Medical Emergency Prevention and Preparedness


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Presented at Annual Dental Conference of Nepal Dental Association on 2nd February 2013 at Chitwan, Nepal.

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Medical Emergency Prevention and Preparedness

  1. 1. Preparedness inDentistryPrevention andPreparedness inDentistryDr Neil PandeBDS MFGDP(UK) MFDS RCS(Eng)General Dental Practitioner
  2. 2. GuidanceMedical emergencies can occur at any time.All members of staff need to know their role inthe event of a medical emergency.Members of staff need to be trained in dealingwith such an emergency.Dental teams should practise together regularlyin simulated emergency situations.
  3. 3. Unexpected EventsAccidental or willful bodily injury,Central nervous system stimulation anddepression,Respiratory and circulatory disturbances,Allergic reactions.
  4. 4. Medical Emergency PlanPreventionAction planDiagnosis and ManagementEmergency drugs and equipment
  5. 5. PreventionMedical History QuestionnaireVerbal HistoryMedical History UpdatePhysical ExaminationAssessment of RiskStress ReductionPain Control
  6. 6. Medical HistoryQuestionnaireFirst thing in dental practiceSimple language understandable to the patientAll relevant questions askedSigned and dated (Minor: Guardian/Parent)Helped by the reception staff in case of difficulty(Training and understanding of the staff)
  7. 7. Verbal Medical HistoryRe-enforces Medical History QuestionnaireMore information on conditionsDegree of severityGives out information that patient feels isirrelevant to dentistryMedical Interactions
  8. 8. Drug MI en dt se cr aa pct eion
  9. 9. Medical History UpdateShould be a part of every long interval dentalvisitsNoted in the record in every instance
  10. 10. Physical ExaminationVisual InspectionBaseline Vital Signs: Pulse, BP, Breathing, Temperature
  11. 11. Risk AssessmentASA PS Classification System PS 1: Normal Healthy Patient (-60) PS 2: Mild Systemic Disease (Anxiety, fear, +60) PS 3: Severe Systemic Disease that limits activity but not incapacitating PS 4: Incapacitating Systemic Disease that is constant threat to life PS 5: Not expected to survive 24 hours
  12. 12. ASA 1Patients are considered to be normal andhealthy.Patients are able to walk up one flight of stairsor two level city blocks without distress.Little or no anxiety.Little or no risk.This classification represents a "green flag" for treatment.
  13. 13. ASA 2Patients have mild to moderate systemic disease or are healthy ASA I with extreme anxiety and fearPatients are able to walk up one flight of stairs or twolevel city blocks, but will have to stop after completionof the exercise because of distress.Minimal risk during treatment.Examples: History of well-controlled disease statesincluding non-insulin dependent diabetes,prehypertension, epilepsy, asthma, or thyroidconditions; ASA I with a respiratory condition,pregnancy, and/or active allergies. May need medicalconsultation.
  14. 14. ASA 3Patients have severe systemic disease that limitsactivity, but is not incapacitating.Able to walk up one flight of stairs or two level cityblocks, but will have to stop enroute because ofdistress.Stress reduction protocol and other treatmentmodifications are indicated.Examples: History of angina pectoris, myocardialinfarction, or cerebrovascular accident, congestiveheart failure over six months ago, slight chronicobstructive pulmonary disease, and controlled insulindependent diabetes or hypertension. Will needmedical consultation.
  15. 15. High Risk Patients Frequent Exertional Angina and hospital admission Asthmatic under oral and inhalational therapy /nebuliser / steroid / hospitalisation Epileptic with recent change in medication/ precipitating factor and time of last attack to be noted Insulin treated diabetics more prone to hypoglycemia / Poorly controlled less aware diabetics!!! Previous reactions to local anaesthetics, antibiotics and latex Preferred to be treated in medically supported
  16. 16. Stress MDAS Increased catecholamines (epinephrine/norepinephrine) Increase load to the heart Increased Heart Rate Increased strength of Myocardial Contraction Increased Oxygen RequirementPS1 can tolerate, but PS 2,3,4 less able totolerate
  17. 17. StressPatient with Angina may develop into chest pain and various dysrhythmias Heart Failure may develop into pulmonary edema Asthma may develop into acute respiratory distress Epilepsy may develop seizures Hyperventilation and Syncope may develop in PS 1
  18. 18. Stress ReductionProtocols Minimize Stress before, during and after treatment 1. Communication / Consultation 2. Premedication Lorazepam 1mg night before & 90 mins. before treatment 3. Appointment Scheduling 4. Waiting Time Reduction 5. Vital Signs Monitoring 6. Sedation, Iatrosedation or Hypnosis Pain Control slideshar e
  19. 19. Post -operative PainManagementAvailability of dentist via telephone round theclockAnalgesicsAntibioticsAntianxiety drugsMuscle Relaxants
  20. 20. Action PlanUnderstandable by all the staff memberGoal: Manage until full recovery or until helparrives Sufficient Oxygenation to the brain Patient Position BLS Role of Each member of the Team Communication and hospital transfer
  21. 21. CPR QuickTime™ and a H.264 decompressorare needed to see this picture. 30:2
  22. 22. Common MedicalEmergencies •Intravascular Injection Asthma •Syncope Anaphylaxis •Postural Angina Hypotension Myocardial •Hyperventilation infarction •Stroke Cardiac Arrest •Choking and Epileptic Seizure Aspiration Hypoglycemia •Adrenal Insufficiency
  23. 23. DR ABCDE International Consensus onDanger CardiopulmonaryResponse Resuscitation andAirway Emergency Cardiovascular CareBreathing Science withCirculation TreatmentDisability Recommendations (CoSTR)Exposure October 2010
  24. 24. Chain of SurvivalEarly recognition of a “sick” patient, a team effort...
  25. 25. “Remember to breathe.It is after all, the secret of life.”
  26. 26. Oxygen cylinder with pressure reduction valve andflowmeter/face mask with reservoir and tubing.Basic set of oropharyngeal airways (sizes 1,2,3 and 4).Pocket mask with oxygen port.Self-inflating bag and mask apparatus with oxygenreservoir and tubing / Child size also.Portable suction with appropriate suction cathetersand tubingSingle use sterile syringes and needles.‘Spacer’ device for inhaled bronchodilators.Automated blood glucose measurement device.Automated External Defibrillator.
  27. 27. Oropharyngeal Airway
  28. 28. Team TrainingMonthly equipment ChecksRegular UpdatesMock TrialsAudit
  29. 29. Ambulance SummoningWritten telephone conversation guide: It is an emergency. A patient has collapsed, most likely, a _____________. I am calling from __________ Dental Clinic located at _________________________ opposite____________beside_________. Please send us an ambulance. I will be waiting outside the _______________ wearing ______________ and a flag. My number is _________________.
  30. 30. ReferencesMalamed SF. Knowing Your Patients. JADA2010; vol. 141 no. suppl 1 3S-7SMEDICAL EMERGENCIES ANDRESUSCITATION STANDARDS FOR CLINICALPRACTICE AND TRAINING FOR DENTALPRACTITIONERS AND DENTAL CAREPROFESSIONALS IN GENERAL DENTALPRACTICE A Statement from TheResuscitation Council (UK) July 2006 RevisedDecember 2012 Published by the ResuscitationCouncil (UK)
  31. 31. ReferencesEuropean Resuscitation Council Guidelines forResuscitation 2010 Section 2. Adult basic lifesupport and use of automated externaldefibrillators Rudolph W. Koster, Michael A.Baubin, Leo L. Bossaert, Antonio Caballero,Pascal Cassan, Maaret Castrén, Cristina Granja,Anthony J. Handley, Koenraad G. Monsieurs,Gavin D. Perkins, Violetta Raffay, ClaudioSandroni.Published online 19 October 2010,pages 1277 - 1292