Prepare for and treat emergencies in the dental office.DRugs,monitors,clinical scenarios. Unfortunately it has been prepared for an italian audience,dentists and assistants in the dentist's office

1. Prevenire e trattare le emergenze
mediche in odontostomatologia
Claudio Melloni
Anestesista libero professionista.

2. Feck A.Preparing for medical emergencies in the dental office. 12.2012
dentaleconomics.com e

3. Feck A.Preparing for medical
emergencies in the dental office.
12.2012 dentaleconomics.com
66%

4. Feck A.Preparing for medical
emergencies in the dental office.
12.2012 dentaleconomics.com

5. Medical Emergencies
in the Dental Office,
6e by Stanley F.
Malamed

6. 407422 visite!!8 anni e 5 mesi,101 mesi
The Nature and Frequency of Medical Emergencies Among Patients in a Dental School Setting
Patrick L. Ander, Robin L. Comeau, Michael Hatton, Mirdza E. Neiders..J.Dental Education,2010;74;390-396.
< 1/mese University at Buffalo School of Dental Medicine

7. Non pazienti!!!
The Nature and Frequency of Medical Emergencies Among Patients in a Dental School Setting
Patrick L. Ander, Robin L. Comeau, Michael Hatton, Mirdza E. Neiders..J.Dental Education,2010;74;390-396.
Quindi tra pazienti e non pazienti circa 1/mese!!
University at Buffalo School of Dental Medicine

8. University dental hospital of
Manchester
• 183 staff;dentists,assistants,radiographers.
• A survey of medical emergencies at the
University Dental Hospital of Manchester:
• 1.8 /anno
• Fainting the commmonest

9. Dentists survey over 12 months
• Germany,620 dentists
• 57% had encountered up to
3emergencies
• 36 %had encountered up to 10
emergencies
• • Vasovagal episode was the most
common reported emergency – average
2 per dentist
• 42 (7%) had encountered an epileptic fit
• • 24 (4%) had encountered an asthma
attack
• 5 dentists (0.8%) had encountered
choking
• • 7 dentists (1.1%) had encountered
anaphylaxis
• •2 dentists (0.3%) had encountered a
cardiopulmonary arrest.
• Müller MP, Hänsel M, Stehr SN, Weber S, Koch T. A state-wide survey of
medical emergency management in dental practices: incidence of
emergencies and training experience. EmergMed J. 2008; 25: 296-300
• Ma solo 620/2998 risposte
• UK ,300 dentists
• Vasovagal syncope (63%) – 596
patients affected
• Angina (12%) – 53 patients affected
• • Hypoglycaemia (10%) – 54 patients
affected
• • Epileptic fit (10%) – 42 patients
affected
• • Choking (5%) – 27 patients affected
• • Asthma (5%) – 20 patients affected
• • Cardiac arrest (0.3%) – one patient
affected
• Girdler NM, Smith DG. Prevalence of emergency events in British
dental practice and emergency management skills of British
dentists. Resuscitation. 1999; 41:159-67

10. The Resuscitation Council (UK)’s statement Medical emergencies and
resuscitation standards for clinical practice and training for dental
practitioners and dental care professionals in general dental practice
• RESUSCITATION COUNCIL (UK) STATEMENT
• provides guidance and recommendations concerning medical emergencies that may occur in the dental
practice. It was revised in June 2011 to incorporate the new resuscitation guidelines as well as other best
practice. It has been endorsed by the General Dental Council.
• Key recommendations
• • Every dental practice should have a procedure in place for medical risk assessment of
their patients
• • All dental practitioners and dental care professionals should follow the systematic
‘ABCDE’ approach when assessing an acutely sick patient
• • Specific emergency drugs and items of emergency medical equipment should be
immediately available in every dental practice (this should be standardised throughout
the UK)
• • Every clinical area should have immediate access to an automated external defibrillator
(AED)
• • Dental practitioners and dental care professionals should receive training in
cardiopulmonary resuscitation (CPR), including basic airway management and the use of
an AED, with annual updates
• • Regular simulated emergency scenarios take place in the dental practice
• • Dental practices should have a protocol in place for calling medical assistance in an
emergency (this will usually be calling 999 for an ambulance)
• • All medical emergencies should be audited.

14. Perchè parlare di emergenze in
odonto?
• Avanzamenti della medicina
• Sopravvivenza più lunga:sempre più
anziani....sempre più comorbidità
• Polifarmacia
• Sedute più lunghe...chirurgia implantare....
• Pressione economica

15. AUSTRALIAN DENTAL ASSOCIATION INC.
GUIDELINES FOR GOOD PRACTICE ON
EMERGENCIES IN DENTAL PRACTICE
• FIVE STEPS IN THE PREPARATION FOR
EMERGENCIES.
• Step 1. Medical History.
• Step 2. Assessment of patient/Recognition of
cause of emergency
• Step 3. Resuscitation - knowledge, training and
practice.
• Step 4. Emergency Drugs and Devices.
• Step 5. Calling for Medical Assistance

16. L’importanza di essere preparati
• Avere le cose giuste:attrezzature e farmaci
• Fare le cose giuste:
– training;dentista e assistenti
• Contenuto,tecnica,frequenza
• Pratica!!!routine + scenari
• Organizzazione:protocolli con compiti precisi
– Simulearn via Gobetti,Bo,Fipes,CEPOSS pd.,SMO
Roma ....

17. Trattamento delle emergenze mediche
Riconoscimento
prevenzione
Preparazione
BLS
CPR
Emergenze mediche specifiche

18. Valutazione di un paziente in
emergenza
• È cosciente?
• Sta respirando?
• Ha un polso?
• RICONOSCERE IL Distress
del paziente !!!

19. Prevenzione
Anamnesi
Anamnesi
Esame fisico
Segni vitali
Ripetizione della storia clinica,aggiornamenti,farmaci,consulto....
Valutazione del rischio medico.ASA PS,altre scale.....
Riduzione dello stress

20. ASA PS CLASSIFICATION
ADATTAMENTO(SUGGERITO) ALLA
PRATICA ODONTO...

21. ASA I
• Un paziente sano,senza
malattie sistemiche
• Può tollerare lo stress
del trattamento
• Non esiste rischio
aggiuntivo di
complicanze serie
Modificazioni del
trattamento non sono in
genere necessarie

22. ASA II
Un paziente con malattia
sistemica lieve
ES::
-diabete ben controllato
-asma ben controllata
 Rappresenta un rischio
minimo durante il
trattamento
 Trattamento routinario
con minime
modificazioni:
 Appuntamenti
brevi,mattina presto(??) -
-profilassi antibiotica
-Sedazione

23. ASA III
Un paziente con malattia
sistemica severa ma non
invalidante
Es:
- angina stabile
- 6 mesi post MI
- 6 mesi dopo ictus con
ripresa funzionale
- COPD
 Il trattamento di
elezione non è
controindicato
 Meglio modificare
l’approccio:
 - Ridurre lo Stress
- Sedazione
- appuntamenti brevi

24. ASA IV
un paziente con malattia
sistemica invalidante
che è un costante
pericolo per la vita
Es:
- Angina instabile
- M I entro i 6 mesi
- Ictus entro 6 mesi
- PA> 200/115
- Diabete non controllato
• Trattamenti elettivi devono
essere rimandati
• Solo cure di emergenza:
– Rx di controllo
– Terapia
antidolorifica e
antinfiammatoria
– Altre terapie in
ospedale:incisione e
drenaggio,estrazioni..
.

25. ASA V
Un paziente gravemente
ammalato che non ci si
aspetta sopravviva
Es:
- mal.renale terminale
- mal.epatica terminale
- Ca terminale
- Mal. Infettive terminali
Il trattamento elettivo eè
controindicato
Terapia solo in emergenza
per il sollievo del
dolore.

26. Il rischio.......
• C.M.,64,kg 100,cm 180
• Cammina molto,va a caccia in collina e montagna
• Chir.pregressa:erniorrafia e appendicetomia
• Lab:BAV 1,PA 140/105….creat 2,06…
• Fisicamente ;uomo forte
• Tuttavia:3 anni prima MI + TIA senza complicazioni
• farmaci:cardicor(bisoprolol),cardioasp,lasix,novonorm(repaglinide),
Lescol(fluvastatina),senikar(olmesartan+ amlodipina),zyloric
• Intervento lungo:7 hrs:rialzo di seno,impianti multipli sopra e sotto
• Il giorno dopo ,dopo avere lavorato in giardino......
• stroke!

27. Rino M.,paz di dott.MV
• Ascesso dentario!
• Maschio,bianco, 88 a, 74 kg,cm 178
• ASA 4 ;Met 2
• EF 25% ;CHF,PM, AAA,IRC ,basse piastrine
• Polifarmacologia : …………………….
• Premed:midaz4;chirurgia dopo 25 min,midaz
0,5+fent 40 microgr ;2 episodi SaO2 <90%;O2 1
lt/min.Per il resto stabile (PA 108/65),
• Durata chir:50 min.

28. Rosa V-paz dott G”J”P.
• Femmina , 70 a, 60 kg, 160 cm,
• ASA 4 (cardiomiop dilat ,diabete)
• Anesth stand by con monitoraggio !!!
• Segni vitali stabili:BP 149 /73
• Durata chir :90 min.

29. R- T.,paz dott PP
• 87 a.,50 kg,155 cm.
• Alzheimer
• Estrazioni multiple ;25 min.
• Midaz 3 mg
• Segni vitali stabili .

30. V V,paz di FP
• Per impianti multipli
• Maschio,76 y,79 kg,cm 174
• ASA 4;cardiomiopatia dilat,(ma FE migliorata fino al
50%),COPD, gastrite cronica
• farmaci:Bisoprolol,valsartan 40,atorvastatin
,furosemide,lansoprazol venlafaxin,clonazepam
• Premed:triazolam 0.5 mg,30’ prima
• Induz;midaz 1,no fent
• Chir dur:115 min
• Segni vitali stabili,no problemi

31. Quando il paziente è un collega..
• Cirrosi con ipertensione portale
,ipopiastrinemia(splenomegalia),forte
fumatore......
• Candidato ad impianti multipli...
•?
• (clinica....)

32. Protocollo di sedazione per i paz.ad
alto rischio...buono per tutti???
• Riconoscere il rischio
• Consulto medico completo prima del trattamento:MMG??Specialista?
• Appuntamento nel momento del giorno quando il loro stress è minimo
• Durante i primi gg della settimana quando l’ufficio è aperto per le
emergenze ed è disponibile il curante e lo specialista
• Monitoraggio dei segni vitali preop,intraop,postop
• Regime sedativo con minime alterazioni fisiologiche
• Controllo adeguato del dolore durante e dopo il trattamento
• La durata del trattamento non deve superare i limiti di tolleranza del
paziente
• Follow up del dolore postop e controllo dell’ansia
• Controllare con :
– Telefonata più tardi il giorno stesso/ sera
Telefonata il giorno seguente

33. Prevenzione:Riduzione dello stress
• Richiesta di consultazione;Medico curante,cardiologo...
• Scelta dell’ora,meglio la mattina presto per i paz ansiosi ,dopo una notte di sonno....
• Minimizzare il tempo di attesa, a meno che non si sfrutti per la sedazione...
• Segni vitali preop e postop
• Premedicazione:
– la notte prima
dell’appuntamento;ipnotico/sedativo:diazepam,triazolam,flurazepam,zolpidem,zaleplon...;prescr
ivere!!!
– all’appuntamento ,almeno mezz’ora prima( 1 h...)
Sedazione durante intervento;iatrosedazione,farmacosedazione
controllo del dolore
Durata del trattamento
Controllo del dolore ;intraop postop
:prescrizione:analgesici,antibiotici,ansiolitici se necessari,

34. Riduzione dello stress
ansia
dolore
Ambiente
attesa
Durata
STRESS
Sedazione:la notte
prima,il giorno
stesso,approccio
psicologico,ecc,ecc
Analgesia;oppioidi,
N2O,A.L.
Musica,relax,TV,distrazione,

36. Avere le cose giuste
Attrezzature e farmaci

37. Farmaci essenziali
• Ossigeno;bombola da 5 lt,come minimo,200 atm,con va e
vieni ,mascherina facciale ,occhialini nasali
– 3 maschere facciali adulti,piccola,media ,grande
Adrenalina,fiale da 1 mg :FASTJECT 2 ml,siringa
preriempita,iniett(77 £):330 microgr o 165 microgr
Video prodotto dall'Allergopharma che illustra come usare
l'adrenalina auto iniettabile (Fastjekt) in caso di shock anafilattico.
• Nitroglicerina:cp sublinguali 0.3-0.4 mg,Carvasin 5 mg ,Natispray
• Antistaminico:clorfeniramina(trimeton) fiale 10
mg,Prometazina(farganesse 50 mg)
• Albuterolo,salbutamolo(Ventolin)
• Aspirina;cp 160-325 mg

38. Farmaci essenziali
farmaco indicazioni Dose iniziale(adulti)
ossigeno sempre Inalazione 100% Bombol
,masch
ere,am
bu
adrenalina anafilassi 0,1 mg ev;0.5 mg i.m. Fiale,pe
nna
Asma che non
risponde al
salbutamolo
0,1 mg ev;0.2—0.5 mg i.m.
Arresto cardiaco 1 mg ev
Fastjekt anafilassi Siringa preriempita 330 0pp 165
microgr ,im.
Nitroglicerina(Trinitrin
a 0.3,carvasin 5 mg)
Dolore anginoso 0.3-0.4 mg,sublinguale Cp,fiale
Natispray,sublinguale)
Clorfeniramina/Trimet
Reaz.allergica 10 mg ev,i.m. fiale

39. Altri farmaci per emergenza
farmaco indicazione Dose iniziale adulto
atropina Bradicardia
significativa,attacco vaso
vagale
0.5 mg ev,im
efedrina Ipotensione significativa 5-10 mg iv,10-25 mg im
idrocortisone Insuff.surrenalica 100-200 mg iv o im
anafilassi 100-200 mg iv o im
Morfina o
protossido d’azoto(N2O)
Buprenorfina
Dolore anginoso che non
risponde all NTG
2 mg ev,3-5 mg im
Inalazione al 30-35% con O2
0.15-0.3 mg subling o im o ev
Lorazepam(Tavor) Crisi epilettica
,attacchi di panico
4 mg i.m o ev lenta
Cp per os 1 mg
Midazolam Crisi epilettica 5 mg i.m. o ev
ranitidina Anafilassi,allergia 50 mg ev o 150 mg p.os
Ondansetron(zofran) Nausea,vomito 4 mg,iv o im

50. Maschera con reservoir
• http://youtu.be/nEbsKfLl1n4
• Acquisti materiale
consumabile;doctorshop,doctorpoint

51. SIAD Ozzano Emilia via Libertà 17
• ALLEGATO 3 – DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE (ai sensi dell’art. 46 del D.P.R. 28/12/2000, n. 445)
•
•
• Il/la sottoscritto/a……………………………………………………………………………..
•
•
• Responsabile dell’Ente di Soccorso/Studio Medico…………………………………………..
•
•
• con sede in……………………………………………………………………………………….
•
•
• Partita IVA/C.F…………………………………………………………………………………
•
•
•
• Consapevole delle sanzioni penali, nel caso di dichiarazioni non veritiere, di formazione o uso di atti falsi, richiamate dall’art. 76 del DPR n. 445/2000
•
•
• DICHIARA
•
• di essere soggetto autorizzato al rifornimento all’ingrosso di gas medicinali e di impiegare gli stessi sotto la propria sola responsabilità.
•
•
•
•
• In fede
•
• ………………………………………………..
•
• Luogo, Data ………………….,……………….
•
www.siad.com
autorizzazione acquisto FU-3.doc

52. • buongiorno,
• non possiamo vendere medicinali a studi medici che non abbiano
sottoscritto l’allegato che Le inoltro...
•
• Riesce ad inoltrare ai due medici il modulo, facendomelo poi avere via e-mail
o via fax allo 051 796026?
• Grazie mille
•
• Massimiliano Lucchina
• Servizio Vendita
•
• SIAD S.p.A. | I-40064 Ozzano dell'Emilia (BO) - Via della Libertà, 17
• Tel. +39 051 799399 | Fax +39 051 796026
• massimiliano_lucchina@siad.eu | www.siad.com

53. Bombola di ossigeno
• 5 litri,200 atm=1000 litri
• Se usate 6 lt/min ce n’è per 166 min......
• Guardate la pressione;quando è ,per es, a 80
atm,significa che ci sono ancora 400 lt...
• A 20-30 atm è meglio sostituire con una altra
piena.

55. La valigetta degli orrori
set di rianimazione
completo di:
bombola
ricaricabile di
ossigeno da 0,5 LT
in acciaio, riduttore
con manometro ed
erogatore, pallone
rianimatore,
maschera
rianimazione, 2
cannule di Guedel,
pinza tiralingua,
apribocca
elicoidale, tubo
atossico, in
contenitore plastico
antiurto.

63. FARMACI UTILI NELLO STUDIO ODONToIATRICO
DI maria/Niso,Roma
• ADRENALINA fiale da i mg
• Anexate fiale da o,5mg (c’è anche da 1 mg)
• Aspirina compresse effervescenti
• Atropina fiale da 0,5 mg
• Bentelan 4mg
• Carvasin compresse sublinguale
• Catapresan fiale
• Emagel 500 1
• Flebocortid da 500mg (almeno 2) o Solu-medrol 500mg (almeno 2)
• Lasix fiale
• Midazolam o ipnovel fiale da 5 mg
• Nifedicor gocce
• Ranidil fiale
• Sol fisiologica in fiale da 10 cc e per fleboclisi ,250 o 500 ml
• Tranex fiale
• Trimeton fiale e/o Farganesse fiale
• Valium o simili in gocce
• Ventolin o Broncovaleas puff

64. Diluenti dei cortisonici
• Il bentelan contiene:Fenolo, sodio cloruro, sodio
metabisolfito, sodio edetato, acqua p.p.i.
• SOLDESAM SOL. INIETTABILE e SOLDESAM FORTE SOL.
INIETTABILE: fenolo, sodio citrato biidrato, acido citrico
anidro, acqua per preparazioni iniettabili
• Solucortef;sodio fosfato,alcool benzilico
• Flebocortid ; una fiala di polvere contiene: sodio fosfato,
Metile–p–idrossibenzoato, Propile–p–idrossibenzoato.
• Una fiala di solvente contiene: sodio cloruro, acqua per
preparazioni iniettabili.

65. Plasma expander
• Le gelatine hanno più reazioni allergiche degli
amidi;quindi preferirei come plasmaexpander
il Voluven o similari.....,;comunque visto che
l’uso sarà eccezionale,la differenza
probabilmente non esiste.....

66. Precauzioni d’uso ;effetti collaterali
• NTG:paziente semisdraiato o
supino(ipotensione!!!)
• Albuterol(Ventolin);tachicardia,ipertensione
• Aspirina:masticare prima di deglutire

67. Altro materiale per emergenza( e non
solo)
• Stetoscopio
• Apparecchio misuratore di pressione
• Siringhe;2,5,5,10 ml
• Aghi monouso:22g,20 g
• Fleboclisi 250-500 ml,plastica,pvc
• deflussori
• Cateteri e v 22 g,20 g.
• Defibrillatore automatico(AED)
• Pulsossimetro(+NIBP....)
• Cannule di Guedel/mayo
• Maschera laringea?
• Tubo endotracheale,laringoscopio???
• Misuratore di glicemia?

73. Approximate FiO2 delivered by nasal
cannula
• Flow rate lt/min approx FiO2
• 1 0.24
• 2 0.28
• 3 0.32
• 4 0.36
• 5 0.40

80. Approximate FiO2 delivered by face
mask
• Flow rate lt/min approx FiO2
• 5-6 0.40
• 6-7 0.50
• 7-8 0.60
• A minimum flow of 5-6 lt/min necessary to prevent
rebreathing

83. Applicare la maschera di anestesia al
paziente

84. The 3 reservoirs of low flow O2 therapy
Pharynx
Mask
Reservoir bag

85. Approximate FiO2 delivered by face
mask with reservoir
• Flow rate lt/min approx FiO2
• 6 0.60
• 7 0.70
• 8 0.80
• 9 >0.80
• 10 >0.80

86. La curva di dissociazione
dell’ossiemoglobina

87. Maschera anestetica(trasparente)
applicata al paziente e connessione al
circuito di anestesia

88. Maschera da ossigenoterapia;aperture
laterali

89. Cannule nasali per ossigenoterapia

90. Allora:sequenza di intervento con
ossigeno
• Prevenzione(paziente in RS):occhialini,flusso 1-
2 lt/min
• Soccorso(paziente in RS):maschera morbida
:flusso 5-6 lt/min
• Emergenza(paziente in RS problematico o
apnea);va e vieni(Unità respiratoria
manuale,URM):6-8 lt/min,guardare pallone se
RS ; se non :assistere manualmente !!!

95. Mobiletto con farmaci e materiale di
emergenza

96. Un vecchio monitor con
ECG,PA,pulsossimetro con saturimetria

97. Mobiletto per farmaci e cose varie,bombola di
ossigeno,defibrillatore automatico

98. Fissaggio (non ottimale) del catetete ev,rubinetto a
tre vie con connettori per farmaci dalle pompa
siringa

99. Cannula brevettata a 2 vie per somministrazione di
ossigeno e campionamento della CO2 espirata
setto che separa
le due vie
Curva della CO2 espirata(etCO2)

100. IL CARRELLO DELLE
EMERGENZE(CRASH CART)

101. Il

102. Contenuto e composizione del carrello
delle emergenze
• Minimum Crash Cart Supplies and Drugs
• (Based on 2010 ACLS Protocols)
• This list is based on the 2011 American Heart Association
Advanced Cardiovascular Life Support Provider Manual and
does not include Adult Immediate Post-Cardiac Arrest Care.
• Disclaimer:This list was created to show the basic supplies
and equipment required for emergency treatment in an
ambulatory surgery center while waiting for EMS to arrive
and must be reviewed by the anesthesia and medical staff
at your facility and approved by the Medical Executive
Committee and Governing Board.

103. Minimum Crash Cart Supplies and Drugs
(Based on 2010 ACLS Protocols
• Defibrillator/EKG monitor with external pacing capabilities
• or
• AED (automated external defibrillator)
• Adult Electrode defibrillator pads
• Portable suction machine
• suction canister
• suction tubing
• Suction Catheters
• Yankauer Suction Tip
• Clipboard, code worksheets, ACLS algorithms
• Electrode pads/ Defibrillator Pads
• Trach Tray; Cuffed Tracheostomy Tubes: Shiley
• Adult Cricothyrotomy Kit
• Cardiac backboard
• Ambu bag with adult mask
• Portable 02 tanks
• Adult Face Mask non-rebreather
• Nasal Cannula
• Nebulizer Kit
• Airway Patency:
• Nasopharyngeal Airways, assorted sizes
• or
• Oropharyngeal Airways: assorted sizes
• Airway Management:
• Advanced:
• Laryngoscope handle and assorted blades
• C-Batteries for laryngoscope
• Endotracheal Tubes:Assorted sizes, Cuffed and uncuffed
• Stylet
• LMA (laryngeal mask airway) - assorted sizes
• or
• Esophageal-tracheal tube
• or
• laryngeal tube
• MEDICATIONS
• NAME DOSE ROUTE
• Adenosine 6 mg/2ml IV
• Albuterol Inhaler 3ml INH
• Aspirin 325mg PO
• Atropine syringe 1mg/10ml IV
• Atropine 0.4mg/ml IV
• Amiodarone 150mg/3ml IV
• Calcium Chloride 10% syringe IV
• Diphenhydramine 50mg/ml IV
• Dextrose 50%W 25gm/50 ml IV
• Dopamine 400 mg/5ml IV
• Epinephrine 1:1,000 amp/ autoinjector IV
• Epinephrine 1:10,000 syringe IV
• Furosemide 40mg/4ml IV
• Hydrocortisone 100mg/ 2ml IV
• Lidocaine 2%syringe 100 mg IV
• Mag Sulfate 50% syringe IV or IM
• Methylprednisolone 125 mg IV
• Morphine sulfate Narcotic Cabinet IV
• Narcan 0.4mg/ml IV
• Nitroglycerine 0.4mg SL
• Procainamide 100mg/ml IV
• Sodium Bicarb 8.4% 50mEq IV
• Sotalol 100mg IV Sterile Water 10ml IV
• 0.9% Na chloride 10ml IV
• Vasopressin 10units/ml IV
• Lidocaine 4% 2gm 500ml IV
• IV catheters, tape, alcohol wipes, tourniquets, tongue blades
• IO Needles
• IV Tubing- primary and piggyback
• IV solutions: Lactated Ringers, Normal Saline
• Needles, syring

104. Inizio della laringoscopia

105. Inizio della laringoscopia;vista frontale

106. Inserimento della lama del laringoscopia
lungo il dorso della lingua mantenendo
un leggero sollevamento verso l’alto

107. Avanzamento della lama del
laringoscopio

108. Avvicinamento alla base della lingua e sollevamento
della lama a 45o

109. Inserimento della lama del laringoscopio nella
vallecula,davanti all’epiglottide;effetto fulcro e
visualizzazione della glottide

110. Avvicinamento alla base della lingua e sollevamento
della lama a 45o

111. Visione laringoscopica diretta :lingua
spostata a sinistra

112. Visione ingrandita laringoscopica

114. Un catetere endovenoso

115. IMG_5312.JPG

116. <iframe src="http://player.vimeo.co

130. Come è fatta la maschera laringea

131. Maschera laringea(LMA) in sede
Palloncino spia
e condotto per gonfiaggio cuffia
lingua epiglottide
trachea
respirazione
Aria/O2/anestetic esofago
o

132. Come si inserisce la maschera laringea

133. Come si prepara e inserisce la
maschera laringea

134. Basic airway management explanation
and practice you tube
• http://youtu.be/I4vyltWT8TU
• http://youtu.be/_1x1mOGoYyc
• http://youtu.be/4YDg-Ppo81c
http://youtu.be/kzHj5LWtdIo

135. Training e pratica

136. •BLS
•ACLS

138. Essere preparati per le emergenze:
• Storia clinica del
paziente;anamnesi con
aggiornamento ad ogni
visita
• Identificazione del paziente
a “rischio” ;presenza
dell’anestesista o
spostamento in altra
sede:casa di cura,day
surg,Hosp...
• Quando si conferma un
appuntamento ricordare ai
paz. di prendere le loro
medicine!

139. • Staff preparato per CPR
• Piano di emergenza scritto
• numero tel di emergenza
ad ogni postazione
• Kit di emergenza pronto e
tutti sanno dove è
• Verifica routinaria del
contenuto e scadenze

140. The health history should include information regarding the patient’s past and
present health status.

141. ASA classification of physical status

142. Estimated Energy Requirements for Various Activities

143. system. This system relates symptoms to
everyday activities and the patient's quality of
life.
NYHA
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary
physical activity does not cause undue fatigue,
palpitation, or dyspnea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or
dyspnea.
Class III (Moderate)
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes fatigue, palpitation, or dyspnea.

144. NYHA Classification - The Stages of
Heart Failure
• In order to determine the best course of of therapy, physicians often
assess the stage of heart failure according to the New York Heart
Association (NYHA) functional classification system. This system relates
symptoms to everyday activities and the patient's quality of life.
• Class Patient Symptoms
• Class I (Mild) No limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation, or dyspnea (shortness of
breath).
• Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation, or dyspnea.
• Class III (Moderate) Marked limitation of physical activity. Comfortable
at rest, but less than ordinary activity causes fatigue, palpitation, or
dyspnea.
• Class IV (Severe) Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at rest. If any physical
activity is undertaken, discomfort is increased.

145. • Class Functional Capacity: How a patient with cardiac disease feels during physical activity
• I Patients with cardiac disease but resulting in no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation,
dyspnea or anginal pain.
• II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in
fatigue, palpitation, dyspnea or anginal pain.
• III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes
fatigue, palpitation, dyspnea or anginal pain.
• IVPatients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal
syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases.
• Class Objective Assessment
• A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.
• B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
• C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary
activity. Comfortable only at rest.
• D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.
• For Example:
• A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe obstruction of the left main coronary artery is
classified:
• Function Capacity I, Objective Assessment D
• A patient with severe anginal syndrome but angiographically normal coronary arteries is classified:
• Functional Capacity IV, Objective Assessment A

149. Segni vitali
• Prima di ogni
trattamento
dovrebbero essere
misurati i segni
vitali:PA,FC,respirazi
one e temperatura....

150. Inserire fot Omron
IMG_6728.JPG

151. Riconoscere una emergenza
• Segni e sintomi di emergenza incipiente:
– Dolore toracico
– Cute pallida
– Sudorazione
– Vomito(nausea)
– RESPIRAZIONE IRREGOLARE
– SENSAZIONI STRANE O INSOLITE
– Modificazioni delle frequenza e/ o della pressione

152. Procedure iniziali nell’emergenza
• Interrompere la procedura
• Chiamare aiuto
• Chiamare il kit di emergenza
• Valutare lo stato di coscienza:se incosciente,abbassare la poltrona
;trendelemburg
• Somministrare O2;se cosciente,occhialini,se incosciente ma
respira maschera ,se incosciente e non respira pallone e maschera

153. Algoritmo di base
• PABCD
• Posizionare
• A airway
• B: breathing
• C:circulation
• D:definitivo o diagnosi

154. Valutare le vie aeree
aprire la bocca
estendere il capo e sostenere il mento
impiegare l’aspirazione se necessario

155. Valutare la respirazione
se non respira,dai due respiri con ossigeno 100%
se in apnea,inserisci la cannula orofaringea
chiama per l’AED

156. Valutare la circolazione
cerca il polso;carotide,(radiale)
in assenza di polso,preparati per CPR:mettere il
paziente in piano,meglio al suolo ,iniziare MCE
applicare l’AED
se c’è il polso,valutare la frequenza e la forza

157. Distress
• Respiratorio:broncospasmo,asma
• Toracico;dolore;angina,MI
• Psicologico;agitazione,convulsioni
• Prevenire il distress:
– Ambiente accogliente,tranquillo,,rilassato
– Minimizzare la paura,il freddo
– Mantenere PA e FC e respirazione nei limiti.....
– Non interrompere la terapia !!!

158. Valutare il paz. e la situazione:
• Controllare i segni vitali del paziente;PA,FC,respirazione,colore..
• Non tentare di trasportare il paziente da soli!!!
• Chiama immediatamente il 118 se:
– Arresto cardiaco
– Arresto respiratorio
– incoscienza> 1 min
– Stato confusionale prolungato
– Dolore toracico > 5 min non alleviato dal venitrin
– Difficoltà respiratoria
– Convulsioni
– Ipotensione grave o tachicardia(???)
• Tratta il paziente in emergenza finchè non arriva il soccorso
• Tieni pronta la cartella e quanto fatto finora per la squadra di soccorso
• Compila la scheda delle emergenze in studio

159. What types of emergencies can be
expected in the dental office?

160. Ostruzione delle vie aeree
• Segni e sintomi:
– Sensazione di soffocamento,improvvisa;afferrare la gola(segno universale)
– Stridore
– Tosse violenta
– Dispnea,spasmi
– Cianosi
• Trattamento:
– Tosse forzata
– Compressione addominale
– Percussione dorsale con paziente curvo in avanti
– Ossigenazione
– Ispezione delle prime vie aeree:
– laringoscopio,pinza di Magill,aspiratore
– Chiamare aiuto
– Trasferimento in ospedale per broncoscopia in urgenza.
How to Perform the Heimlich Maneuver You tube
http://youtu.be/kJDpr05zmB4

163. • How to Perform the Heimlich Maneuver
• Edited by Bob Robertson, Rob S, Nicole
Willson, Travis Derouin and 37 others
• Google/wikihow

164. Airway obstruction management

165. Asma,broncospasmo
• Segni e sintomi:
– Sensazione di soffocamento
– Sensazione di peso sul torace
– stridore
– Tosse
– Dispnea
– Cianosi
• Trattamento:
– Posizionare il paz.seduto,braccia in avanti
– Ossigeno
– Spray con salbutamol 2 puff;ripeti dopo 5 min se inefficace
– Chiamare aiuto
– Valutare i segni vitali e riferire al personale di emergenza

169. • http://youtu.be/kff3co6xwik
• http://youtu.be/EK8nzKzdnIM
• http://youtu.be/wlygTaY4ioc

170. Arresto cardiaco
• Segni e sintomi:
• Non risponde
• Non respira
• Non ha polso
• Trattamento:
– Mettere il paz supino;tavola sotto il torace o stendere sul
pavimento;
– Chiamare aiuto
– Attaccare AED e seguire le istruzioni
– Iniziare CPR
– Ossigenare ;ventilazione con pallone e maschera

172. • http://youtu.be/I-eFjl2G9vg

173. Angina
• Segni e sintomi:
– Dolore o sensazione di oppressione sottosternale ,irradiato
alle spalle,dorso,epigastrio,collo,mandibola…..
– sollievo con NTG...si spera....
• Trattamento:
– Seduto
– NTG sublinguale ogni 5 min:Natispray
sublinguale
– Ossigeno
– Chiamare aiuto
– Valutare i segni vitali e riferire al personale di emergenza

174. Infarto miocardico
• Segni e sintomi:
– Dolore o sensazione di oppressione sottosternale ,irradiato alle
spalle,dorso,epigastrio,collo,mandibola…..
– Mancato sollievo con NTG
– Dispnea,sincope,diaforesi,morte improvvisa
• Trattamento:
– Seduto
– NTG sublinguale ogni 5 min
– Ossigeno
– Aspirina 165-325 mg.
– Analgesico:morfina???buprenorfina??N2O??
– Chiamare aiuto
– Posizionare AED
– Valutare i segni vitali e riferire al personale di emergenza
– MONA:Morfina,ossigeno,nitroglicerina,aspirina

175. Puntata ipertensiva
• Segni e sintomi:
– Cefalea,vertigini,ronzii
– Disturbi della vista
– Cardiopalmo(tachicardia)
– (dispnea)
– Epistassi
• Trattamento:
– Nifedipina(nifedicor).5-15 gtt sublinguali
Opp
– Clonidina(catapresan) mezza/1 fiala im o ev lenta
Opp
– Furosemide(Lasix) 1/ 2 fl im o ev lenta
– Ossigenoterapia(occhialini)

176. Aritmie
• Senza ECG...
• ipocinetiche/ipercinetiche

177. Allergia
– Limitata ad un sistema o generalizzata
– Faringe e prime vie aeree;edema angioneurotico
– Tratto respiratorio;asma,broncospasmo,stridore
– Cute;orticaria,prurito
– Anafilassi;tutti i precedenti+collasso cardiocircolatorio
– Segni e sintomi
– Prurito,arrossamento,pomfi,edema labbra,mucose bocca,faringe…..
– Distress respiratorio,asma,
– Ipotensione,polso piccolo,frequente,pallore
– Ossigeno
– Chiamare aiuto
– Valutare i segni vitali e riferire al personale di emergenza

178. anafilassi
• Posizione supina
• Ossigenazione
• Adrenalina i.m 0.5mg
• Liquidi ev
– Antistaminico: trimeton 10 mg im.
– Cortisone
• Chiamare aiuto
• In caso di arresto,CPR

179. Sincope vasovagale,svenimento
• Segni e sintomi
Fattori scatenanti psicogeni:
paura,ansia,stress emotivo,cattive notizie,dolore,specie se
improvviso ed inaspettato,
vista del sangue,strumenti chirurgici,siringhe...
– Svenimento
– Nausea
– Debolezza
– Pallore
– Cute fredda e sudata
– Polso rallentato,ma prima tachi
– Ipotensione
– Discomfort addominale
– Midriasi
– sbadiglio
• Trattamento
– Posizione supina
– Elevare gli arti inf
– Ossigeno
– Monitorizzare
– Atropina 0.5 mg i.m. o iv
Fattori scatenanti non psicogeni:
Stazione eretta
Fame da salto del pasto o da dieta
Esaurimento,stanchezza
Cattive condizioni fisiche
Ambiente caldo-umido
Affollamento
Sesso maschile
Giovani:16-35 anni

180. Pathophysiology:
Stress
Catecholamines release
Decreased peripheral vascular resistance & ↑ blood flow to peripheral muscles
↓ venous return
↓ circulatory blood vol. & drop in arterial B.P.
Activation of Compensatory mechanisms
Reflex bradycardia develops (< 50)
Significant drop in cardiac output associated with fall in B.P below the critical level
Cerebral ischemia & loss of consciousness

181. Assess consciousness (loss of response to sensory stimulation)
Activate office emergency system
P- Position patient supine with feet elevated slightly
A→B→C – Assess & open airway (head tilt &chin lift); assess airway patency& breathing; assess
circulation (palpation of carotid pulse)
D – Definitive care:
Administer O2
Monitor vital signs
Perform additional procedures:
Administer aromatic ammonia
Administer atropine if bradycardia persists
Do not panic!
Post syncopal recovery- delayed recovery-
Postpone dental treatment Activate EMS
Determine precipitating factors

182. POSTURAL HYPOTENSION
Predisposing factors:
• Administration and ingestion of drugs e.g. antihypertensives like sodium
depleting diuretics, calcium channel blockers &ganglion blocking agents,
sedatives and narcotics, histamine blockers, levo dopa
• Prolonged period of recumbency or convalescence
• Inadequate postural reflex
• Late stage pregnancy
• Advanced age
• Venous defects in legs (e.g. varicose veins)
• Recovery from sympathectomy
• Addisson’s disease
• Physical exhaustion and starvation
• Chronic postural hypotension (Shy – Drager syndrome)

183. Clinical manifestations:
• Precipitous drops in blood pressure and lose consciousness whenever they
stand or sit upright
• Do not exhibit any prodromal signs and symptoms
• May become lightheaded, or develop blurred vision
• Clinical signs and symptoms - precipitating drugs
• Blood pressure during syncopal period is quite low
• Un like vasodepressor syncope , heart rate during postural hypotension
remain at the baseline level or somewhat higher
• Consciousness returns rapidly once the patient is returned to the supine
position

184. Pathophysiology:
When patient moves into an upright position
SBP drops and approaches 60 mm Hg in one minute
DBP also drops
Slight changes in heart rate and not at all
Cerebral blood flow drops below the critical level
May lose consciousness
Once the patient is placed into supine position, reestablishment of
cerebral blood flow occurs

185. P- Position patient supine with feet elevated slightly
A→B→C – Assess & open airway (head tilt &chin lift); assess airway patency&
breathing; assess circulation (palpation of carotid pulse)
D – Definitive care:
Administer O2
Monitor vital signs
Patient recovers consciousness-slowly
reposition chair delayed recovery -
activate EMS
Continue BLS as needed and discharge patient

186. iperventilazione
• Segni e sintomi
– Dispnea
– Respirazione rapida
– Svenimento
– Parestesia delle estremità
– Palpitazioni
• Trattamento
– Calmare
– Incoraggiare respirazione lenta
– Rebreathing( rirespirazione in un sacchetto di carta)

187. Epilessia(convulsioni)
• Segni e sintomi:
– Incoscienza improvvisa
– Apnea transitoria
– Cianosi(nella fase tonica)
– Movimenti involontari degli arti
– Assenza???
• Trattamento:
– Assumere decubito laterale
– Proteggere dai danni,lasciare spazio,spostare dai pericoli
– Monitoraggio dei segni vitali
– Ossigeno
– Midazolam 5 mg im o iv,
– Buccolam 10 mg
– MAD???per via nasale

189. http://youtu.be/7sJMaSOoH88

190. http://youtu.be/7sJMaSOoH88

191. ipoglicemia
• Segni e sintomi:
• Senso di fame
– Parola strascicata,incoerente
– Comportamento alterato
– Polso rapido
– Apprensione,ansia,irrequietezza,aggressività
– Disorientamento,perdita di coscienza
– Tremori
– sudorazione
• Trattamento:
– Succo di frutta,caramella,zuccherino pos.
– Se è avvenuta perdita di coscienza,glucosio ev.
– Nel dubbio tra iper e ipoglicemia,meglio somministrare glucosio comunque!
– destrostick

193. Riconoscere l’ictus
• Sorridi!o mostra i denti!
• Alza entrambe le braccia e tienile alzate!
• Dicci una frase semplice
–Alterazioni improvvise!!!!!

194. cefalea
Perdita vista
Improvvisa
confusione

195. ROSIER scale (Recognition of Stroke In
the Emergency Room)
• Appendix G: ROSIER scale
• Recognition of Stroke in the Emergency Room (ROSIER)18
• Assessment Date: ___________________ Time: ___________________
• Symptom onset Date: ___________________ Time: ___________________
• GCS E=___ M=___ V=___ BP= ____ / ____ *BG= __________
• *If BG < 3.5 mmol/L, treat urgently and reassess once blood glucose normal
• Has there been loss of consciousness or syncope? Y (-1) ?N (0)
• Has there been seizure activity? Y (-1) ?N (0)
• Is there a NEW ACUTE onset (or on awakening from sleep)
• I. Asymmetric facial weakness Y (+1) ?N (0)
• II. Asymmetric arm weakness Y (+1) ?N (0)
• III. Asymmetric leg weakness Y (+1) ?N (0)
• IV. Speech disturbance Y (+1) ?N (0)
• V. Visual field defect Y (+1) ?N (0) ?
• Total Score ________ (-2 to +5)
• Provisional diagnosis
• ?Stroke ?Non-stroke (specify) __________________________
• Note: Stroke is unlikely, but not completely excluded if total scores are ≤0.
• ROSIER (95% CI) CPSS (95% CI) FAST (95% CI) LAPSS (95% CI)
• Sensitivity 93 (89-97) 85 (80-90) 82 (76-88) 59 (52-66)
• Specificity 83 (77-89) 79 (73-85) 83 (77-89) 85 (80-90)
• Positive Predictive Value 90 (85-95) 88 (83-93) 89 (84-94) 87 (82-92)
• Negative Predictive Value 88 (83-93) 75 (68-82) 73 (66-80) 55 (48-62)
Perdita di coscienza e convulsioni
Stroke Unit

196. Interferenza con un pacemaker
cardiaco
• pacing activity of both pacemakers and the
dual-chamber ICD was inhibited by
• 1)a battery-operated composite curing light at between
2 and 10 cm from the leads.
• 2)The use of an ultrasonic scaler(ablatore) interfered
with the pacing activity of the dual-chamber pacemaker
between 17 and 23 cm from the leads, the
single-chamber pacemaker at 15 cm from the leads and
both ICDs at 7 cm from the leads.
• 3) ultrasonic cleaning system,
• Roedig JJ, Shah J, Elayi CS, Miller CS. Interference of cardiac pacemaker and
implantable cardioverter-defibrillator activity during electronic dental
devices use. J Am Dent Assoc 2010;141:521-6.

197. Summary.
• It has been estimated that one or two life threatening
emergencies will occur in the lifetime practice of a
general dentist.
• Obtaining a health history and a set of vital signs is the
first step in identifying the patient likely to develop a
medical emergency. With proper training, thorough
preparation, and regular practice, the staff of the dental
office will be able to provide appropriate medical care
should the need arise.

198. FONTI DI INFORMAZIONE ED
AGGIORNAMENTO

199. ADA courses
• DT DENTAL OFFICE EMERGENCIES
• You will receive 2 unit(s) of continuing education credit
upon successful completion of this course. The
registration fee is only $76.00
• DESCRIPTION:
• This course discusses how the dental office team can
prepare itself to handle medical emergencies.
• AUTHOR:
• American Dental Association, Continuing Education
and the Council on Dental Practice and Product
Development and Sales.

200. LEARNING OBJECTIVES:
• Upon completion of this course, participants should be able to do
the following:
– Describe why it’s important to have a dental office emergency plan.
– Identify what types of emergency training are important for dental
office staff.
– Identify ways in which dental office staff can prepare for medical
emergencies
– Identify the steps involved in taking a good health history.
– Identify some ways to help alleviate patient anxiety.
– Identify some of the symptoms that may indicate an impending
emergency.
– Identify some components in a dental office emergency kit.
– Discuss the importance of recordkeeping in the event of a dental
office emergency.
– Describe some of the legal aspects of dental office emergencies.

201. ADA
• Medical Emergencies in Dentistry: Prevention
and Preparation
• Pamela Sparks Stein, DMD
• Dr. Stein is on the faculty full-time at the
University of Kentucky College of Medicine and
College of Dentistry in both the Dept. of Anatomy
and Neurobiology and the Dept. of Restorative
Dentistry. She authored the award-winning
“Dental Emergency Protocol Manual” and In-
Office Emergency Protocol Software Program.
Contact her at pam.stein@uky.edu

203. FINE

204. Some (simple)calculation:
• O2 flow :6 lt/min
• Mask (dead) space:50 ml
• Pharynx (dead) space:50 ml
• TV:500 ml
• RR:20/min,I/E ratio ½
• Insp time:1 sec
• O2 flow/sec= 100 ml
• In the next inspiration( 1 sec) the patient will get 500
ml,of which 50 ml(mask)+ 50 ml (pharynx) + 100 ml (O2
flow in 1 sec) of pure Oxygen:
• Then 200 ml of FiO2 =1 and 300 ml of FiO2= 0.21:Total
260 ml of O2= FinspO2=260/500=0.52 FiO2

205. Some working variables
• Higher O2 flows may increase FiO2
• Lower TV increase FiO2
• Larger TV decrease FiO2
• Faster RR decrease FiO2
• Lower RR increase FiO2
• L’equazione completa è un integrale………..

206. Vt 250 ml,mask
• O2 flow :6 lt/min
• Mask (dead) space:50 ml
• Pharynx (dead) space:50 ml
• TV:250 ml
• RR:20/min,I/E ratio ½
• Insp time:1 sec
• O2 flow/sec= 100 ml
• In the next inspiration( 1 sec) the patient will get 250
ml,of which 50 ml(mask)+ 50 ml (pharynx) + 100 ml
(O2 flow in 1 sec) of pure Oxygen:
• Then 200 ml of FiO2= 1 and 50 ml of FiO2 = 0.21:Total
210 ml of O2= FinspO2=210/250=0.84 FiO2

207. VT 500 ml,nasal cannula
• O2 flow :6 lt/min
• Nasal cannula:no (dead) space
• Pharynx (dead) space:50 ml
• TV:500 ml
• RR:20/min,I/E ratio ½
• Insp time:1 sec
• O2 flow/sec= 100 ml
• In the next inspiration( 1 sec) the patient will get 500
ml,of which 0 from cannula+ 50 ml (pharynx) + 100 ml
(O2 flow in 1 sec) of pure Oxygen:
• Then 150 ml of FiO2 = 1 and 350 ml of FiO2 = 0.21:Total
150 +73,5 ml of O2= FinspO2=223/500=0.44 FiO2

208. Anticoagulazione e chirurgia dentaria
• Chest. 2008 Jun;133(6 Suppl):299S-339S.
The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J; American College of Chest Physicians. McMaster University, Hamilton, Ontario, Canada.
• Abstract
• This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving vitamin K antagonists (VKAs) or antiplatelet
drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with
low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery.
The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S-131S). Briefly, Grade 1 recommendations
are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that
individual patient values may lead to different management choices. The key recommendations in this article include the following: in patients with a mechanical heart valve or atrial
fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over
no bridging during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we
suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade
2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose
SC LMWH or IV UFH (Grade 2C). In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and
clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing
aspirin and clopidogrel in the perioperative period (Grade 1C). In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing
VKAs around the time of the procedure and co-administering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are
receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we
recommend continuing VKAs around the time of the procedure (Grade 1C).
•
• Arch Intern Med. 2003 Apr 28;163(8):901-8.
Perioperative management of patients receiving oral anticoagulants: a systematic review.Dunn AS, Turpie AGCONCLUSIONS:
• Most patients can undergo dental procedures, arthrocentesis, cataract surgery, and diagnostic endoscopy without alteration of their regimen.
• For other invasive and surgical procedures, oral anticoagulation needs to be withheld, and the decision whether to pursue an aggressive strategy of perioperative administration of
intravenous heparin or subcutaneous low-molecular-weight heparin should be individualized.
• The current literature is substantially limited in its ability to help choose an optimal strategy. Further and more rigorous studies are needed to better inform this decision.
• Comment in
• Dental procedures can be undertaken without alteration of oral anticoagulant regimen. [Evid Based Dent. 2005]
• Oral anticoagulant and dental procedures. [Arch Intern Med. 2003]
• Perioperative management of patients receiving oral anticoagulants. [Arch Intern Med. 2003]
• The perioperative management of warfarin therapy. [Arch Intern Med. 2003]
• J Oral Sci. 2007 Dec;49(4):253-8.
• Dentalmanagement of patients receiving anticoagulation or antiplatelet treatment.
• Pototski M1, Amenábar JM.
• Author information
•
•
• Abstract
• Antiplatelet and anticoagulant agents have been extensively researched and developed as potential therapies in the prevention and management of arterial and venous thrombosis. On
the other hand, antiplatelet and anticoagulant drugs have also been associated with an increase in the bleeding time and risk of postoperative hemorrhage. Because of this, some
dentists still recommend the patient to stop the therapy for at least 3 days before any oral surgical procedure. However, stopping the use of these drugs exposes the patient to vascular
problems, with the potential for significant morbidity. This article reviews the main antiplatelet and anticoagulant drugs in use today and explains the dental management of patients on
these drugs, when subjected to minor oral surgery procedures. It can be concluded that the optimal INR value for dental surgical procedures is 2.5 because it minimizes the risk of either
hemorrhage or thromboembolism. Nevertheless, minor oral surgical procedures, such as biopsies, tooth extraction and periodontal surgery, can safely be done with an INR lower than
4.0.
• PMID: 18195506 [PubMed - indexed for MEDLINE] Free full text

209. The Nature and Frequency of Medical Emergencies Among
Patients in a Dental School Setting
Patrick L. Ander, Robin L. Comeau, Michael Hatton, Mirdza E. Neiders.
.J.Dental Education,2010;74;390-396.
• University at Buffalo School of Dental Medicine
• Direct correspondence and requests for reprints to Dr. Patrick L. Anders, University at Buffalo
School of Dental Medicine, 355 Squire Hall, Buffalo, NY 14214; 716-829-2241 phone; 716-829-3554
fax; planders@buffalo.edu.
• Received July 23, 2009.
• Accepted January 6, 2010.
•
As health care improves and life expectancy increases, dentists and dental students are treating a
growing number of elderly and medically compromised patients, increasing the likelihood of a medical
emergency during treatment. Previous studies examining emergencies in a dental setting have relied
upon self-reports and are therefore subject to biases in reporting. The purpose of this study was to
examine data generated from documentation of CODE-5 medical emergency events at the University at
Buffalo School of Dental Medicine over an eight-and-a-half-year period. The incidence of emergencies
was found to be 164 events per million patient visits, which is lower than reported in previous studies.
Most emergencies involved suspected cardiovascular events, syncope, complications related to local
anesthesia, and hypoglycemia. Twenty percent of emergencies involved people who were in the
building for reasons other than to receive dental care, underscoring the need for an operational CODE-5
system whenever a building is occupied. We suggest strategies to reduce the incidence of medical
emergencies and increase ability to manage those that do occur

210. Emerg Med J 2008;25:296-300 Prehospital care
A state-wide survey of medical emergency management in dental
practices: incidence of emergencies and training experience
M P Müller, M Hänsel, S N Stehr, S Weber, T Koch
• +
• Author Affiliations
• Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, University of
Technology, Dresden, Germany
• Dr M P Müller, Department of Anaesthesiology and Intensive Care Medicine, Carl Gustav Carus University
Hospital, University of Technology, 01307 Dresden, Germany; mp-mueller@web.de
• Accepted 18 November 2007
• Abstract
• Background: Only a few data exist about the occurrence of emergencies in dental practice and the training
experience of dental practice teams in life support. This study evaluates the incidence of emergencies in dental
practices, the attitude of dentists towards emergency management and their training experience.
• Methods: Anonymous questionnaires were sent to all 2998 dentists listed in the Saxony State Dental Council
Register in January 2005.
• Results: 620 questionnaires were returned. 77% of the responders expressed an interest in emergency
management and 84% stated that they owned an emergency bag. In the 12-month study period, 57% of the
dentists reported up to 3 emergencies and 36% of the dentists reported up to 10 emergencies. Vasovagal syncope
was the most frequent emergency (1238 cases). As two cardiac arrests occurred, it is estimated that one sudden
cardiac arrest occurs per 638 960 patients in dental practice. 42 severe life-threatening events were reported in all
1 277 920 treated patients. 567 dentists (92%) took part in emergency training following graduation (23%
participated once and 68% more than once).
• Conclusion: Medical emergencies are not rare in dental practice, although most of them are not life-threatening.
Improvement of competence in emergency management should include repeated participation in life support
courses, standardisation of courses and offering courses designed to meet the needs of dentists.

211. • Self-reported preparedness for medical emergencies among dentists in two hospitals in Benin City
• PI Ugbodaga, O Ehigiator, AO Ehizele
• Abstract
• Context: Medical emergencies have been known to occur in dental offices and can lead to loss of life if not well
managed. Objective: The objective of this study was to assess self-reported preparedness by practicing dentists
for management of medical emergencies in Benin City, Nigeria. Methods: A self-administered questionnaire was
completed by dentist in a teaching and general hospital in Benin City. Results: Majority of respondent (86.6%)
reported to have received either theoretical or practical or both training in medical emergency at undergraduate
level. While only 46.7% have had training post graduation. Only 6.7% of respondent have certification in both
basic life support and advanced trauma life support, while only 20% participated in emergency drills in the last six
months prior to this study. Non availability of emergency kit was reported by 43.3% of the respondent. No
respondent knew of the availability of a complete emergency kit. Only adrenaline, oral glucose, diazepam, oxygen
and AMBU bag were reported to be available by 36.7%, 16.7%, 33.3%, 33.3% and 23.3% of the
respondents respectively. Only 40% of the respondents felt competent to perform mouth-to-mouth
resuscitation. Conclusion: Preparedness for management of medical emergencies was found to be inadequate
among the surveyed dentists. The need for improvement of the training of practicing dentists in the management
of medical emergencies at the undergraduate, postgraduate, and continuing education levels as well as the need
for organization of the dental workplace to handle such emergencies cannot be overemphasized.
• Keywords: Medical emergency, preparedness, Competence, Dentists

212. pathway
Approaches medication levels comparable to
injections*
*R Wolfe, D Braude. Intranasal Medication
Delivery for Children: A Brief Review and
Update. Pediatrics. 2010.
ww.pediatrics.org/cgi/doi/10.1542/peds.2010-
0616.Accessed 03/12/13.
Reduce Pain and Bleeding Associated with:
Nasal and oral instrumentation
Nasogastric tube placement
Controlled Administration
Exact dosing, exact volume
Titratable to effect (repeat if needed)
Atomizes in any position
Atomized particles are optimal size for
deposition across broad area of mucosa
Needle-Free for Painless Delivery
No needle, no pain
No risk of needle stick injury
Minimal Resource Utilization
Nasal drug administration is quick, easy

213. PREPARAZIONE

214. Profilassi antibiotica
• Pazienti particolari;endocardite,valvole
cardiache...
• Protesi articolare;dopo 1 anno?dopo 2?
• Pazienti
immunodepressi;diabetici?malnutriti,emofilici
....
• Apriamo una parentesi o passiamo oltre????

215. • Endocarditis prophylaxis RECOMMENDED:
• High-risk category-
• Prosthetic cardiac valves- bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Cyanotic congenital heart disease- e.g., single ventricle states,
trans position of great arteries, tetralogy of fallot
• Surgically constructed systemic pulmonary shunts
• Moderate-risk category-
• Other congenital cardiac malformations
• Acquired valvular dysfunction- e.g., rheumatic heart disease
• Hypertrophic cardiac myopathy
• Mitral valve prolapse with valvar regurgitation or thickened
leaflets