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Management of Medical Emergencies in Dental Office

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In this presentation, Dr. H. Ryan Kazemi, oral surgeon in Bethesda, MD, discussed management of common medical emergencies in dental office.

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Management of Medical Emergencies in Dental Office

  1. 1. Management of Medical Emergencies in Dental Office
  2. 2. facialart.com/presentations To view this presentation & download handout
  3. 3. Emergency Response Plan Prevention Basic Principles of Medical Emergencies Airway Management Medical Emergencies Syncope Anxiety Attack Asthma Hypoglycemia Anaphylaxis Allergy Angioneuro Edema Bronchospasm / COPD Hyperventilation
  4. 4. Emergency Response Plan Receptionist: Recognition of incident; Notification of EMS; Crowd control Administrative: Documentation Team Leader: Dentist; Provides patient assessment and treatment Assistant: Airway management; Assist with patient monitoring; Vital signs
  5. 5. Emergency Response Plan
 Preparation Every office should have a written emergency protocol utilizing a team approach Design policies to include: Written guidelines defining those conditions that should be referred to local EMS. Directions for accessing EMS. Easily accessible Hospital telephone numbers and directions to ER Staff training and role playing CPR certification- Health care provider course
  6. 6. Prevention Complete Past Medical & Surgical History Careful Review of Current Medications Allergies Review of Systems Proper preoperative Management Pre-operative Consultation (not clearance) with Patient’s Physician
  7. 7. 10 Core Questions 1.Are you now under a physician’s care or have you been during the past 5 years, including hospitalization and surgery? 2.Are you currently under a doctor’s orders or taking any medications, including any BCP, OTC drugs, or homeopathic preparations? 3.Do you have any allergies or are you sensitive to any drugs or substances such as Penicillin, novocaine, aspirin, latex or codeine?
  8. 8. 10 Core Questions 4. Have you ever bled excessively after a cut, wound, or surgery? Have you ever received a blood transfusion? 5. Are you subject to any fainting, dizziness, nervous disorders, seizures, or epilepsy? 6. Have you or your family ever had any anesthesia related problems
  9. 9. 10 Core Questions 7. Have you ever had any breathing difficulty including asthma, emphysema, chronic cough, pneumonia, tuberculosis, or any other lung disorders? Do you use any tobacco products? 8. Do you have heart disease or a history of chest pain or palpitations?
  10. 10. 10 Core Questions 9.Is there anything you would like to discuss alone with the doctor? 10.Do you currently use or have a history of using recreational drugs?
  11. 11. Anaphylaxis Description: A catastrophic and potentially fatal type of allergic reaction, which can occur within minutes after administration of drugs of non-human proteins Key Signs & Symptoms: –Laryngeal Edema: Stridor, Throat tightening, Choking –Bronchospasm: Wheezing, Chest tightness –Vascular collapse: Confusion, Syncope, Seizures, Hypotension, Tachycardia Assessment Notations: –Generalized urticaria or edema –Sudden onset of symptoms –Onset of shortness of breath
  12. 12. Anaphylaxis 
 Management Position: comfortable, or lay down if hypotensive Airway: 100% O2 by non-rebreather mask Call Emergency Medical Services Epinephrine: 1:1000, 0.3 to 0.5 cc SQ. Pediatric: 0.01 ml/kg to maximum of 0.3 cc. Repeat in 5-10 minutes. Dosage should 0.1 - 0.2 mg SQ. If severe, vascular Collapse or marked airway embarrassment and no response to SQ epinephrine, then give Epinephrine ==>
  13. 13. Anaphylaxis
 Management ==> 1:10,000, 0.3 to 0.5mg IVP over 3-5 minutes. (Pediatrics 0.1 cc/kg) Repeat Epinephrine as needed every 5 minutes Without an IV, Epinephrine May be injected sublingually, 0.1 to 0.2 cc of 1:1000 concentration; (Pediatrics: Use 0.01 cc/ kg) Obtain Vital Signs Diphenhydramine (Benadryl) may also be given: 25-50 mg IVP/IM. (Pediatrics: 20cc/kg IM) Solumedrol: 125mg IVP/IM (Pediatrics: 2mg/kg IVP/IM)
  14. 14. Drug-Induced Allergy Symptoms: – Uticaria: Red eruptions or hives & rashes – Pruritus: Itching Treatment: – Withdraw drug in question – Severe Reaction: Epinephrine 0.3 cc of 1:1000 I.M. or IV.; Oral antihistamines; – Mild-Moderate Reaction: Benadryl 50 mg orally or I.M. every 6-8 hours
  15. 15. Angioneurotic Edema An IgE-mediated allergic painless swelling of an entire anatomic part such as lips, eyelids, cheeks, or pharynx – May be either drug or food induced – Not painful – Pruritus, Uticaria, hoarseness, stridor, cyanosis Treatment: – Antihistamines: Diphenhydramine 50mg P.O. or Hydroxyzine 25-100 mg QID. – In severe cases: 0.3 cc of 1:1000 Epinephrine SQ.
  16. 16. Asthma/Bronchospasm A condition of acute narrowing, inflammation, and swelling of the smaller airways. Signs and Symptoms: – Wheezing, dyspnea, breathlessness – Cough Assessment: – Past Medical History – Patient examination: Auscultation of lungs
  17. 17. Asthma/ Bronchospasm 
 Management Position patient is a comfortable sitting position. Administer supplemental 100%O2 at 15 LPM. – Assist ventilation with bag-valve-mask if patient becomes cyanotic or develops respiratory distress. Administer nebulizer treatment of Albuterol (Proventil), 2 puffs; Repeat every 10-20 minutes if symptoms persist. If symptoms are severe and no improvement after 2 treatments: – Epinephrine 1:1000, 0.3-0.5 ml, SQ. (Ped.: 0.01 cc/kg); or terbutaline 0.25 mg SQ. If patient on steroids or remain symptomatic: Methylprednisolone, 125 mg IV push.
  18. 18. COPD COPD (Chronic Obstructive Pulmonary disease) involves loss of normal elasticity of the airways. It may be the consequence of either chronic bronchitis or of parenchymal disease represented by emphysema. Airway obstruction is defined in terms of diminished flow of air during forced expiration. Signs and Symptoms: Shortness of breath; Cough
  19. 19. COPD 
 Management Call Emergency Medical Services Ascertain that the airway is open Begin O2 at 2 liters per minute by nasal cannula. If severely tachypneic and is cyanotic, place on 100% Oxygen 15 LPM via non-rebreather mask. Albuterol (Proventil)- Two puffs Methylprednisolone, 125 mg IVP or Prednisone 40 mg P.O.
  20. 20. Hyperventilation Signs: –Rapid breathing with a feeling that you can’t get enough air. –Crying –Convulsions –Loss of consciousness Management: –Help patient breath in paper bag –Calm and reassure patient –Monitor BP and O2 saturation –Consider sedation with Valium
  21. 21. Case #1 55 year old male, with history of heart murmur due to aortic valve insufficiency, is scheduled for periodontal surgery. Patient is given 2.0 g of Amoxicillin for prophylaxis against bacterial endocarditis. Ten minutes later patient begins to complain of SOB, and lightheadedness. He then reports throat tightening and exhibits increased wheezing. He also begins to show evidence of urticaria over his chest and extremities. Diagnosis? Management?
  22. 22. Position: comfortable, or lay down if hypotensive Airway: 100% O2 by non-rebreather mask Call Emergency Medical Services Epinephrine: 1:1000, 0.3 to 0.5 cc SQ. Pediatric: 0.01 ml/kg to maximum of 0.3 cc. Repeat in 5-10 minutes. Dosage should 0.1 - 0.2 mg SQ. If severe, vascular Collapse or marked airway embarrassment and no response to SQ. epi, then give Epinephrine 1:10,000, 0.3 to 0.5mg IVP over 3-5 h (Pediatrics 0.1 cc/kg) Repeat Epinephrine as needed every 5 minutes Without an IV, Epinephrine May be injected sublingually, 0.1 to 0.2 cc of 1:1000 concentration; (Pediatrics: Use 0.01 cc/kg) Obtain Vital Signs Diphenhydramine (Benadryl) may also be given: 25-50 mg IVP/ IM. (Pediatrics: 20cc/kg IM) Solumedrol: 125mg IVP/IM (Pediatrics: 2mg/kg IVP/IM) Anaphylaxis
  23. 23. Case #2 45 year old obese male with history of coronary artery disease and heavy smoking is undergoing general restorative procedures. Patient is given 4 carpules of 2% lidocaine with epinephrine for bilateral mandibular blocks. During the procedure, patient begins to complain of chest tightness and SOB. He also reports pain radiating to his left side of jaw and arm. Diagnosis? Management? Prevention?
  24. 24. Place patient in a comfortable semi-inclining position. Ascertain that the airway is open & breathing is unlabored. Administer 100% Oxygen at 4 liters via nasal cannula. Monitor vital signs: Blood pressure, pulse, & respiration. Administer Nitroglycerin, 1/150 sublingually (0.4 mg). Repeat Nitroglycerin every 5 minutes, until pain resolves or blood pressure becomes <90, or a maximum of 3 doses. IF PAIN DOES NOT RESOLVE, SUSPECT MYOCARDIAL INFARCTION Administer Morphine Sulfate, 2-5mg IV. if pain persists after 3 doses of NTG. Transfer to Hospital Angina Pectoris
  25. 25. Case #2 (Continued) Patient is now on 100% oxygen and has been given 3 doses of Nitroglycerin in 5 minute intervals. At this time, patient loses consciousness and becomes unresponsive. Diagnosis? Management?
  26. 26. ABC now changed to CAB sequence Chain of Survival”: Immediate recognition of cardiac arrest and activation of emergency response system Early CPR with emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post-cardiac arrest care Call First, Call Fast, Call 911 Position patient comfortably (Semi-sitting) Start chest compressions Open Airway Rescue breaths (100% O2 via mask; IV started) Compression / breaths in 30:2 ratio for 100 compressions per minute Vital signs: EKG, Oximeter, and BP Nitroglycerin- Sublingual 0.4 mg; repeat Q5min up to three doses; or spray inhaler, repeat every 5 minutes Morphine Sulfate 1 to 3 mg IV q5 to 30 min. Myocardial Infarction
  27. 27. Case #3 25 year old female is undergoing impression of implant tooth #18. During placement of the impression coping, the patient suddenly coughs, and the operator loses the screw driver toward the back of the throat. The patient sits up and begins to cough violently. What action should the dentist take? Next the patient stops coughing and is no longer able to speak. While he is holding his neck, he becomes unconscious. What action should the dentist take?
  28. 28. Position: Conscious adult and child: Standing Conscious adult or child: Perform Heimlich maneuver Unconscious adult or child: Perform Abdominal thrusts; then visualize airway for obstruction. DO NOT PERFORM BLIND FINGER SWEEPS ON PEDIATRIC PATIENTS Attempt to ventilate patient, look for chest rise. If none, reposition head and try again; Repeat steps until successful. Circulation: Check for pulse. If none, refer to cardiac arrest protocol. If pulse is present, maintain airway and monitor patient Airway FB Obstruction
  29. 29. Case #3 (Continued) While performing abdominal thrusts, a rush of air is felt as the patient’s airway becomes open and the patient is now breathing. The oral cavity is then inspected, but the screwdriver can not be seen. Patient now begins to regain consciousness. Diagnosis? Management? Prevention?
  30. 30. Direct patient to hospital ER for chest X-ray Need to rule out aspiration Use preventive measures: ‘throat pack’, floss around small components, high suction FB Aspiration
  31. 31. Case #4 17 year old female is about to undergo removal of impacted third molars under local anesthesia. The patient appears quite anxious, diaphoretic and pallor. As the dentist begins to administer local anesthesia, the patient becomes unconscious and unresponsive. Her pulse is 45 beats per minute. Diagnosis? Management? Prevention?
  32. 32. Place patient in supine position with feet elevated. Administer 100% Oxygen via mask. Ascertain airway is open and breathing is unlabored. Assist ventilation with bag-valve-mask if patent is unresponsive to O2 therapy, has marked respiratory distress, altered LOC, or apnea. Monitor vital signs: If Hypotensive, give 300-500 cc Fluid Permit patient to inhale aromatic ammonia vaporole Determine etiologies: Hypoglycemia, Hypovolemia (hypotension), Arrhythmia, psychogenic, seizure Consider transfer to hospital with prolonged symptoms Syncope
  33. 33. Case #5 40 year old male with history of COPD (Chronic Obstructive Pulmonary Disease) is undergoing root canal treatment of tooth #3 under local anesthesia. During the procedure, patient begins to complain of heart palpations. His breathing becomes more labored at this time, with increased wheezing. Diagnosis? Management?
  34. 34. Call Emergency Medical Services Ascertain that the airway is open Begin O2 at 2 liters per minute by nasal cannula. If severely tachypneic and is cyanotic, place on 100% Oxygen 15 LPM via non- rebreather mask. Albuterol (Proventil)- Two puffs Methylprednisolone, 125 mg IVP or Prednisone 40 mg P.O. Asthma
  35. 35. Clinical Condition Step 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient. Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Ammonia vaporole respiratory stimulant (optional). Supplemental oxygen with Non-rebreathing face mask 15 L/minute or Nasal cannula/Nasal hood 4 L/minute. Raise the legs. Step 3 Reversal agent(s) if indicated. Step 4 Respiratory deterioration. Raise the legs. Clinical Condition Step 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient. Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Ammonia vaporole respiratory stimulant. Raise the legs. Step 3 Reversal agent(s) if indicated. Clinical Condition Step 1 Verify unresponsiveness. Call for emergency equipment. Monitor patient. Step 2 Open the airway with head tilt, chin lift, and jaw thrust. Verify not breathing. Check Pulse oximeter (BP >80 systolic) and/or Carotid pulse present (BP >60 systolic) which indicate chest compressions not needed. Step 3 Raise the legs. Step 4 Reversal agent(s) if indicated. Ventilation Management - Apnea / Hypoventilation / Obstruction Apnea without Carotid Pulse - see Adult Cardiac Management Action Action Action Respiratory rate 0 Apnea with Carotid Pulse Ten Minutes Saves A Life! is a registered trademark of the ADSA Anesthesia Research Foundation / © 2013 EmergSim LLC / 10Min Resp Mgmt 131108 (1) Step 6 Confirm supraglottic airway placement with chest rise. Step 7 If no chest rise seen after advanced airway placement, continue with evaluation for larynospasm, foreign body, bronchospasm, or chest wall rigidity. Step 5 Consider advanced supraglottic airway with gastric venting capacity if unable to ventilate with bag mask easily. Step 1 Open the airway with head tilt, chin lift, and jaw thrust. Step 2 Consider oral or nasal airway if apneic. Step 3 Bag Mask ventilation - preferably two person. One breath every 6 seconds, breath volume 400-800 mL, pressure <20 cm H 2O, oxygen flow 15 L/minute. Step 4 Confirm chest rise with each breath. Adult Respiratory Distress - The Unresponsive Patient Ten Minutes Saves A Life!® Monitoring (blood pressure, heart rate, pulse oximetry, respiratory rate) ongoing throughout evaluation and management. All initial actions are performed simultaneously after verification of unresponsiveness by stimulating the patient including head tilt and jaw lift. Reversal agents (naloxone and flumazenil) may be administered at any time. Respiratory rate >10 and Oxygen saturation > 95% Respiratory rate <10 and/or Oxygen saturation <95% Breathing Normally and Unresponsive Respiratory Depression and Unresponsive Ventilation Management (see below) Ventilation Management (see below) Ventilation Management (see below) Ten Minutes Saves A Life Download www.facialart.com/presentation Order www.sedationresource.com
  36. 36. To Access This Presentation: www.facialart.com/presentations
  37. 37. Grand Opening
  38. 38. Dental ForumDentists Staff
  39. 39. www.facialart.com/CE

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