Medical Emergencies in Dental Practice

James G. Green, M.D., D.D.S., F.A.C.D. Dept. of Oral and Maxillofacial Surgery University of Florida College of Dentistry

Medical Emergencies

When you prepare for emergencies, they cease to exist! Malamed

Medical Emergencies

You have to have seen it to recognize it.

Greens Rule

Medical Emergencies

In case of an office emergency, the first procedure is to take your own pulse.

House of God Rule #3 (modified)

Medical Emergencies in the Dental Office

Hyperventilation Seizures Hypoglycemia Vasodepressor syncope Postural hypotension Asthma Angina Allergy 29% 20% 14% 11% 7% 7% 5% 5%

Medical Emergencies
Office preparation
Emergency procedure manual
Define each individuals responsibilities Standardize equipment and train employees on location, set-up, function and use Establish a regular maintenance schedule and equipment checks

Medical Emergencies
Office preparation
Practice emergency procedures
Identify problems Demonstrates capabilities Set-up and use of equipment Improve performance Determine additional needs

Medical Emergencies

Office preparation
Post emergency numbers on or around each telephone

Medical Emergencies
Office preparation
Determine equipment needs
Dependent upon:
Training Skills Patient base Practice type Types of emergencies frequently seen

Medical Emergencies
Emergency protocols
Develop treatment protocols for each common dental office emergency Post where easily retrieved Write in simple and easily followed stepby-step instructions

Airway Management
It is essential that every practitioner be able to: 1. Maintain an airway 2. Manage an upper airway obstruction

Physical Evaluation
Main purpose is to estimate the risk or probability of a patient having an emergency during treatment

Airway Evaluation
Body habitus
Size of Neck
Short, muscular neck

Height and weight

Status of dentition
Full dentition vs. edentulous Protruding central incisors

Retrognathia

Airway Evaluation
High arched palate with long narrow mouth Trismus or TMJ disease Cervical mobility Distance from chin to thyroid cartilage

Mallampati Airway Classification

Airway Angles

Airway Angles

Airway Angles

Airway Obstruction
Most common cause
Tongue
Treat by jaw thrust or chin lift - head tilt maneuver

Tongue Obstruction

Head Tilt - Open Airway

Airway Obstruction
Other causes
Foreign bodies
Treat by retrieving foreign body
Finger sweep Heimlich maneuver Chest thrust

Darwin Award Nominee - 1998

Phillipsburg, NJ An unidentified 29 year old man choked to death on a sequined pastie he orally removed from an exotic dancer. The dancer referred to only as Ginger said, She didnt know he was going to eat it.

Airway Obstruction
Other causes
Laryngospasm
Suction hypopharynx Positive pressure ventilation Succinylcholine (if experienced) Cricothyroidotomy (if experienced)

Airway Obstruction
If unable to clear obstruction by standard measures within 4-5 minutes:
Emergent cricothyroidotomy

Neck - Topographical Anatomy

Anterior Neck Anatomy

Anterior Neck Anatomy

Cricothyroid Membrane

Airway Adjuncts
Oropharyngeal airways Nasopharyngeal airways Mask-to-mouth airway Bag valve mask with reservoir

Airway Adjuncts
Nasopharyngeal airways

Airway Management
Nasopharyngeal airways
Length - nose to tragus of ear Size - little finger (guide) Insertion
Lubrication Insertion Position

Surgilube

Nasopharyngeal Airway

Airway Adjuncts
Oropharyngeal airways

Airway Management
Oropharyngeal airways
Unconscious patients only!! Correct size
Age

Insertion Position

Oropharyngeal Airway

Mouth-to-Mask Airway

Mouth-to-Mask Airway

Mouth-to-Mask Airway

Bag Valve Mask

Bag Valve Mask Reservoir

Bag Valve Mask

Bag Valve Mask

Airway Management
Ambu bag
Experience Practice Volume How many dentists does it take to use an Ambu bag?

Airway Adjuncts
Oxygen
All patients with medical emergencies need oxygen
No distress 2 L/m via nasal cannula Mild distress 5-6 L/m via face mask Moderate to severe distress 10 L/m via face mask with reservoir Unconscious 100% via intubation

Oxygen

Oxygen Masks
Nasal cannula
1-6 L/m 24-44% oxygen

Face mask
8-10 L/m
10 L/m

40-60% oxygen
~100% oxygen

Face mask with reservoir

Venturi mask
24, 28, 35, 40% oxygen

Airway Management
Nasal cannula
Readily accepted

Mask with reservoir

Poorer acceptance

Mask-to-mouth device
Separate provider from patient Oxygen inlet valve Clear mask Seal

Airway Adjunct
Paper bag

Airway Adjuncts
Yankauer Suction

Resuscitation
ABCs
Airway Breathing
Assess for airway obstruction Assess for respiratory arrest

Circulation
Assess for cardiac arrest

Resuscitation
CPR
BLS designed to maintain circulation of oxygenated blood to the heart and brain until definitive medical treatment can restore normal or sufficient heart and ventilatory function Rapid EMS response with early ACLS required for best chances of survival

Resuscitation
Most cardiac arrest victims have ventricular fibrillation
Supports early use of automated external defibrillators (AEDs) or manual defibrillators

Resuscitation
Ventricular fibrillation
Only treatment is defibrillation 90% of patients with V-fib survive neurologically intact if treated with defibrillation within 1-2 minutes Success of resuscitation decreases linearly with each minute (50% - 4-5 minutes, <10% - 9 minutes) Converts to asystole in minutes

Resuscitation
Survival of other cardiac arrest rhythms poor (~ 85 % die)

Case Scenario
An 14 year old female presents for routine restorative dentistry. She has never had a cavity diagnosed until today. She is in your office and will need two simple Class I restorations.

Case Scenario
Past Medical History
Medications: None

Allergies: None
PSH: None ROS: Noncontributory

Case Scenario
Prior to the injections you note she is sighing frequently. During the injections, she yells that it hurts and starts crying. She becomes panicky and inconsolable. Two minutes later she starts complaining of midsternal chest pain.

Case Scenario
What is your diagnosis?

Case Scenario
Five minutes after the injections, she becomes unconscious.

Hyperventilation

Causes of Hyperventilation
Anxiety
Most common

Metabolic conditions
Pain Metabolic acidosis Drug intoxication Hypercapnia CNS disorders

Predisposing Factors
Anxiety
Most common

Age
15 - 40 years of age No sex difference

May develop with other medical conditions

Case Scenario
What is the pathophysiology of this minor emergency?

Pathophysiology
Increased respiratory rate causes:
Acute decrease in PaCO2 and rise in blood pH
Cerebral vessels constrict Decreased PaCO2 depresses respiratory drive Unconscious Apnea

When PaCO2 rises and pH decreases, the patient will begin breathing again
May repeat cycle

Case Scenario
What other physical signs and symptoms assist in making the diagnosis?

Hyperventilation
Signs
Tachypnea Tachycardia Unconsciousness

Symptoms
Dizziness Lightheadedness Chest pain Palpitations Numbness
Lips, extremities

SOB Nausea / Pain

Case Scenario
How do you treat it?

Management
Terminate procedure Position patient Calm patient Rebreathing bag Sedation

Case Scenario
A 25 year old male construction worker presents for removal of his third molars. He has 4 erupted thirds which you feel you can remove without difficulty or sedation. He has come from a job site. The outside temperature today was 103 F. He passed up his usual beers after work with his buddies.

Case Scenario
PMH:
Meds: None Allergies: None Illnesses: None PSH: ORIF of left femur fracture from a motorcycle accident ROS: Noncontributory

Case Scenario
During administration of local anesthesia, he becomes jittery, pale and diaphoretic. He appears anxious and disoriented.

Case Scenario
What is your differential diagnosis?
Be specific!

What would you do first? What is your treatment?

Case Scenario
Vital signs
BP - 80/40 P 80 regular R 14

Case Scenario
After your treatment, he recovers sufficiently to allow you to do the extractions. The case goes well and after the procedure, the assistant sits him up and he again becomes faint and dizzy. A half hour later, you need to go home. You put him in a wheelchair and your assistant takes him to his car.

Case Scenario
His girlfriend who met him at your office will drive him home. When he stands up to get into the car, he passes out.

Case Scenario
What is your differential diagnosis?
Be specific!

How does treatment for this differ from your previous treatment? How can you differentiate clinically between these two types?

Syncope

Syncope
Syncope and death are the same except that in one you wake up. Anonymous

Syncope

The sudden transient loss of consciousness

Usually < 1 minute

Syncope
Incidence
Presyncope Syncope Universal 50%

Syncope accounts for ~ 3% of all ER visits and may account for up to 6% of hospital admissions

Syncope
Definitive diagnosis of syncope is made in only about 50% of case. ER physicians can make a definitive diagnosis in only ~ 25% of cases 25% of all patients referred to cardiologist for cardiac work-up have syncope and not cardiac disease

Pathophysiology of Syncope
Lack of oxygen and blood to the brain
Nonspecific with multiple causes

Lack of glucose to the brain Seizure activity

Causes of Syncope
Cardiac Peripheral vascular Cerebrovascular Hyperventilation Hypoglycemia Seizures

Seizures and Syncope

Difficulty is determining whether the seizure caused the faint or the faint caused the seizure
Generalized clonic jerks result from cerebral anoxia Cant rely on tongue-biting and urination

Seizures and Syncope

Evaluate by history
Abrupt loss of consciousness with simultaneous tonic-clonic seizure activity with a slow recovery phase
Suggests seizure

Syncope rapid recovery

Cardiac Events and Seizures

Most remediable cause of seizures Most lethal cause of seizures 3 broad catagories:
Rhythm disturbances Ventricular outflow obstruction Myocardial ischemia

Arrhythmias and Syncope

Often difficult to prove Usually requires a heart rate of >150 or <40 beats per minute

Ventricular Outflow and Syncope

Aortic stenosis
Prevalvular Postvalvular

Mitral stenosis Tumors (rare)

Vasovagal Syncope
Most commonly observed potentially lifethreatening emergency seen in the dental office

Vasovagal Syncope
Synonyms
Simple faint Swoon Vasodepressor syncope Psychogenic syncope Neurogenic syncope

Precipitating Factors
Psychogenic
Fright Anxiety Emotional stress Pain Site of Blood

Precipitating Factors
Nonpsychogenic
Prolonged sitting or standing Hunger Exhaustion Poor physical condition Hot humid crowded environment

Early Signs
Feeling of warmth Loss of color (pale) Sweating Nausea Faint Tachycardia Normal BP

Late Signs
Yawning Cold Dizziness Rapid breathing Pupillary dilation Hypotension Bradycardia Loss of consciousness

Stages
Presyncope Syncope Postsyncope

Presyncopal Management
Terminate treatment Protect patient from falling Trendelenberg position Oxygen if necessary

Syncopal Management
Trendelenberg position Protect the airway Monitor vital signs Oxygen

Postsyncopal Management

Discontinue treatment Determine cause of event

Treat appropriately

Arrange for patient to be taken home by relative or friend when stable or to hospital

Recurrent Syncope
Look for other causes
Orthostatic Seizures Cardiac TIA Hypoglycemia Hyperventilation

May need hospitalization

Case Scenario
A 55 year old female presents for dental implants with IV sedation.

Case Scenario
PMH:
Medications: Allergies: Illnesses: PSH: None None None None

Case Scenario
An IV is started and she is given Versed and Fentanyl initially. She receives 1 g of Kefsol IV as antibiotic prophylaxis and 2 minutes later complains of itchy skin, develops a diffuse patchy rash, watery eyes and a runny nose. She feels nauseated and complains of stomach cramps.

Case Scenario
What is your diagnosis?

Allergy

Allergy
Hypersensitivity state
Requires exposure to antigen Body develops antibodies to antigen Re-exposure to antigen elicits reaction

Allergy
Variable reactions
Dermatological (most common) Respiratory
Nasal / Pulmonary

CNS CV Generalized anaphylaxis (rare)

Type I Reaction

IgE-mediated Immediate response Affects 10% population Inherited tendency

Type I - Antigens
Drugs most commonly associated with allergic reactions
PCN Sulfa derivatives Narcotics ASA NSAIDS

Case Scenario

What are some of the common dermatological manifestations of allergic reactions?

Dermatological Reactions
Urticaria Wheal and flare Pruritis Angioedema Conjunctivitis Rhinitis
Rarely life-threatening if sole reaction May be first indication of a more generalized reaction to follow

Case Scenario

What are the available treatments for dermatological signs of allergic reactions?

Treatment
Dermatological reactions
Delayed (> 1 hour)
Benadryl 50 mg PO q 6 h for 3-4 days

Immediate (< 1 hour)

Epinephrine 0.3 mg IM or SC Benadryl 50 mg IM Transfer to ER Benadryl 50 mg PO q 6 h for 3-4 days

Case Scenario
You give the patient Benadryl 50 mg IV and 20 minutes later she starts to wheeze and complain of shortness of breath. Her blood pressure is slowly decreasing. What should you do now?

Bronchospasm Treatment
Terminate therapy Position patient to comfort Oxygen 5-6 liters/minute via cannula or mask Epinephrine 0.3 mg IM or SC or Medihaler-epi q 5 minutes as required Benadryl 50 mg po q 6 h for 3-4 days Start an IV (if capable) and give NS Call 911

Respiratory Reactions
Bronchospasm
Dyspnea, wheezing, flushing, cyanosis, diaphoresis, tachycardia, anxiety, accessory muscle use

Laryngeal edema
Stridor or crowing

May be indication of a developing generalized reaction

Laryngeal Edema Tx
Epinephrine 0.3 mg IM or SC q 5 minutes prn Maintain airway Oxygen 5-6 liters/minute by face mask Start IV (if capable) with NS Benadryl 50 mg IM or IV Solucortef 100 mg IM or IV Cricothyroidotomy (if necessary)

Case Scenario
You cant find your emergency drug kit. The patient is now confused and uncooperative. His BP is 70/0 and his HR is 140. What should you do?

Generalized Anaphylaxis
BLS Epinephrine 0.3 mg IM or IV q 5 minutes prn Oxygen Monitor VS q 5 minutes

Generalized Anaphylaxis
Usually rapid onset (5 to 30 minutes, occasionally delayed for hours) Respiratory and cardiovascular problems predominate and occur early in the reaction Death can occur in minutes

Local Anesthetics
Esters >>> Amides
Overall incidence very, very low No esters available in dental cartridges

Antigenic components
Parabens - PABA, Methylparabens Metabisulfite Bisulfites

Local Anesthetics
Allergy History
Must try to differentiate between true allergy, overdose, intravascular injection, vasoconstrictor reaction or idiosyncratic reaction
Requires good dialogue history with patient

If questionable history, refer to allergist

Penicillin
2.5 million people allergic Allergic reaction reported in 5-10% of patients receiving penicillin Fatal reaction in 1 per 100,000 Most frequent cause of generalized anaphylaxis in dental practice

Chest Pain

Chest Pain
Origin
Cardiac Pulmonary Musculoskeletal
Neck, thorax, shoulder

Upper abdominal viscera

Chest Pain
Classification
Recurrent
Mild to moderate intensity

Severe
Prolonged pain

Recurrent Chest Pain

Angina pectoris
Most important but not the most frequent cause of recurrent chest pain Secondary to transcient myocardial ischemia (imbalance between oxygen supply and tissue oxygen demands)

Musculoskeletal
Responsible for the majority of recurrent chest pain

Recurrent Chest Pain

Other causes
Anxiety states Reflux esophagitis +/- hiatal hernia
Associated with large meals, alcohol, highly seasoned food, chocolates, coffee Nocturnal and associated with recumbancy Relieved by nitroglycerin

Diffuse esophageal spasms

Associated with meals Relieved by nitroglycerin

Musculoskeletal Pain
Characteristics
Neck, shoulder and thorax most common locations Tends to occur at night Precipitated or intensified by fatigue, posture, movement, coughing, sneezing Long duration of pain (often hours) Pain dull, aching with sharp twinges Relief characterized by rest, heat, postural exercises and analgesics

Angina Pectoris
Causes:
Coronary artery atherosclerosis Coronary artery spasm Coronary artery thrombosis Multiple other cardiac and pulmonary etiologies:
Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection

Angina Pectoris
May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X) Uncommon in males less than 40 Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia

Angina Pectoris
Clinical characteristics
Poorly localized pain
Usually retrosternal but may occur anywhere from lower jaw to umbilicus

Brief duration
2-10 minutes

Moderate intensity pain described as squeezing, oppressive, burning or heavy

Angina Pectoris
Clinical characteristics
Precipitated by:
Emotional distress Physical exertion Heavy meals Cold Walking up stairs or hills

Exacerbated by:
Recumbency

Angina Pectoris
Clinical characteristics
Excluded if:
Pain localized with one finger Lasts less than 30 seconds or longer than 30 minutes Pain described as sticking, jabbing, throbbing or constantly severe

Angina Pectoris
Types of angina pectoris
Stable
Pain pattern repeatable for frequency, intensity, duration, provocation and response to nitroglycerin and rest

Unstable
Pain pattern changed in one or more characteristics (frequency, intensity, duration, provocation, response to nitroglycerin or cessation of activity) May occur at night or rest

Angina Pectoris
Unstable angina pectoris
Indicative of progressive coronary artery disease Indistinguishable from MI Requires admission to rule out MI
Enzymes - CPK-MB, LDH, Troponin I and T Serial EKGs Clinical history

Angina Pectoris
Dialogue history
Determine:
Angina description
Classical, atypical or equivalent angina

Frequency Duration of pain Precipitating factors

Activity level Stressors

Treatment
Medications

Angina Pectoris
Dialogue history
Risk factors
Smoking Hyperlipidemia Obesity Sedentary life style Alcohol consumption Hypertension Diabetes mellitus

Angina Pectoris
Dialogue history
Risk factors
Sex
Male Postmenopausal female

Age Genetics
Family history

Race
Blacks > Caucasians

Angina Pectoris
Treatment
Stop procedure Position patient to comfort Oxygen 2-3 L per NC or face mask Nitroglycerin 0.4 mg SL
Repeat q 5 minutes x 3 total doses If no response, assume MI or unstable angina Activate EMS and transfer to ER

Angina Pectoris
Diagnostic approach
Nitroglycerin
Normally relieves pain in 3 minutes or less Failure to relieve pain after 10 minutes evidence against angina Failure to relieve pain indicates either unstable angina or myocardial infarction

Angina Pectoris
Function of nitroglycerin
Dilates coronary arteries to increase blood flow and improve oxygen delivery to cardiac tissue Platelet disaggregation

Angina Pectoris
Dental treatment
Early AM appointments Short appointments Consider oxygen and prophylactic nitroglycerin Stress reduction protocols
Good local anesthesia Nitrous oxide PO or IV sedation

Myocardial Infarction

Myocardial Infarction
Cardiac ischemia which results in myocardial necrosis

Myocardial Infarction
Pain more intense and longer in duration than angina pectoris Pain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectoris Not relieved by SL nitroglycerin or cessation of activity

MI Signs and Symptoms

Symptoms
Pain Nausea/Indigestion Weakness/Fatigue Dizziness Palpitations Sense of impending doom SOB Lightheadedness

Signs
Restlessness Acute distress Vomiting Diaphoresis Cardiac arrhythmia Pallor Cyanosis Dyspnea Wheezing

Myocardial Infarction
Dialogue history
History of angina pectoris Changes in angina pectoris Previous MI
When, Treatment, Outcome, Current status

Medications Risk factors

Management of Acute MI
Recognition BLS
Airway Breathing Circulation Activate EMS

Oxygen - 4-5 L by NC or face mask

Management of Acute MI
Monitor VS Position to comfort Pain relief
Morphine sulfate 2-5 mg IM/IV q 5-15 minutes prn
Controls pain and reduces anxiety

Prepare to perform CPR or provide ACLS (if properly trained)

Management of Acute MI
Transfer to ER

Chest Pain

Chest Pain
Origin
Cardiac Pulmonary Musculoskeletal
Neck, thorax, shoulder

Upper abdominal viscera

Chest Pain
Classification
Recurrent
Mild to moderate intensity

Severe
Prolonged pain

Recurrent Chest Pain

Angina pectoris
Most important but not the most frequent cause of recurrent chest pain Secondary to transcient myocardial ischemia (imbalance between oxygen supply and tissue oxygen demands)

Musculoskeletal
Responsible for the majority of recurrent chest pain

Recurrent Chest Pain

Other causes
Anxiety states Reflux esophagitis +/- hiatal hernia
Associated with large meals, alcohol, highly seasoned food, chocolates, coffee Nocturnal and associated with recumbancy Relieved by nitroglycerin

Diffuse esophageal spasms

Associated with meals Relieved by nitroglycerin

Musculoskeletal Pain
Characteristics
Neck, shoulder and thorax most common locations Tends to occur at night Precipitated or intensified by fatigue, posture, movement, coughing, sneezing Long duration of pain (often hours) Pain dull, aching with sharp twinges Relief characterized by rest, heat, postural exercises and analgesics

Angina Pectoris
Causes:
Coronary artery atherosclerosis Coronary artery spasm Coronary artery thrombosis Multiple other cardiac and pulmonary etiologies:
Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection

Angina Pectoris
May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X) Uncommon in males less than 40 Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia

Angina Pectoris
Clinical characteristics
Poorly localized pain
Usually retrosternal but may occur anywhere from lower jaw to umbilicus

Brief duration
2-10 minutes

Moderate intensity pain described as squeezing, oppressive, burning or heavy

Angina Pectoris
Clinical characteristics
Precipitated by:
Emotional distress Physical exertion Heavy meals Cold Walking up stairs or hills

Exacerbated by:
Recumbency

Angina Pectoris
Clinical characteristics
Excluded if:
Pain localized with one finger Lasts less than 30 seconds or longer than 30 minutes Pain described as sticking, jabbing, throbbing or constantly severe

Angina Pectoris
Types of angina pectoris
Stable
Pain pattern repeatable for frequency, intensity, duration, provocation and response to nitroglycerin and rest

Unstable
Pain pattern changed in one or more characteristics (frequency, intensity, duration, provocation, response to nitroglycerin or cessation of activity) May occur at night or rest

Angina Pectoris
Unstable angina pectoris
Indicative of progressive coronary artery disease Indistinguishable from MI Requires admission to rule out MI
Enzymes - CPK-MB, LDH, Troponin I and T Serial EKGs Clinical history

Angina Pectoris
Dialogue history
Determine:
Angina description
Classical, atypical or equivalent angina

Frequency Duration of pain Precipitating factors

Activity level Stressors

Treatment
Medications

Angina Pectoris
Dialogue history
Risk factors
Smoking Hyperlipidemia Obesity Sedentary life style Alcohol consumption Hypertension Diabetes mellitus

Angina Pectoris
Dialogue history
Risk factors
Sex
Male Postmenopausal female

Age Genetics
Family history

Race
Blacks > Caucasians

Angina Pectoris
Treatment
Stop procedure Position patient to comfort Oxygen 2-3 L per NC or face mask Nitroglycerin 0.4 mg SL
Repeat q 5 minutes x 3 total doses If no response, assume MI or unstable angina Activate EMS and transfer to ER

Angina Pectoris
Diagnostic approach
Nitroglycerin
Normally relieves pain in 3 minutes or less Failure to relieve pain after 10 minutes evidence against angina Failure to relieve pain indicates either unstable angina or myocardial infarction

Angina Pectoris
Function of nitroglycerin
Dilates coronary arteries to increase blood flow and improve oxygen delivery to cardiac tissue Platelet disaggregation

Angina Pectoris
Dental treatment
Early AM appointments Short appointments Consider oxygen and prophylactic nitroglycerin Stress reduction protocols
Good local anesthesia Nitrous oxide PO or IV sedation

Myocardial Infarction

Myocardial Infarction
Cardiac ischemia which results in myocardial necrosis

Myocardial Infarction
Pain more intense and longer in duration than angina pectoris Pain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectoris Not relieved by SL nitroglycerin or cessation of activity

MI Signs and Symptoms

Symptoms
Pain Nausea/Indigestion Weakness/Fatigue Dizziness Palpitations Sense of impending doom SOB Lightheadedness

Signs
Restlessness Acute distress Vomiting Diaphoresis Cardiac arrhythmia Pallor Cyanosis Dyspnea Wheezing

Myocardial Infarction
Dialogue history
History of angina pectoris Changes in angina pectoris Previous MI
When, Treatment, Outcome, Current status

Medications Risk factors

Management of Acute MI
Recognition BLS
Airway Breathing Circulation Activate EMS

Oxygen - 4-5 L by NC or face mask

Management of Acute MI
Monitor VS Position to comfort Pain relief
Morphine sulfate 2-5 mg IM/IV q 5-15 minutes prn
Controls pain and reduces anxiety

Prepare to perform CPR or provide ACLS (if properly trained)

Management of Acute MI
Transfer to ER

Case Scenario #10

Case Scenario
A 25 year old female presents for initial periodontal debridement with local anesthesia.

Case Scenario
PMH:
Medications: Allergies: Illnesses: None Sulfa, PCN, Tetracycline, Erythromycin Asthma, Bladder infections, Pneumonia x 2 Bronchoscopies x 2, T&A

PSH:

Case Scenario
Vital signs:
BP HR RR Temp Weight 90/60 85 12 37 F 110 lb (50 kg)

Case Scenario
She receives 6 carpules of 2% Xylocaine with 1:100,000 epinephrine. Five minutes later, she tells the hygienist that she feels really great. She stutters as she says it and she now has twitching of her facial and extremity muscles. She begins to perspiring and c/o the room being hot.

Case Scenario
You are summoned back to the room. When you enter, she begins to seize in the chair.

Case Scenario
What do you suspect is happening? How would you treat it? What is the pathophysiology for this problem? How can this occur and what are the differences?

Overdose

Overdose
Clinical signs and symptoms from high blood levels of a drug in various target organs and tissues Most common adverse drug reaction

Overdose
Requirements
Access to the vascular system Alteration of steady state
Rapid absorption Intravascular injection Delayed redistribution Delayed biotransformation Delayed elimination Excessive dosage

Mechanisms of Overdose
Overdose Rapid Absorption Occurrence Common Most If no epi common Onset Rapid 3-5 3-5 minutes minutes Intensity Most Gradual Gradual intense onset onset Duration 2-3 minutes Prevention Aspirate, 1 minute Drugs Amides / esters 5-30 minutes Minimal dose Amides 5-30 minutes Epi, Neo Amides Rapid IV Slow Slow Biotransformation Elimination Uncommon Least common 10-30 minutes 10 min / many hrs Gradual onset, Gradual slow intensity onset, slow intensity Longer (variable) Longer (variable) Adequate med hx Adequate med hx Amides / esters Amides / esters

Overdose
Predisposing factors
Patient factors Drug factors

Patient Factors
Age
Young and elderly

Weight
Lean vs. fat, overall weight

Sex Other medications Presence of disease

Renal, liver

Genetics

Drug Factors
Vasoactivity Concentration Dose Route of administration Rate of injection Vascularity at injection site Vasoconstrictors

Local Anesthetic Overdose

Minimal - Moderate
Talkativeness Apprehension Excitability Euphoria Sweating Disorientation Increased BP, P, RR Loss of reason

Moderate - High
Light headedness Restlessness Nervousness Metallic taste

Visual, auditory disturbances

Seizures CNS depression CV collapse

Local Anesthetic Overdose

CNS precede CV symptoms CNS symptoms
CNS depression or excitation Seizures Generalized CNS depression

Local Anesthetic Overdose Tx

Oxygen Monitor VS BLS IV line*
Anticonvulsant (Valium) *

Protect patient* Transfer to ER*

* If necessary

Drugs

Drugs
Just what drugs do you need? Do I need a crash cart? How extensive does your crash cart need to be? What if I dont have the training to use the equipment?

Crash Cart

Crash Cart
How much do you need? What is your training?
Match your training to the amount of drugs and equipment you require
Do not overbuy via an emergency kit.

Small tackle box may be all that is necessary vs, major crash cart

Must have certain necessary equipment to administer the drugs in your emergency kit or temporaily treat emergencies (needles, fluids, tubing, tourniquets, etc.)

Oxygen
All medical emergencies require oxygen initially!
What specific conditions require oxygen? What is the one exception?

Aspirin

Aspirin
81, 162 or 325 mg crush and swallow Who should be on it? Who gets it? What does it do? How does it supposedly work?

Epinephrine

Epinephrine
What concentrations does it come in? Name 3 dental office emergencies where you would consider using it? What is the normal dosage? How often can it be repeated?
Why would you repeat it?

What adverse effects could occur?

Epinephrine
Pharmacology
Increases
SVR SBP/DBP Myocardial electrical activity Coronary and cerebral blood flow Myocardial contraction Automaticity

Nitroglycerin

Nitroglycerin
What forms does it come in? When is it given? How often is it given? How do you know it is effective/active? How does it work? How is it stored? What are the adverse side effects?

Atropine Sulfate

Atropine Sulfate
Indications? How does it work? How much do you give? What adverse side effects can occur? How often can you repeat it?

Benadryl

Benadryl
Name 3 dental emergencies in which this is used? How is it administered? What dosage is usually given? How does it work? What are the side effects?

Ventolin Inhaler

Ventolin Inhaler
Used to treat what conditions? How much and how often can it be administered? How should it be administered? Side effects?

Insta-Glucose

Insta-Glucose
Used to treat what condition? When should this not be used? How is it administered?

Dextrose - 50

Dextrose - 50
Used to treat what condition? How is it given? Can it produce any problems if administered?

Succinylcholine

Succinylcholine
What is it and what is it used to treat what conditions? How is it administered and how much is given? How long does it take to be effective and how long does it last? How is it metabolized? What must you be able to do if you administer this medication? Are there any risks to administration of succinylcholine?

Narcan

Narcan
For what condition is this used? How is it administered? What special precautions must be utilized? What are the risks of giving this medication? If the patient doesnt respond after repeated dosing, what is suggested?

Romazicon

Romazicon
For what condition is this used? How is it administered? What is the maximum dosage? What risks are associated with giving this medication?

Valium

Valium
For what condition is this used? How much and how is it given? What is the biggest concern with giving this drug?