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Medical Emergencies in the Dental Office
- 1. فارس اورژانس تروم تحقیقات مرکزا DDS Medical Emergencies MJ Moradian MD, MPH, PhD Assistance Professor Head of Fars EMC and EMS Shiraz University of Medical Sciences Advisor of National EMC Ministry of Health and Medical Education 2109 E-mail: drmoradian@sums.ac.ir Website: dr-Moradian.ir
- 2. DDSEmergencies dr-moradian.ir 2 Topics فیزیولوژی و آناتومی عالئمحال شرح و حیاتی های اورژانسدندانپزشکی پایه احیاء تزریقات
- 4. The Heart Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings DDSEmergencies dr-moradian.ir 5
- 12. Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 11.8b The Vascular System DDSEmergencies dr-moradian.ir 13
- 14. Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Most arterial blood is pumped by the heart Veins use the milking action of muscles to help move blood Movement of Blood Through Vessels DDSEmergencies dr-moradian.ir 15
- 16. Arteries in our body DDSEmergencies dr-moradian.ir 17
- 20. Nervous System مرکزی عصبی دستگاه((CNS نخاع و مغز محیطی عصبی دستگاه(PNS) خودکار عصبی سیستم پاراسمپاتیک و سمپاتیک ارادی/خودکار غیر 31نخاعی زوج C—8 , T—12 , L—5 , S—5 12مغزی عصب جفت Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Brain Spinal cord Spinal nerves Cranial nerves DDSEmergencies dr-moradian.ir 21
- 22. General Organization of the Nervous System DDSEmergencies dr-moradian.ir 23
- 26. ار بر پاراسمپاتیک و سمپاتیک آثارگانها DDSEmergencies dr-moradian.ir 27
- 27. ار بر پاراسمپاتیک و سمپاتیک آثارگانها DDSEmergencies dr-moradian.ir 28
- 29. اعصاب در سازش چندثانیه صدم(پاچینی) 2روز(کاروتید فشاری) مکانیکی غیر گیرنده برای سازش بدون(درد) DDSEmergencies dr-moradian.ir 30
- 30. حال شرح و حیاتی عالئم DDSEmergencies dr-moradian.ir 31
- 31. Risk Factors for DDS Emergencies Aging Medical Advances Longer appointment?! Drug use DDSEmergencies dr-moradian.ir 32
- 32. Our Bodies Change Over Time • There are anatomic differences between infants, children, and adults • Body systems continue to develop and mature in the young • Aging body systems show signs of dysfunction DDSEmergencies dr-moradian.ir 33
- 33. Goals of Physical Evaluation Physically tolerate the stress? Psychologically tolerate the stress? Treatment modification is required? Phsychosedation is required? DDSEmergencies dr-moradian.ir 34
- 34. Drugs: Local Anesthesia CNS depressants: alcohol, antidepressant, antihistamine, antihypertensive, muscle relaxant, opioid: Additive CNS/respiratory suppression Limit maximum dose DDSEmergencies dr-moradian.ir 35
- 35. Drugs: Vasoconstrictor α Blockers: ↓ BP (Large doses of Epi); low dose of VasoC. β Blockers: ↑ BP (Esp. Epi); Monitor BP CNS stimulants (amphetamine, dihydroergotamine): ↑ effect (stimulants- VasoC.) Cocaine: Arrest DDSEmergencies dr-moradian.ir 36
- 37. Vital Signs Blood Pressure Heart Rate Respiratory Rate Temperature BMI DDSEmergencies dr-moradian.ir 38
- 41. “Volume-pressure curves”: stimulation or inhibition of the sympathetic nerves DDSEmergencies dr-moradian.ir 42
- 42. Blood pressure is the force of blood pushing against the arteries. Blood is carried to all parts of your body in vessels called arteries. What Is Blood Pressure? DDSEmergencies dr-moradian.ir 43
- 43. Effects of gravity on arterial and venous pressures. Each cm of distance produces a 0.77 mmHg change. DDSEmergenciesdr- moradian.ir 44
- 44. Click to edit Master title styleHow to Measure Blood Pressure
- 46. Equipment for accurate BP measurement Functional & calibrated machine Right-sized cuff Pen or pencil Flowsheet, chart, or medical record Clean hands and fingers! Patient in a comfortable & relaxed position Wait 5 minutes if patient was active Blood Pressure – An Overview DDSEmergencies dr-moradian.ir 47
- 47. Right Cuff in the Right Place Cuff width = 20% more than upper arm diameter Cuff width = 2/3 of upper arm length Cuff bladder length encircles 80% of upper arm Cuff arrow aligned with brachial artery Inside of the elbow http://connection.lww.com/products/evans-smith DDSEmergencies dr-moradian.ir 48
- 48. Blood Pressure Procedure 1. Wash hands & put on gloves, if appropriate 2. Provide privacy 3. Assist patient to a comfortable & relaxed position 4. Back supported, legs uncrossed DDSEmergencies dr-moradian.ir 49
- 49. DDSEmergencies dr-moradian.ir 50 CAUSE SYSTOLIC BP CORRECTIVE ACTION Sit without back support + 6 to 10 Support back (sit in chair) Full bladder + 15 Empty bladder before BP taken Tobacco/caffeine use + 6 to 11 Don’t use before clinic appointment BP taken when arm is: Parallel to body Unsupported Elbow too high Elbow too low + 9 to 13 + 1 to 7 + 5 False low While seated in chair, patient’s arm must be straight out and supported, with elbow at heart level “White coat” reaction + 11 to 28 Have someone else take the BP Talking or hand gestures + 7 No talking or use of hands during BP Cuff too narrow/small + 8 to 10 Right-sized cuff properly placed over bare upper arm Cuff too wide/large False low Cuff not centered + 4 Cuff over clothing + 5 to 50 (Pickering et al., 2005; Perry & Potter, 2006)
- 50. MEASURING BLOOD PRESSURE TURBULENT FLOW 1. Cuff pressure > systolic blood pressure--No sound. 2. The first sound is heard at peak systolic pressure. 3. Sounds are heard while cuff pressure < blood pressure. 4. Sound disappears when cuff pressure < diastolic pressure. DDSEmergencies dr-moradian.ir 51
- 52. Vital Signs Pulse Rate Respiratory Rate DDSEmergencies dr-moradian.ir 53
- 53. Chain of Medical emergencies Management In Dentistry Comprehensive medical history Vigilant observation & prompt recognition of symptoms of an emergency Basic life support Affiliation to definitive medical care DDSEmergencies dr-moradian.ir 54
- 54. شرایط از گیری پیش برای مهم اقدامات اورژانس شرححالکامل سابقهبیماری سابقهحضوردردندانپزشکی سابقهبیماریخانوادگی وضعیتسالمتروحی/اجتماعی وضعیتتغذیه DDSEmergencies dr-moradian.ir 55
- 55. Patient Has Heart Attack, Dies; Dentist Also Stricken DDSEmergencies dr-moradian.ir 56
- 56. دندانپزشکی در شایع های اورژانس Syncope Allergy/Anaphylactic reaction Angina pectoris/ MI/Cardiac arrest Seizures Asthmatic Attack Hyperventilation Airway obstruction Insulin Shock/Hypoglycemia CVA, Adrenal Insufficiency, Thyroid storm DDSEmergencies dr-moradian.ir 57
- 57. TYPES OF EMERGENCIES UNCONSCIOUSNESS / SYNCOPE Vasodepressor Syncope Postural/Orthostatic Hypotension Acute Adrenal Insufficiency Hypoglycemia SEIZURES RESPIRATORY EMERGENCIES Airway Obstruction Hyperventilation Asthma DDSEmergencies dr-moradian.ir 58
- 58. TYPES OF EMERGENCIES CARDIOVASCULAR EMERGENCIES Angina Pectoris Myocardial Infarction DRUG RELATED EMERGENCIES Overdose Reactions Allergies FUNCTIONAL EMERGENCIES Needle Stick Injury Needle Breakage DDSEmergencies dr-moradian.ir 59
- 61. Methods to Recognize the Anxiety Medical History Written -Ve hx of coming to dentistry office Anxiety Questionnaire The art of Observation ↑ BP & ↑ HR Trembling Excessive sweating Dilated Pupils DDSEmergencies dr-moradian.ir 62
- 62. Anxiety hints Majority of Adult Male hide their fear Severely anxious: infection or sever toothache (unable to sleep few nights) Smart receptionist Good welcoming Shake hand (cold, sweaty…) Prior dental experience Gesture on dental chair Answer quickly DDSEmergencies dr-moradian.ir 63
- 63. Anxiety approach Straightforward What is the cause? Morning Minimal waiting time Pain control (During and after) Medical consultation DDSEmergencies dr-moradian.ir 64
- 64. PREVENTION Via prevention of predisposing factors: Use of psychosedative drugs PO: alprazolam(0.25-0.5mg 4mg/day), diazepam(2-10mg), Oxazepam (10-30mg) I.M/I.V: midazolam(5mg), butorphenol (1mg), Inhalation-N2O+O2 (15%+85%) Persuasion/hypnosis DDSEmergencies dr-moradian.ir 65
- 65. Alprazolam (Xanax) Benzodiazepines Anxiety and panic disorders (CNS: GABA) Do not use: narrow-angle glaucoma, ketoconazole, allergy, pregnancy, with alcohol Caution: seizures or epilepsy; kidney or liver disease, asthma or other breathing disorder; open-angle glaucoma; history of depression or suicidal thoughts or behavior; history of drug or alcohol addiction; with narcotic (opioid) medication DDSEmergencies dr-moradian.ir 66
- 67. میدازوالم 70-80 mcg/kg (dose range ~5 mg) 30-60 minutes before surgery (reduce 50% for chronically ill or geriatric patients): دربیمارباالی60،سالمبتالیانبهCOPD، بیمارانباریسکباالی،جراحیوآنهاییکهاپیوئید یادپرسانتهایدیگرمصرفمیکنند DDSEmergencies dr-moradian.ir 68
- 68. Steps of Management of Emergencies P- POSITION What is proper position? A-AIRWAY Is the airway open? Shall I protect it? B- BREATHING RR? Is it normal? Sounds? Extra effort? Ventilation? C- CIRCULATION PR? BP? Rhythm? Bleeding? ECG? BG? DDSEmergencies dr-moradian.ir 69
- 70. TYPES OF EMERGENCIES UNCONSCIOUSNESS / SYNCOPE Vasodepressor Syncope Postural/Orthostatic Hypotension Hypoglycemia Acute Adrenal Insufficiency SEIZURES RESPIRATORY EMERGENCIES Airway Obstruction Hyperventilation Asthma DDSEmergencies dr-moradian.ir 71
- 72. Unconsciousness / Syncope “Sudden transient loss of consciousness in which one shows no responsiveness to non-deliberate environmental stimuli” DDSEmergencies dr-moradian.ir 73 Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011.“syncope”;p.348
- 73. Precipitating Factors for Syncope in a Dental Office Psychogenic: Fright, anxiety, emotional stress, and receipt of unwelcome news Non psychogenic factors: Hunger from dieting or missing meals, erect sitting or standing posture, Hot or humid environment DDSEmergencies dr-moradian.ir 74
- 74. VASODEPRESSOR/VASOVAGAL SYNCOPE The most common medical emergency in dental office (53%) A reflex which is mediated by ANS Fight or Flight without muscular movement Widespread vasodilatation, bradycardia, diminished cerebral perfusion. DDSEmergencies dr-moradian.ir 75
- 75. Vasodepressor Syncope Clinical Presentation Death like appearance (Pallor) Brief episodes of convulsive activity Heart rate of less than 60 BPM Blood pressure to an extremely low DDSEmergencies dr-moradian.ir 76
- 76. Management of Vasodepressor Syncope Supine (horizontal) position Brain at the same level as the heart Feet elevated slightly (10-15 degree angle) Avoid head down (Trendelenberg) position (Diaphragm) If Lasted more than few minutes EMS Evaluate for other causes If SBP<90: IV (N/S-Ringer 1 litr-10-20 cc/kg) Aromatic Amonia DDSEmergencies dr-moradian.ir 77
- 77. POSTURAL /ORTHOSTATIC HYPOTENSION Pt attains upright position SBP falls =<60 mm/Hg due to ANS response failure Cerebral blood flow<critical level Loss of consciousness Supination=revival DDSEmergencies dr-moradian.ir 78
- 78. POSTURAL /ORTHOSTATIC HYPOTENSION Drugs: α Blockers (Prazosin, Trazodone) Prolonged recumbency/ convalescence Late stage pregnancy Varicosities Addison’s Disease (cortisol and aldosterone) Severe exhaustion Shy-Drager Syndrome progressive disorder of the CNS and sympathetic systems DDSEmergencies dr-moradian.ir 79
- 81. HYPOGLYCEMIA Empty stomach/ Morning insulin Low blood glucose level=<50mg/100ml Danger/ anxious disposition Weakness/dizziness, pale skin, depressed respiration Unattended-Loss of consciousness/ syncope DDSEmergencies dr-moradian.ir 82
- 82. HYPOGLYCEMIA: Rx If Pt. is conscious: Fast-acting carbohydrates: glucose tablets or gel, fruit juice, soft drinks Symptoms are more severe, cannot take sugar by mouth: Glucagon: 1 mg (1 unit) IM/SC/IV Repeat q15min once or twice Intravenous glucose DDSEmergencies dr-moradian.ir 83
- 83. Adrenal Gland Outer part = cortex Secretes Cortisol (stress), Androgens, Aldosterone (electrolytes) Inner part = medulla Secretes EPI & NEPI & Dopamine (fight or flight) SNS control DDSEmergencies dr-moradian.ir 84
- 84. کلیه فوق غده های هورمون کورتیزول: متابولیک:،گلوکونئوژنز،قندخونتجزیه ،پروتئینهاسنتزپروتئینهادر،کبدضعف ،عضالتچربیدرشکموپشت(کوهان) مقابلهبااسترس:تولید،انرژیصبحبیشتراست ضدالتهاب:منع،هیستامینتثبیتغشای ،لیزوزوم DDSEmergencies dr-moradian.ir 85
- 85. ACUTE ADRENAL NSUFFICIENCY: Rx Lack of an adrenaline response in medullary deficient patients+ Salt & Water depletion P: Supine ABC EMS 1L of 0.9% N/S over 30-60 min with 100mg of i.v. Bolus hydrocortisone.(+ Dextrose) DDSEmergencies dr-moradian.ir 86
- 86. TYPES OF EMERGENCIES UNCONSCIOUSNESS / SYNCOPE Vasodepressor Syncope Postural/Orthostatic Hypotension Hypoglycemia Acute Adrenal Insufficiency SEIZURES RESPIRATORY EMERGENCIES Airway Obstruction Hyperventilation Asthma DDSEmergencies dr-moradian.ir 87
- 87. SEIZURES: Prevention If Pt. is a known epileptic, make sure he/she has taken their regular dose of anti- convulsant on the day of appointment. Instruct him/her to alert you as the aura of the impending seizure manifests itself. Inhalational sedation, based on individualized severity levels. Keep life support equipment ready in case of an emergent status epilepticus DDSEmergencies dr-moradian.ir 88
- 88. SEIZURES: Management Self limiting emergency Remove dangerous objects from the mouth and around the pt.eg. sharp instruments, needles, etc. Loosen any tight clothing. Avoid restraining the pt. In case the ictus fails to subside within a maximum of 5-10 minutes, declare status epilepticus and proceed with BLS + EMS (definitive care) DDSEmergencies dr-moradian.ir 89
- 92. Anticonvulsant Drugs Lorazepam: more effective (Large vein) 4 mg/dose slow IV at 2 mg/min Diazepam: Respiratory suppression 5-10 mg IV/IM (max:30mg-0.5 mg/kg) Phenytoin: Many complication Phenobarbital : Many complication and drug interaction Midazolam: 5-10 mg IM (0.2 mg/kg IM) DDSEmergencies dr-moradian.ir 93
- 93. TYPES OF EMERGENCIES UNCONSCIOUSNESS / SYNCOPE Vasodepressor Syncope Postural/Orthostatic Hypotension Hypoglycemia Acute Adrenal Insufficiency SEIZURES RESPIRATORY EMERGENCIES Hyperventilation Asthma Airway Obstruction DDSEmergencies dr-moradian.ir 94
- 94. HYPERVENTILATION Excessive rate and depth of respiration leading to abnormal loss of carbon dioxide (Hypocapnia-Respiratory Alkalosis). Characterized by: Rapid short strained breaths Cold Sweats Palpitations Dizziness Chest muscle fatigue DDSEmergencies dr-moradian.ir 95
- 95. HYPERVENTILATION PREVENTION stress reduction MANAGEMENT: Position Pt. UPRIGHT comfortably Reassure pt. & stabilize vitals Remove dental materials/instruments from pt’s mouth Re-establish O2:CO2 ratio by inhalation of exhaled air (85%:15%) Check vitals & patient status again DDSEmergencies dr-moradian.ir 96
- 96. ASTHMA A clinical state of hyper reactivity of the tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing In diagnosed pts, not an emergency. Results from constriction of smooth muscles of the tracheobronchial tree resulting from infection, inflammation or a genetic disposition. DDSEmergencies dr-moradian.ir 97
- 98. Asthma Management Recognize symptoms Stop dental procedure Position pt. upright or bending forwards with arms Administer bronchodilator & O2. Episode terminates? YES: Continue dental procedure NO: Declare status asthmaticus, Call EMS DDSEmergencies dr-moradian.ir 99
- 99. Asthma Management β2-adrenergic agonist bronchodilators are first-line therapy Ipratropium bromide, a short-acting anticholinergic bronchodilator, has a slower onset of action than the β2-adrenergic bronchodilators Epinephrine 1:1000 (0.3 ml) IM-SQ Systemic corticosteroids (100–400 mg hydrocortisone-Isoprotrenol) DDSEmergencies dr-moradian.ir 100
- 101. AIRWAY OBSTRUCTION May occur due to: Pathology in the airway Dental instruments Tongue Patient demonstrates symptoms ranging from coughing, gurgling, gagging to choking & gasping with panic. Aspired object may pass into the trachea or the esophagus DDSEmergencies dr-moradian.ir 103
- 105. AIRWAY OBSTRUCTION: Prevention Rubber dam Oral packing Chair position Dental assistant Magill’s intubation forceps DDSEmergencies dr-moradian.ir 107
- 106. AIRWAY OBSTRUCTION: Management Re-establishment of airway: NON INVASIVE PROCEDURES: Forceful coughing Back blows Heimlich Maneuver Chest thrust Finger sweeps Loosen any tight clothing Provide fresh air DDSEmergencies dr-moradian.ir 108
- 110. Head Tilt Chin Lift Maneuver DDSEmergencies dr-moradian.ir 112
- 111. Rescuer Emergency CPAP System Continuous positive airway pressure Congestive heart failure, asthma and COPD, toxic inhalations, drowning, and pneumonia DDSEmergencies dr-moradian.ir 113
- 113. TYPES OF EMERGENCIES CARDIOVASCULAR EMERGENCIES Angina Pectoris Myocardial Infarction DRUG RELATED EMERGENCIES Overdose Reactions Allergies FUNCTIONAL EMERGENCIES Needle Stick Injury Needle Breakage DDSEmergencies dr-moradian.ir 115
- 117. ANGINA PECTORIS Definition- “A condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, owing to an inadequate blood supply to the heart.” Types: Stable (classic or exertional) Variant (prinzmetal , vasospastic) Unstable (crescendo, acute coronary insufficiency) Prevention includes stress reduction, reassurance & psychosedation. DDSEmergencies dr-moradian.ir 119
- 118. ANGINA PECTORIS P – Position, patient comfortably usually upright A → B → C –Assess and perform BLS Hx of Angina Pectoris? YES: O2, TNG (3 dose of 0.4mg) IF PAIN RESOLVES: continue with dental procedure IF PAIN DOES NOT RESOLVE: EMS, Aspirin, Monitor NO: EMS, O2, Aspirin, Monitor DDSEmergencies dr-moradian.ir 120
- 119. MYOCARDIAL INFARCTION DEFINITION- “A clinical syndrome caused by deficient coronary arterial blood supply resulting in ischemia to a region of the myocardium and causing cellular death and necrosis.” DDSEmergencies dr-moradian.ir 121
- 121. SIGNALS OFA HEART ATTACK Pain is described as: Uncomfortable pressure Squeezing Crushing Tightness Aching Constricting Heavy sensation in the chest AMERICAN RED CROSS FIRST AID–RESPONDING TO EMERGENCIES FOURTH EDITION Copyright © 2006 by The American National Red Cross DDSEmergenciesdr- moradian.ir 123
- 122. SIGNALS OF A HEART ATTACK Any severe chest pain Pain lasting longer than 3 to 5 minutes Chest pain accompanied by other signals: Trouble breathing Paleness Ashen skin or bluish skin, particularly around the face Skin may also be moist AMERICAN RED CROSS FIRST AID–RESPONDING TO EMERGENCIES FOURTH EDITION Copyright © 2006 by The American National Red Cross DDSEmergencies dr-moradian.ir 124
- 123. SIGNALS OF A HEART ATTACK (CONTINUED) As with men, women’s most common heart attack signal is chest pain or discomfort Women are somewhat more likely to experience other warning signals, particularly: Shortness of breath Nausea or vomiting Back or jaw pain AMERICAN RED CROSS FIRST AID–RESPONDING TO EMERGENCIES FOURTH EDITION Copyright © 2006 by The American National Red Cross DDSEmergencies dr-moradian.ir 125
- 124. CARE FOR A HEART ATTACK Position: Comfortable Call 115 Have the victim stop all physical activity Loosen any restrictive clothing and have the victim rest Monitor the victim closely Do not try to drive the victim to the hospital yourself Demonstrate a calm, reassuring manner AMERICAN RED CROSS FIRST AID–RESPONDING TO EMERGENCIES FOURTH EDITION Copyright © 2006 by The American National Red Cross DDSEmergencies dr-moradian.ir 126
- 125. MI: Management Avoid overstressing the patient O2 via nasal cannula or nasal hood Pain control during therapy – appropriate use of LA– smaller dose with maximum effect – slow administration Psychosedation – N2O – O2 is preferable It is strongly recommended that elective dental care is avoided until at least 6months after MI Inferior alveolar NB and Posterior superior alveolar NB –risk of hemorrhage – should be avoided DDSEmergencies dr-moradian.ir 127
- 126. MI: Management Aspirin (160-325 mg) Intravenous access Oxygen Nitrates Analgesia (morphine 2.5–5 mg) Anti-emetics (Cyclizine 50mg, metoclopramide 10mg) ECG DDSEmergencies dr-moradian.ir 128
- 128. نیتروگلیسرین مصرف منع موارد هیپوتانسیونیافشارخونسیستولیکبیشاز30 مترمیلیجیوهزیرسطحپایه ضربانقلبکمتراز50یابیشاز100باردر دقیقه انفارکتوسبطنراست(باعالیمافتفشارخ،ون JVP،برجستهتنگینفسبدونادمریه) مصرفاخیرمهارکنندهاسترازفسفودی DDSEmergencies dr-moradian.ir 130
- 130. TYPES OF EMERGENCIES CARDIOVASCULAR EMERGENCIES Angina Pectoris Myocardial Infarction DRUG RELATED EMERGENCIES Overdose Reactions Allergies FUNCTIONAL EMERGENCIES Needle Stick Injury Needle Breakage DDSEmergencies dr-moradian.ir 132
- 131. OVERDOSE REACTIONS In a dental practice, commonest overdosage: LA High blood levels of the drug may be due to repeated injections or from a single inadvertent iv administration. Predisposing factors for over dosage: Pt age/body wt Route of administration Presence of vasoconstrictor Type of local anesthetic DDSEmergencies dr-moradian.ir 133
- 132. Local Anesthetic Classified as amide (e.g. lidocaine, articaine, mepivacaine) or ester (e.g. tetracaine, procaine) In dentistry, the most commonly used LA is lidocaine (also called xylocaine or lignocaine) Topical anesthetic benzocaine is an ester DDSEmergencies dr-moradian.ir 134
- 133. Local Anesthetic Maximum dose of lidocaine (plain, without vasoconstrictor) is 4.5 mg/kg (not to exceed 300 mg) The maximum safe dosage of LA is generally increased when used in combination with a vasoconstricting agent DDSEmergencies dr-moradian.ir 135
- 134. Recommended maximum doses of LA Drug Max. Dose Max. No. of cartridges (1.8ml) Lidocaine2% 7 mg/kg (up to 500 mg) 13 Articaine4% 7 mg/kg (up to 500 mg) 5 mg/kg in children 7 Mepivacaine 3% 6.6 mg/kg (up to 400 mg) 11 (or 7 if plain) Prilocaine4% 8 mg/kg (up to 600 mg) 8 Bupivacaine (Long acting)0.5% 2 mg/kg (up to 90 mg) 10 DDSEmergencies dr-moradian.ir 136
- 135. CLINICAL MANIFESTATIONS Primary systemic toxicities: CNS dysfunction Initially CNS stimulation manifesting as tremors and/or convulsions Subsequently CNS depression may occur with respiratory failure and cardiovascular disturbances Sedative effects may be synergistically increased when using in combination with narcotics DDSEmergencies dr-moradian.ir 137 (Catterall & Mackie, Curtis et al).
- 136. CLINICAL MANIFESTATIONS Confusion, talkativeness, blurred speech Muscular twitching, facial tremor Headache, tinnitus Drowsiness, disorientation Elevated BP, HR, RR If uncontrolled, generalized tonic clonic seizures, generalized CNS carbopathy. DDSEmergencies dr-moradian.ir 138
- 137. LA Overdose Management Call EMS Administer basic life support (P-ABC) 100% O2 + Deep Breath (hyperventilate) IV open vein Anticonvulsants Manage BP Allow recovery to occur (few-120 min) DDSEmergencies dr-moradian.ir 139
- 138. Vasoconstrictor (Epi.) in LA Epinephrine: (Max dose:200 µg) α1 receptor: Vasoconstriction in mucous membranes ß1 receptor (heart): increasing heart rate, strength of contraction and myocardial oxygen consumption ß2 receptors: vasodilating blood vessels in the skeletal muscle Levonordefrin (Max.dose1000 µg) 1:20,000 (equivalent to 1:100,000 epi) Contraindicated for patients receiving tricyclic antidepressants DDSEmergencies dr-moradian.ir 140
- 139. Treatment modifications if there is concerns regarding vasoconstrictors Minimize administration limiting epinephrine to 40 µg, levonordefrin to 200 µg Avoid epinephrine 1:50,000 Monitor blood pressure and heart rate 5 min after injection DDSEmergencies dr-moradian.ir 141 1 cartridge of epinephrine 1:200,000 = 9 µg 1 cartridge of epinephrine 1:100,000 = 18 µg 1 cartridge of epinephrine 1:50,000 = 36 µg 1 cartridge of levonordefrin 1:20,000 = 90 µg
- 140. ALLERGY “A hypersensitive state of skin and various mucosae acquired through exposure to a particular allergen, reexposure to which produces a heightened emergent capacity to react” Occurring via expression of IgE in response to allergen exposure DDSEmergencies dr-moradian.ir 142
- 141. Anaphylactic Shock Skin reactions such as hives, flushed skin, or paleness Suddenly feeling too warm Feeling like you have a lump in your throat or difficulty swallowing Nausea, vomiting, or diarrhea Abdominal pain A weak and rapid pulse Runny nose and sneezing Swollen tongue or lips Wheezing or difficulty breathing A sense that something is wrong with your body Tingling hands, feet, mouth, or scalp DDSEmergencies dr-moradian.ir 143
- 143. MANAGEMENT Reassure pt. Call EMS Initiate basic life support as needed Antihistaminics (diphenhydramine 50mg) Epinephrine 0.3-0.5 mg (0.01mg/kg) of 1:1000 I.M /auto-injector (Epipen) Monitor vitals regularly DDSEmergencies dr-moradian.ir 145
- 145. BLS Recognition of unconsciousness “Tap & shout” Check for protective reflexes Management (P-C-A-B) Position victim-supination C: Puls? Assess & open airway-head tilt, chin lift Artificial ventilation & cardiac massage- cardiopulmonary resuscitation DDSEmergencies dr-moradian.ir 147
- 146. Tap & Shout-Ask for Help & AED DDSEmergencies dr-moradian.ir 148
- 147. Check for Pulse and Breathing DDSEmergencies dr-moradian.ir 149
- 153. Roots of drug Administration ENTERAL ORAL SUBLINGUAL/INTRALINGUAL BUCCAL RECTAL PARENTERAL IV/IO IM TOPICAL DDSEmergencies dr-moradian.ir 155
- 154. Route for administration -Time until effect- Intravenous 30-60 seconds Intraosseous 30-60 seconds Endotracheal 2-3 minutes Inhalation 2-3 minutes Sublingual 3-5 minutes Intramuscular 10-20 minutes Subcutaneous 15-30 minutes Rectal 5-30 minutes Ingestion 30-90 minutes Transdermal (topical) variable (minutes to hours) DDSEmergencies dr-moradian.ir 156
- 160. Shiraz Eram Garden Photo credit: MR Rastegar-Fars EMS DDSEmergencies dr-moradian.ir 162