Medical Emergencies in the Dental Office (ODQ Protocol) PDF

Medical emergencies in the dental office DR DEBORAH IERA Cardiovascular emergencies Angina/Infarct Stroke Vasovagal syncope Angina/Infarct Signs and symptoms: Severe retrosternal chest pain, numbness or pain in the arms, back, jaw, difficulty breathing, sweating, pallor, nausea, vomiting Patient...

Medical emergencies in the dental office DR DEBORAH IERA Cardiovascular emergencies Angina/Infarct Stroke Vasovagal syncope Angina/Infarct Signs and symptoms: Severe retrosternal chest pain, numbness or pain in the arms, back, jaw, difficulty breathing, sweating, pallor, nausea, vomiting Patient known to have angina: Nitroglycerin is contraindicated if patient has taken medication for erectile dysfunction (Viagra 24hrs, Cialis 48hrs) Patient should be in semi-seated position If systolic pressure is >100 mm Hg and pulse between 50 and 100 beats/minute, administer a dose of nitroglycerin (0.4mg spray) If discomfort persists after 5 minutes, call 911 and administer a second dose of nitroglycerin if pressure has not dropped more than 30 mmHg since the first dose Angina/Infarct If patient is not asthmatic or allergic to ASA or NSAIDS, have patient chew and swallow 4 tablets of ASA 81mg or 1 tablet of ASA 325mg If discomfort persists after another 5 minutes, administer a 3rd dose of nitroglycerin if the pressure has not dropped more than 30 mm Hg since the first dose_ 3 doses maximum Patient not known to have angina: Call 911 immediately ASA protocol Patient should be in a semi-seated position IF patient is not asthmatic or allergic to ASA or NSAIDS, have patient chew and swallow 4 tablets of ASA 81mg or 1 tablet of ASA 325mg Stroke Signs and symptoms: Sudden weakness or numbness, speech problems, vision problems (unilateral), sudden headache with no apparent cause, unexplained numbness F- Face: one side of the face droops A-Arms: Inability to lift both arms normally S-Speech: slurred or unusual speech T-Time to act: extreme emergency Call 911 immediately. Do not administer ASA Reassure patient Check vital signs If respiratory difficulty, administer oxygen if saturation is below 94% If patient loses conscious ness, initiate CPR and AED protocol Vasovagal syncope Signs and symptoms: Loss of consciousness preceeded by: weakness, pallor, sweating, dizziness, nausea, bradycardia, hypotension, pale, cold and clammy extremities Patient should be in a supine position (legs raised) Apply cold water to forehead and neck Clear airways If respiratory difficulty, administer oxygen if saturation is below 94% If symptoms persist or patient has convulsions call 911 If sudden syncope (no preceeding symptoms), call 911 Allergic reactions Hives Asthma Anaphylactic shock Hives Signs and symptoms: Skin rash, itching, swollen eyes, lips and extremities (if tongue is swollen, refer to the anaphylactic shock protocol) Administer Diphenhydramine (Benadryl) orally. Oral dose (syrup or tablets)to be repeated every 6 hours for 24 hours Monitor signs and symptoms: If there is a change in condition, refer to the anaphylaxis protocol. Adult dose: 40ml syrup (6.25mg/5ml); or 50mg tablet (2x25mg) Child dose: syrup 6.25mg/5ml Under 2 years old (2.5ml), 2-5 years (5ml), 6-11years (20ml), 12 years and older 40ml Asthma Signs and symptoms: noisy breathing, wheezing, coughing, rapid breathing, tachycardia, altered consciousness, confusion, cyanosis, bradycardia Patient should be seated Administer salbutamol (Ventolin) (100ug/inhalation) If respiratory difficulty, administer oxygen if saturation is below 94% If symptoms persist call 911 12 years and older: 2 inhalations 1 minute apart using an aerochamber with mouthpiece. Repeat after 10 minutes, if necessary 4 to 11 years: 1 inhalation via an aerochamber with medium mask for children. Repeat after 10 minutes if necessary Have the patient take 5-6 breaths to inhale the medicine before you administer the next puff. Anaphylactic shock Signs and symptoms: Hives or angioedema, Respiratory difficulty or distress (Laryngeal edema, bronchospasm, noticeable swelling of the tongue), circulatory malfunction or shock (vascular collapse/hypotension, altered consciousness), Gastrointestinal symptoms (nausea, vomiting, abdominal cramps) Inclusion criteria: Known or suspected contact with an allergen in the previous 4 hours AND 1 of the following 2 situations Respiratory distress or circulatory malfunction OR 2 of the following 4 situations Hives or angioedema Respiratory difficulty Circulatory malfunction (e.g. extreme weakness) Gastrointestinal symptoms (abdominal cramps, nausea, vomiting) Anaphylactic shock Call 911 immediately Administer epinephrine (to outer thigh) Repeat epinephrine after: 5 minutes if symptoms worsen, 10 minutes if no improvement or if inclusion criteria persist Administer Diphenhydramine (Benadryl) Oral administration is preferred Administer injections only to patients who are unconscious or cannot swallow Always prioritize administration of epinephrine over diphenhydramine If respiratory difficulty, administer oxygen if saturation is below 94% Drug dosages Adults: Pre-dosed adult auto-injector (EpiPen) 0.3 ml of 1:1000 epinephrine for IM injections 40ml syrup 50mg tablets Child: Pre-dosed child auto-injector (EpiPen Jr) 0.15ml of 1:1000 for IM injection Syrup and tablet doses as per hives protocol Postural hypotension Signs and symptoms: similar to syncope Immediately return patient to supine position, or Trendelenburg if possible Maintain open airway Administer oxygen Monitor pulse and vital signs Call 911 if unsure or if patient’s condition deteriorates Hypoglycemia Signs and symptoms: Fatigue, pale and clammy skin, excessive sweating (diaphoresis), hunger, nausea, vomiting, shaking, palpitations, psychomotor retardation Administer Insta-Glucose or other glucose source If blood glucose is <4 recommend a medical follow up (normal is between 4-7) Once hypoglycemia is resolved, suggest patient eat a snack or meal because glucose has a rapid but short-term effect If symptoms persist or patient has convulsions, call 911 If patient loses consciousness, Initiate CPR and AED protocol Seizure disorders Leave patient in dental chair (supine is ideal) and remove all objects from oral cavity Call 911 Maintain open airway Administer oxygen by mask Suction to keep airway patent Monitor pulse and vital signs Be prepared for post-ictal state (lethargy following seizures), support respiration Hyperventilation Signs and symptoms: Anxiety, dizziness, weakness, shortness of breath and rapid breathing, palpitations, shaking Encourage patient to breath calmy and slowly into the belly. (Some say to breath into cupped hands or into paper bag) Reassure patient Anesthetic overdose Signs and symptoms: Anxiety, agitation, palpitations, nausea, vomiting, confusion, drowsiness, cardiovascular collapse (shock) Call 911 Patient should be semi-seated Clear airway If respiratory difficulty, administer oxygen if saturation is below 94% If Loss of consciousness, respiratory arrest or cardiac arrest, Initiate CPR and AED protocol Panic attack Signs and symptoms: chest pain, hyperventilation, anxiety, nausea, paresthesia (numbness or tingling in extremities), restlessness, trance-like state Position patient for comfort, Do not administer oxygen if hyperventilation is part of the attack, monitor pulse and blood pressure (monitor all vital signs) Call 911 if patient’s condition deteriorates References 1. Ordre des Dentistes Du Quebec Basic Emergency Kit and Protocols May 2018 2. Dental Office Medical Emergencies. A Manual of Office Response Protocols. Lexicomp. 3. Review McGill Dentistry Emergency Medical Response Plan