MEDICAL EMERGENCIES. Erik Richmond Clackamas Dental Society February 26, Sunday, February 24, 13

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Gilbert Singleton
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1 MEDICAL EMERGENCIES Erik Richmond Clackamas Dental Society February 26, 2013

2 911 Main St., #180 Oregon City, OR (503) SE 223rd, #180 Gresham, OR (503)

6 EMS Services

7 What to Say When Calling 911 Exact location with street names, room #, landmarks, cross streets Phone number call is being made from Caller s name and office name Description of what happened Condition of Victim Treatment being provided Any medical history you can give them

8 Emergency Scripts

10 Recognize Problem Discontinue Treatment Activate Office Emergency Team P Position Patient Appropriately If conscious, Comfortably If unconscious, Supine, legs elevated

11 Emergency Response Team Member #1 First Person on the Scene. Provides BLS. Remains with Victim. Member #2 Bring Equipment, Assist with BLS. Member #3 Monitor Vitals, Prepare Drugs, Keep a Record of What has been done or given. Remaining Office Staff. Contact EMS/Direct them to the office Console/Communicate to Family

12 Recognize Problem Discontinue Treatment Activate Office Emergency Team P Position Patient Appropriately If conscious, Comfortably If unconscious, Supine, legs elevated

13 A B C Assess Airway, Breathing and Circulation Perform Intervention as Needed If conscious and able to speak, ABC Adequate If Unconscious, Assess and Treat D Definitive Care (Diagnosis, drugs, defib, prn) E - Activate EMS

15 Part of ABC s Provide Oxygen Check Vitals Physical Exam Short cut with in this survey is Rate, Respiration, Wrist.

16 Responsibilities CPR Call 911 Oxygen Vitals Meet EMS Drug Kit Recorder Family

17 Medical Emergencies Private practice 30,608 emergencies Syncope 15,407(50.3%) Cardiac Arrest 331(1.1%) Mild allergy 2,583(8.4%) Anaphylaxis 304(1.0%) Angina Pectoris 2,552(8.3%) Myocardial Infarction 289(0.9%) Postural hypotension 2,475(8.1%) L.A. Overdose 204(0.7%) Seizure 1,595(5.2%) Acute Pulm Edema 141(0.5%) Asthmatic attack 1,392(4.5%) Diabetic Coma 109(0.4%) Hyperventilation 1,326(4.3%) Stroke 68(0.2%) Epinephrine Rxn 913(3.0%) Adrenal Insufficiency 25(0.09%) Hypoglycemia 890(2.9%) Thyroid Storm 4(0.01%) Malamed, JADA 1993

18 #1 Vasodepressor Syncope Simple Fainting 50.3%

19 Signs and Symptoms Early Feeling of Warmth Pale or Ashen-gray Skin Normal or near normal blood pressure Tachycardia Late Pupillary dilation Yawning Increased respiration Hypotension Bradycardia

20 Treatment of Vasodepressor Syncope Simple Fainting Position the patient supine with feet elevated Assess Breathing LOOK, LISTEN, FEEL. Provide ventilation if needed. Administer Oxygen Definitive Management Aromatic Ammonia Inhaler Cold Towel TLC If delayed recovery, activate EMS

21 #2 Allergy 8.4%

23 Treatment of Allergy Skin Reaction Only Position Patient Comfortably Monitor Vital Signs Administer Antihistamines Benadryl 50mg IM Benadryl 50 mg by mouth 4 times per day

24 Additional Respiratory Symptoms Present Position the patient comfortably Monitor Vital Signs Administer Medications Bronchodilator, 2 puffs Benadryl 50mg IM Epinephrine 0.3 to 0.5 mg IM/SC Follow up with PO Benadryl

25 #3 Angina 8.3%

26 Signs and Symptoms of Angina Sudden onset of pain Squeezing or tight chest Pain that radiates to shoulders, face and arms. Women are more likely to complain of feeling poorly or upper back pain. Subsides with rest or Nitroglycerin (NTG)

27 Treatment of Angina Terminate Procedure Apply Oxygen Administer NTG q 3 to 5 minutes up to 3 doses Monitor HR and BP Modify dental treatment to prevent recurrence

28 #4, Postural Hypotension 8.1%

29 Orthostatic Hypotension Predisposing Factors Drugs Antihypertensives Phenothiazines Tricyclic antidepressants Narcotics Antiparkinsons Prolonged recumbency and convalescence Inadequate postural reflex Pregnancy Age

30 Treatment of Orthostatic Hypotension Position Patient Supine with Feet Elevated Maintain Airway Administer Oxygen Monitor Vital Signs Slowly reposition the patient Discharge patient If recovery delayed activate EMS

31 #5, Seizure 5.2%

32 Seizure A sudden change in normal brain activity that causes abrupt changes in behavior and body function. Epilepsy is defined as recurrent seizure. N

33 Secondary Questions With Seizures What type of seizures? How often do they occur? What signals the onset of your seizure? Can you tell when a seizure is going to happen? How long does a seizure last? How are you after a seizure?

34 Types of Seizure Grand Mal Generalized muscle contractions followed by jerking movements of the arms and legs. Petit Mal Staring into space. Rapid eye blinking and altered awareness. Status Epilepticus A series of seizures without restoration of consciousness between seizures.

35 Possible Triggers of Seizures Emotional Stress Alcohol or Drug Use Flashing Lights Loud Music Hunger Fatigue

36 Treatment of Grand Mal Seizures Terminate Treatment Prevent Injury by Protecting Patient Loosen Tight or Restrictive Clothing Allow Seizure to End

37 Treatment of Grand Mal Seizures DO NOT try to restrain patient. DO NOT try to force anything into the patients mouth.

38 #6, Asthma 4.5%

40 Secondary Questions With Asthma How often do you have an asthma attack? What precipitates your asthma attack? When was your last asthma attack? What treatments do you use for your asthma? Are they effective? Have you been hospitalized or gone to the ER for your asthma? If so, when?

41 Signs and Symptoms of Asthma Difficulty Breathing Wheezing Tachycardia Anxiety

42 Treatment of Asthma Terminate the dental procedure Position the patient upright and comfortable Albuterol 2 puffs Epinephrine 0.3mg to 0.5mg IM/SC Discharge patient appropriately

43 #7, Hyperventilation 4.3% Anxiety causes hyperventilation. This in turn causes respiratory alkalosis, decreased cerebral perfusion and increased levels of catacholamines.

44 Treatment of Hyperventilation Remove Anxiety Causing Agent Position the patient upright Re-breathe with paper bag or into cupped hands. Sedative Medications Nitrous Oxide Sedatives Discharge Patient

45 #8, Epinephrine Reaction 3%

46 Local Anesthetic Overdose Excessive Dosage IV Administration Rapid Absorption at the Injection Site Slow Biotransformation or Excretion

47 Epinephrine Overdose Cartridge of 1:100,000 has mg of epinephrine. Maximum Doses of Epinephrine Healthy Patient: 0.2 mg Cardiac Patient: 0.04 mg N

48 Treatment of Epinephrine Overdose Supportive Therapy Administer Oxygen Monitor Vital Signs BLS as needed Recovery and/or discharge

49 #9 Hypoglycemia 2.9%

50 Hypoglycemia Normal Blood Sugar is between 80 and 140 mg/dl. Hypoglycemia occurs most often in patients with diabetes who can not regulate their blood sugar.

51 Diabetes occurs in 7% of the population. Type I Diabetic Decreased insulin production due to destruction of insulin producing cells in the pancreas Type II Diabetic Decreased sensitivity of insulin receptors on target sites of action. Therefore, decreased glucose uptake into cells, and decrease in glycogen synthesis in liver.

52 Complications of Diabetes Vascular System Atherosclerosis and Microangiopathy Kidneys Glomerulo and Nephrosclerosis Nervous System Sensory and Autonomic Neuropathy. Eyes Retinopathy Mouth Periodontitis

53 Secondary Questions With Diabetes How long have you had diabetes, and what type of treatment are you taking to control it? How often do you monitor your glucose levels and what have the results been for the past few days? Glucose/HbA1c Levels? How often do you have hypoglycemic episodes?

54 Secondary Questions With Diabetes Can you feel when a hypoglycemic episode is about to occur? When one occurs what do you do to stop it? When did you last have something to eat?

55 Signs and Symptoms of Hypoglycemia Moist Pale Skin Confused Mental State Lethargic Seizures Normal Pulse and BP

56 Treatment of Hypoglycemia, The Conscious Patient Recognize hypoglycemia Administer BLS as needed Administer Oral Carbohydrate Unresponsive Patients Receive Parenteral Therapy 50% Glucose 25 to 50ml IV Glucogon 1mg IM Epinephrine 0.5mg SC or IM

57 Airway Obstruction

58 Signs and Symptoms of Airway Obstruction Weak ineffective cough High pitched crowing sounds on inhalation Use of accessory muscles to breath Ashen gray color of skin Cyanosis

59 Treatment of Airway Obstruction Conscious Person Confirm help is needed Heimlich until successful

61 Treatment of Airway Obstruction Unconscious Person Activate EMS Position Patient in Supine Position Chest Compressions Open Airway/2 Breaths Repeat until Successful

62 PREVENTION

65 References Handbook of Medical Emergencies in the Dental Office American Red Cross Community CPR Workbook Internal Medicine For Dentistry Dental Management of the Medically Compromised Patient Dental School Bookstore # (503)

66 References Google and Wikipedia Dr. Malamed Met Life Dental Epocrates medemerg

76 Here comes the Boomers % 14.4% 17.9% ( % > 65y/o )

78 PREVENTION Thorough Medical History Vital Signs Assess Medical Risk Treatment Modifications

79 Thorough Medical History

81 Six Questions to Ask Any allergies? Any Medications? Any shortness of breath? Do you have or had chest pain? Hospitalizations in the last year? Any bleeding problems? Positive response to any of these should be investigated.

82 Physical Exam/Vital Signs Pulse Blood Pressure Respirations

83 Pulse Palpation reveals Heart rate Heart rhythm Amplitude of pulse wave

84 Pulse - Rate Normal = beats/min Bradycardia = < 60/min Drugs B-blockers Heart Block Athletic heart (vagal) Tachycardia = > 100/ min Anxiety, exercise Hypovolemia, anemia Drugs, fever Hyperthyroidism

85 Pulse - Rhythm Regular I I I I I I I I I I Regularly Irregular I I I I I I I I Irregularly Irregular I I I I I I I I I I

86 Blood Pressure N

87 Blood Pressure

88 Blood Pressure What is Normal Blood Pressure?

89 Blood Pressure Classification of Hypertension in Adults Category Systolic (mmhg) Diastolic (mmhg) Normal < 130 < 85 High normal Hypertension > 140 > 90 Stage I (mild) Stage II (moderate) Stage III (severe) Stage IV (very severe) > 209 > 119 Arch Intern Med, 1993

90 Management of Blood Pressure Category Systolic BP Diastolic BP Follow-up Dental Tx Normal < 130 < 85 Check 2 yrs High normal Check 1 yr Hypertension Stage I (mild) Stage II (moderate) Stage III (severe) Stage IV (very severe) Check 2 mnths Refer 1 mnth No restrictions No restrictions No restrictions No restrictions Refer 1 week Urgent care > 209 > 119 Refer immed Palliation Arch Intern Med, 1993only

91 Management of Blood Pressure Category Systolic BP Diastolic BP Follow-up Dental Tx Normal < 130 < 85 Check 2 yrs High normal Check 1 yr Hypertension Stage I (mild) Stage II (moderate) Stage III (severe) Stage IV (very severe) < 180 Check 2 mnths Refer 1 mnth No restrictions No restrictions No restrictions No restrictions Refer 1 week Urgent care > 209 > 119 Refer immed Palliation Arch Intern Med, 1993only

92 Management of Blood Pressure Category Systolic BP Diastolic BP Follow-up Dental Tx Normal < 130 < 85 Check 2 yrs High normal Check 1 yr Hypertension Stage I (mild) Stage II (moderate) Stage III (severe) Stage IV (very severe) < 180 < 110 Check 2 mnths Refer 1 mnth No restrictions No restrictions No restrictions No restrictions Refer 1 week Urgent care > 209 > 119 Refer immed Palliation Arch Intern Med, 1993only

93 Management of Blood Pressure Category Systolic BP Diastolic BP Follow-up Dental Tx Normal < 130 < 85 Check 2 yrs High normal Check 1 yr Hypertension Stage I (mild) Stage II (moderate) Stage III (severe) Stage IV (very severe) < 180 < 110 Check 2 mnths Refer 1 mnth No restrictions No restrictions No restrictions No Restrictions No restrictions Refer 1 week Urgent care > 209 > 119 Refer immed Palliation Arch Intern Med, 1993only

94 BP Accuracy Factors Cuff Size Arm supported Cuff Position N

95 BP Accuracy Factors Cuff Size Arm supported Cuff Position 1 N

96 BP Accuracy Factors Differences in Sides Cuff Size Too small, higher BP Too large, lower BP N

97 Respirations - Rate Normal = cycles/min

98 Respirations - Rate Bradypnea < 14 cycles/min Tachypnea > 18 cycles/min Narcosis Increased ICP Uremia Exertion, pain Fever Anemia, hyperthyroid

99 Blood Sugar

100 Assessment of Risk Physically tolerate stress of Tx? Psychologically tolerate stress? Is increased medical risk present? Treatment modifications required? Is psychosedation indicated? Referral or consultation?

101 The "Great" Implant Case

102

103 ASA Classification ASA I A patient without systemic disease. ASA II A patient with mild systemic disease. ASA III A patient with severe systemic disease. ASA IV A patient with incapacitating disease which is a constant threat to life. ASA V A patient not expected to live 24 hours.

104 Medical Consultation Goal: Determine the ability of the patient to withstand the stress of the dental treatment we are proposing for them.

105 Assessment of Risk The Quick Medical Consultation Talk with a nurse Ask for a Problem List Ask for Medication List Dental treatment planned Stability of medical conditions Modifications of dental Tx

106

107 What do you know?

108 What do you want to do?

109 What can you do for me? Optimize

110

111

112 Prevention Stress N

113 75% of Emergencies Stress Induced

114 Stress Reduction Protocol Short Appointments Profound Local Anesthesia Supplemental Oxygen Pre-op Sedatives Sedation during appointment Nitrous Oxide Oral/IV Sedation Prophylactic Meds Inhalers Glucose Nitroglycerin Pre Op Vitals Pulse/BP Blood Sugar Post Op Pain Control N

115 Preoperative Sedation Ativan (Lorazepam) Halcion (Triazolam) Take half dose the night before and take 1 hr prior to appt. Must have driver/escort

116 PREPARATION

117 Office Preparation Defined Roles in Emergency Emergency Book Emergency Kit

118 Medical Emergencies Handbook Summary of Each Emergency Secondary Questions to Ask with Health History Description of Physiology of Underlying Medical Conditions Step By Step Treatment Algorithms for Each Emergency Scenarios to Practice Role Playing How to Handle Medical Emergencies in Your Office

119

120

121 Role Playing Seating a crown Antibiotic premed Diabetic mother of twins 60 year old overweight smoker 90 year old from the local care center

122 Go to My Website Down load and print my Medical Emergencies Handouts

123 Minimal Emergency Equipment Oxygen Delivery System Positive Pressure Oxygen BP Cuff and Stethoscope Syringes and Needles Glucose Meter

124 Primary Emergency Equipment O 2 delivery system Bag-valve mask, pocket mask

125 Primary Emergency Equipment

126 Primary Emergency Equipment Key ventilation volume: enough to produce obvious chest rise

127 Southern Anesthesia (800)

128 Other Emergency Equipment Suction / Tonsil tip

129 Other Emergency Equipment Suction / tonsil tip portable Glucometer IV bag and tubing

130 Emergency Kits Putting Your Kit Together

131 Commercial Kits Banyan International Corporation Stat Kit 700 ($735) Stat Kit 900 ($1095) Annual Update Service $

132 Minimal Emergency Drugs Anti-allergy Epinephrine Bronchodilator - Albuterol Antihistamine Benadryl Vasodilator Nitroglycerine Respiratory Stimulant Ammonia Inhalants Anti-hypoglycemic Juice, Cake Frosting Thrombolytic Chewable Aspirin N

133 Minimal Emergency Drugs Cost Anti-allergy Epinephrine; $0.65 -$ Bronchodilator - Albuterol; $25.50 Antihistamine Benadryl; $4.25 Vasodilator Nitroglycerine; $ $32.75 Respiratory Stimulant; Ammonia Inhalants - $3.50 Thrombolytic Chewable Aspirin - $3.50 Anti-Hypoglycemic Juice, Cake Frosting; $1.50- $3.50 Total Cost $41.35 $232.00

134 Optional Drugs Narcan/Flumazenil Atropine Amiodirone D50 Dextrose

135 Emergency Kits

136 Your Emergency Kit Individualize to your practice Have antidotes for drugs you use Easily accessible drugs Card with drug doses Commercially available kits $$$$$ Update expired drugs

137 Emergency Drugs Routes of Administration

138 Sublingual Nitroglycerin Rapid absorption 2 3 minute

139 Intravenous Rapid onset of action Profound peak effect Short duration Titratability

140 Intramuscular Relatively rapid onset High drug concentration Profound duration Deltoid, thigh, buttock

141 Intramuscular

142 Subcutaneous Slow absorption Sustained effect Ease of technique

143

144

145 Intralingual Rapid onset Central circulation 35 sec Easy access Familiarity

146 What drug to give? Drugs are not necessary for Tx of most emergencies. Primary management of all emergency situations is BLS. When in doubt, never medicate.

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MEDICAL EMERGENCIES HANDBOOK Last Update 1/26/2013

MEDICAL EMERGENCIES HANDBOOK Last Update 1/26/2013 Legal Disclaimer - The information provided here is the opinion of the author,and does not claim to be a substitute for obtaining this knowledge through