Medical Emergencies in Dental Practice Part I
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Transcript of Medical Emergencies in Dental Practice Part I
Medical Emergencies in Dental Practice Part I
Abtin Shahriari DMD, MPHOral & Maxillofacial SurgeonStaff Attending Northside HospitalStaff Attending Atlanta Medical Center
Medical Emergencies in Dental Office Objectives
◦Present various emergency situations Definition Causes Signs/Symptoms Treatment Prevention
Medical Emergencies in Dental Office Outline:
I. Loss of consciousness II. Respiratory distress III. Chest pain IV. Cardiac dysrythmias V. Allergy/Drug Reactions VI. Altered sensation VII. StrokeVIII. Blood Pressure Abnormalities IX. Emesis/Aspiration X. Malignant Hyperthermia
Be prepared
Most office emergencies are minor, but should be aggressively treated before they become major problems
P-R-A-YPreparedness- of the office and personnel
to treat the impending emergency in a timely and efficient manner.
Recognition- of predisposing signs and symptoms of an impending emergency
Action- Develop a plan to stabilize and support the emergency patient
Yell- To know when and where to obtain help in activating EMS when necessary
Loss of Consciousness (LOC)SyncopeHypoglycemiaCardiac arrest
LOC- SyncopeDefinition:
◦Sudden brief loss of consciousness caused by decreased blood flow to the CNS.
Usually the victim regains consciousness within a few minutes, but prolonged LOC leads to a seizure
LOC- SyncopeCauses:
◦Vasovagal◦Panic/Anxiety◦Hypoglycemia◦Heart Disease (arrhythmia/blocks)◦Seizures◦Diseases that interfere with CNS regulation
of BP (vasodepressor) & HR (cardioinhibitory) DM ETOH BP Medications
LOC- SyncopeSigns/Symptoms
◦Presyncope Nausea Sensation of warmth Light-headedness Diaphoresis Palor Tachycardia
◦Syncopal Stage (LOC) Hypotension Bradycardia Pupillary dilation
LOC- Syncope Treatment:
◦ Early Trendelenberg Assess level of consciousness ABCs Cause Checklist
Medication Hypoglycemia CVA Seizure Arryhthmias Anaphylaxis Anxiety attack
Head tilt 100% Oxygen Monitor BP/Pulse/Respirations Ammonia capsule Cold compresses to forehead & neck Reassure patient
LOC- SyncopeTreatment:
◦Advanced LOC>5 minutes or recovery > 20 minutes 911 Activate ACLS
ABC’s IV access
LOC- SyncopeBradycardia <60 bpm,
symptoms:◦Altered mental status◦Chest pain◦Hypotension◦SOB◦Seizures◦Syncope
LOC- SyncopePrevention (1 ounce= 1 pound of
cure)◦Sedation as needed◦Monitor carefully◦Supine position◦100% oxygen early◦Identify presyncopal stage
LOC- SyncopeSummary
◦Trendelenberg◦Airway◦100% oxygen◦Cold compress/ammonia◦Assess LOC◦Monitor vital signs
LOC- HypoglycemiaDefinition:
◦Reduction in blood glucose levels to below 50 mg/dl, resulting in glucose deprivation of the CNS
Causes:◦Excessive insulin/ oral hypoglycemic
therapy◦Missed/delayed meals◦Illness/infection◦Excessive exercise◦Alcohol ingestion
LOC- HypoglycemiaSigns/Symptoms
◦Mild- (<60-65 mg/dl) Cold clammy wet skin Extreme hunger Nausea Tachycardia Numbness/ tingling fingers Trembling
LOC- HypoglycemiaSigns/Symptoms
◦ Moderate- (<50 mg/dl) Extreme tiredness Irritability Anxiety Restlessness Fatigue/lethargy Headache Dizziness Slurred speech
◦ Severe (<10 mg/dl) LOC Seizures Hypothermia Coma
LOC- HypoglycemiaTreatment
◦Early- patient is conscious Stop treatment Supine position Maintain airway Monitor vitals Check blood glucose level Treat if less than 50 mg/dl,
Oral glucose Regular soft drink, fruit juice ½ cup
LOC- HypoglycemiaTreatment
◦Advanced (patient becomes unconscious) Basic life support (BLS) Activate Emergency Medical Service (EMS)
With IV access One ampoule glucose (50ml of 50% solution) Check blood glucose q10 min I.V. infusion of 5% to 20% dextrose solution
Without IV access One mg glucagon IM Check blood glucose q 10 min Repeat glucagon as needed
LOC- HypoglycemiaPREVENTION
◦H&P◦Maintain glycemic/insulin control,
avoid hyper- or hypo- glycemia.◦Short appointments/early AM◦Early identification and management
LOC- HypoglycemiaPreoperative-
◦Type I DM consider: ½ dose insulin if fasting Measure blood glucose on presentation IV D5W
◦Type II DM Avoid oral hypoglycemic medication on
the morning of surgery Metformin, Glyburide
Check blood glucose on presentation
LOC- HypoglycemiaSUMMARY
◦Stop treatment◦Supine position◦Airway◦Monitor vitals◦Check blood glucose levels◦Oral glucose
LOC- Cardiac arrestABCs of CPR
◦ Check responsiveness◦ If no response call 911◦ AED/ defibrillator◦ Start CPR
A- AIRWAY- Open airway with head tilt chin lift B- BREATHING- Look, listen, feel for breathing
If not breathing give 2 rescue breaths C- CIRCULATION- Check pulse, look for other signs of
circulation such as breathing, movement & coughing◦ If no pulse begin chest compressions between nipples◦ 30 compressions @ rate of 100/min
30 to 2 compressions to ventilation ratio◦ New guidelines: the compressions are more important
than ventilation
LOC- Cardiac arrestABCs of CPR Cont.
◦When to Shock- VF or pulse-less VT If shock does not work add pressors to
treatment. Epinephrine 1 mg Vasopressin 40 units 1 time
◦When not to Shock Pulseless electrical activity- PEA Asystole
Epinephrine, Vasopressin, Sodium bicarbonate, Magnesium
LOC- Cardiac arrestABCs of CPR Cont’
◦Think of the cause: 5Hs
Hypoxia Hypovolemia Hyperthermia Hyper/Hypokalemia Hyperglycemia
5Ts Toxins Tamponade Tension Pneumothorax Thrombosis Trauma
Respiratory Distress (RD)LaryngospasmAirway obstructionDyspneaBronchospasm/ Asthma
Respiratory Distress: LaryngospasmDefinition:
◦A protective reflex to prevent foreign matter from entering the larynx, trachea, or lungs.
Cause: Foreign material in the region of the vocal
cords. Light general anesthesia.
Respiratory Distress: LaryngospasmSigns/Symptoms
◦Increased respiratory effort◦“Crowing” sound- partial laryngospasm◦No air movement or sound- complete
laryngospasm◦Development of cardiac arrhythmias
secondary to: Hypoxia Hypercarbia Hyperkalemia
Respiratory Distress: LaryngospasmTreatment
◦Early: Rapid recognition and initiation of treatment
is essential Pack off surgical site 100% oxygen Immediate pharyngeal suction (yankhauer) Head-tilt position to establish and maintain
airway Pull tongue anterior (towel clip, Russian,
Suture) Observe/ listen for air exchange
Respiratory Distress: LaryngospasmTreatment
◦Advanced: Complete spasm: positive pressure 100% O2 Continuing spasm: Anectine 10-20 mg IV
Prepare for intubation. After Anectine you must breath for the patient
until they recover. Assist ventilation until and after respiration
returns as needed. Kids without IV give Anectine IM 3-4 mg/Kg or
One mg/kg sublingual
Respiratory Distress: LaryngospasmPREVENTION:
◦Throat pack◦Proper airway management◦Adequate suctioning◦Deepen anesthesia- with partial
laryngospasm
Respiratory Distress: LaryngospasmSummary:
◦Pack off surgical site◦100% oxygen◦Suction◦Tongue position anteriorly
Respiratory Distress: Airway ObstructionDefinition:
◦Obstruction caused by soft tissue in the head & neck, bronchoconstriction, secretions, or solids causing a decrease or absence of ventilatory movement.
Cause:◦Supraglotic- Tongue displaced posteriorly
due to loss of tone of pharyngeal muscles secondary to anesthesia or sedation.
◦Foreign body in larynx and pharynx- secretions or solids.
Respiratory Distress: Airway ObstructionSign/Symptoms
◦Choking◦Gagging◦Violent expiratory effort◦Substernal notch retraction◦Cyanosis◦Labored breathing◦Tachycardia, followed by bradycardia,◦Respiratory arrest◦Cardiac arrest
Respiratory Distress: Airway ObstructionAirway obstruction leads to
hypoxia which leads to cardiovascular complications.
Respiratory Distress: Airway ObstructionTreatment: Early
◦Position upright◦Pack off surgical site◦Suction oropharynx◦Tongue traction
Gauze Tongue forceps Hemostat Suture
Respiratory Distress: Airway ObstructionTreatment:
Advanced◦ Place patient supine◦ Chin-lift, jaw-thrust◦ Tilt head back and
continue to try to open airway
◦ Check for sounds of respiration and ventilate if possible
◦ Abdominal thrusts if unable to ventilate
Respiratory Distress: Airway ObstructionTreatment:
Advanced◦ Continued
obstruction Oral/Pharyngeal
airway Positive pressure
ventilation
Respiratory Distress: Airway ObstructionTreatment:
AdvancedContinued
obstruction LMA ET tube
Respiratory Distress: Airway ObstructionTreatment:
AdvancedContinued
obstruction Oxygen via
transtracheal catheter
Activate EMS
Respiratory Distress: Airway ObstructionTreatment:
AdvancedContinued
obstruction◦ Cricothyrotomy
Respiratory Distress: Airway ObstructionSigns of deterioration
◦Cyanosis◦LOC◦Cardiac or respiratory arrest
Re-establish airway before addressing circulatory issues
Re-evaluate diagnosis Maintain BLS
Signs of recovery◦Normal breathing returns◦Foreign body removed or swallowed
Respiratory Distress: Airway ObstructionSwallowed Objects:
◦ Cough to attempt to remove it
◦ Sit upright fast and coughing if conscious
◦ Complete airway obstructions Heimlich- Adult and kids
> 1year old◦ Partial obstruction
Heimlich NOT recommended
Coughing
Respiratory Distress: Airway ObstructionSwallowed Objects:
◦ Heimlich maneuver Stand behind patient Place a fist of one hand
slightly above navel Grasp fist with other
hand Quick upwards thrusts
to the abdomen Chest thrusts in
pregnant women Continue until object is
expelled or LOC occurs
Respiratory Distress: Airway ObstructionAn inhaled object
not coughed out:◦ X-ray chest and
upper GI ◦ Some GI and all
pulmonary objects must be removed.
Respiratory Distress: Airway ObstructionPrevention
◦Proper throat pack◦Removal of dentures, partials◦Adequate suctioning◦Adequate visualization of the
surgical field◦Maintain head position
Respiratory Distress: Airway ObstructionChocking and Looses Consciousness:
◦911◦Lower patient to ground ◦Place patient on their back◦Tongue-jaw lift and finger sweep◦Open airway and attempt ventilation◦If obstructed reposition and try again◦ If obstruction persists give 5 abdominal
thrusts using the heel of one hand above the navel
◦Repeat until obstruction is relieved◦Consider surgical airway
Respiratory Distress: Airway ObstructionSummary
◦Upright position◦Pack off surgical site◦Suction◦Determine if obstruction is indeed
occurring◦Heimlich maneuver
Respiratory Distress: DyspneaDefinition:
The sensation of labored, difficult, and uncomfortable breathing. It occurs when there is inadequate control of respiration, oxygenation and ventilation.
Cause:◦Heart disease◦COPD ( asthma, emphysema, chronic
bronchitis)◦Anxiety/hyperventilation◦Aspiration◦Lung infection◦Pulmonary embolism
Respiratory Distress: DyspneaSign/ Symptoms
◦Moderate Not enough air sensation Shallow slightly labored breathing SOB on mild exertion Cannot complete sentences due to SOB
◦Severe Chest tightness Severe wheezing Anxiety, fear, agitation and restlessness Drowsiness
Respiratory Distress: DyspneaTreatment:
◦Airway◦Assist ventilation as necessary◦100% O2◦Monitor
Pulse oximeter End tidal CO2 BP
◦Transport or Call EMS if unstable