Recognition and Management in Dental Practice

Daniel E. Becker, DDS

Associate Director of Education

Miami Valley Hospital

debecker@mvh orgdebecker@mvh.org

BLS for all Personnel

Designated Responsibilities

Mock Simulations

EMS Access

Attention to Medical Evaluation Practice Stress Reduction:

• Psychological Interventions• Pharmacological Interventions

Medical HistoryPhysical

AssessmentASA Physical Class

Medications BP & Pulse Based on disease severity and limitationsAllergies SpO2 (?)

Disease by system Appearance Medical Consultation (prn)

Hospitalizations Mentation Condition(s) of Concern

Treatment Plan (including drugs and anticipated doses)

Anesthetic Experience Exercise tolerance

Preoperative Assessment“Never Treat a Stranger !”

ASA Physical Status

1 Healthy patient

2 Mild systemic disease. No significant impact on daily activity.

3 Significant or severe systemic disease. Significant impact on daily activity.

4 Severe disease that is a constant threat to life. Serious limitation of daily activity.

Activity Points

Run short distance 8Swim, singles tennis, basketball, ski 7.5Golf, bowling, dancing, doubles tennis 6Climb a flight of stairs 5.5Sexual relations 5.25Yard work: raking, weeding, mowing 4.5Moderate work: vacuuming, sweeping 3.5Personal care (dress, eat, bath, toilet) 2.75Walk 1-2 blocks (level ground) 2.75Light work: dusting, wash dishes 2.7Walk around in house 1.75

Overall Functional CapacityExcellent >7 Moderate 4-7 Poor <4

The overall functional capacity of a patient is estimated based on a point scale derived using metabolic equivalents (MET) calculated as 1 MET=3.5 mL/kg/min oxygen utilization.

Hlatky MA, Boineau RE, et. al. Am J Cardiol 1989;64:651-54.Modified by: Hollenberg SM. Chest 1999;115:51s-57s.

Duke Activity Status Index

Primary Assessment Simultaneous Assessment by Team

If Apneic: EMS + BVM Ventilation Q 6-8 sec

If Pulseless: EMS + CPR

A irway Assessment• Must assure patency

• Head tilt-chin lift / Jaw thrust

B reathing• Look, listen and feel

• Note rate and depth

• Maintain patency

Doctor’s Job !

Becker DE. Medical Emergencies 1

Oxygen Source and Regulator

Oxygen Supplementation• Nasal Cannula (4-6 L/Min):

• FIO2 = 20+(4 x L/Min)• Nonrebreathing mask (6-10 L/Min)

• FIO2 = 60+ 5 for each L/Min above 6.

If COPD, supplement to SpO2 >90

OxygenationAuxiliary’s Job !

Increased Oxygen Concentration in FRC Greater Time From Apnea to Hypoxemia

Oxygen Supplementation

Why Oxygen ?

Time to Hb Desaturation

Benumof JL, et al. Anesthesiology 1997;87:979-82

Preoxygenated (~FaO2 = 0.87)

Analysis of 7 Studies

Must Ventilate if Not Breathing• BVM with Reservoir

• Highest Flow Rate (10-15 L/Min)

• FIO2 = 75-90

Oropharyngeal Airway (?)

Ventilation

Prepare Index Card

Cannula: 4 L/Min NRB Mask: 10 L/Min BVM or Pocket Mask: Maximum L/Min

Turn on Oxygen BEFORE applying device !

If BP Difficult:

• SBP ~ 80 if Radial Pulse

• SBP ~70 if Brachial Pulse

• SBP ~ 60 if Carotid Pulse

Is Perfusion Adequate ?• Orientation x 3 (Time, Place, Person)

Assessing Circulation:BP & Pulse

Auxiliary’s Job !

Becker DE. Medical Emergencies 2

Comfort Level of Practitioner EMS Response Times Preparations

• Amps• Vials• Prefilled Syringes

Routes• IV• IM• SC• SLI

Drug TherapyEmergency Drugs

Drug Formulation Action Indication Dosage

Epinephrine1:1000

(1 mg/mL)Alpha/beta

agonistAnaphylaxis /

Asthma0.3 mg IM

Diphenhydramine 50 mg/mL Antihistaminic Minor allergy 25-50 mg IM

Atropine 1mg/mL Anticholinergic bradycardia0.5mg SLI

Q5M to 2mg

Ephedrine 50 mg/mLAlpha/beta

agonist Hypotension20-30 mg SLI Q5M to 50mg

Nitroglycerin 0.4 mg tabs Venodilator Angina/HTN1 tab SL Q5M

x 3

Aspirin 81 mg tabs Antiplatelet MI4 tabs: chew and swallow

Additional Options: Albuterol and Concentrated Glucose

How Many Do You Need?

Baggy for Each Event

Drugs and Syringes for Event

Card with Instructions that YOU Prepared & Understand!

Flowchart ?

Bulleted List ?

Complete Primary Assessment If Major Reaction: EMS

Epinephrine: Tuberculin Syringe 0.3 mg (0.3 mL) IM If Minor Reaction:

Benadryl: 3 mL Syringe 50 mg (1 mL) IM

Vasovagal Syncope

Pain

Fear / Anxiety

Cardiac Mechanoreceptors

Arterial baroreceptors

Bladder / bowel strain

Enhanced vagal discharge

Vasodilator output

“The only difference between syncope and sudden death is that in one you wake up.” Engel GL. Ann Intern Med 1978;89:403-412

A transient and abrupt loss of consciousness due to inadequate cerebral blood flow.

Vasomotor Center

(Neurocardiogenic Syncope)

SBP DBP

MAP

Rate Stroke Volume

Preload

Contractility

Afterload

Arterial Resistance

-

**

* High MVO2

‘Bainbridge’‘Frank-Starling’

Arterial Blood Pressure

Ach = ↓ Rate

Beta1 = ↑ Rate and Force

Alpha = Vasoconstriction

Beta2 = Vasodilation

Ach = Bronchoconstriction

Beta2 = Bronchodilation

1

2

Autonomic Receptors

Ach

2Ach

Parasympathetic (Ach) Sympathetic ( Alpha, Beta)

Becker DE. Medical Emergencies 3

Drugs for Hypotension Atropine

• Anticholinergic Action Blocks Vagal Slowing of Heart Rate

• 1 mg/mL SDV

Ephedrine• Mixed Action: Alpha and Beta Agonist &

Stimulates Release of Norepinephrine• 50 mg/mL SDV

If Symptomatic, Administer DrugIf Symptomatic, Administer Drug

If Hypotension, Confirm HR

If Hypotension, Confirm HR

Primary Assessment

Primary Assessment

Airway Breathing

Supplemental Oxygen

Pulse Blood Pressure

HR <60

Atropine0.5 mg SLI

Q5M x 4

HR >60

Ephedrine20-30 mg SLI

Q5M x 2

Hypotension Algorithm

Tuberculin Syringe1 mL Total

0.1 mL Increments

JNC 7 JAMA 2003; 289:2560-72

Use Highest Reading

Classifications SBP DBP

Normal < 120 < 80

Pre-hypertension 120-139 80-89

Stage 1 140-159 90-99

Stage 2 160 100

Stage 3 >180 >110

Stage 4 >210 >120

Stage 1 and 2 (Up to: SBP 180 / DBP 110)

• Generally OK to treat

Stage 3 (SBP >180 / DBP >110)

• Must consider other medical conditions

• Delay if significant diabetes, CAD or CHF

Stage 4 (Formerly SBP 210 / DBP 120)

• Immediate referralFleisher LA. JAMA 2002;287(16):2043-6

Hypertension Classifications

Hypertensive Crisis Urgency if No Symptoms

• Rarely Require Treatment• Address Possible Causes for Sudden

Elevation Emergency if Symptoms

• Headache, Paresthesia, Chest Pain• EMS Transport

“The most sensible approach to the patient in the ED found to have very high blood pressure, without evidence of acute end organ damage, is referral for outpatient management of serious disease that needs to be treated; not urgently, but for life. Focusing on the height of the column of mercury in the sphygmomanometer confers no demonstrable benefit on the patient and risks doing harm.”

Gallagher EJ. Ann Emerg Med 2003;41:530-31

Treatment Options

Treatment Options

Significant Increase in BP?

Symptomatic?

Significant Increase in BP?

Symptomatic?

Primary Assessment

Primary Assessment

Airway Breathing

Supplemental Oxygen

Pulse Blood Pressure

Asymptomatic:Urgency

Time Out!R/O Cause

Symptomatic: Emergency

EMSNTG 0.4 mg SL

Q5M x 3

Hypertensive Crisis Algorithm

Abrams, J. N Engl J Med 2005;352:2524-2533

Coronary Artery Disease

“An imbalance between myocardial oxygen supply and myocardial oxygen demand.”

Heart RateWall Tension, eg, BP

↑ Demand ↓ Supply

( Ischemic Heart Disease )

Becker DE. Medical Emergencies 4

Vulnerable Plaque

Physical Exertion

Mechanical Stress

• Contractility

• Pulse Rate

• Blood Pressure

• Vasospasm

Factors in Plaque Rupture

Yeghiazarians Y, et al. NEJM 2000; 342(2) 101-14.

Chest Pain…What’s Happening?

Coronary Stenosis

Atherosclerosis

Vasospasm

Symptoms

Angina or

(Silent)

Thrombosis

Occlusion

Myocardial Infarction

ArrestNon-Arrest Continued Angina

AV Blocks

Valve Prolapse

Pump Failure

Wall Rupture

Fibrillation

Chest Pain (Angina)

ACS

Myocardial Infarction

STEMI NSTEMI

Unstable Angina

At Rest New Onset

Stable Angina

On Exertion

Previous Occurrence

+ Serum Markers - Serum Markers

Acute Coronary Syndrome

Nitroglycerin Vasodilation (Veins > Arteries) Reduces MVO2 (preload & SBP) Chest pain / Hypertension

• 0.4 mg tabs (1 tab Q5M x 3)

Aspirin if Suspected AMI

160-300mg provides complete platelet cyclooxygenase inhibition < 1 Hr

Inhibition maintained at ~ 75 mg/day

Collins R., et al. NEJM 1997; 336(12):847-60

Angina / MI Algorithm

Current Guidelines suggest 3 doses NTG for stable but only 1 dose for unstable before alerting EMS. But how do you know?

Pollack CV, Braunwald E. Ann Emerg Med 2008;51:591-606

Chest Pain Persists

Chest Pain Persists

Primary Assessment

Airway Breathing

Supplemental Oxygen

Pulse Blood Pressure

If Provoked:Nitroglycerin

1 Tab SL

EMSNTG Q5M; SBP >90

ASA 300 mg

If Unprovoked, New Onset, or Unsure: EMS

Cardiac Arrest

Various ECG Patterns• V. Tach and V. Fib Most Common

• Asystole/PEA Worst Prognosis

CPR and Defibrillation are Key!• 30:2 Ratio for one and two-person

• 15:2 for HCP 2-Person child

Epinephrine Improves Coronary Perfusion, but must be administered IV

Becker DE. Medical Emergencies 5

When in cardiac cycle and WHY?

What drives perfusion ?

CoronaryPerfusion

BLS Sequence

ACLS Sequence Stroke Pathogenesis

Sensory DeficitVisual

Paresthesia

Motor DeficitAphasia

Dysarthria

Ischemic / HemorrhagicInsult

Ischemic Stroke - (~80%)• Thrombosis vs Embolism• TIA vs CVA• Ischemic Penumbra

Hemorrhagic Stroke – (~20%) • Often Fatal• Leads to Compression

If Positive, Suspect Stroke

If Positive, Suspect Stroke

Aphasia, Paresthesia, Paralysis ?

Aphasia, Paresthesia, Paralysis ?

Primary Assessment

Primary Assessment

Airway Breathing

Supplemental Oxygen

Pulse Blood Pressure

Stroke Scale:

Raise Both Arms

Smile, Speak

EMSConsider Glucose

Do Not Tx. Hypertension

Stroke Algorithm Allergic Reactions

Autacoid ReleaseAutacoid Release

CutaneousCutaneous

Urticaria, Rash, PruritusUrticaria, Rash, Pruritus

SystemicSystemic

Laryngeal Edema, Bronchospasm,

Hypotension

Laryngeal Edema, Bronchospasm,

Hypotension

PG’s & LeukotrienesHistamine

IgE

Allergy

Non-IgE

Pseudo-Allergy

[Histamine, PGs, LTEs]

Minor vs

Major Mast Cells Basophils

Becker DE. Medical Emergencies 6

Epinephrine

AlphaHypotension

Laryngeal Edema

Beta-1Hypotension

Beta-2Bronchospasm

Concentration Dose / Volume Route

1:1000 (1 mg/mL) 0.3 mg/0.3 mL IM

1:10,000 (0.1mg/mL) 0.1 mg / 1 mL IV

Antagonist at H1 receptors counters histamine

Pruritus, urticaria, nausea• 50 mg/mL amp or SDV

• 50 mg IM

Diphenhydramine

TreatmentTreatment

Allergy Symptoms

Allergy Symptoms

Primary Assessment

Primary Assessment

Airway Breathing

Supplemental Oxygen

Pulse Blood Pressure

CutaneousPruritus, Rash, Hives

Benadryl50 mg PO, IM

AirwaySwelling: mouth or throat / Wheezing

EMSEpinephrine

0.3 mg IM

Allergic Reaction Algorithm

Additional Agents

Albuterol (and Spacer ?)

Glucocorticoids• Influence delayed 6-12 hours

Aminophylline• Questionable efficacy; complex

administration

IV Fluids• Definite efficacy if hypotension Primary

Genetic, UnknownSecondaryTumor, Trauma

ReactiveStress, Fever,

Drugs

Focal CorticalDischarge

ConvulsiveAbsence

Seizure Pathogenesis

Status Epilepticus Definition based on duration until

injury to CNS neurons• Uninterrupted for 20-30 minutes

• Repeated without full recovery

Operational Definition• Continuous for 5 minutes

• Two or more seizures without complete recovery

Lowenstein, Alldredge. NEJM 1998;338:970-76

Airway Considerations• Despite periods of apnea and cyanosis,

most patients breath adequately provided airway maintained

• Administer supplemental oxygen

Protect Patient

< 5 minutes

Primary Assessment

> 5 minutes

EMSRebreathing MaskMidazolam (Versed)

IM/Intranasal

Seizure Algorithm

Age Dose

1-4 YO 2.5 mg/ 0.5 mL

5-10 YO 5 mg / 1 mL

>10 YO 10 mg / 2 mL

Intranasal: ½ volume in each nostril (~ dose based on 0.2 mg/kg)

Holsti, M, et al. Pediatr Emerg Care. 2007 Mar; 23(3)148-53.

MucosalAtomizationDevice

Becker DE. Medical Emergencies 7

Emergency Drugs

Drug Cost

Epinephrine 1:1000 (1 mg/mL) 1mL SDV $1.99

Diphenhydramine 50 mg/mL 1mL SDV $1.99

Ephedrine 50 mg/mL 1mL SDV $6.99

Atropine 1.0 mg/mL 1mL SDV $1.99

Glucose GEL 37.5 Gm (3/PACK) $15.99

Nitroglycerin 0.4 mg Tab (25/BTL) $13.99

Albuterol 60-Dose Inhaler $26.00

Medical Purchasing SolutionsPhone: 602-476-1595www.medicalpurchasingsolutions.com

Emergency Supplies

Sedation ResourcePhone: 800 753 6376

www.sedationresource.com

Order # Item Cost

10-002-03 O2 Regulator 69.95

1-001-04 / -05 BVM adult/Pedo 29.95 / 34.95

10-000-50 Nasal Cannulas 32.50 (50/case)

10-102-02 NRB 3.49

1-101-6 Oral Airways 7.50 (5/set)

6-301-01 1 mL TB Syringes (25G x 5/8”) 9.95 (100/box)

6-403-22 3 mL 22G x 1 ½” 11.50 (100/box)

6-199-00 Nasal Atomizer/3 mL syringe 3.79

Also Available: Monitors, AEDs, Manual BP Devices

Becker DE. Medical Emergencies 8