Dr. Neil J. Gajjar,
BSc, DDS, MAGD, FADI, FPFA, FICD, FACD, Cert. IV Sedation

Private Practice
Mississauga, Ontario
Dr. Neil J. Gajjar,
BSc, DDS, MAGD, FADI, FICD, FPFA, FACD, Cert. IV Sedation
Private Practice:
16-735 Twain Avenue, Missi...
1/18/2014

(c) 2014 Neil J. Gajjar, DDS

3
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AIRWAY
BREATHING
CIRCULATION
DEFIBRILLATION
EMERGENCY DRUGS

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A change in the order of sequence!
From A-B-C to C-A-B

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




Make it easier for lay rescuers.
If you don’t know anything than do
compressions.
It has been found that compressi...
The Heart:
• Pumps blood (Deoxygenated & Oxygenated)
• Size of a fist
• Weighs 250 to 300 grams

• Located in the centre o...
The Lungs:
• Clusters of air sacs (alveoli)
• Alveoli site of Oxygen and Carbon Dioxide
exchange
• Air entering lungs cont...






Sensation of
pressure, tightness, fullness, squeezing, or
pain
Localized behind the sternum or throughout
from o...


Precipitating factors
 Any factor that will increase myocardial oxygen
demand beyond available supply
 Increased hear...


Relieving factors
 Reversal of precipitating factors
 Rest
 Nitroglycerin

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

Death of part of the heart muscle due to
inadequate blood oxygen supply

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Causes
 Coronary atherosclerosis
 Blood clot formation

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

Precipitating events
 Can occur at rest
 Can occur with mild to moderate exertion

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

With known coronary disease
 Chest pain or discomfort not relieved by 1
nitroglycerin tablet at 3-5 minute intervals t...


Importance of prompt emergency medical
care during the first symptom hour
 Ventricular fibrillation very frequent duri...
Brain Death
No
Oxygen

10-12 Minutes

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For each minute that defibrillation is delayed
Survival is reduced by 10%

Survival Rate (percent)

100

80
60
40
20
0

5

...
•

CPR (only) ……………………… 0-2%

• EMS/ER …………………… 5-15%
• CPR+AED…….. 30-75%
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DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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Chest Compressions Video

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

Assessment: Determine pulselessness

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Locate correct hand position
 Landmarks
 Hand positioning

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

Begin chest compressions
 Depress minimum 2 inches (5cm) 1/3 AP
 Rescuers must provide compressions of adequate rate ...
Compression-ventilation ratio 30:2
 Check for return of pulse and spontaneous
breathing after five cycles
 Resume cycles...
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DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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

Assessment: Determine unresponsiveness
Call for help



1/18/2014

“Phone first” and get the AED and return to star...



Position the victim
Open the airway:
 Opening the airway remains a priority for an
unresponsive trauma victim with s...
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Large pieces of food
Alcohol
Dentures
Other foreign objects

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

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Forceful coughing
Wheezing
Do not interfere

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


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Weak, ineffective cough
High-pitched breath sounds
Blueness of skin
Manage as complete airway obstruction

1/18/2...




Unable to speak, breath, or cough
Clutches neck (universal distress sign)
Bluish colour

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If the person can cough, speak, or breath, do not
interfere

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

Abdominal thrusts

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

Chest thrusts (late pregnancy and obesity)

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

Abdominal thrusts
 Victim standing



Chest compressions
 Victim lying down



Chest compressions in late pregnancy...
Adult Choking Video

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

Position victim
Activate EMS (911)
Perform up to 30 chest compressions
Attempt ventilation; reattempt ventilation



R...


Determine unresponsiveness
Activate EMS (911)
Position victim
Perform up to 30 chest compressions
Attempt ventilation

...
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

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DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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


Assessment: Determine breathlessness
If victim is unresponsive but obviously
breathing, place in recovery position

1...


If victim is not breathing, give two slow rescue
breaths (2 seconds)
 Excessive ventilation (too many breaths per minu...
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


Infant: < 1 year
Child: 1 – 8 years
 Healthcare provider “child” CPR guidelines now apply to
victims 1 year to the o...






DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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

Assessment: determine pulselessness

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


Finger/hand position for compressions
Begin compressions

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

Infant: Depth minimum 2 inches (5cm) 1/3AP
 Rate of at least 100 per minute



Child: Depth minimum 1.5 inches (4cm) ...


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DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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



Assessment: determine unresponsiveness
Position the victim
Open the airway: head tilt-chin lift

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(c) 201...
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



Determine airway obstruction
Perform abdominal thrusts
Repeat until:
 Good air exchange is resumed (foreign body i...
Infant Choking Video

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

Determine unresponsiveness; call for help; position victim
Perform up to 30 chest compressions
Open the airway; determi...


Determine unresponsiveness; call for help; position victim
Perform 30 chest compressions
Open the airway; determine bre...






DEFIBRILLATION
CIRCULATION
AIRWAY
BREATHING
EMERGENCY DRUGS

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


Assessment: determine breathlessness
Ventilate twice

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Infant BLS Video

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Mandatory for healthcare providers
Ventilator assesses victim
Compression to ventilation ratio 30:2 A...
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Adult CPR-2 Video

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

The most probable victim on whom you will be
required to perform CPR will be either a family
member or friend.

1/18/20...




Transparent mask
Oxygen inlet
One-way valve

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

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Provides adequate ventilation
Supplemental oxygen is possible
Aesthetically more acceptable

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Adult

Child

Infant

Age

> 8 years

1 –8 years

< 1 year

Help

Call 911 ?

2 Cycles

2 Cycles

Breath

1.5-2 sec

1-1.5...
Dr. Neil J. Gajjar,
BSc, DDS, MAGD, FADI, FPFA, FICD, Cert. IV Sedation

Private Practice
Mississauga, Ontario
Ventricular
Fibrillation
Chaotic
Quivering
but

NO Heartbeat
NO Breathing

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80-90%
of sudden deaths
are caused by

V-fib

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The

Only Correction for

V-fib

De-fib
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If you see patient collapse or you find him down…

…you don’t know if it’s

Sudden Death
or a

Heart Attack
1/18/2014

(c)...
Is Help Needed?
• Recognize that someone needs
emergency medical help

• Check The Area
for personal dangers

1/18/2014

(...
Prepare the Chest for Electrodes
 Expose the patient’s bare chest

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Prepare the Chest for Electrodes
(if necessary)

 Shave hair at pad sites
 Wipe/dry pad site area
 Remove Bra
ZOLL AED ...
CPR-D Padz Placement

1.

• Open the foil Padz pouch

• Unfold CPR-D Padz
• Position center “puck”
( as shown)
1/18/2014

...
 Don’t Touch Patient During Analysis

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 Stay Clear of Patient During Shocks
 Verbal Command to Clear
 Visually Confirm All Are Clear

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AED Plus
ONLY Advises Treatment
If there is a

Shockable Rhythm
Push Shock Button

1/18/2014

No Shock Needed

(c) 2014 Ne...
• Delivers an electrical charge to the heart

• Momentarily stop the hearts electrical activity
• Hopefully the heart star...
Normal Sinus Rhythm
Ventricular Fibrillation
Ventricular Tachycardia
Asystole
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Transfer of Care
• Verbal Report
 Initial Condition
 Care Delivered (including # of

shocks)
 Estimated “Down Time”
 A...
Precautions & Concerns
Avoid Placing the Electrode Directly Over

Implanted Heart Devices
R

Pacemaker

1/18/2014

(c) 201...
Implanted Heart Devices
Pacemaker
Defibrillator
If scar or “bulge” on
right side of chest

Slightly “Rotate” Padz
Medicatio...
Additional Factors
When using an AED

Personal Safety
Sensitivity to Family
Crowd Control
Periods of “Inactivity”
Talk to ...
Patient is less than 8 yrs of age
Patient is under 80 pounds
Explosive environment
Patient is immersed in water
Following ...
Drug Guidelines

Dr. Neil J. Gajjar,
BSc, DDS, MAGD, FADI, FPFA, FICD, Cert. IV Sedation

Private Practice
Mississauga, On...



Known disorders
Current medications
 Prescription
 Over the counter (OTC)
 Herbal Medicines
 Ginkgo—inhibits plat...



General appearance
Vital signs
 Ideally taken at initial visit and recalls



Response to exertion

1/18/2014

(c) ...



Pre-operative blood pressure and heart rate
Stress reduction
 Chairside manner
 Profound local anasthesia
 Conscio...




Pre-operative blood pressure and heart rate
Stress reduction
 Chairside manner
 Profound local anasthesia
 Consci...


Physiologic release about 25mg daily
Stress can increase release to 300mg



Management



 Double daily dose pre-op...


Hypoglycemia
 Rapid
onset, cool, wet, pallor, weak, dizzy, hunger, nausea, ment
al confusion, lethargy, increase HR, d...
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AIRWAY
BREATHING
CIRCULATION

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

Most common emergency!



Position
ABC’s
Oxygen
Consider oral glucose when conscious
If blood pressure low and heart r...


Major signs
 Bronchospasm
 Hypotension
 Laryngeal edema



Minor signs





1/18/2014

Urticarial rash
Generali...





ABC’s
Oxygen
Call 911
Epinephrine 1:1000, 0.5 mL intra-muscular
 Repeat epinephrine q10 min prn



Diphenhydram...
OPA:
• semicircular
• frequently plastic and disposable
• used to hold tongue away from
back of throat
• variety of sizes
...


Diphenhydramine 50 mg 1 mL intra-muscular

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106


Salbutamol inhaler, 2 puffs
 Repeat as necessary



Oxygen

If symptoms worsen than add:


Epinephrine 1:1000, 0.5 m...






Call 911
CPR
100% oxygen
AED if available
Epinephrine 1mg iv as long as CPR not interrupted

1/18/2014

(c) 201...
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109

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







ABC’s
Oxygen
Nitroglycerin, allow 3 minutes
If no relief repeat Nitro, allow 3 minutes
If no relief repe...












Call 911
ABC’s
Oxygen
Nitroglycerin, allow 3 minutes
If no relief repeat Nitro, allow 3 minutes
If no...




Systolic BP >210 or diastolic BP>120
Transfer to physician immediately
Consider nitroglycerin 0.3 or 0.4mg sublingu...






Systolic BP <90 or BP drops by 15-20%
Position
ABC’s
Oxygen
If blood pressure low and heart rate < 60
 Atropin...




Signs and symptoms include: sudden
headache, dizziness, nausea and vomiting
Transfer to hospital immediately!

1/18/...
History of steroid use combined with the following
signs and symptoms: confusion, nausea and
vomiting, abdominal pain, hyp...


If conscious
 Oral carbohydrates



If unconscious





1/18/2014

ABC’s
Oxygen
Call 911
1mg glucagon im

(c) 201...


If conscious
 Hospitalize



If unconscious
 ABC’s
 Oxygen
 Call 911

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117



Protect patient
If seizure continues > 5 minutes
 Call 911
 Lorazepam (Ativan) 4mg im
 Midazolam (Versed) 5mg im

...



Calm the patient
Correct alkalosis (re-breathe into paper bag)

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119


Bisphosphonates




Fosamax®/Actonel®/Boniva®

Anticoagulants
 Plavix/Aspirin/Coumadin/Heparin

1/18/2014

(c) 2014 ...


The consensus from reviews on the management of dental patients taking warfarin is that patients
requiring dental surgi...







Up to 1 out of every 2 women over 50 will break a bone (such as wrist, spine or
hip) due to osteoporosis in the...









Key office staff should have CPR!
Know your drugs!
Know where they are!
Review protocols!
Have in office d...
For Your Commitment To

Safety, Health & Life
1/18/2014

(c) 2014 Neil J. Gajjar, DDS

124
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Emergency Lecture 2014

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CPR & Medical Emergencies in the Dental Office presentation by Neil Gajjar, DDS.

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  • The Adult BLS Healthcare Providers algorithm incorporates changes designed to simplify lay-rescuer training and to continue to emphasize the need to provide early chest compressions delivered to the victim of a sudden cardiac arrest.  The circle design has been developed place the emphasis on continuous chest compressions with minimal interruptions.
  • Emergency Lecture 2014

    1. 1. Dr. Neil J. Gajjar, BSc, DDS, MAGD, FADI, FPFA, FICD, FACD, Cert. IV Sedation Private Practice Mississauga, Ontario
    2. 2. Dr. Neil J. Gajjar, BSc, DDS, MAGD, FADI, FICD, FPFA, FACD, Cert. IV Sedation Private Practice: 16-735 Twain Avenue, Mississauga, ON L5W 1X1 Email: personal@drgajjar.com 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 2
    3. 3. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 3
    4. 4.      AIRWAY BREATHING CIRCULATION DEFIBRILLATION EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 4
    5. 5.   A change in the order of sequence! From A-B-C to C-A-B 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 5
    6. 6.    Make it easier for lay rescuers. If you don’t know anything than do compressions. It has been found that compressions are more important and need to be delivered first. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 6
    7. 7. The Heart: • Pumps blood (Deoxygenated & Oxygenated) • Size of a fist • Weighs 250 to 300 grams • Located in the centre of the chest between the breastbone and backbone • 4 chambers •Sinoatrial node creates electrical activity to generate heart beat 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 7
    8. 8. The Lungs: • Clusters of air sacs (alveoli) • Alveoli site of Oxygen and Carbon Dioxide exchange • Air entering lungs contains 21% oxygen, little Carbon Dioxide •Air leaving the lungs contains 16% oxygen and 5% Carbon Dioxide • Air we breathe out has enough Oxygen to help someone who has stopped breathing 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 8
    9. 9.     Sensation of pressure, tightness, fullness, squeezing, or pain Localized behind the sternum or throughout from of chest May radiate to shoulders, arms, neck jaw, back of chest, upper abdomen Steady, usually lasting from a few minutes up to 10-15 minutes 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 9
    10. 10.  Precipitating factors  Any factor that will increase myocardial oxygen demand beyond available supply  Increased heart rate  Increased blood pressure 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 10
    11. 11.  Relieving factors  Reversal of precipitating factors  Rest  Nitroglycerin 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 11
    12. 12.  Death of part of the heart muscle due to inadequate blood oxygen supply 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 12
    13. 13.  Causes  Coronary atherosclerosis  Blood clot formation 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 13
    14. 14.  Precipitating events  Can occur at rest  Can occur with mild to moderate exertion 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 14
    15. 15.  With known coronary disease  Chest pain or discomfort not relieved by 1 nitroglycerin tablet at 3-5 minute intervals to a maximum dose of 3 tablets  Without previously know cardiac disease  Chest pain or discomfort lasting more than a few minutes. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 15
    16. 16.  Importance of prompt emergency medical care during the first symptom hour  Ventricular fibrillation very frequent during first symptom hour  Blood clot-dissolving medications, if appropriate, should be given ASAP  Average delay between onset of symptoms and decision to seek medical assistance: 3 hours 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 16
    17. 17. Brain Death No Oxygen 10-12 Minutes 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 17
    18. 18. For each minute that defibrillation is delayed Survival is reduced by 10% Survival Rate (percent) 100 80 60 40 20 0 5 10 15 20 25 30 Time to Defibrillation (minutes) 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 18
    19. 19. • CPR (only) ……………………… 0-2% • EMS/ER …………………… 5-15% • CPR+AED…….. 30-75% 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 19
    20. 20.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 20
    21. 21.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 21
    22. 22. Chest Compressions Video 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 22
    23. 23.  Assessment: Determine pulselessness 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 23
    24. 24.  Locate correct hand position  Landmarks  Hand positioning 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 24
    25. 25.  Begin chest compressions  Depress minimum 2 inches (5cm) 1/3 AP  Rescuers must provide compressions of adequate rate and depth and allow adequate chest recoil with minimal interruptions in chest compressions. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 25
    26. 26. Compression-ventilation ratio 30:2  Check for return of pulse and spontaneous breathing after five cycles  Resume cycles with compressions  (if no pulse; if pulse than rescue breaths, 1/6-8 or 1/3-5secs) 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 26
    27. 27.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 27
    28. 28.   Assessment: Determine unresponsiveness Call for help   1/18/2014 “Phone first” and get the AED and return to start CPR and use the AED for all adults and any children with out-of hospital sudden collapse. “CPR first” (provide about 5 cycles or 2 minutes of CPR before activating the emergency response number) for unresponsive infants and children (except infants and children with sudden, witnessed collapse) and for all victims of likely hypoxic (asphyxial) arrest (eg, drowning, injury, drug overdose). (c) 2014 Neil J. Gajjar, DDS 28
    29. 29.   Position the victim Open the airway:  Opening the airway remains a priority for an unresponsive trauma victim with suspected cervical spine injury; if a jaw thrust without head extension does not open the airway, healthcare providers should use the head tilt–chin lift maneuver. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 29
    30. 30. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 30
    31. 31. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 31
    32. 32.     Large pieces of food Alcohol Dentures Other foreign objects 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 32
    33. 33.    Forceful coughing Wheezing Do not interfere 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 33
    34. 34.     Weak, ineffective cough High-pitched breath sounds Blueness of skin Manage as complete airway obstruction 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 34
    35. 35.    Unable to speak, breath, or cough Clutches neck (universal distress sign) Bluish colour 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 35
    36. 36.  If the person can cough, speak, or breath, do not interfere 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 36
    37. 37.  Abdominal thrusts 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 37
    38. 38.  Chest thrusts (late pregnancy and obesity) 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 38
    39. 39.  Abdominal thrusts  Victim standing  Chest compressions  Victim lying down  Chest compressions in late pregnancy  Victim standing  Victim lying down 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 39
    40. 40. Adult Choking Video 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 40
    41. 41.  Position victim Activate EMS (911) Perform up to 30 chest compressions Attempt ventilation; reattempt ventilation  Repeat last three steps until successful    1/18/2014 (c) 2014 Neil J. Gajjar, DDS 41
    42. 42.  Determine unresponsiveness Activate EMS (911) Position victim Perform up to 30 chest compressions Attempt ventilation  Repeat last three steps until successful     1/18/2014 (c) 2014 Neil J. Gajjar, DDS 42
    43. 43.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 43
    44. 44.   Assessment: Determine breathlessness If victim is unresponsive but obviously breathing, place in recovery position 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 44
    45. 45.  If victim is not breathing, give two slow rescue breaths (2 seconds)  Excessive ventilation (too many breaths per minute or breaths that are too large or too forceful) may be harmful and should not be performed.  Mouth to mouth rescue breathing  Mouth to nose rescue breathing  Mouth to stoma rescue breathing 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 45
    46. 46. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 46
    47. 47.   Infant: < 1 year Child: 1 – 8 years  Healthcare provider “child” CPR guidelines now apply to victims 1 year to the onset of puberty. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 47
    48. 48.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 48
    49. 49.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 49
    50. 50.  Assessment: determine pulselessness 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 50
    51. 51.   Finger/hand position for compressions Begin compressions 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 51
    52. 52.  Infant: Depth minimum 2 inches (5cm) 1/3AP  Rate of at least 100 per minute  Child: Depth minimum 1.5 inches (4cm) 1/3AP  Rate of at least 100 per minute   Compression to ventilation ratio of 30:2 Active chin lift is often needed during ventilation of the child 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 52
    53. 53.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 53
    54. 54.    Assessment: determine unresponsiveness Position the victim Open the airway: head tilt-chin lift 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 54
    55. 55. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 55
    56. 56.    Determine airway obstruction Perform abdominal thrusts Repeat until:  Good air exchange is resumed (foreign body is expelled)  Victim becomes unconscious 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 56
    57. 57. Infant Choking Video 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 57
    58. 58.  Determine unresponsiveness; call for help; position victim Perform up to 30 chest compressions Open the airway; determine breathlessness Attempt ventilation; reattempt ventilation  Repeat last 3 steps until successful    1/18/2014 (c) 2014 Neil J. Gajjar, DDS 58
    59. 59.  Determine unresponsiveness; call for help; position victim Perform 30 chest compressions Open the airway; determine breathlessness Attempt ventilation; reattempt ventilation  Repeat last 3 steps until successful    1/18/2014 (c) 2014 Neil J. Gajjar, DDS 59
    60. 60.      DEFIBRILLATION CIRCULATION AIRWAY BREATHING EMERGENCY DRUGS 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 60
    61. 61.   Assessment: determine breathlessness Ventilate twice 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 61
    62. 62. Infant BLS Video 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 62
    63. 63.          Mandatory for healthcare providers Ventilator assesses victim Compression to ventilation ratio 30:2 Adult Compression to ventilation ratio 30:2 Child/Infant No Pause for ventilations when airway in place Need for switch every 2 minutes (5 Cycles) Ventilator delivers breath Rescuers change places New cycle begins 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 63
    64. 64. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 64
    65. 65. Adult CPR-2 Video 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 65
    66. 66. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 66
    67. 67.  The most probable victim on whom you will be required to perform CPR will be either a family member or friend. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 67
    68. 68.    Transparent mask Oxygen inlet One-way valve 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 68
    69. 69.    Provides adequate ventilation Supplemental oxygen is possible Aesthetically more acceptable 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 69
    70. 70. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 70
    71. 71. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 71
    72. 72. Adult Child Infant Age > 8 years 1 –8 years < 1 year Help Call 911 ? 2 Cycles 2 Cycles Breath 1.5-2 sec 1-1.5 sec 1-1.5 sec Depth 2 inches 2 inches 1.5 inches Rate 100 100 100 Cycle 5:30:2 5:30:2 5:30:2 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 72
    73. 73. Dr. Neil J. Gajjar, BSc, DDS, MAGD, FADI, FPFA, FICD, Cert. IV Sedation Private Practice Mississauga, Ontario
    74. 74. Ventricular Fibrillation Chaotic Quivering but NO Heartbeat NO Breathing 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 74
    75. 75. 80-90% of sudden deaths are caused by V-fib 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 75
    76. 76. The Only Correction for V-fib De-fib 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 76
    77. 77. If you see patient collapse or you find him down… …you don’t know if it’s Sudden Death or a Heart Attack 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 77
    78. 78. Is Help Needed? • Recognize that someone needs emergency medical help • Check The Area for personal dangers 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 78
    79. 79. Prepare the Chest for Electrodes  Expose the patient’s bare chest 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 79
    80. 80. Prepare the Chest for Electrodes (if necessary)  Shave hair at pad sites  Wipe/dry pad site area  Remove Bra ZOLL AED Plus units come with potentially needed accessories: Scissors Razor Towel Gloves CPR Face Shield 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 80
    81. 81. CPR-D Padz Placement 1. • Open the foil Padz pouch • Unfold CPR-D Padz • Position center “puck” ( as shown) 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 81
    82. 82.  Don’t Touch Patient During Analysis 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 82
    83. 83.  Stay Clear of Patient During Shocks  Verbal Command to Clear  Visually Confirm All Are Clear 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 83
    84. 84. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 84
    85. 85. AED Plus ONLY Advises Treatment If there is a Shockable Rhythm Push Shock Button 1/18/2014 No Shock Needed (c) 2014 Neil J. Gajjar, DDS 85
    86. 86. • Delivers an electrical charge to the heart • Momentarily stop the hearts electrical activity • Hopefully the heart starts beating normally after the shock is delivered 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 86
    87. 87. Normal Sinus Rhythm Ventricular Fibrillation Ventricular Tachycardia Asystole 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 87
    88. 88. Transfer of Care • Verbal Report  Initial Condition  Care Delivered (including # of shocks)  Estimated “Down Time”  Any Changes in Patient’s Condition  Any available Medical History • Cooperate and Assist (as necessary & requested) 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 88
    89. 89. Precautions & Concerns Avoid Placing the Electrode Directly Over Implanted Heart Devices R Pacemaker 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 89
    90. 90. Implanted Heart Devices Pacemaker Defibrillator If scar or “bulge” on right side of chest Slightly “Rotate” Padz Medication Patches Remove Patch – Wipe Chest Clean 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 90
    91. 91. Additional Factors When using an AED Personal Safety Sensitivity to Family Crowd Control Periods of “Inactivity” Talk to the Patient 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 91
    92. 92. Patient is less than 8 yrs of age Patient is under 80 pounds Explosive environment Patient is immersed in water Following serious trauma 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 92
    93. 93. Drug Guidelines Dr. Neil J. Gajjar, BSc, DDS, MAGD, FADI, FPFA, FICD, Cert. IV Sedation Private Practice Mississauga, Ontario
    94. 94.   Known disorders Current medications  Prescription  Over the counter (OTC)  Herbal Medicines  Ginkgo—inhibits platelet activating factor. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 94
    95. 95.   General appearance Vital signs  Ideally taken at initial visit and recalls  Response to exertion 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 95
    96. 96.   Pre-operative blood pressure and heart rate Stress reduction  Chairside manner  Profound local anasthesia  Conscious sedation   Monitor BP and HR 5 minutes post injection Be aware of orthostatic hypotension 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 96
    97. 97.   Pre-operative blood pressure and heart rate Stress reduction  Chairside manner  Profound local anasthesia  Conscious sedation   Monitor BP and HR 5 minutes post injection Consider  Prophylactic nitroglycerin  Oxygen by nasal cannula  Avoiding elective treatment within 6 months of MI 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 97
    98. 98.  Physiologic release about 25mg daily Stress can increase release to 300mg  Management   Double daily dose pre-operatively 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 98
    99. 99.  Hypoglycemia  Rapid onset, cool, wet, pallor, weak, dizzy, hunger, nausea, ment al confusion, lethargy, increase HR, decrease in BP, LOC, seizure  Hyperglycemia  Slow onset, hot, dry, flushed, malaise, nausea, vomiting, drowsy , irritable, headache, acetone odor, increase HR, decrease in BP, LOC 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 99
    100. 100. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 100
    101. 101.    AIRWAY BREATHING CIRCULATION 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 101
    102. 102.  Most common emergency!  Position ABC’s Oxygen Consider oral glucose when conscious If blood pressure low and heart rate < 60      Atropine 0.6mg, 1 mL intra-muscular 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 102
    103. 103.  Major signs  Bronchospasm  Hypotension  Laryngeal edema  Minor signs     1/18/2014 Urticarial rash Generalized flush Nausea Abdominal pain (c) 2014 Neil J. Gajjar, DDS 103
    104. 104.     ABC’s Oxygen Call 911 Epinephrine 1:1000, 0.5 mL intra-muscular  Repeat epinephrine q10 min prn  Diphenhydramine 50 mg 1 mL intra-muscular 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 104
    105. 105. OPA: • semicircular • frequently plastic and disposable • used to hold tongue away from back of throat • variety of sizes 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 105
    106. 106.  Diphenhydramine 50 mg 1 mL intra-muscular 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 106
    107. 107.  Salbutamol inhaler, 2 puffs  Repeat as necessary  Oxygen If symptoms worsen than add:  Epinephrine 1:1000, 0.5 mL intra-muscular  Repeat epinephrine q10 min prn 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 107
    108. 108.      Call 911 CPR 100% oxygen AED if available Epinephrine 1mg iv as long as CPR not interrupted 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 108
    109. 109. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 109
    110. 110.         ABC’s Oxygen Nitroglycerin, allow 3 minutes If no relief repeat Nitro, allow 3 minutes If no relief repeat Nitro, allow 3 minutes If no relief after 3 doses, call 911 ASA 325 mg Consider morophine or Nitrous Oxide 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 110
    111. 111.          Call 911 ABC’s Oxygen Nitroglycerin, allow 3 minutes If no relief repeat Nitro, allow 3 minutes If no relief repeat Nitro, allow 3 minutes If no relief after 3 doses, call 911 ASA 325 mg Consider morophine or Nitrous Oxide 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 111
    112. 112.    Systolic BP >210 or diastolic BP>120 Transfer to physician immediately Consider nitroglycerin 0.3 or 0.4mg sublingually 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 112
    113. 113.      Systolic BP <90 or BP drops by 15-20% Position ABC’s Oxygen If blood pressure low and heart rate < 60  Atropine 0.6mg, 1 mL intra-muscular 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 113
    114. 114.   Signs and symptoms include: sudden headache, dizziness, nausea and vomiting Transfer to hospital immediately! 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 114
    115. 115. History of steroid use combined with the following signs and symptoms: confusion, nausea and vomiting, abdominal pain, hypotension     Position ABC’s Oxygen If blood pressure low and heart rate < 60  Atropine 0.6mg, 1 mL intra-muscular  Hydrocortisone 100mg im 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 115
    116. 116.  If conscious  Oral carbohydrates  If unconscious     1/18/2014 ABC’s Oxygen Call 911 1mg glucagon im (c) 2014 Neil J. Gajjar, DDS 116
    117. 117.  If conscious  Hospitalize  If unconscious  ABC’s  Oxygen  Call 911 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 117
    118. 118.   Protect patient If seizure continues > 5 minutes  Call 911  Lorazepam (Ativan) 4mg im  Midazolam (Versed) 5mg im 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 118
    119. 119.   Calm the patient Correct alkalosis (re-breathe into paper bag) 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 119
    120. 120.  Bisphosphonates   Fosamax®/Actonel®/Boniva® Anticoagulants  Plavix/Aspirin/Coumadin/Heparin 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 120
    121. 121.  The consensus from reviews on the management of dental patients taking warfarin is that patients requiring dental surgical procedures in primary care and who have an International Normalised Ratio (INR) below 4.0 should continue warfarin therapy without dose adjustment.  Continuing warfarin during dental surgical procedures may increase the risk of postoperative bleeding requiring intervention.  Most cases of postoperative bleeding are easily treated with local measures such as packing with a haemostatic dressing, suturing and pressure.  Stopping warfarin increases the risk of thromboembolic events; the risk of thromboembolism after withdrawal of warfarin therapy outweighs the risk of oral bleeding as bleeding complications, while inconvenient, do not carry the same risks as thromboembolic complications.  Stopping warfarin is no guarantee that the risk of postoperative bleeding requiring intervention will be eliminated as serious bleeding can occur in non-anticoagulated patients. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 121
    122. 122.     Up to 1 out of every 2 women over 50 will break a bone (such as wrist, spine or hip) due to osteoporosis in their lifetime. Each year, about 250,000 will break a hip due to osteoporosis. Of these, up to 24% will die, and less than 25% regain full function. Vertebral (spine) fractures, which occur twice as often as hip fractures, also cause back pain and increased mortality. Up to 1 out of 4 men over 50 will break a bone due to osteoporosis in their lifetime. Each year, about 80,000 men will break a hip. Oral or IV bisphosphonates have been shown to prevent 50-70% of vertebral fractures in postmenopausal women and 40-50% of hip fractures in clinical trials. Denosumab (Prolia) has been shown to reduce vertebral fractures in 70% of postmenopausal women and 40% of hip fractures. Given the risk of osteoporotic fracture, and the low risk of ONJ associated with potent antiresorptive therapy use, the benefit of preventing osteoporotic fracture clearly far exceeds the risk of ONJ. 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 122
    123. 123.        Key office staff should have CPR! Know your drugs! Know where they are! Review protocols! Have in office drills! Know your role! Check expiry dates! 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 123
    124. 124. For Your Commitment To Safety, Health & Life 1/18/2014 (c) 2014 Neil J. Gajjar, DDS 124

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