Medical Emergencies in the Dental Office

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1 Medical Emergencies in the Dental Office Beth Stirling, D.D.S., M.D. Resident in OMFS University of Maryland

2 Overview Emergencies do occur IT WILL HAPPEN IN YOUR OFFICE Failure to plan is planning for failure Management Prevention Recocgnition Treatment

3 Emergency Number Emergency Number Syncope 15,407 Cardiac arrest 331 Mild allergic reaction 2583 Anaphylaxis 304 Angina 2552 Myocardial infarction 289 Postural hypotension 2475 LA overdose 204 Seizure 1595 Heart failure 141 Asthma 1392 Diabetic coma 109 Hyperventillation 1326 CVA 68 Epinephrine reaction 913 Adrenal insufficiency 25 Hypoglycemia 890 Thyroid storm 4 N=4309 over 10 years Fast TB, Martin MD & Ellis TM, emergencies per dentist over 10 years

4 Most common emergencies Stress related: Syncope & hyperventillation Medical conditions exacerbated by stress: Cardiovascular, bronchospasm (asthma) & seizures Drug related Overdose & allergy

5 Timing of the emergency Time % of total Waiting room 1.5 Local anesthesia* 55 During treatment 22 After treatment 16 After leaving the office 5.5 Matsuura H, 1990

6 U.S. Aging Population 35 million people (12%) 65 years or older Life expectancy was 40 years in 1900 & 77 years in Number will increase by nearly 75% by year 2030

7 Increasing risk Aging population Medical advances Surgical procedures Longer appointments Increased drug use

8 PREVENTION & PREPARATION Prevention Know your patient Clinical judgment Medical consult Optimize treatment Preparation Know your patient Train your staff BLS, ACLS, PALS Prepare your office equipment Practice Team roles

9 Preparation AED (Automated External Defibrillator) Survival rate <5% if defibrillation after 10 mins* Chance of successful resuscitation decreases 10% per minute that defibrillation is delayed after cardiac arrest.

10 Emergency drugs Injectable: Non-injectable: sympathomimetic - epinephrine (1 mg/ml) antihistamine - diphenhydramine (50 mg/ml) anticonvulsant - midazolam (5 mg/ml) corticosteroid hydrocortisone (50mg/ml) 50% dextrose antihypoglycemic - glucagon (1 mg/ml) analgesic morphine (10 mg/ml) Anticholinergic atropine (0.5mg/ml) Oxygen vasodilator nitroglycerin (sublingual tablets or spray) bronchodilator - Ventolin aromatic ammonia source of sugar glucose - gel, table sugar antiplatelet - ASA (325 mg tablets)

11 Emergency equipment oxygen delivery system (Ambu bag, nasal prongs) large bore suction tips needles and syringes oropharyngeal & nasopharyngeal airways Chemstrips

12 Obtain Adequate Medical History Medications Allergies Cardiovascular System Respiratory System Endocrine System Renal System Gastrointestinal System Nervous System

13 MEDICAL CONSULTATION IDENTIFY PATIENT PROPOSED TREATMENT SPECIFIC QUESTION

14 STRESS REDUCTION PROTOCOL Recognition Morning & short appointments Minimize waiting time Premedication Psychosedation Intra and postoperative pain control

15 Case # 1

16 19 year old female Attends your office for a root canal on tooth #8 which. As you are talking to her at the start of her appointment she tells you that she feels weird, you ask her to sit down but as she is sitting on the chair she slumps and becomes unresponsive. PMH - None, but extremely anxious about dental treatment.

17 19 year old female She appears pale and diaphoretic. Breathing is shallow & pupils are dilated. Some convulsive movements of hands and feet that subside in 10 seconds Pulse = 48 (Difficult to palpate) BP = 75/30

18 UNCONSCIOUSNESS Syncope Drug administration/ingestion Orthostatic hypotension Epilepsy Hypoglycemia Adrenal insufficiency, AMI, CVA

19 VASODEPRESSOR SYNCOPE Management: position patient supine with head lower that heart establish airway, oxygen Monitor vital signs ammonia inhalant atropine for profound bradycardia If delayed recovery >15 min suspect alternate diagnosis & EMS

20 Case # 2

21 17 year old female Presents to your office for an extraction. Her mother tells you she has asthma. What questions do you ask?

22 Questions to ask an asthmatic How often How severe (medication, hospitalization, intubation) Getting worse or better over time Initiating factors Treatment Currently symptomatic Compliant with meds / take meds today Have medication with you

24 ASTHMA Increased reactivity of bronchioles to a variety of stimuli resulting in widespread, but reversible narrowing of the airways due to bronchoconstriction, edema, and secretions Types Extrinsic Intrinsic Exercise induced

25 ASTHMA Extrinsic Allergen induced (IgE, mast cells, histamine, prostaglandins) Children & often regresses at puberty Intrinsic Upper respiratory irritants or infection Adults Exercise induced Drug induced NSAIDs, Aspirin (association with nasal polyps)

26 Asthma Definitive treatment: position patient upright calm patient ABC s oxygen Bronchodilator inhaler (spacer) Vital signs

27 Severe bronchospasm Definitive treatment: position patient upright calm patient ABC s oxygen Bronchodilator inhaler (spacer) Parenteral bronchodilator (epinephrine) 0.3ml of 1:1000 or 3ml of 1:10,000 BLS

28 Case # 3

29 69 year old male Presents to your office for extraction of 4 teeth. No PMH except pressure meds but he has run out of meds. 3 BP readings were 215/110, 208/103 & 210/108

30 Blood Pressure SYSTOLIC DIASTOLIC Normal < 120 < 80 Prehypertension Stage 1 - Hypertension Stage 2 - Hypertension Stage 3 - Hypertension Stage 4 - Hypertension >210 >120 A blood pressure of 130/80 mmhg or higher is considered high blood pressure in people with diabetes and chronic kidney disease. Affects 50 million Americans only 59% are treated HTN underlies most cardiovascular disease

31 HTN Prognosis: Relationship between BP and life expectancy is linear Risk of cardiovascular disease doubles for every increment of 20mmHg SBP or 10mmHg DBP (JNC-7) Sustained HTN results in: Renal failure, CVA, Coronary insufficiency, LVH/CHF, MI, Aneurysms, Blindness

32 HTN Diastolic HTN: increased peripheral resistance, classically a greater risk. Systolic HTN: increased cardiac output and/or large vessel stiffness. More important risk factor in patients older than 50. Target BP <140/90 (Diabetics 130/80)

33 Treatment of HTN Target BP <140/90 (Diabetics 130/80) Reduces risk of: CVA by 35-40% MI by 20-25% Heart failure by >50%

35 Malignant Hypertension 1% of hypertensive patients *Severe elevation in BP resulting in end organ damage: Papilledema Acute left heart failure Acute renal failure Cerebral hemorrhage & encephalopathy IMMEDIATE, AGGRESSIVE MEDICAL ATTENTION

36 Dental management DO NOT TREAT OUR PATIENT & SEND HIM TO ER or PHYSICIANS OFFICE (Call ahead) Recommendation: SBP >180 or DBP >110 is used as cut off for most dentists JNC-7*

Dental management Identification Monitoring Stress reduction protocols Avoid orthostatic hypotension Limit vasopressors (topical & injectable) Exogenous - 0.

37 Dental management Identification Monitoring Stress reduction protocols Avoid orthostatic hypotension Limit vasopressors (topical & injectable) Exogenous mg epinephrine = 2.2 carpules 1:100,000 Endogenous potentially a bigger problem (adrenal stress response 0.28mg of epi / min) Drug interactions & effects (MAOI, beta blockers)

39 Case # 4

40 55 year old male Presents to your office for RCT & crown preparation. PMH: MI 5 months ago Angioplasty with stent 4.5 months ago HTN Mitral valve prolapse with regurgitation Would you treat him? Any special measures?

41 Treatment following an MI ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery exec summary. Circulation 2002; 105: It appears reasonable to wait 4 to 6 weeks after an MI to perform elective surgery

42 AHA 2007 Guidelines on SBE prophylaxis Prophylactic antibiotics, the authors state, should not be given based on a lifetime risk for infective endocarditis but are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients, according to the guidelines, include those with the following: Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous IE Congenital heart disease (CHD)* Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) Cardiac transplantation recipients who develop cardiac valvulopathy

43 CONSIDER antiplatelet therapies, b- blockers, antihypertensive regimen Given CAD history, risk for repeat infarction Correspondence with cardiologist- risk stratification for minor procedure under local anesthestic with vasocontrictor O2, reduce stress, manage pain and anxiety, cardiac monitors, nitrates PRN

44 Case # 5

45 59 year old male In your office for restoration tooth # 30. PMH: Angina HTN High cholesterol Type II diabetes During treatment he complains of substernal chest pain, and on questioning he reports pain down his left arm, nausea and dyspnea. You notice that he appears diaphoretic.

46 Causes of Chest Pain Chest pain may originate in the chest wall (muscle, bone, skin), or intrathoracic viscera (heart, lungs, esophagus)

47 Causes of Chest Pain Myocardial infarction Angina pectoris Pericarditis Pleuritic/Pulmonary chest pain Gastrointestinal (GERD, Hiatal hernia, PUD) Musculoskeletal/aneurysm Aortic dissection

Management of Angina & AMI Terminate treatment Position patient 45 degrees or Trendelenberg if SBP <100 ABC s Oxygen 100% (Facemask @10 L/min) Sublingual nitroglygcerin 0.

48 Management of Angina & AMI Terminate treatment Position patient 45 degrees or Trendelenberg if SBP <100 ABC s Oxygen 100% L/min) Sublingual nitroglygcerin 0.4mg Should relieve pain in 3-5 mins Repeat at 5 min intervals as needed Failure to relieve pain suspect MI Aspirin 325mg Morphine 2-5mg every 10 min PRN Monitor vital signs

49 Case # 6

50 33 year old female In your office for routine hygiene appointment. But her chart is missing. You decide to proceed with your scaling and polishing During treatment she complains of itching, and you notice a rash developing on the face, neck and arm. Very quickly she tells you that her throat is swelling and that she forgot to remind you of her severe latex allergy, before starting to wheeze.

51 Anaphylactic reaction Type I hypersensitivity reaction (IgE)* Life threatening emergency

3ml of 1:1000 IM every 10 mins Diphenhydramine 50mg IM

52 Anaphylactic reaction management Terminate treatment & remove latex Position in Trendelenberg ABC s Oxygen Epinehphrine 0.3ml of 1:1000 IM every 10 mins Diphenhydramine 50mg IM (Chlorpheniramine is less sedative) IV access & fluids? Hydrocortisone 250mg IV

53 Case # 7

26 year old male Undergoing a root canal on a traumatized tooth #8 PMH: Epilepsy (poorly controlled) Dental phobia During treatment he becomes unresponsive and soon after his eyes

54 26 year old male Undergoing a root canal on a traumatized tooth #8 PMH: Epilepsy (poorly controlled) Dental phobia During treatment he becomes unresponsive and soon after his eyes roll upwards and he becomes rigid for about 20 seconds and then begins to have violent muscle contractions, and becomes cyanotic. He is incontinent of urine and is hypersalivating.

55 SEIZURES A paroxysmal disorder of cerebral function characterized by a change in the state of consciousness, motor activity, and sensory phenomena

56 SEIZURES Generalized seizures: Affect both hemispheres with altered consciousness Absence (petit mal) Lapse of attention and staring in children Short duration (10 seconds) Tonic-clonic (grand mal) Adults prodrome, preictal, tonic, clonic and postictal phases 2-15 minute duration Status epilepticus = >5 minutes or multiple back to back (mortality of 10%)

57 SEIZURES Partial seizures: Affect one hemisphere but may become generalized Simple = no loss of consciousness Complex = with loss of consciousness Short duration 2-3 mins End spontaneously

Dental management Medication regimen, compliance, degree of seizure control communicate with PCP, consider pre-procedure bloodwork and EKG Consider

58 Dental management Medication regimen, compliance, degree of seizure control communicate with PCP, consider pre-procedure bloodwork and EKG Consider medication interactions and adverse drug effects Stress reduction in the office consider adjunctive anxiolysis or sedation Be prepared to manage a seizure

60 Management of Seizure Terminate dental procedure Position patient & prevent injury Seizure stops - reassure patient, allow patient to recover and then discharge patient with an escort, recommend follow up with PCP Seizure continues Activate EMS (911) Airway monitoring/ maintenance, administer O 2, monitor VS, 3- lead EKG, pulse check >5 min administer anticonvulsant drug I.V. diazepam 5 mg/min (children 0.3mg/kg) and

61 SUMMARY 1. Know your patient: history and physical 2. Have a plan & practice 3. Maintain emergency kit 4. BLS, ACLS & PALS training 5. Consider AED in the office

Conscious Sedation Permit Evaluation. General Comments Emergency Algorithms

Conscious Sedation Permit Evaluation. General Comments Emergency Algorithms General Comments Emergency Algorithms These algorithms delineate appropriate responses to the simulated emergencies listed in Article 5, Section 1043.4c of the California Code of Regulations. Each algorithm