive patient care. Baseline vital signs are needed for comparison during medical emergency to determine severity. Vital signs – determine the body’s ability to pump blood and breathe – also determine health status of patient. An elevated temperature may indicate the presence of infection. Vital signs and health history are used to determine a patient’s health before providing dental treatment.** 11-14 Vital Signs Pulse Respiration Blood pressure Temperature TAKE AT EVERY APPOINTMENT!! 11-14 From the moment patient walks in, start to evaluate their health: Gait Eyes Speech Skin color Weight gain/loss • It is okay to ask “Are you feeling okay today?” Vital Signs • Baseline pulse, respiration, temperature and blood pressure essential. • Irregular vital signs can be an indication of a medical emergency. • Hypertensive (high BP) or hypotensive (low BP) Patients are more likely to experience various medical emergencies. 4-14 Normal Pulse Rates •Babies to age 1: 80-120 BPM •Children 1 to 10 yrs: 70-130 BPM •Children age 10+ and adults: 60-100 BPM •Well-conditioned athletes: 40-60 BPM 11-14 Pulse Bradycardia – less than 60 BPM May be caused by sleep, certain drugs, fasting, or disease.** May cause lightheadedness, dizziness, chest pain, syncope, circulatory collapse. Treated with atropine to increase heart rate. If patient often experiences bradycardia may need a medical referral for an implantable pacemaker. Should also assess rhythm and strength. Rhythm – relation of one pulse to another as measured by regularity of action. Irregular pulse could be a sign of arrhythmia. 11-14 Respiration External respiration Process by which O2 and CO2 exchanged O2 taken in and CO2 eliminated via lungs Internal respiration Use of O2 Production of CO2 Exchange between cells Involuntary 11-14 Respiration Rate • Tachypnea – abnormally fast rate > 20 breaths/min • Often seen in hyperventilation (discussed in separate chapter) • Bradypnea – slow rate < 12 breaths/min • Often seen in syncope • Apnea – absence of breathing • If continues results in respiratory arrest • Cannot sustain life as brain requires O2 • O2 deprivation of 10 minutes or longer leads to coma or death 11-14 Respiration Process ◦ Immediately following pulse so patient is unaware and is not controlling breathing ◦ Move patient’s arm over stomach and continue as if monitoring pulse rate ◦ Count number of times patient’s chest rises in 30 seconds, multiply by 2 ◦ If respiration is irregular count respirations for 60 seconds 11-14 Respiration ◦Abnormal patterns ◦ Biot’s – periods of shallow breathing, alternating with apnea (pt’s with neurological problems, head trauma, brain abscesses and heat stroke) ◦ Cheyne-Stokes – increased rate and depth alternating with apnea ◦ Often seen in heart failure and drug overdose ◦ Kussmaul – increased depth and rate > 20 ◦ Often seen in hyperventilation, diabetic ketoacidosis, or renal failure 4-14 Temperature Measure of heat associated with metabolism of body Normal 98.6° F (37.5° C) +/- 1 degree Body temp of 99.5 considered elevated** In clinic, patient’s with a temp of 100.4 will be dismissed. Wait 15 minutes to take temp if patient has been eating, smoking or drinking something hot.** 11-14 Temperature Pyrexia/fever – abnormal elevation in body temp ◦ Infection ◦ Neurological disease ◦ Malignancy ◦ CHF: Congestive Heart Failure ◦ Trauma ◦ Drugs ◦ Convulsions or delirium may occur with extremely high fevers ◦ Exercise** ◦ Ingestion of hot food or drink** ◦ Smoking** 11-14 Temperature Hypothermia • reduced body temperature • Shivering • Cool skin • Pallor Etiologies • Starvation** • Shock** • Illness • Trauma • Malnutrition • Medications • Should refer to MD 11-14 Factors Affecting Blood Pressure Blood pressure depends on: heart’s contractile force, peripheral vascular resistance, and vascular volume.** Blood vessel resistance ◦ Reduced elasticity of vessels (atherosclerosis) increases BP Age ◦ Elderly higher BP due to atherosclerosis Gender ◦ Men and postmenopausal women, higher BP 11-14 Factors Affecting Blood Pressure Blood volume Additional blood (transfusion) increases BP Reduction in blood (hemorrhage) decreases BP Blood viscosity Increased thickness causes heart to contract more forcefully thus increasing BP 11-14 Factors Affecting Blood Pressure Blood pressure depends on: heart’s contractile force, peripheral vascular resistance, and vascular volume.** Blood vessel resistance ◦ Reduced elasticity of vessels (atherosclerosis) increases BP Age ◦ Elderly higher BP due to atherosclerosis Gender ◦ Men and postmenopausal women, higher BP 11-14 Blood Pressure Risks Higher diastolic readings in people 50 or younger at risk for heart attacks, strokes (CVAs), and kidney failure. Higher systolic readings in people 50 and over can be at risk for hypertension, stokes (CVAs), heart attacks (MI), heart failure, kidney damage, blindness, and other conditions. 11-14 4 Classifications of BP Levels in Adults Category Systolic Diastolic Normal <120 And <80 Prehypertension 120 – 139 Or 80 - 89 Stage 1 Hypertension 140 – 159 Or 90 - 99 Stage 2 Hypertension >160 Or > 100 High Blood Pressure Case Scenario 1 Conclusion •John Brown’s vital signs are significantly elevated. His pulse is 102. Normal pulse range is 60-90 beats/min. His respirations are 22 and exaggerated, whereas the normal RR is 12-20. His BP places him in stage 1 hypertension range. Taken in combination, this individual should be referred to his physician for an examination prior to treatment. 4-14 Case Scenario 2 Your 2:00 p.m. patient, Harry Fredericks, is a 62-year-old male postal worker and is new to your practice. His history indicates daily intake of hypertension medications, but he states that he does not like to take them due to the side effects. Other than the hypertension, his medical history is negative. You take his blood pressure and find that it is 188/112 mmHg. His pulse rate is 86 and his respiration rate is 16. What is the medical significance of the information stated by the patient and the recorded blood pressure? 11-14 Hypertensive Emergency/Crisis** Symptoms – similar to MI or CVA – difficult to determine exact emergency – Sudden increase in BP > 180/110 often as high as 220/140 – Dyspnea (labored breathing) – Chest pain – Dysarthria (difficulty speaking) – Weakness – – – – – 11-14 Altered consciousness Visual loss Seizures Nausea/vomiting Eventually coma Hypertensive Emergency/Crisis • Treatment Treat quickly to reduce the blood pressure to prevent further end organ damage like acute MI, aortic dissection, or CVA. Treating hypertension secondary Seat patient upright Contact EMS Monitor vital signs Administer O2 4-6L/minute In hospital setting pt given vasodilators, nitroglycerin. 11-14 Case Scenario 2 Conclusion •Harry Fredericks indicated that he has a history of hypertension, but is noncompliant in the use of antihypertensives. His extremely high BP and lack of any other form of target end organ damage should indicate to the clinician that he is most likely suffering from hypertensive urgency; however, the final determination on the diagnosis will be performed in the emergency department. The clinician retook Harry’s BP and determined it to be significantly elevated at 186-110mmHg. Harry was seated upright, and EMS was contacted. Oxygen was administered via nasal cannula at 4L/minute. Harry was treated in the emergency room for hypertensive urgency and was given Captropril, an angiotensin-converting enzyme inhibitor. He was administered the drug orally, and within 30 minutes his BP had returned to a reasonable range. After this experience Harry was convinced that his hypertension was a serious concern and he took his antihypertensive medication as prescribed. 4-14 Hypotension Abnormal condition in which BP is not adequate for perfusion and oxygenation of body tissues Usually reduction in baseline systolic or diastolic BP of 15 – 20 mmHg Often caused by medications (antihypertensive) Can lead to shock due to the sudden blood pressure reduction. 11-14 Hypotension Treatment ◦Position supine with feet raised ◦Assess airway ◦Administer O2 4-6L/minute ◦Monitor vital signs ◦If no improvement, contact EMS 11-14 Orthostatic Hypotension • Postural hypotension • Sudden drop in BP due to change in body position • Usually from supine to sitting or standing • Dizziness or loss of consciousness may occur • Etiologies Prolonged supine positioning Illness Medications (anti-hypertensive) Normally hypotensive individuals Orthostatic Hypotension • Symptoms Dimming of vision Decreased hearing Lightheadedness • Treatment Position supine with feet raised Assess airway Administer O2 4-6L/minute Monitor vital signs every 5 minutes If no improvement, contact EMS Board ? If the mask becomes fogged when oxygen is delivered to a patient, it indicates which of the following? a. Flow meter is set too high. b. Mask does not fit the patient correctly c. Tank is empty, and no further oxygen is available d. Patient has started breathing D ` 4-14