MEDICAL EMERGENCIES IN THE DENTAL CLINIC .pdf

MEDICAL EMERGENCIES IN THE DENTAL CLINIC Medical Emergency: Any sudden change in normal physiology from an expected pattern - With preventive and/or corrective measures, the occurrence of most “life threatening” medical emergencies can be prevented - Most of the emergenc...

MEDICAL EMERGENCIES IN THE DENTAL CLINIC Medical Emergency: Any sudden change in normal physiology from an expected pattern - With preventive and/or corrective measures, the occurrence of most “life threatening” medical emergencies can be prevented - Most of the emergencies happens “During or immediately following local anesthesia 54.9% ” - Most common medical emergency “Syncope” Prevention: Prior knowledge of patients medical status will guide you to the likely cause of emergency 90% of medical emergencies can be prevented by following some simple rules and procedures. Remaining 10% would occur despite preventive measures To prevent you need the following: Medical history& physical examination Medical consultation (if needed) ASA classi cation Prepare for a medical emergency RECOGNITION Be aware of the patient’s medical history prior to the appointment Review medical charts Place alerts in the chart to remind yourself and sta of critical medical conditions, allergies or treatment modi cations Be on the look out for changes 1 of 16 fi fi ff  PREPERATION Clinic protocols should be clear & supplies should always be easily accessible within the o ce Sta need to be trained in BLS and they should be up to date with the clinic's protocol and their responsibilities to prevent confusion Mock emergency drills periodically are bene cial Example: Dentist - team leader, administers CPR, gives medications (Team #1) Assistant/hygienist - assist with equipment, help with CPR (Team #2) Assistant/hygienist/sta - call for assistance (112), assist Team #2 (Team #3) BASIC EMERGENCY EQUIPMENT 1. Blood pressure monitor 5. High volume suction 2. Oxygen source 6. Blankets 3. Bag valve mask of appropriate size 7. Emergency drug kit 4. Automated External De brillator (AED) 8. Emergency light source EMERGENCY DRUG KIT contains: 1. Oxygen 7. Bronchodilators 2. Anti-allergy medications 8. Corticosteroids 3. Analgesics 9. Vasopressors 4. Anticonvulsants 10. Vasodilators 5. Anticholinergic 11. Aspirin 6. Anti-hypoglycemics STRESS REDUCTION PROTOCOL The rational approach to stress reduction: 1. Recognize medical risk & anxiety 2. Consider medical consult Methods ”Useful for all patients”: Premedicate, if needed Consider sedation Morning appointments Adequate pain control Shorten waiting time MEDICAL EMERGENCY PROTOCOL Treatment: active intervention of a situation to resolve an emergency P —> C —> A —> B —> D Treatment P: position patient Based on level of consciousness Most comfortable vs. supine C —> A —> B: Monitor and support Call for assistance (if needed) Maintain respiratory and cardiac function D: Administer medications 2 of 16 ff ff fi fi ffi 3 of 16 CARDIOVASCULAR SYSTEM I. Hypertension IV. Myocardial Infarction (MI) II. Orthostatic hypotension V. Acquired Coagulation Disorders III. Angina I. HYPERTENSION Disease of elevated blood pressure (BP) Prevalence of HTN in Kuwait amongst adults (30-79yrs) is 41% Risk factor for CVD, stroke, renal failure & heart failure Most of the cases are idiopathic (90%) BP can also be elevated due to dental anxiety (white coat hypertension) DENTAL CONSIDERATIONS Avoid long term use of (>2 weeks) NSAIDs OR use Paracetemol Anesthesia: A —> B 4. With symptoms, 1. Oxygen 4-6 L/min 2. Nitroglycerin - sublingual tablet or spray every 5 minutes 3. Consider other vasodilators – esmolol, metoprolol, labetolol 5. Continue to monitor until EMS arrives WHITE COAT HYPERTENSION (WCH) De nition of WCH: an o ce BP ≥130/80 mm Hg but A —> B D:Oxygen Cold cloth to forehead Aromatic ammonia salts Raise chair back incrementally, & slowly, sit with feet on oor, stand without walking III. ANGINA De nition of Angina pectoris – sensation of aching, heavy, squeezing pressure or tightness in the mid- chest that may radiate to the shoulder , left or right arm, neck or lower jaw. TYPES 1. Stable angina: Pain is reproducible, unchanging and consistent over time 2. Unstable angina: New-onset pain, increasing in frequency and intensity that may occur at rest or minimal exertion, 3. Prinzemetal variant angina: Caused by a focal spasm of the coronary artery. Occurs at rest 5 of 16 fi fi ffi fl  ANGINA Patients that have long standing angina or stable angina are used to it They know what precipitates it and what relieves it Unstable angina is worrisome.Why? Sings and symptoms: - Chest pain - Indigestion - Chest pressure - Pain that spread to the neck, jaw, back or - Squeezing sensation in chest belly DENTAL CONSIDERATIONS Stress Reduction protocol Profound LA Be careful with epinephrine dosage Healthy patients can receive.2 mg of epinephrine Cardiac patients have to stay below.04 mg,( x2 1.8ml carpules of 1:100,000 epinephrine) DENTAL MANAGEMENT 1. Terminate dental procedure 2. Activate o ce emergency team 3. P: place pt in their most comfortable position 4. BLS: C —> A —> B 5. De nitive care: Oxygen Nitroglycerin- sublingual spray or tab (.4 mg) every 5 minutes until symptoms resolve or until 3 doses are administered 6. If symptoms resolve, monitor, reschedule appointment, and send home otherwise send to ED DANGER ZONE All incidents of rst time chest pain should always be considered as an MI, unless patient has a history of angina pectoris and says his/her pain is consistent with her “usual” angina When MI is suspected, the rst thing you do is activate Emergency Medical Services (112) IV. MYOCARDIAL INFARCTION AKA heart attack Initially di cult to distinguish from angina Lasts more than 30 mins Elective dental care should be deferred if A —> B 5. De nitive care (MONA): M-Morphine (2-5mg IV) O-Oxygen (4/6 L/min) N- Nitroglycerin- sublingual spray or tab (.4 mg) every 5 minutes until symptoms resolve or until 3 doses are administered A- Aspirin (325mg) 6. Continue to monitor vitals 7. Transport to ED 8. With loss of consciousness, administer CPR 6 of 16 fi fi ffi ffi fi fi  V. ACQUIRED COAGULATION DISORDERS Medical indications for anticoagulation Signi cant cardiovascular disease Prior MI Atherosclerosis Angina Deep venous thrombosis (DVT) History of atrial brillation or utter Prosthetic heart valves Pulmonary embolism Direct Oral Anticoagulants (DOAC) Newer anticoagulants are direct inhibitors of factor Xa Rivaroxaban (Xarelto®) Dabigatran (Pradaxa®) Apixaban (Eliquis®) Require little/no monitoring A 2015 consensus guideline from the European Heart Rhythm Association suggests that interventions not necessarily requiring discontinuation of the newer anticoagulants include extraction of 1 to 3 teeth; periodontal surgery; abscess incision; or implant positioning. Extensive procedures require consultation with hematologist. Discontinuation of drug 24 hours prior to surgery and resuming it 24-48 hrs after surgery is the usual recommendation. Anti-platelets: 7 of 16 fi fi fl  RESPIRATORY SYSTEM I. Asthma II. Aspiration I. ASTHMA Chronic in ammatory disorder characterized by reversible obstruction of the airways Causative factors: Extrinsic (allergic) Intrinsic (non-allergic) Most patients are well managed, know what brings on an attack and how to treat it DENTAL CONSIDERATIONS Stress Reduction protocol Sedation Inhalational (Nitrous Oxide with Oxygen) Oral (Benzodiazipine) Barbiturates and opioids are contraindicated Treat only when patient is stabilized i.e ASA II Always have patient get his/her inhaler to appointment DENTAL MANAGEMENT 1. Terminate dental procedure 2. P: place pt in their most comfortable position. Usually upright. 3. BLS: C —> A —> B 4. De nitive care (BO): B- Bronchodilator O-Oxygen (5-7 L/min) 5. Continue to monitor vitals 6. If episode terminates, discharge pt. If not, activate EMS and administer parenteral drugs until EMS arrives. II. ASPIRATION Foreign body airway obstruction Most cases are preventable with diligent suctioning and use of rubber dams If object goes missing it will end up in several di erent places Back of throat Stomach Larynx Suction Lungs (right) Floor All objects must be accounted for Follow up is crucial, if con rmed Even if patient says he/she did not swallow or aspirate object, a chest and abdominal radiograph must be done to con rm whereabouts If fully aspirated, treatment will depend on location, size, and type of material GI tract? Objects that end in the larynx will cause: 1. Partial airway obstruction: Encourage patient to cough it out till retrieved. Otherwise, refer to ED. 2. Complete airway obstruction: Must be managed immediately with the Heimlich maneuver 8 of 16 fi fl fi fi ff  CENTRAL NERVOUS SYSTEM I. Hyperventilation III. Seizures II. Vasovagal syncope IV. Cerebral Vascular Accident (CVA) I. Hyperventilation Increase in frequency and depth of respiration Stress-induced More common in young females Rarely lose consciousness but might feel lightheaded Stress reduction protocols crucial DENTAL MANAGEMENT 1. Terminate appointment 2. P: Position comfortably 3. Reassure patient that they will be OK 4. Have patient cup his/her hands in front of mouth and nose and continue to breathe into it to increase amount of inspired CO2 5. No longer recommended to breathe in paper bag 6. Consider pre-medication or nitrous oxide for next appointment II.VASOVAGAL SYNCOPE More common in young males “Fight-or- ight” ” mechanism—> decrease perfusion to the brain —> transient loss of consciousness Risk factors are either psychogenic or non-psychogenic Mostly associated with injection of local anesthetics Consider sedation DENTAL MANAGEMENT P: Supine position with raised legs BLS: C —> A —> B De nitive care: Oxygen Loosen tight clothing Cold cloth to forehead Aromatic ammonia salts Cancel appointment? If patient loses consciousness and bradycardia persists, start IV and administer- Atropine.4 mg VASOVAGAL SYNCOPE Allow patient to rest for some time “Go home, lie down, get lots of uids” Arrange for a ride home, if possible Warn patient that he is likely to experience recurrences for the next 24 hours 9 of 16 fi fl fl  III. SEIZURES De nition: Sudden, uncontrolled burst of electrical activity in the brain that leads to changes in muscle tone, sensations and consciousness Loss of consciousness is usually self-limiting. One episode of a seizure, is not epilepsy! Most common reasons for seizures in the dental o ce: 1. Seizure in a known epileptic patient 3. Hypoxia secondary to syncope 2. Hypoglycemia 4. Local anesthesia overdose TYPES Partial seizure – involve limited area of the brain; brief or no loss of consciousness General seizures – associated with loss of consciousness Absence (Petit Mal) Tonic-clonic (Grand Mal) Psychomotor Status epilepticus: A medical emergency demanding prompt diagnosis and treatment Seizure >5 mins or a repeated seizure Most common cause is non- compliance with medications Grand mal status is life- threatening TONIC CLONIC SEIZURES - Prodromal phase: The appearance of the aura - Pre-ictal phase: Pt loses consciousness & The stage of the epileptic cry - Ictal phase: Tonic & clonic components - Post-ictal phase: Regains consciousness DENTAL CONSIDERATIONS Stress Reduction protocol Sedation Inhalational (Nitrous Oxide with Oxygen) Oral (Benzodiazipine) Alcohol contraindicated Prevention is important Make sure they are on their medications Avoid triggers - ashing lights, loud music DENTAL MANAGEMENT 1. P: position pt on oor or dental chair? 2. Activate emergency medical services (call 112) 3. BLS: C —> A —> B 4. De nitive care Prevention of injury Do not place anything in pts mouth Post-ictal phase: ( Monitor vital signs & Administer Oxygen) 5. If the seizure continues >5mins, IV access and administer Midazolam 1ml/min until seizure stops DISCHARGE —>>>>>>> 10 of 16 fi fi fl fl ffi  IV. CEREBROVASCULAR ACCIDENT (Stroke) AKA Stroke Blood supply to brain interrupted, resulting in focal necrosis and permanent damage Patient will not fully recover Causes: Ischemic or hemorrhagic Signs and symptoms (FAST): - Face (drooping) - Arm (Weakness) - Speech (Di culties) - Time (to call) *Remember, recognize and act fast DENTAL CONSIDERATIONS No elective therapy < 6 months of episode Stress Reduction protocol Consider inhalational sedation (nitrous oxide and oxygen) Avoid use of Aspirin and NSAIDs Adequate pain control is fundamental (limit to 2 carpules) Anticoagulants or anti-platelet therapy? Modi cations to oral hygiene may be needed DENTAL MANAGEMENT P: position comfortably Activate dental o ce emergency team BLS: C —> A —> B De nitive care Activate emergency medical services Monitor vital signs Administer Oxygen BP elevated? Semi-fowler position Transport ED 11 of 16 fi fi ffi ffi  ENDOCRINE SYSTEM I. Hypoglycemia II. Hyperglycemia III. Thyroid storm IV. Adrenal insu ciency I. HYPOGLYCEMIA Usually seen in diabetic patients, but may happen with anyone Blood glucose < 4mmol/L Patients will take their medications and not eat before appointment Make sure patient ate a well-balanced meal before appointment Instruct patient to get his glucose monitor and check on the dental chair Be prepared Sings and symptoms: - Cold sweat - Palpitation - Weakness - Trembling - Drowsy - Excessive Hunger - Firs DENTAL MANAGEMENT P: most comfortable As long as patient is conscious, administer an oral sugar source 3-4 glucose tablets or any sugar source Recheck vitals and glucose levels after 15 mins Cancel appointment Monitor before discharge Discharge with escort DENTAL MANAGEMENT If patient loses consciousness: Stop procedure Activate Emergency Medical Services BLS: C —> A —> B De nitive care: Oxygen Establish IV access and administer solution 50ml 50% Dextrose (D50) IV Glucagon - 1 mg IM or IV Monitor vitals until EMS come Discharge HYPOGLYCEMIA AFTER DENTAL CARE Must inform patients about post-operative intake and glucose monitoring necessity Patient may need to decrease insulin intake, or consult physician for advice 12 of 16 fi ffi  II. HYPERGLYCEMIA Not likely to see an acute hyperglycemic episode Diabetic ketoacidosis Pt usually not compliant with medications Most common with type I diabetes Signs and symptoms: Dry mouth Increased thirst Blurred vision Hunger Fatigue Frequent urination LATE SIGNS & SYMPTOMS Bright red coloured face Tachycardia Ketone breath (sweet fruity breath) Hypotension Increased rate and depth of respirations Altered level of consciousness (Kaussmal’s respiration) DENTAL MANAGEMENT Terminate dental therapy P: position supine with legs elevated BLS: C —> A —> B De nitive care Activate emergency medical services Administer oxygen Establish IV line and administer saline Transport to ED THYROID DISEASES Not likely to experience any acute medical emergencies Hyperthyroidism is more of a concern Dental o ce can seem intimidating and you may induce a thyroid storm III. THYROID STORM A cause for concern Limit dose of epinephrine to cardiac dose,.04 mg, or 2 carpules of 1:100,000 Symptoms: - Sweating - Fever (>41°) Severe hypotension - Tachycardia Coma and death - Exophthalmos DENTAL MANAGEMENT Terminate dental therapy P: position supine with legs elevated BLS: C —> A —> B De nitive care Activate emergency medical services Cold towels to prevent hyperthermia Administer oxygen Establish IV line and administer saline Treat with IV propylthiouracil Treat with IV beta-blocker, propranolol, 0.5 mg Transport to ED ‫تطلعلك بليل‬ 13 of 16 fi fi ffi  IV. ADRENAL INSUFFICIENCY These patients should be under physician supervision Requires oral steroids to maintain adequate levels of corticosteroids Medical consult is needed if you are planning a large or stressful procedure Patient may require additional doses of steroids to compensate for additional stressors in the dental o ce Stress reduction protocol is a valuable tool GLUCOCORTICOSTEROID THERAPY DENTAL MANAGEMENT Terminate dental therapy P: position in comfortable position BLS:C —> A —> B De nitive care Activate emergency medical services Monitor vital signs Administer oxygen Treat with 100mg Hydrocortisone IV or IM slowly Transport to ED 14 of 16 fi ffi Local Anesthesia 15 of 16 16 of 16