Medical Emergencies Update 2018
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- Jewel Williamson
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1 Medical Emergencies Update 2018
2 Professional Responsibility Medical Emergency Preparedness
3 Medical Emergencies Update 2018
4 Medical Emergencies Update 2018 Goal
5 Misconceptions about Med Emerg The Five Deadly Misconceptions A medical emergency will not happen to me. A medical emergency will not happen in my office. Calling EMS/9-1-1 is the answer. My staff and I will not panic during a medical emergency. CPR is all we need to know
6 IMEP - Six Links of Survival The average response time for medical emergency services (EMS) to respond to a 911 call can be 11 minutes in an urban setting and 15 minutes in a rural setting.
7 IMEP - Six Links of Survival The average response time for medical emergency services (EMS) to respond to a 911 call can be 11 minutes in an urban setting and 15 minutes in a rural setting. 1. Doctor training 2. Staff training 3. Medical emergency plan 4. Emergency drug kit 5. Proper equipment 6. Mock drills
8 Basic Outline for Lecture Preparation Prevention Recognition Management Satisfactory Outcome
9 Medically Complicated Patients Cardiac Disease Diabetes Mellitus Renal Dialysis Organ Transplants Immune Disorders Liver Failure Anticoagulated Pt
10 Here Come The Baby Boomers 2016 => 15% U.S. Population > 65y/o (with life expectancy of 19.3yr)
11 Here Come The Baby Boomers
12 Age => Multimorbidity
13 Age => Multimorbidity Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet 2012, 380:37-43
14 A Pill Cures All The American Way
15 A Pill Cures All The American Way Billions of Prescriptions The current population of the United States of America is 325,964,929 as of Sunday, February 25, 2018,
16 Polypharmacy Those older patients are also using more drugs!
17 Polypharmacy
18 Older patients + Multimorbidities + Polypharmacy + Longer appts + Invasive procedures More Emergencies
19 Looking at the Road Ahead
20 Frequency of Med Emerg in Dental Office Journal of Family And Community Medicine 2015 Sep-Dec 22(3):
21 Frequency of Med Emerg in Dental Office Orthodontic Journal of Nepal, Dec 2015, 5(2):33-37
22 Frequency of Med Emerg in Dental Office Orthodontic Journal of Nepal, Dec 2015, 5(2):33-37
23 Frequency of Med Emerg in Dental Office Orthodontic Journal of Nepal, Dec 2015, 5(2):33-37
24 Frequency of Med Emerg in Dental Office Orthodontic Journal of Nepal, Dec 2015, 5(2):33-37
25 What precipitates the medical emergency Stress is a common etiologic factor in emergency situations Stress
26 Frequency of Med Emerg in Dental Office
27 Office Preparation
28 Office Preparation The components of a sound medical emergency plan for the dental office should include: Medical emergency prevention
29 Office Preparation The components of a sound medical emergency plan for the dental office should include: Dental office emergency team Medical emergency prevention Development of an action plan Vital Signs BLS Oxygen Crash Cart Action Plan EMS Record Tx AED
30 Office Preparation The components of a sound medical emergency plan for the dental office should include: Need a record of what you did during event! Medical emergency prevention Development of an action plan Vital Signs BLS Oxygen Crash Cart Action Plan EMS Record Tx AED
31 Office Preparation The components of a sound medical emergency plan for the dental office should include: Medical emergency prevention Development of an action plan
32 Office Preparation The components of a sound medical emergency plan for the dental office should include: Medical emergency prevention Development of an action plan Recognizing a patient s distress and management of medical emergencies
33 Office Preparation The components of a sound medical emergency plan for the dental office should include: Medical emergency prevention Development of an action plan Recognizing a patient s distress and management of medical emergencies Emergency drugs and equipment
34 Emergency Equipment
35 Critical Emergency Equipment Medical Emergencies in the Dental Office, Malamed, 7 th Edition
36 Basic Emergency Equipment
37 Basic Emergency Equipment Automated External Defibrillator (AED)
38 Basic Emergency Equipment Automated External Defibrillator (AED)
39 Emergency Drugs
40 Critical Emergency Drugs Medical Emergencies in the Dental Office, Malamed, 7 th Edition
41 EpiPen 2-Pak kg / lbs > 30 kg / > 66 lbs
42 Epinephrine Autoinjector Instructions
43 Non-Critical Emergency Drugs Drugs available should match what you do in your practice Medical Emergencies in the Dental Office, Malamed, 7 th Edition
44 Antidotal Emergency Drugs These drugs should be maintained in the emergency drug kit only as warranted by the nature of the dental practice. Medical Emergencies in the Dental Office, Malamed, 7 th Edition
45 Prevention of Medical Emergencies
46 Prevention of Med Emerg Recognition of risk
47 Comprehensive Medical History Past Medical History Review of Systems Current Medications Past Hospitalizations Medication Allergies
48 Vital Signs BP & Pulse
49 Blood Pressure Hypertension JNC-8 Hypertension Today: JNC-8 Evidence-Based Guidelines
50 Blood Pressure Hypertension JNC-8 Hypertension Today: JNC-8 Evidence-Based Guidelines US Dept Health & Human Services, NIH, JNC8
51 Blood Pressure Hypertension JNC-8 Hypertension Today: JNC-8 Evidence-Based Guidelines
52 Hypertension in the Dental Office Is it safe to treat you today? BP = 178/96 Should we treat the patient?
53 Hypertension in the Dental Office JNC 7 Medical Risk Factors (MRF) Prior Myocardial Infarction IHD Angina High coronary disease risk Recurrent stroke prevention Diabetes Kidney disease US Dept Health & Human Services, NIH, JNC7
54 Hypertension in the Dental Office Dental Treatment and Blood Pressure SBP DBP MRF* Dentist Guidelines Yes/No Routine Tx OK; Discuss HTN guidelines Yes/No Routine Tx OK; Refer for Med/Consult No Routine Tx OK; Refer for Med/Consult Yes Urgent Tx OK; Refer for Med/Consult No No Tx w/o consult; Refer prompt Med/Consult Yes No dental Tx; Refer emergent Med/Consult > 210 > 120 Yes/No No dental Tx: Refer emergent Med/Consult *MRF = Medical Risk Factors US Dept Health & Human Services, NIH, JNC7
55 Hypertensive Crisis Hypertensive Urgency & Emergency
56 Hypertensive Crisis Autoregulation of blood flow
57 Hypertensive Crisis Hypertensive Urgency & Emergency
58 Hypertensive Crisis End Organ Damage Neurological Deficit (HTN encephalopathy, cerebral infarction/hemorrhage) Features of Acute LV Heart failure Coronary insufficiency (Angina) Aortic Dissection Pulmonary Edema Acute Kidney failure (Anuria)
59 Hypertensive Crisis Hypertensive Urgency & Emergency Systolic BP >180 mmhg Diastolic BP>120 mmhg Hypertensive crisis Urgency Emergency End organ damage present?
60 Hypertensive Crisis End Organ Damage S/S E O D
61 Hypertensive Crisis >180/120 S/S E Hypertensive Emergency >180/120 O D Hypertensive Urgency
62 Patient Assessment
63 Patient Assessment - P C A B D E Position Circulation Airway Breathing Definitive Treatment Activate EMS?
64 Patient Assessment - P C A B D E Position Circulation Airway Breathing Definitive Treatment Activate EMS
65 Patient Management BLS
66 1. Unable to make diagnosis 2. Know the diagnosis but are uncomfortable with it 3. Whenever you think EMS is warranted
67 Reference Textbooks
68 Unconscious Patient
69 Unconsciousness Mechanisms Inadequate blood flow to brain Inadequate oxygen to brain Metabolic deficiencies Disorders of nervous system Psychiatric mechanisms
70 Unconsciousness in the Dental Chair Differential Diagnosis Medical Emergencies in the Dental Office, Malamed, 7 th Edition
71 Basic Unconsciousness Treatment Recognition of Unconsciousness Position patient supine, feet elevated Assess Circulation (Carotid pulse) Artificial circulation if needed Assess Breathing (Look, Listen, Feel) Artificial ventilation if needed Activate EMS if delayed recovery Definitive management of cause
72 Unconscious Patient Vasodepressor Syncope
73 Syncope - Etiology Temporary loss of consciousness caused by a fall in blood pressure
74 Syncope - Etiology
75 Syncope Predisposing Factors Psychogenic Fright Anxiety Emotional stress Unwelcome news Sight of blood Nonpsychogenic Upright position Hunger Exhaustion Male gender Age yrs
76 Normal Fight or Flight Response
77 Normal Flight or Fight Response Pain or fear Release of catecholamines (Adrenalin) Blood pumped to peripheral muscles Muscle activity run or fight Blood pumped back to heart Normal cardiac output maintained
78 Syncopal Reaction Nerve Damage Cyst Fracture Dry Socket
79 Syncopal Reaction Pain or fear Catecholamine release Blood to muscles No muscle activity - Blood pools in muscles Compensatory => vasoconstriction, tachycardia Mechanoreceptors => reflex bradycardia, vasodilation Reduced cardiac output & hypotension Cerebral ischemia loss of consciousness
80 Syncope Early signs and symptoms Feeling of warmth Loss of skin color pale, ashen Heavy perspiration Nausea Feel bad, feel faint Tachycardia ( pulse)
81 Syncope Late signs and symptoms Pupils dilation Yawning Rapid respirations Cold hands and feet Hypotension Bradycardia ( pulse)
82 Syncope Management Assess level of consciousness Position supine, feet elevated Assess Circulation, Airway, Breathing Provide BLS/CPR as indicated Activate EMS if recovery is not immediate Administer oxygen Monitor vital signs sec Diagnosis correct?
83 Syncope Management Definitive management Aromatic ammonia inhalants Cold towel on face Stimulate patient (Post-syncopal recovery) Postpone dental treatment? (Delayed recovery) Activate EMS Escort for patient? Patient to hosptial
84 Prevention of Syncope Patient positioning Anxiety relief Preop sedation Nitrous oxide
85 Unconscious Patient Postural Hyoptension
86 Postural Hypotension
87 Postural Hypotension Predisposing factors Drug administration Prolonged recumbency Inadequate postural reflex Pregnancy Addison s disease
88 Postural Hypotension Drugs causing postural hypotension Antianginals Antiarrhythmics Antidepressants Antihistamines Antihypertensives Antipsychotics Beta-blockers Diuretics Phenothiazines Tranquilizers
89 Postural Hypotension Management Assess consciousness Position supine, feet elevated Assess Circulation, Airway, Breathing Provide CPR if needed Administer oxygen Monitor vital signs (Episode terminates) (Episode continues) Slowly reposition chair, discharge Summon medical assistance
90 Prevention of Postural Hypotension PMH: medications, fainting Hx Slowly discharge from supine
91 Respiratory Emergencies
92 Respiratory Distress Potential Causes Hyperventilation Acute MI Syncope Anaphylaxis Asthma Angioedema Heart Failure Stroke Hypoglycemia Epilepsy
93 Respiratory Emergencies Obstructed Airway
94 Airway Obstruction Relaxed Tongue Blocks Airway
95 Airway Obstruction
96 Airway Obstruction Opening the Airway => HTCL Head Tilt Chin Lift
97 Airway Obstruction Opening the Airway Trauma Patient
98 The Lost Tooth Magill s Forceps X
99 The Lost Tooth Aspirated Object Cough, wheeze, choking, shortness of breath Symptoms present within one hour 90% of the time Symptoms may be delayed up to six hours
100 Management of Possible Aspiration Place patient in left lateral decubitus position Head tilted down over edge of chair Encourage patient to cough Object is retrieved Object not retrieved Consult physician or pulmonologist Post-aspiration complications? Transport to E.R. Flat plate abdomen Lateral and PA Chest X-rays
101 Management of Possible Aspiration
102 Management of Swallowed Object Swallowed object => Asymptomatic
103 Management of Swallowed Object Potential for Bowel Perforation? Swallowed and aspirated dental prostheses and instruments in clinical dental practice. M Abusamaan; JADA 2014; 145(5):
104 Management of Swallowed Object
105 Avoiding Aspiration
106 Respiratory Emergencies Hyperventilation
107 Hyperventilation
108 Hyperventilation - Pathophysiology
109 Hyperventilation - Manifestations Anxious patient Shortness of breath Air hunger Hyperventilation Hyperventilation Palpitations Tachycardia Lightheadedness Circumoral paresthesia Carpopedal tetany
110 Hyperventilation - Management Position patient comfortably (upright) C A B BLS as needed Remove dental materials from patient s mouth Calm patient Correct respiratory alkalosis Drug management if needed Versed, Valium Complete treatment, discharge
111 Respiratory Emergencies Asthma
112 Asthma
113 Asthma - Pathophysiology Hyperactivity of tracheobronchial tree Bronchial smooth muscle contraction Bronchial wall edema Mucus hypersecretion Narrowed airways Wheezing Shortness of breath Coughing
114 Asthma Medical Management of Asthma
115 Asthma Signs and Symptoms Chest congestion/tightness Cough, wheezing, SOB Anxiety or agitation Increased respiratory rate Increased heart rate Pt wants to sit or stand up Use of accessory muscles
116 Asthma Indicators of a Severe Attack SaO 2 (pulse oximeter) is below 91% Bronchodilator doesn t improve Sx after two treatments Patient has difficulty speaking Sentences < phrases < words < mute Patient is struggling for air
117 Asthma Management Position patient comfortably (upright) C - A B BLS as needed Administer bronchodilator via inhalation (Alubuterol inhaler) (Episode terminates) (Episode continues) Complete dental treatment Administer oxygen, call EMS Discharge patient Epinephrine 0.3mg SQ or IM Discharge or hospital
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