Lesson 7: Seizures and Drug-Related Emergencies PDF

LESSON 7: SEIZURES A N D D R U G R E L AT E D EMERGENCIES Karen M. Maasch RDH, BSDH READING ASSIGNMENTS  Malamed: Ch 21-25  Wilkins: Ch 57 and 59 LECTURE OBJECTIVES  7.0 Management of Emergencies: Seizures, Drug Allergies and Overdose  The Dental Hygiene student will be able t...

LESSON 7: SEIZURES A N D D R U G R E L AT E D EMERGENCIES Karen M. Maasch RDH, BSDH READING ASSIGNMENTS  Malamed: Ch 21-25  Wilkins: Ch 57 and 59 LECTURE OBJECTIVES  7.0 Management of Emergencies: Seizures, Drug Allergies and Overdose  The Dental Hygiene student will be able to: 7.1 Define the following terms: grand-mal seizure, petit mal seizure, Jacksonian epilepsy, psychomotor seizures, status epilepticus. 7.2 Identify the various types of seizure disorders. 7.3 Discuss common causes of seizures as well as predisposing factors. 7.4 Discuss the dental management considerations related to seizure disorder. 7.5 Describe the clinical manifestations of petit mal and generalized tonic- clinic seizures. L E C T U R E O B J E C T I V E S ( C O N T. 1 )  7.6 Discuss the management of various seizures  7.7 Define Grand Mal status of seizures  7.8 Define allergy and the four classifications of allergic reactions, anaphylaxis, angioedema, pruritic, urticarial.  7.9 Determine the predisposing factors for allergies.  7.10 Discuss the prevention of allergic emergencies.  7.11 describe the types of anaphylaxis and the progression.  7.12 Describe the clinical manifestations of allergic reactions as related to the skin, respiratory system, GI tract, and cardiovascular system. L E C T U R E O B J E C T I V E ( C O N T. 2 )  7.13 Discuss management of various anaphylactic reactions.  7.14 Compare and contrast adverse reaction and drug overdose.  7.15 Discuss methods of preventing drug overdose.  7.16 Identify common drugs in dentistry that could result in ADR.  7.17 Discuss local anesthetic overdose including prevention, signs/symptoms, management.  7.18 Discuss epinephrine overdose signs/symptoms and management.   Boyd and Mallone (2023). Wilkins’ clinical practice of the dental hygienist,14th edition (ISBN: 9781284255997). Burlington, MA: Jones & Bartlett Learning.  Malamed, S.F. (2023). Medical emergencies in the dental office, REFERENCES 8th edition (ISBN: 978-0-323-77615- 8). St. Louis, MO: Mosby/Elsevier  Note: Additional Images obtained from Google Images. https://www.google.com/imghp?hl= en&tab=ri&authuser=0&ogbl SEIZURES  SEIZURE  Transient alterations in brain function characterized by the abrupt onset of motor, sensory, or psychic symptoms.  Paroxysmal excessive brain activity  Usually benign  All patients with Epilepsy have seizures SEIZURE ( C O N T. ) However, many patients may have a seizure in their lifetime, and are NOT considered to have Epilepsy TYPES OF SEIZURE DISORDERS GENERALIZED PA RT I A L S E I Z U R E S SEIZURES (CONVULSIVE OR NONCONVULSIVE)  Simple (AKA: Focal or Local)  Clonic No loss of consciousness  Myoclonic  Complex  Tonic Impairment of  Absence consciousness   Tonic-clonic Partial Seizures progressing to Generalized Seizures  Atonic  TYPES OF SEIZURE DISORDERS ( C O N T. )  Unclassified Epileptic Seizures All seizures that cannot be classified because of inadequate or incomplete data. FOCAL-ONSET SEIZURES ( A K A : PA RT I A L S E I Z U R E S )  Involve only one lobe of the brain, with signs and symptoms relating to the affected area of the brain  Simple Partial Seizures Include specific motor and/or sensory symptoms No loss of consciousness  Complex Partial seizures “Spells” with impairment of consciousness  Illusions, hallucinations, déjà vu, jamais vu  possible amnesia   Major Forms: 1. Grand Mal G E N E RA L I Z E D 2. Petit Mal SEIZURES 3. Jacksonian 4. Psychomotor GRAND MAL EPILEPSY AKA: TONIC-CLONIC SEIZURES  The most common seizure disorder  “Great Illness”  Effects 90% of epileptics  Result of various neurological disorders ( ex: CVA, meningitis, encephalitis, tumor), or from systemic metabolic or toxic disturbance (drug/alcohol intoxication or withdrawal, photic stimulation, menstruation, fatigue, falling asleep or waking up, etc.)  Clonic Convulsive part: muscle contractions followed by relaxation, jerking motions  Tonic Rigid or Stiff – sustained contraction  Duration is usually 5 – 15 minutes  PETITE MAL SEIZURES AKA: ABSENCE SEIZURES  Effects approx. 25% of epileptics  Develops in childhood ages 3 – 15 years  Incidence decreases with age – rare beyond age 30  40% – 80% will develop tonic-clonic seizures  Possible myoclonic jerks  Blank spells – no movement – “zoning out”  Duration of 5 – 10 seconds  If occurs when patient is standing, patient remains standing through the process  Cyclic blinking of eyelids  https://www.youtube.com/watch?v=mWK-oqwrJz0 (Examples of absence seizures)  https://www.facebook.com/100064819057474/videos/hyperventilation-can-trigger-absence-seiz ures-to-test-this-the-examiner-asks-the/213689120315049/ (Hyperventilation being used as a diagnostic test for absence seizures) JACKSONIAN SEIZURES  Starts as a simple partial seizure, but may progress into progress into loss of consciousness and into generalized Tonic-clonic seizure  Begins in a limg that spreads in an orderly fashion  If it crosses over to the opposite side of the body, it leads to loss of consciousness  https://www.youtube.com/watch?v=5OADO9ucNiM Example of Jacksonian simple partial seizure P S YC H O M O T O R S E I Z U R E S A K A : C O M P L E X PA RT I A L S E I Z U R E S  Effects 15% -50% of adults  Duration of 1 – 2 minutes  Onset is more gradual and often progresses into generalized seizures  Often exhibit incoherent speech, turning of head, shifting of eyes, smacking of the lips, twisting and writhing, moving of extremities, amnesia  Includes seizures that do not meet the criteria of the ones we’ve already discussed   S TAT U S Series of seizures without recovery in between; may continue for more EPILEPTICUS than 1 hour, or repeated seizures  ANY CONTINOUS SEIZURE ACTIVITY FOR 5 MINUTES OR LONGER should be treated as status epilepticus  A life-threatening true medical emergency; can progress to: Cerebral damage, cardiac failure, renal failure, death  Most common cause is failure to take Rx antiepileptic drugs (AEDs)  CAUSES OF SEIZURES  65% = Idiopathic ( no known cause) C A U S E S O F S E I Z U R E S ( C O N T. )  35% = Result of underlying brain lesions  Possible Causes: Congenital Abnormalities and Perinatal Injuries: maternal rubella, hypoxia, trauma during delivery Metabolic Disorders: hypoglycemia, alcohol and drug withdrawal Toxic Disorders: penicillin, hypoglycemic meds, local anesthetics, recreational drug use and withdrawal Head Trauma C A U S E S O F S E I Z U R E S ( C O N T. 1 ) Tumors and other Space-Occupying Lesions Vascular Disease: Arteriosclerosis, stroke, Degenerative Disorders: Alzheimer’s disease Infectious Diseases: TB, HIV, malaria, meningitis, herpes encephalitis TV interference, flickering lights, geometric patterns of video games Photosensitive Epilepsy Febrile Convulsions: High fever (102°F or higher) in children ages 3 months to 5 years PHOTOSENSITIVE EPILEPSY  1997 in Japan: “Pokémon Shock”  Approximately 1,000 children were sent to the hospital with seizures while watching the same episode  Flashing red and blue lights were probable cause  M O S T L I K E LY CAUSES OF SEIZURES IN D E N TA L O F F I C E  Known epileptic patient  Hypoxia secondary to syncope  Hypoglycemia  Local anesthetic overdose The most likely nonepileptic cause in this setting P R E D I S P O S I N G FA C T O R S F O R S E I Z U R E S  May be idiopathic  Physical or emotional stress  Noncompliance with AED regimen  Alcohol or other drugs  Flashing lights  Fatigue  Sleep cycles  Missed meals  Menstrual cycles M E D I C A L H I S T O RY Q U E S T I O N S T O A S K  Have you ever experienced fainting  When did you last have a seizure? spells or seizures?  Are you allowed to drive?  What medications are you taking?  What signals the onset of your See Box 21.2 and 21.3 seizures?  What type of seizures have you had?   How long do your seizures How often do you experience seizures? Auras can include pleasant taste or normally last? smell, sensation in epigastric region,  Have you ever been hospitalized visual or auditory hallucinations, because of your seizures? sense of fear, numbness in limbs D E N TA L M A N A G E M E N T C O N S I D E RAT I O N S Oral Medications for moderate IV or IM sedation N₂O₂ is highly sedation for extremely recommended Adults: Benzodiazepines (diazepam, oxazepam, phobic patients midazolam) Children: midazolam, promethazine, hydroxyzine Alcohol self- ASA II if well medication is controlled; ASA III contraindicated or ASA IV if not C L I N I C A L M A N I F E S TAT I O N S O F SEIZURES C L I N I C A L M A N I F E S TAT I O N S O F PA RT I A L S E I Z U R E S ( F O C A L S E I Z U R E S ) S I M P L E PA RT I A L S E I Z U R E S C O M P L E X PA RT I A L S E I Z U R E  Remains fully alert and conscious Aura is experienced  Consciousness is altered  A limb may jerk for several seconds  Ability to respond is impaired  Fumbling of hands or smacking of lips,  If it spreads to opposite side = chewing or sucking movements Complex Partial seizure  The entire seizure may last a few minutes  May return to normal in 1 minute  Slightly lethargic for approx. 3 minutes  C L I N I C A L M A N I F E S TAT I O N S O F ABSENCE SEIZURES (PETIT MAL) Suppression of Sudden Abrupt onset all mental immobility and functions blank stare Minor facial (intermittent Terminates as May last 5 – 30 blinking) or abruptly as it seconds mouth started movements  Prodromal Phase CLINICAL Preictal Phase M A N I F E S TAT I O N S OF G E N E RA L I Z E D TONI C - C LONI C Ictal Phase SEIZURES Postictal Phase PRODROMAL PHASE  May begin several minutes to several hours before the seizure  Subtle or obvious changes in emotional reactivity  Onset of aura which lasts a few seconds Ringing in ears Seeing spots Distinct smell of something Bad tase Etc. P R E I C TA L P H A S E  Patient loses consciousness  Major myoclonic jerks occur  “Epileptic Cry “  Increase in heart rate and blood pressure  Increased bladder pressure, cutaneous vascular congestion, piloerection, superior ocular deviation, mydriasis, apnea  Video of seizure with Epileptic Cry: https://www.jle.com/en/revues/epd/e-docs/seizure_semiology_ilae_glossa ry_of_terms_and_their_significance_322503/article.phtml?tab=videos&cl e_video_une=322578 I C TA L P H A S E TONIC C LO N I C  Sustained contractions of skeletal  Movements of the body accompanied muscles by stertorous breathing (grunting)  Contractions are first in flexion, then  Alternating muscular relaxation and are rigid extensions of the extremities and trunk violent flexor contractions  Contracted respiratory muscles =  May see frothing from the mouth inadequate ventilation = dyspnea and  May see blood from the mouth as a cyanosis may be evident result of injury  Lasts 10 to 20 seconds  Ends with a final flexor jerk I C TA L P H A S E ( C O N T. ) TONIC PHASE C LONIC PH A SE P O S T I C TA L P H A S E  Consciousness gradually returns to normal  Urinary or fecal incontinence may occur as muscles relax  Patient relaxes and often sleeps  If seizure is severe, may be comatose  Upon awakening, confused and disoriented  Alertness increases with time  May complain of headache and muscle soreness  Amnesia of ictal and postictal phases  Full recovery takes 2 hours MANAGEMENT OF SEIZURES Focus is on prevention of injury and maintenance of adequate ventilation MANAGEMENT OF ABSENCE SEIZURES (PETIT MAL) A N D PA RT I A L S E I Z U R E S 1. Recognize problem 2. Terminate dental procedure 3. Activate Office Emergency Team 4. Position Supine with feet elevated, chair close to the floor Move light, bracket tray, etc. Maintain CABs 5. Reassure the patient 6. Discharge in the care of adult companion/guardian M A N A G E M E N T O F G E N E RA L I Z E D TONI C - C LONI C S EI Z U R E S P R O D R O M A L ( P R E I C TA L ) P H A S E I C TA L P H A S E 1. Recognize problem/aura and 2. Activate Office Emergency team terminate procedure 3. Position Supine with feet elevated ; lower dental chair to floor, move objects out of the way 4. Summon EMS – have them evaluate for further tx 5. CABs Maintain head tilt-chin lift Remove all small objects to avoid airway obstruction NEVER put anything in pt’s mouth M A N A G E M E N T O F G E N E RA L I Z E D T O N I C - C L O N I C S E I Z U R E S : P R E I C TA L A N D I C TA L P H A S E S ( C O N T. )  6. Definitive Care NEVER hold a patient down – gently restrain but allow for controlled movements by using pillows or blankets to protect from injury Loosen tight clothing Position yourself on side of chair to keep patient from falling off – one person near the chest, the other near the feet M A N A G E M E N T O F G E N E RA L I Z E D T O N I C - C L O N I C S E I Z U R E S : P O S T I C TA L P H A S E 7. Position – Keep supine with feet slightly elevated 8. CABs – BLS as needed Administer O₂ with nasal canula or simple face mask 9. Monitor Vital Signs every 5 minutes– return to baseline is gradual 10. Reassure Patient – recovery may take up to 2 hours 11. Discharge – EMS personnel must decide Transport to hospital or Discharge from dental office in custody of responsible adult relative or close friend M A N A G E M E N T O F G RA N D M A L S E I Z U R E  Follow all steps for Tonic-clonic Seizures  If seizure persists for more than 5 minutes, continue with BLS and protection of pt until EMS arrives or:  Administer anticonvulsant drugs Midazolam or lorazepam  Follow up with 50% dextrose solution IV to rule out hypoglycemia as a possible cause for the seizure and to maintain blood sugar levels  Local Anesthetic Analgesics s COMMON DRUGS USED IN Central D E N T I S T RY Nervous System Antibiotics (CNS) depressan ts  Adverse Drug reaction An unintended, undesirable effect of a drug May be associated with the administration of the drug rather POSSIBLE than the clinical actions of the drug EMERGENCIES Allergic reaction A hypersensitivity response to an allergen Overdose reaction Results from an overly high blood level of a drug ALLERGIC REACTION A L L E R GY  A hypersensitivity response to an allergen to which the person has been previously exposed and to which the individual has developed antibodies. Sensitization  Reactions may be mild, delayed or life-threatening.  ADRs are much more common than allergic reactions.  C L A S S I F I C AT I O N O F A L L E R G I C R E A C T I O N *TYPE I – T Y P E I I - C Y T O T OX I C ANAPHYLACTIC*  Immediate reaction  IgG or IgM antibody mediated Minutes – hours, depending on route of exposure  Time of reaction varies  IgE antibody mediated Transfusion reactions  Examples: Certain drug reactions Urticaria  Examples: Angioedema Hemolytic anemia Bronchospasms Neutropenia Pruritus Gastrointestinal symptoms Thrombocytopenia Anaphylaxis C L A S S I F I C AT I O N O F A L L E R G I C R E A C T I O N ( C O N T. ) TYPE III: IMMUNE *TYPE I V: C E L L - COMPLEX M E D I AT E D ( D E L AY E D ) *  IgG antibody mediated  Activation and expansion of drug- specific T cell  Reaction in 1 – 3 weeks  Reaction 2 to 7 days after  Examples: exposure Serum sickness  Examples: Vasculitis Allergic contact dermatitis Drug fever (latex allergies) Morbilliform eruptions P R E D I S P O S I N G FA C T O R S F O R A L L E R G I E S  Genetics  Patients with multiple allergies May have additional unknown allergies  Previous allergic reactions  Some drugs are more highly allergenic PENICILLIN is the #1 most common cause of drug-induced anaphylaxis NSAIDS are the #2 most common cause of drug-induced anaphylaxis Other drug groups with the potential for allergic response: muscle relaxants, vaccines. Insulin, thiamine, protamine, chemotherapy drugs, monoclonal antibodies P R E D I S P O S I N G FA C T O R S F O R A L L E R G I E S ( C O N T. 1 )  Bee or wasp stings A leading cause of death due to allergic reactions  Iatrogenic administration of drugs Aspiring and anti-inflammatory drugs – they mimic IgE anaphylaxis reactions  Latex and peanut allergies Leading causes of death due to allergic reactions P R E D I S P O S I N G FA C T O R S F O R A L L E R G I E S ( C O N T. 2 )  Local Anesthetics Decreased since the introduction of Amides However, ADR may occur due to administration process Possible allergy to sulfites  Topical Anesthetics Esters have a high potential for allergies  Self-cure acrylic resins of dentures can cause reaction sometimes confused with “denture sore mouth” Monomer – methyl methacrylate Heat-cured are less likely to cause allergic reaction PREVENTION OF ALLERGIC EMERGENCIES  Thorough Medical History to include: Any allergies? Describe symptoms or reaction. Allergic to any drugs? Doctor or EMS required? Medical consult possible See p. 389-391, Malamed  Dental Therapy Modifications MEDCAL ALERT with allergies must documented in chart Avoid allergen Use latex free products Use LA without vasopressor if allergic to sulfites (use prilocaine “plaina’ or mepivacaine “plain” ASA II with any allergies G E N E RA L I Z E D A N A P H Y L A X I S  The most severe form of allergic reaction  Acutely life-threatening  Symptoms can occur in the first 5 – 30 minutes, but may be delayed for several hours Delayed response or delayed sensitivity reaction  Most deaths occur within 30 minutes – 2 hours if not treated  SKIN EYES, NOSE USUAL PROGRESSION OF GI SYSTEM ANAPHYLAXIS RESPIRATORY SYSTEM CARDIOVASCULA R SYSTEM G E N E R A L I Z E D A N A P H Y L A X I S ( C O N T. )  Fatal Anaphylaxis  First signs are usually seen in the Respiratory and cardiovascular skin and perioral, periorbital and disturbances predominate intraoral regions of the face C L I N I C A L M A N I F E S TAT I O N S O F T H E S K I N  Erythema (rash)  Pruritus (itching)  Angioedema (localized swelling measuring several cm)  Urticaria (hives) C L I N I C A L M A N I F E S TAT I O N S O F R E S P I R AT O RY A L L E R G I C R E A C T I O N S  Rhinitis Nasal congestion, itching, edema  Laryngeal Edema Dyspnea, hoarseness, throat tightness, hypersalivation, laryngeal stridor (shrill, high-pitched noise on inhalation due to narrowing of the airway), glottic edema  Bronchospasm Cough, wheezing, retrosternal tightness, dyspnea, tachypnea, respiratory distress, cyanosis  https://www.youtube.com/watch?v=MdBUZn1PG58 C L I N I C A L M A N I F E S TAT I O N O F G I T R A C T  Cramping  Abdominal pain  Nausea  Vomiting  Diarrhea  Spasms of rectum or bladder  C L I N I C A L M A N I F E S TAT I O N S O F A L L E R G I C C A R D I O VA S C U L A R REACTIONS  Circulatory collapse Pallor, lightheadedness, weakness, syncope, ischemic chest pain, tachycardia, hypotension, shock  Dysthymias  Cardiac arrest ANAPHYLAXIS D E AT H Airway obstruction Hoarseness or stridor from laryngeal edema are signs of laryngeal or cardiovascular edema and indicate Death from asphyxia collapse from the possibility of may occur vasodilation may lead impending airway to death obstruction MANAGEMENT OF D E L AY E D - O N S E T S K I N R E A C T I O N S  Recognize Problem  Definitive Care: Administer histamine blocker  Terminate dental treatment 50 mg Benadryl  Activate office emergency (Diphenhydramine) 3-4 x/day for 2-3 days team  Recovery and Discharge  Position patient comfortably Monitor until symptoms have  CABs as needed resolved No driving if Benadryl administered  Monitor vitals Refer for Consult with MD or allergist MANAGEMENT OF RAPID- ONSET SKIN REACTIONS  Recognize problem  Definitive Care: Administer O₂: 6-10 L/min via facemask  Terminate dental treatment Administer Epinephrine if evidence of  Activate office emergency team cardiovascular, respiratory, or edema of facial or intraoral tissue – repeat every 5-  Position patient comfortably 15 minutes Summon EMS if Epi is administered  CABs as needed Reposition to supine if hypotensive,  Monitor and record vitals cardio or respiratory distress Consider administration of bronchodilator continuously or Benadryl Transport to hospital per EMS decision MANAGEMENT OF R E S P I R AT O RY ( L A RY N G E A L E D E M A ) R E A C T I O N S  Recognize problem  Definitive Care  Summon EMS Terminate dental procedures Administer Epinephrine; repeat  Activate office emergency team every 5 minutes  Position patient upright or semi- Maintain airway erect Administer O₂  CABs as needed Consider administration of Benadryl EMS may administer steroids or perform Cricothyrotomy M A N A G E M E N T O F G E N E RA L A N A P H Y L A X I S  Recognize problem  Definitive Care  Summon EMS Terminate dental procedure Administer Epinephrine  Activate office emergency team Administer O₂: 6-10 mL via simple  Position supine with feet slightly face mask elevated Once is improvement is noted,  CABs as needed consider administration of diphenhydramine (Benadryl) and  Monitor and record vitals every 5 corticosteroid (Solu-Cortef) minutes Transport to hospital per EMS DRUG OVERDOSE REACTIONS DEFINITIONS ADVERSE DRUG REACTION OVERDOSE REACTION (ADR)  Precipitated by a patient’s  Clinical signs and symptoms that response to a drug, side effects, result from overly high blood or drug overdose levels in various target organs  The most common ADR in and tissues dentistry is a psychogenic  Also called toxic reactions reaction to local anesthesia (LA)  Account for 85% of all ADRs resulting in syncope or hyperventilation  PREVENTION OF DRUG OVERDOSE Pharmacologi Be familiar with properties of all drugs c properties Medical history Patient Look for drug interactions, dangerous screening side effects, drug allergies D R U G S I N D E N T I S T RY T H A T C O U L D R E S U LT I N A D R  Local and topical anesthetics  Inhalation sedation (N₂O₂)  Allergy never reported Antibiotics Over-sedation may occur  Analgesics (opioids) Loss of consciousness  Antianxiety drugs (CNS Will need to decrease % of depressants) nitrous oxide and increase % of oxygen  Vasoconstrictors (Epinephrine)  L A OVERDOSE Now referred to as Local Anesthetic Systemic Toxicity or LAST L A S T R E A C T I O N S : P R E D I S P O S I N G FA C T O R S  Attitude and environment Increased stress = may over-react to stimuli  Weight of patient Greater lean body weigh = greater dose tolerated Larger (non-obese) = less likely to develop overdose due to large capacity of blood volume  Pathology present in patient Pre-existing disease may alter drug biotransformation  Pregnancy Renal function may be altered, leading to impaired secretion of some drugs  Age Be cautious with elderly and children  D R U G FA C T O R S R E L A T E D T O A N E S T H E T I C O V E R D O S E I N D E N T I S T RY  Nature of drug Amides are safer than esters  Dose of drug/amount The larger the dose = the higher the blood level Topicals are absorbed through the mucous membranes = absorption rates can be high = use cautiously/sparingly  Rate of injection The more rapid the injection = the faster the absorption  Technique of injection Always aspirate to be sure you are not injecting into a vessel  Presence of vasoconstrictor Vasoconstrictors decrease the rate of systemic absorption; helos the anesthetic remain in the localized area longer R E VE R S E C A R OT I D B LOOD F LOW PREVENTION OF L A DRUG OVERDOSE REACTION  Thorough medical history  Note causes of overdose – too large of a dose, type of anesthetic, speed of injection  Proper drug selection  Proper administration technique PREVENTION OF TOPICAL ANESTHETIC ADR  Use topical amides, not esters  Limit the area of administration  Use metered dose forms of topical to control dose  O RA Q I X  Non-injectable local anesthetic  30-second onset  20-minute duration  5 cartridge maximum per treatment session S I G N S / S Y M P T O M S O F L O W T O M O D E R AT E LAST SIGNS SYMPTOMS  Confusion  Headache  Talkativeness  Lightheadedness and dizziness  Apprehension, excitedness  Blurred vision  Slurred speech  Ringing in ears  Generalized stutter  Flushed or chilled feeling  Muscular twitching & tremor of face and  Drowsiness extremities  Elevated BP, heart rate, respiratory rate  Loss of consciousness S I G N S / S Y M P T O M S O F M O D E R AT E T O H I G H LAST  Generalized tonic-clonic seizure  CNS depression  Depressed BP, heart rate and respiratory rate MANAGEMENT OF MILD LAST WITH RAPID OR D E L AY E D O N S E T  Recognize symptoms  Definitive Care 5 – 10-minute onset = rapid onset Administer O₂ via simple face mask More than 10 minutes = delayed Monitor vital sign onset Administer anticonvulsant  Terminate dental procedure (midazolam, etc.) if needed Summon EMS at DDS discretion  Position patient comfortably If signs/symptoms seem to be  Reassure patient increasing Recover as long as necessary;  CABs as needed postpone treatment MANAGEMENT OF SEVERE LAST WITH RAPID OR D E L AY E D O N S E T  Recognize Symptoms  Definitive Care Onset of seconds to minutes Administer O₂ via nasal cannula or non-rebreather  Terminate dental procedure Monitor and document vitals  Position Patient If seizing, administer anticonvulsant Supine with legs slightly elevated (diazepam) if DDS is trained to do so  Summon EMS Postictal management EMS transport to hospital  CABs as needed E P I N E P H R I N E ( VA S O C O N S T R I C T O R ) O V E R D O S E REACTIONS SIGNS SYMPTOMS  Fear and anxiety  Elevated heart rate  Tenseness  Elevated blood pressure  Restlessness  Throbbing headache  Tremor  Perspiration  Weakness and dizziness  Pallor  Respiratory difficulty  Palpitations MANAGEMENT OF EPINEPHRINE OVERDOSE  Recognize symptoms  Definitive Care  Reassure patient Terminate dental procedure Monitor vitals  Position Summon EMS if BP and heart rate Semi-fowler of semi-upright are elevated  CABs as needed Administer O₂ Allow time for patient to recover Administer vasodilator if BP and pulse do not return to baseline EMS will decide about discharge OPIOID AGONISTS  Fentanyl and meperidine are the mist frequently administered opioids in dentistry Primary pharmacological effects are on CNS Produce analgesia, sedation, euphoria, and some respiratory depression Deaths from opioid overdose = result from respiratory arrest  Codeine, hydrocodone, and oxycodone are frequently prescribed for postsurgical pain control. D I A G N O S T I C C LU E S T O O V E R D O S E O F S E D AT I V E - HYPNOTIC DRUGS:  Recent administration of the drug  Decreased level of consciousness  Sleepy → unconscious  Respiratory depression (rapid rate, shallow depth)  Loss of motor coordination (ataxia)  Slurred speech  Inability to maintain airway MANAGEMENT OF OPIOID OVERDOSE  Recognize problem  Definitive Care Summon EMS if recovery is not  Discontinue dental treatment immediate  Administer O₂ Position patient Monitor and record vitals every 5  CABs minutes Maintain airway Administer antidotal drug (opioid antagonist; 4-mg Narcan) Palpate carotid pulse for up to 10 Recover seconds Continue to observe and monitor the pt for at least 2 hours Discharge Hospitalization is usually not necessary