Medical emergencies in the dental office

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1 Medical emergencies in the dental office Robert G. McNeill, DDS, MD Diplomate, American Board of Oral & Maxillofacial Surgery Fellowship, Integrative Medicine Staff dentist, Investigations, Texas State Board of Dental Examiners

2 Who am I? Grew up in Canada Oral and maxillofacial surgeon with offices in Preston Center and North Garland Fellowship, Integrative Medicine from the University of Arizona School of Medicine Staff dentist, TSBDE

3 Conflicts of interest Consultant and speaker for Neodent dental implant system No conflicts with any products I will be speaking about today I am not here in my official capacity as an employee of the TSBDE

4 What is our game plan? Managing common emergencies Preventing common emergencies Office drills Customize an emergency plan

5 This is a DRILL

6 We are in the Perfect Storm Sugar consumption with increased caries in young children Increased obesity causing poor airways Increased rates of depression and anxiety for all ages Increased drug use Increased rates of ADHD and Autism People are living longer and how is that going to change your decision making Medically compromised patients Everyone is on a blood thinner

10 Avoiding a medical emergency in the office: Know when not to treat Are there concerns about their PMH? Cardiac issues, blood thinners, anxiety issues, respiratory issues What are you learning from the physical exam and patient interview? When do they need to see their physician?

12 Dental board rule: (1) Patients name; (2) Date of visit; (3) Reason for visit; (4) Vital signs, including but not limited to blood pressure and heart rate when applicable in accordance with of this title. (5) If not recorded, an explanation why vital signs were not obtained. (c) Further, records must include documentation of the following when services are rendered: (1) Written review of medical history and limited physical evaluation; (2) Findings and charting of clinical and radiographic oral examination: (A) Documentation of radiographs taken and findings deduced from them, including radiograph films or digital reproductions. (B) Use of radiographs, at a minimum, should be in accordance with ADA guidelines. (C) Documentation of the findings of a tactile and visual examination of the soft and hard tissues of the oral cavity; (3) Diagnosis(es); (4) Treatment plan, recommendation, and options; (5) Treatment provided; (6) Medication and dosages given to patient; (7) Complications; (8) Written informed consent that meets the provisions of 108.7(7) of this title;

13 How are you going to treat this patient?

14 Avoiding medical emergencies Limit epinephrine with older patients Use appropriate local anesthesia Keep on current medications when possible, including blood thinners

15 Patient presents for full mouth extractions 59 year old male, farmer VS: 138/84 P: 87 PE: general exam normal Oral exam: generalized decay A/P: Generalized decay Plan to remove all teeth (25) with IV sedation and place immediate dentures

16 IV sedation performed: 5mg Versed (titrated to effect) 50 µg of Fentanyl (titrated) 2 carpules 0.5% Marcaine with 1:200k epi 5 carpules 2% Lidocaine with 1:100K epi Nitrous oxide and oxygen Vital signs stable during procedure After the procedure, IV was removed and the patient complains of right shoulder pain Started MI protocol Oxygen started ASA crushed 911 activated Restarted IV Monitors reapplied ST segment changes, PVC s on EKG (change from baseline) Quickly decompensated, decreased pressure (elevated legs) Stress reduction

17 What did I learn? Limit epinephrine when possible (use 1:200,000 dosage when possible) Use non-epi containing local anesthesia (along or in combination) You don t know if they have cardiac disease Should I have sent him to his MD for a pre-op evaluation? Call 911 early When something happens, sit down and figure out if you would do anything differently

18 Call 911 early!!!

19 Call 911 early!!!

20 Call 911 early!!!

21 Call 911! When should you call for help? You get that gut feeling You don t know what to do

22 What are our obligations as doctors in an emergency? Keep the patient alive until they get better Keep the patient alive until someone comes who is better trained & takes over

23 Basic Life Support: Always do this first! Position: Lay flat or head slightly down and elevate legs (asthma or cardiac patients will want to sit up) Airway: Head tilt, chin lift (place oxygen) Breathing: Get close and listen/feel Circulation: Check pulse

24 You are going to be in for a very long seconds Stay as calm as you can Call for help when you don t know what to do If you are not sure, don t give a drug Give oxygen (unless hyperventilating)

25 Survey of 4,300 dentists with 30,000 emergencies, Stanley Malamed, DDS

26 Most emergencies occur when the patient s stress level is highest Increased stress, increased epinephrine/norepinephrine 55% during the injection 25% during treatment (majority being extractions and endodontic access)

27 Be mindful of fear versus pain stress and manage both Get good at a stress reduction protocol (premed sedation, breathing exercises, music, relaxation techniques, hypnotic techniques, nitrous/iv sedation..) Good pain control is crucial Let s look at 95% of the emergencies that you will see

28 Syncope vasovagal reaction passed out Reposition them and they recover quickly Usually big tough guys that are trying to hide their fear Try to avoid this with a stress reduction protocol Act quickly when you see the early signs Do you call 911 Should they drive home?

29 Postural hypotension Get dizzy when they stand up too quickly Sit them up before you leave the operatory Don t let them bonk their heads!

30 Allergies Mild itching Non-life threatening Treatment may be diphenhydramine, albuterol or epinephrine Be prepared to manage anaphylaxis: injector or draw it up ( mg subq or IM - NOT IV)

31 Seizures You are not going to like this one Patient history is essential Keep them safe - BLS It should stop, if not activate EMS IV/IM/nasal benzodiazepines Prevent it from happening Good medical control and stress reduction

32 Angina If a patient has a history of angina they will diagnose it for you No history of angina, activate 911 immediately Oxygen Nitroglycerin if SBP not too low (<90mg HG) or pulse <50 Chew aspirin (non-coated) Set up AED and use if chest pain continues Prevent it by: Limiting epinephrine Stress reduction Medical evaluation

33 Hyperventilation Try to calm them down Psychology is causing a physiological problem Use a paper bag for rebreathing (recapture inhaled carbon dioxide) Have them hold it Do not use oxygen unless they lose consciousness

34 Asthma The patient will likely diagnose this for you Albuterol inhaler, oxygen They might even tell you when to activate EMS Prevent it will prophylactic inhaler use and stress reduction

35 Hypoglycemia Check blood sugar (get a glucometer) Give oral sugar gel IV access if able (dextrose/glucagon) Prevent with appropriate medical management of diabetes, shorter morning appointments

36 Epinephrine reaction to injection Heart racing with injection Slow and easy The more white knuckled the patient, inject a very small amount first Consider 1:200,000 epi or none at all Stress reduction Get good at your injection technique!

37 The other 5% MI/cardiac arrest: MONA ACLS protocol if trained Don t give a drug if you are unsure Prevent with medical consultation, stress reduction, continue all meds when possible True anaphylaxis Activate EMS immediately IM epi ( mg) lateral middle thigh q5 minutes as needed Oxygen Inhaler, steroids Start IV

38 So what do you need in your emergency kit? This will be different for each of us! Oxygen with regular/bag valve mask and oral airway device Stethoscope, BP monitor Magill forceps 325mg Aspirin (non-enteric coated) Nitro spray Albuterol Glucose source and glucometer AED

39 BRP data for Texas Six major sedation events (death/permanent disability) Child under 8 or adults with high risk factors A deeper level of sedation than intended occurred in many cases Poor pre-op evaluation, drug over dosage, poor monitoring and poor emergency management

40 Anesthesia mishaps in the State of Texas mishaps with 8 involving children under 8 or high risk adults (obese, compromised health or elderly) Poor pre-operative evaluation Drug overdose Premature discharge Bolus drug administration Not using required monitors Poor problem recognition Poor emergency management

41 Emergency Failures from BRP Report Emergency drugs given at the wrong dose Ventilation equipment was available but used ineffectively Ventilation equipment was not available Supplemental oxygen was available but not administered when indicated The provider was slow the activate EMS!!! (most common finding)

42 Have an emergency plan and use it for emergency drills with your staff Activate 911 early Practice using ventilation equipment Careful sedation usage What can you do?

44 Limit medications Avoid local anesthesia over dosage Be careful with 4% solutions Is it really a failure of local anesthesia? Limit epinephrine when appropriate to 0.04 mg (4 carps of 1:200k versus 2 carps 1:100k)

45 Failure It is okay to have your sedation technique fail It is okay to say NO to a procedure or abort a procedure We do not need to do everything It is likely not the best thing for you or the patient Should the patient be managed in a different environment?

46 Appreciate how important stress reduction is! Eyes Forehead Hands Shoulders/posture Heart rate Blood pressure

47 Psychology versus physiology Very often the two are interconnected A problem with one causes a problem with the other (e.g. panic attack) Is it safer to try and maintain baseline physiology/vitals during a dental appointment?

48 Differentiate yourself! Physicians are not discussing stress with their patients We see the consequences of stress and are in a great position to discuss it What would it be like if you could help your patients (and yourself) better manage stress? Increase empathy

49 How can you be best prepared? Have an emergency plan and practice with it Customize it to your practice Practice the doctor down drill Be mindful of stress reduction techniques Be mindful of dosages of medications (including local anesthesia) that you are using Evaluate and document your patient medical evaluation

51 Stress

Who am I? Medical Emergencies in the Dental Office 10/11/2018. Conflicts of interest. Other disclaimers. What is our game plan?

Who am I? Medical Emergencies in the Dental Office 10/11/2018. Conflicts of interest. Other disclaimers. What is our game plan? Medical Emergencies in the Dental Office Robert G. McNeill, DDS, MD Diplomate, American Board of Oral & Maxillofacial Surgery Who am I? Grew up in Canada Oral and maxillofacial surgeon in North Garland