Medical_Emergencies_ _ د حاتم البيطار

1. 01005684344 9/5/2022 1

2. Management of Medical Emergencies • Medical emergencies can and do happen – Advances in medicine – Longer lifespan – Multiple medications – Medically compromised – Longer appointments 2

3. Incidence • A survey done in the 90’s showed that, over a 10 year period, 90% of dentists have encountered at least one medical emergencies. 3

4. Types TYPE OF EMERGENCY NUMBER PERCENT Altered Consciousness 17,782 59 Cardiovascular 4,280 14 Allergy 2,887 9.5 Respiratory 2,718 9 Seizures 1,595 5 Diabetes-Related 999 3 4

5. Management of Medical Emergencies • Basic Life Support • Advanced Life Support 5

6. Management of Medical Emergencies Emergency situations • Managed properly most emergencies are resolved satisfactorily • Mismanaged even benign emergencies can turn disastrous • Recognize • Position • Stabilize • Diagnose • Treat • Refer 6

7. Management Of Medical Emergencies 1. Recognition 2. Prevention 3. Preparation 4. Basic life support (BLS) 5. Cardiopulmonary resuscitation (CPR) 6. Specific medical emergencies 7

8. Prevention • IS THE BEST TREATMENT Know your patient Never treat a STANGER 8

9. Prevention • 90% of life-threatening situations can be prevented • 10% will occur in spite of all preventive efforts (sudden unexpected death) 9

10. Prevention • Medical History • Physical Evaluation • Vital Signs • Dialogue History • Determination of Medical Risk • Stress Reduction 10

11. Prevention MEDICAL HISTORY • Review • Update • Medication • Medical consultation 11

12. Prevention PHYSICAL EVALUATION • Length of time since last evaluation • Vital signs • Visual inspection of patients • Referral to physician 9/5/2022 12

13. Prevention VITAL SIGNS • Blood pressure • Pulse rate • Respiratory rate • Temperature • Height • Weight 13

14. Prevention DIALOGUE HISTORY • Putting it all together • Check accuracy of medical history • Recognize anxiety 14

15. Prevention DETERMINATION OF MEDICAL RISK. • Ability of patient to safely tolerate dental treatment. • Does patient represent increased medical risk? • Can patient be managed in the dental office? 15

16. Determination Of Medical Risk American Society of Anesthesiology Physical Status Classification System 16

17. ASA I • Can tolerate stress involved In dental treatment • No added risk of serious Complications • Treatment modification Usually not necessary • A patient without systemic disease • A normal healthy patient 9/5/2022 17

18. ASA II • Represent minimal risk during dental treatment • Routine dental treatment With minor modifications -Short early appointments -Antibiotic prophylaxis -Sedation A patient with mild systemic disease Example: -Well-controlled diabetic -Well-controlled asthma -ASA I with anxiety 9/5/2022 18

19. ASA III • Elective Dental Treatment is not Contraindicated • Treatment Modification is Required - Reduce Stress - Sedation - Short Appointments A patient with severe systemic disease that limits activity but is not incapacitating Example: - a stable angina - 6 mos. Post - MI - 6 mos. Post - CVA - COPD 19

20. ASA IV • Elective dental care should be postponed • Emergency dental care only – Rx only to control pain and infection – Other treatment in hospital • (I&D, extraction) A patient with incapacitating systemic disease that is a constant threat to life Example: - Unstable angina - M I within 6 months - CVA within 6 months - BP greater than 200/115 - Uncontrolled diabetic 20

21. ASA V A morbid patient not expected to survive Example: - End stage renal disease - End stage hepatic disease - Terminal cancer - End stage infectious disease Elective treatment definitely contraindicated Emergency care only to relieve pain 21

22. Prevention STRESS REDUCTION • Premedication • Sedation • Pain control (intra and post-op) • Early appointments • Short appointments 22

23. Preparation • Team Effort • BLS for all office personnel • CPR for all office personnel • Emergency drills • Emergency phone numbers (911) • Emergency equipment 23

24. BASIC LIFE SUPPORT (BLS) CARDIOPULMONARY RESUCITATION (CPR) 24

25. SBE Prophylaxis • In 2012, the guidelines were updated and now premedication is needed for fewer conditions. The conditions for which premedication is necessary includes: – artificial heart valves – a history of infective endocarditis – a cardiac transplant that develops a heart valve problem – the following congenital (present from birth) heart conditions: *unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits *a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure *any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device • 25

26. SBE Prophylaxis • Patients who previously needed antibiotic prophylactic but no longer need them include: – mitral valve prolapse – rheumatic heart disease – bicuspid valve disease – calcified aortic stenosis – congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy 26

27. SBE Prophylaxis • Procedures needing prophylaxis: – All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. – procedures that do not require prophylaxis are radiographs, placement of removable prosthesis, and placement orthodontic bracket. 27

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29. Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures AMOXCICILIN Adults 2 grams Children 50 mg/kg (not to exceed adult dosage) Orally 1 hour before procedure No repeat dose 29

30. Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Allergic to Penecillin Clindamycin Adult 600 mg Children 20 mg/kg Cefalexin or Cfadroxil 2 gr. 50 mg/kg Azithromycin or Clanthromycin 500 mg 15mg/kg ORALLY 1 HOUR BEFORE PROCEDURE 30

31. Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Unable to take Oral Medication Ampicillin Adults: 2 gr IM or IV Children: 50 mg/kg IM or IV Within 30 minutes of procedure 31

32. Management of Medical Emergencies Antibiotic Prophylaxis • Amoxicillin vs. Penecillin – Both equally effective against Streptococus viridan – Amoxicillin is better absorbed from the GI tract, and provides higher and more sustained serum level – 2 gr. Provides as effective coverage as 3 gr. With less GI adverse effects. – 2nd dosage not required due to prolonged serum level above the inhibitory period for most oral Streptococci. 32

33. Management of Medical Emergencies Antibiotic Prophylaxis • ERYTHROMYCIN No longer recommended due to GI side effects. Practitioners who have used it successfully in the past, may continue to use it following the previously published regimen. 2 gr. 2 hours before procedure 1 gr. 6 hours later 33

34. Management of Medical Emergencies Antibiotic Prophylaxis • Patient already taking antibiotic used for prophylaxis: 1. Select an antibiotic from a different class, rather than increasing the dosage 2. Delay treatment if possible 9 to 14 days after completion of antibiotic to allow usual flora to reestablish Example: Amoxicillin, go to Clindamycin. No Cephalosporin due to cross resistance 34

35. Management of Medical Emergencies Antibiotic Prophylaxis Prophylaxis for dental patients with TOTAL JOINT REPLACEMENT 35

36. Management of Medical Emergencies Antibiotic Prophylaxis • The most crucial period is up to 2 years following a joint replacement • Prophylaxis not recommended for dental patients with: Pins, Plates, and Screws. • Prophylaxis is not routinely indicated for most dental patients with total joint replacement 36

37. Management of Medical Emergencies Antibiotic Prophylaxis Patients at potential increased risk of total joint infection • Immunocompromized/Suppressed patients • Other Patients: – Insulin Dependent diabetics – 1st 2 years following joint replacement – Previous prosthetic joint infection – Malnourishement – Hemophilia 37

38. Management of Medical Emergencies Antibiotic Prophylaxis • Procedures and regimens are the same as discussed earlier for SBE prophylaxis. • A cephlosporin is preferable to Amoxicillin due to its affinity to cynovial fluids 38

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