Medical Emergencies in the Dental Office

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Presentation at the Humboldt Del Norte Dental Society meeting 11/17/11

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  • Medical Emergencies in the Dental Office

    1. 1. A Buffalo Squirrels Production
    2. 2. Why are you grabbing your chest? What to do when the problem isn’t intra-oral Veronica Bonales, M.D. CEPAmerica Emergency Medicine
    3. 3. Why are you sweating, Mr. Wilson? What to do when the problem isn’t intra-oral Veronica Bonales, M.D. CEPAmerica Emergency Medicine
    4. 4. Why are you sweating, Mr. Wilson?
    5. 5. Why are you sweating, Mr. Wilson?
    6. 6. What’s wrong with Mr. Wilson?
    7. 7. What’s wrong with Mr. Wilson?Diaphoresis
    8. 8. What’s wrong with Mr. Wilson?Diaphoresis Vagal response
    9. 9. What’s wrong with Mr. Wilson?Diaphoresis Vagal response Anxiety
    10. 10. What’s wrong with Mr. Wilson?Diaphoresis Vagal response Anxiety Heart attack
    11. 11. What’s wrong with Mr. Wilson?Diaphoresis Vagal response Anxiety Heart attack Low blood sugar
    12. 12. What’s wrong with Mr. Wilson?Diaphoresis Vagal response Anxiety Heart attack Low blood sugar Drug reaction
    13. 13. GoalsRecognize thesymptomsHave the propertoolsBe prepared
    14. 14. GoalsRecognize thesymptomsHave the propertoolsBe preparedwww.slideshare.net/docmontey
    15. 15. Dr. Carl Howell
    16. 16. Syncope50 - 80% of all medical emergencies **Cardiac arrest until proven otherwise Most common cause is hypotension Can be from other medical conditions (cardiac, diabetes, etc)
    17. 17. Syncope
    18. 18. SyncopeHypotension Orthostatic Most common cause Most likely in elderly Vasovagal Stressful physical, psychological or surgical stimuli (pain, coughing, gagging) Get bradycardia and vasodilation
    19. 19. Syncope - SymptomsHypotension Postural NOT due to stress Obesity Poor physical condition Prolonged spine position Medications
    20. 20. Syncope - SymptomsEarly Late Nausea Hypotension Warmth Bradycardia Perspiration Hyperpnea Pallor Dilated pupils Tachycardia LOC
    21. 21. Syncope - Symptoms Syncopal Phase Due to decreased blood flow to brain Loss of postural tone Loss of consciousness If prolonged --> Sz’s, cerebral ischemia
    22. 22. Syncope - TreatmentABC’s, Vitals, O2Evaluate B/P
    23. 23. Syncope - TreatmentABC’s, Vitals, O2Evaluate B/P If no cuff remember: 6, 7, 8
    24. 24. Syncope - TreatmentABC’s, Vitals, O2Evaluate B/P If no cuff remember: 6, 7, 8 Carotid 60mm Hg
    25. 25. Syncope - TreatmentABC’s, Vitals, O2Evaluate B/P If no cuff remember: 6, 7, 8 Carotid 60mm Hg Brachial 70mm Hg
    26. 26. Syncope - TreatmentABC’s, Vitals, O2Evaluate B/P If no cuff remember: 6, 7, 8 Carotid 60mm Hg Brachial 70mm Hg Radial 80mm Hg
    27. 27. Tredelenberg...?
    28. 28. Tredelenberg...?No literature tosupportFound to bepossibly moreharmfulPlace patient inposition ofcomfort
    29. 29. Syncope - SymptomsCall EMS LOC > 5 minutes Recovery > 20 minutes Multiple medical problemsOtherwise d/c with family
    30. 30. AnxietyHyperventilation syndrome Anxiety, hyperpnea, “tingling” extremities, circumoral numbness, lightheadedness, rare LOC Treated by modifying breathing: pursed lip, into a bag, one nostril
    31. 31. Questions...?
    32. 32. Dr. Wilbur Wonka
    33. 33. Cardiac Events
    34. 34. Cardiac EventsChest Pain Differential Angina Myocardial Infarction Aortic Dissection
    35. 35. Cardiac EventsAlso have to consider: GERD PE Pneumothorax Esophageal rupture Panic disorder
    36. 36. Cardiac EventsAngina - blocked artery causes pain whenflow blocked due to spasm, low volume,unstable plaque
    37. 37. Cardiac EventsAcute coronary syndrome (ACS) - blockage ofartery by thrombus or plaque leads tomyocardial ischemia
    38. 38. Cardiac EventsSymptoms of ACS Chest pain Shortness of breath Diaphoresis Nausea
    39. 39. Cardiac EventsSymptoms of Aortic Dissection Chest pain Shortness of breath Diaphoresis Nausea
    40. 40. Cardiac EventsACS Dissection Pressure Sudden onset, sensation, ripping, squeezing, tearing with weight sitting radiation to on chest, back radiation to arm/jaw; may be gradual
    41. 41. Cardiac Events - CP
    42. 42. Cardiac Events - CP M - morphine, 2mg O - oxygen, 2l N - nitroglycerin, q5 min, up to 3 sl sprays or tabs A - aspirin, 325mg
    43. 43. Cardiac EventsABC’s (or CAB’s if cardiac arrest)Call EMSPlace patient in position of comfortMonitor if available
    44. 44. Cardiac EventsHypertension For Dx, need 3 readings White Coat Syndrome NPO End organ damage
    45. 45. Brain Events
    46. 46. Brain EventsStrokes Brain cell death due to ischemia Flow interrupted Aneurysm Thrombus/embolus Low blood pressure
    47. 47. Brain EventsStrokes
    48. 48. Brain EventsStrokes Facial Droop
    49. 49. Brain EventsStrokes Facial Droop Arm weakness
    50. 50. Brain EventsStrokes Facial Droop Arm weakness Slurring
    51. 51. Brain EventsStrokes Facial Droop Arm weakness Slurring Time is brain!
    52. 52. Brain EventsTreatment Call EMS Position of comfort Do not give blood pressure medications Oxygen
    53. 53. Brain EventsSeizures Usually known history Find out meds, when last sz, auras, provoking factors Can be due to toxins, drugs, hypoxia or metabolic factors
    54. 54. Brain EventsDuring seizure Keep patient and others protected Call EMS Protect airway, have suction available
    55. 55. Brain EventsTreatment Call EMS Most seizures last < 2 minutes If > 2 minutes, IV or IM benzodiazepine (diazepam, lorazepam, midazolam) Oxygen and protect airway Vitals when stable
    56. 56. Brain EventsPost-ictal patient Disoriented Lethargic Cannot protect airway May be injured
    57. 57. Questions...?
    58. 58. Dr. Philip Sherman
    59. 59. DiabetesAffects about 6% of the populationand is rising Type I - IDDM, islet cell dysfunction Type II - NIDDM, insulin receptor dysfunction
    60. 60. DiabetesHypoglycemia Most often secondary to med error or decreased p.o. intake Can also be from alcohol consumption, excessive exercise, illness
    61. 61. DiabetesGlucose important for brain,liver, and muscles When low, do not function properly
    62. 62. DiabetesSweating DizzinessTrembling ConfusionPalpitations HeadacheAnxiety WeaknessNausea Blurred vision
    63. 63. DiabetesTreatment Glucose - orange juice, regular soda, 4 teaspoons of sugar in water - glucose tablets, glucagon EMS if not resolving, unconscious or seizure
    64. 64. Questions...?
    65. 65. Hermey
    66. 66. Allergic ReactionsIgE mediated reaction/anaphylaxisLocal toxicityDrug interaction
    67. 67. Allergic ReactionsIgE Mediated Re-exposure to substance causes severe hypersensitivity reaction Fatal in 154/million hospitalized patients per year
    68. 68. Allergic Reactions
    69. 69. Allergic Reactions
    70. 70. Allergic ReactionsMast cell mediated Bronchospasm Airway constriction Angioedema Vasodilation Hypotension Increased capillary permeability
    71. 71. Allergic ReactionsMinor - localized - wheal and flarerash, itching, angioedema (face,lips, or periorbital swelling)Major - generalized - anaphylaxis
    72. 72. Allergic Reactions
    73. 73. Allergic ReactionsMinor - antihistamines, observe,consult physician
    74. 74. Allergic ReactionsMajor - ABC’s, EMS, Epi 1:1000 0.3 -0.5 mg or ml SQ or IM, antihistamine- 50mg diphenhydramine, H2 blocker,albuterol, oxygen, steroid -solumedrol 125mg or dexamethasone20mg IM or IVMonitor vital signs, start IV ifable, IVF if hypotension
    75. 75. Allergic ReactionsLocal toxicity Too large a dose - most common Rapid intravascular - common Slow elimination - least common
    76. 76. Allergic Reactions
    77. 77. Allergic Reactions Confusion, HA, blurred vision, talkativeness, dizziness, flushed, apprehension, drowsy, disoriented,excitedness, slurred ringing in ear, speech, moderate numbness of tongue twitching, or perioral tissues nystagmus, tachycardia, Seizures, CNS hypertension depression, LOC, hypotension, bradycardia
    78. 78. Allergic ReactionsHow to prevent: give minimal dose,aspirate and then push slowly, goodhistory and physicalTreatment: ABC’s, monitor vitals,oxygen, call EMS
    79. 79. Allergic ReactionsDrug interactions Prilocaine in excess or with Lidocaine and other oxidizing bupivacaine medication anesthetic (dapsone) can lead toxicity additive to methemoglobin- emia Anesthetic with opioid sedation Anesthetic with may increase risk metabolic of toxicity esp. inhibitor in children (cimetidine)
    80. 80. Allergic ReactionsAsthma Usually allergy-induced but can be stress-induced Slow progressing bronchospasm Coughing, wheezing, anxiety, dyspnea, pressure in chest
    81. 81. Allergic ReactionsTreatment Position of comfort, albuterol, EMS, epinephrine if severe bronchospasm
    82. 82. Questions...?
    83. 83. Dr. Orin Scrivello
    84. 84. Medical Emergencies Respiratory Arrest Cardiac Arrest
    85. 85. Medical Emergencies Prevention Preparation Action
    86. 86. Medical EmergenciesPrevention Thorough health history including allergies and medications, prior experience with anesthetics Appropriate physical exam Vitals Heart Lungs
    87. 87. Medical Emergencies • Epinephrine injection, 1:1000 solution (1mg adrenaline in 1ml saline) • Aspirin tablets 325mg • Diphenhydramine 50mg IV or capsules • Flumazenil 100ug/ml 5ml ampoule • Glucose, as dextrose 20% or 50% solution & an oral glucose solution. • Glucose intravenous infusion 50ml prefilled syringes • Glucagon 1mg injection • NTG tablets and sprays • Hydrocortisone (as sodium succinate or sodium phosphate)(100mg and water for injection). • Midazolam (5mg/ml 2ml ampoules) • Oxygen • Albuterol aerosol inhalation
    88. 88. Medical Emergencies
    89. 89. Medical EmergenciesStaff preparedness Knowledge of equipment location Drills ALS, BLS, First Aid / First Responder training Address at all phones
    90. 90. Medical EmergenciesDrills Everyone has a role One person responsible for patient One person calls EMS, waits for the crew, clears the area, copies patient chart One person go-between, gets equipment, applies equipment/ performs procedures One person records events (vitals, timing of medications)
    91. 91. Medical EmergenciesRespiratory Arrest (pure, secondary toairway obstruction) Place patient on floor Activate EMS, get equipment (oxygen, bag-valve mask, protective airway mask, monitor and AED)
    92. 92. Medical Emergencies ABC’s Airway - look, listen and feel for breath sounds, if none, tilt chin lift
    93. 93. Medical Emergencies ABC’s Airway - look, listen and feel for breath sounds, if none, tilt chin lift
    94. 94. Medical EmergenciesWhat about heavier patients, elderlypatients, children..?
    95. 95. Medical EmergenciesWhat about heavier patients, elderlypatients, children..?
    96. 96. Medical EmergenciesWhat about heavier patients, elderlypatients, children..?
    97. 97. Medical EmergenciesWhat about heavier patients, elderlypatients, children..?
    98. 98. Medical EmergenciesWhat about heavier patients, elderlypatients, children..?
    99. 99. Medical EmergenciesGive 2 rescue breathsIf breaths do not go in, readjust,perform jaw thrust, then give 2 breathsEstablish IV or give medications IM atthe same time evaluating patientStart placing on monitor
    100. 100. Medical EmergenciesIf breaths do not go inafter readjustment andjaw thrust, may need toconsider surgicalairway Foreign body Laryngeal swelling Tongue swelling
    101. 101. Medical Emergencies Cricothyrotomy
    102. 102. Medical Emergencies Cricothyrotomy
    103. 103. Medical Emergencies Cricothyrotomy
    104. 104. Medical Emergencies Cricothyrotomy
    105. 105. Medical Emergencies Cricothyrotomy
    106. 106. Medical Emergencies Cricothyrotomy
    107. 107. Medical Emergencies Cricothyrotomy
    108. 108. Medical Emergencies Cricothyrotomy
    109. 109. Medical Emergencies Cricothyrotomy
    110. 110. Medical Emergencies Cricothyrotomy
    111. 111. Medical EmergenciesOnce breathing established, then checkpulse (patient’s first, then your own)Pedis get needle ventilation
    112. 112. Medical EmergenciesCardiac Arrest #1 cause is ventricular arrhythmia Usually v-fib
    113. 113. Medical Emergencies Place patient on floor Immediately start chest compressions and get AED, have someone call EMS Remember: HARD, FAST, DEEP! Place and follow AED commands
    114. 114. Medical Emergencies Hard, Fast, Deep!
    115. 115. Medical Emergencies
    116. 116. Medical Emergencies Use algorithm if available Change CPR participant q2 minutes Check rhythm after 6 minutes of CPR Establish IV Epinephrine 1mg Atropine 1mg
    117. 117. Questions...?
    118. 118. GoalsRecognize thesymptomsHave the propertoolsBe prepared
    119. 119. Medical EmergenciesPreventionPreparationAction
    120. 120. Medical Emergencies Hard, Fast, Deep!
    121. 121. THANK YOU..!
    122. 122. THANK YOU..!A Buffalo Squirrels Production Veronica Bonales, M.D. docmontey@yahoo.com www.slideshare.net/docmontey

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