Management of Medical Emergencies In the Dental Office

1. Management of Medical Emergencies In the Dental Office

2. Hypertension • Defined as blood pressure Greater Than 140/90 • Risk factors: • CVA • MI • CHF • Renal Failure

3. ASA Risk Status I <140 and < 90 Routine dental management Recheck in 6 months ASA Risk Status II 140-160 and 90 to 95 Recheck BP for next 3 appointments, if elevated get medical consultation Routine dental care Stress reducyion Hypertension

4. ASA Risk Status III 160-200 and 95 to 115 Recheck BP in minutes If elevated, medical consult before dental treatment Stress reduction ASA Risk Status IV >200/115 Recheck BP in 5 minutes Immediate medical consultation No routine treatment Emergency treatment in hospital Rx for pain and infection Hypertension

5. Hypertension Management • Control BP before elective treatment • Reasonable control of severe hypertension before emergency treatment • Medical consult before treatment for uncontrolled hypertension

6. Management of Medical Emergencies Common Medical Emergencies in the Dental Office

7. Vasovagal Syncope Cause: Loss of vasomotor tone due to a massive parasympathetic discharge leading to decreased pulse rate, and decreased blood pressure which leads to cerebral hypoxia and pooling of blood.

8. Fainting: Vasovagal Syncope In Dentistry • The most common cause is psychogenic due to fear and anxiety; especially from local anesthetic • Most common between the ages of 16 and 35 • Males more prone than females • Fainting is considered SERIOUS in PEDIATRIC patients and patients OVER 40 years of age

9. Signs/Symptoms: Frightened anxious patient. Decreased pulse rate. Decreased blood pressure. Cool, moist, clammy skin. Pale appearance. Treatment: Place patient in Trendelenberg’s position. Monitor vital signs. Administer aromatic spirits of ammonia. Apply cold towel to forehead. Administer 100% oxygen. Reassurance. Vasovagal Syncope

10. Postural Hypotension Cause: • disorder of the autonomic nervous system in which syncope occurs when the patient assumes the upright position.

11. Fainting: Postural Hypotension • The second most common cause of transient loss of consciousness. • Not associated with fear an anxiety • Predisposing factors • Administration of Drugs • Antihypertensives • Psychotropics, Sedatives, and Tranquilizers. • Age: increases with increasing age • Prolonged recumbency

12. Signs/Symptoms: Decrease in BP and loss of consciousness without prodromal signs and symptoms Heart rate is normal, unlike Bradycardia in Vasovagal Syncope. All manifestations of unconsciousness When patient is placed in the supine position, consciousness rapidly returns. Treatment: Stop treatment Assess consciousness Place patient in the supine position with legs elevated Oxygen Monitor vital signs Slowly reposition patient Postural Hypotension

13. Fainting: Postural Hypotension Pregnancy (2 forms of hypotension) • Postural hypotension:during the first trimester when getting out of bed in the morning; does not reoccur during the day. • Supine hypotensive syndromeof pregnancy occurs in the third trimester. If the patient is in the supine position for more than 3 to 7 minutes, the uterus can compress the inferior vena cava decreasing venous return from the legs. Turning the patient on her left or right side will alleviate the pressure and blood flow returns to normal.

14. Hyperventilation Causes: • Acute anxiety attack, • Metabolic and endocrinologic disorders (hypoglycemia, hyperthyroidism, Cushing’s syndrome, pheochromocytoma).

15. Signs/Symptoms: Tachypnea. Tachycardia. Parasthesia around mouth and fingers. Tetany, cramps. Nausea. Faintness. Diaphoresis. Acute anxiety. Shortness of breath. Treatment: Assure patient airway. Reassure patient. Have patient “re-breathe” in a paper bag. Hyperventilation

16. Hypovolemic Syncope Causes: • External fluid loss; • Internal sequestration of fluid; • Decrease in cardiac output; • Arrhythmias; • Hypocapnia (hyperventilation); • Hypoglycemia.

17. Signs/Symptoms: Blood pressure low normal or elevated; Tachycardia. Orthostatic hypotension and increased pulse rate. Altered mental states; anorexia; apathy, weakness. Cold clammy skin. Treatment: Maintain patient airway – turn head to one side to prevent aspiration. Administer 100% oxygen. DO NOT use aromatic spirits of ammonia because it stimulates the sympathetic system and augments arrythmogenicity. Hypovolemic Syncope

18. Acute Angina Pectoris Cause: Diminished blood supply to myocardium due to an imbalance between myocardial oxygen supply and demand.

19. Signs/Symptoms: Chest pain – substernal pressure or crushing sensation. May radiate to neck, left shoulder and down arm, and left side of jaw. Treatment: Place patient in supine position. Assure patient airway. Administer nitroglycerine – if patient’s prescription not available – administer 0.3 mg sublingually. If pain persists five minutes after nitroglycerine dose, repeat administration. If still no response, repeat nitroglycerine and administer 100% oxygen. If angina does not subside – concerned that myocardial infarction is developing. Transferto emergency room. Acute Angina Pectoris

20. Myocardial Infarction Cause: Inadequate supply of oxygen to myocardium.

21. Signs/Symptoms: Chest pain – substernal pressure or crushing sensation, may radiate to neck, left shoulder, down arm, left side of jaw. Feeling of impending doom; Nausea. Pale and diaphoretic. Treatment: Usually does not respond to nitroglycerine. Administer 100% oxygen. Position patient in semi-sitting position. Transport to medical facility immediately. Note: Narcotics for pain should be avoided initially, so as not to interfere with differential diagnosis, but if desired give Demerol 25-75 mg IM or IV. Myocardial Infarction

22. Cardiopulmonary Arrest Causes: • Hypoxia; • myocardial infarction; • anesthesia – local or general; • anaphylaxis; • excessive vagal tone.

23. Signs/Symptoms: Absence of pulse. Absence of blood pressure. Absence of heart beat. Absence of respiration. Coma. Cyanosis. Dilated pupils. Treatment: Rule out aspiration. “Precordial Thump” within one minute of arrest. Assure patient airway. Provide CPR – do not interrupt CPR for more than 5 seconds, for any reason. Transport to medical facility. Cardiopulmonary Arrest

24. Acute Congestive Heart Failure Cause: Primary “pump” problem.

25. Signs/Symptoms: Right Sided CHF Systemic congestion Ankle swelling Jugular vein distention Pleural effusion Dsypnea Accumulation of fluids in peritoneum. Left Sided CHF Pulmonary congestion Dsypnea Orthopnea Great anxiety Very labored breathing Productive cough Cyanosis Treatment: Place patient in semi-sitting position. Assure patient airway. Administer 100% oxygen. Transport to medical facility immediately. Acute Congestive Heart Failure

26. Asthmatic Attack Cause: Reversible bronchospasm. Two Subtypes: • Extrinsic or allergic type is caused by environmental allergens. • Intrinsic (endogenous) type – mechanism inducing attacks is unknown.

27. Signs/Symptoms: Wheezing Effortless inspiration, prolonged expiration. Distended chest. Severe attack: Tachypnea (>35) or Bradypnea (<12) Tachycardia (>30) Exhaustion; altered consciousness Use of accessory muscles of respiration. Cyanosis. Silent chest (i.e. no wheezing with dyspnea and tachypnea) Hydration Treatment: Put patient in sitting position; assure patient airway; give 100% oxygen. Two inhalations of isoproterenol HCl. If no response to isoproterenol, and in severe attacks, administer epinephrine (1:1,000), sublingually, 0.3 to 0.5 ml over 5 minutes. May be repeated every 30 minutes up to 3 doses. Children’s dose: epinephrine (1:1,000) 0.01 mg/kg (0.02 mg/lb) repeat only once after one hour. Contact patient’s physician. Asthmatic Attack

28. Seizures Causes: • Neurologic disorders; • Syncope; • Drug toxicity; • Hypoxia.

29. Signs/Symptoms: Involuntary or bizarre movements. Tongue biting. Loss of consciousness Treatment: Assure patient airway. Administer 100% oxygen. Place soft/padded bite protector. Transport to medical facility. Seizures

30. Insulin Shock Cause: Hypoglycemia

31. Signs/Symptoms: Rapid fall in blood glucose level. May see parasympathetic response: hunger, nausea Catecholamine release Anxiety Tachycardia Palpitation Diaphoresis Slow fall in blood glucose level. Increasing lethargy Slurred speech Lassitude Progressive decreasing mental status Treatment: If conscious – give oral glucose (orange juice, candy, sugar cubes). If unconscious – patient is in need of IV administration of 50% dextrose – transport to medical facility immediately. Insulin Shock

32. Diabetic Coma Cause: Hyperglycemia

33. Signs/Symptoms: Frequent urination. Loss of appetite. Thirst. Acetone odor of breath. Hyperpnea. Nausea and vomiting. Warm, dry skin. Rapid pulse. Decreased blood pressure. Coma. Treatment: Place patient in supine position. Assure patient airway. Administer 100% oxygen. Call 911. Transport to medical facility. Diabetic Coma

34. Anaphylaxis Cause: Antigen interaction with antibody coated target cells.

35. Signs/Symptoms: Sense of impending doom; Bronchial obstruction: wheezing, laryngeal edema. Hypoxia. Hypotension. Prutitis, urticaria, angioedema. Nausea, vomiting, diarrhea, abdominal pain. Convulsions may occur. Treatment: Place patient in Trendelenberg position. Airway maintenance. Administer 100% oxygen. Administer epinephrine 1:1,000 sublingually 0.3 to 0.5 ml over 5 minutes. May be repeated every 30 minutes up to 3 doses. Children: epinephrine 1:1,000 sublingually 0.01 mg/kg (0.02 mg/lb). Repeat only once after one hour. Transport to medical facility. Anaphylaxis

36. Allergic Reaction Cause: Delayed hypersensitivity reactions.

37. Signs/Symptoms: Mild Reaction Urticaria Pruritis Skin eruptions Mild angioneurotic edema Severe Reaction Bronchial congestion Respiratory depression Edema Treatment: Place patient in supine position. Assure patient airway. Give 100% oxygen. Mild reaction: 50mg diphenhydramine HCl (Benadryl) orally. Severe reaction: 50mg diphenhydramine HCl (Benadryl) intramuscularly. Transport to medical facility. Allergic Reaction

38. Sphygmomanometer with various cuff sizes: a.) children, b.) average adult, c.) large adult. Stethoscope. 100% oxygen, E size compressed cylinder, portable unit, flow rate indicator. Clear resuscitation face masks (to allow for recognition of vomiting) of various sizes: a.) children, b.) average adult, c.) large adult. Self-inflating resuscitation bag (amber type bag). Small paper bags. Gauze 4x4. Alcohol pads. 1” adhesive tape. Tourniquet. Oropharyngeal airways – various sizes. Soft plastic bite protector. Backboard for CPR in dental chair. Medical emergency kit (Benadryl, Epinephrine, glucose, Isoproterenol Inhaler, Nitroglycerin, and Aspirin). EquipmentListIn order to successfully manage a dental emergency in the dental office you must be properly equipped with the necessary armamentarium which should include:

39. Emergency Drugs and Equipments • ATROPINE SULFATE • Actions • Parasympatholytic agent • Indications • Symptomatic bradycardia • Sinus bradycardia with hypotension • Dosage • 0.5 to 1 mg IV bolus (every 5 minutes) • Total dose is 2.0 mg for cardiac patients • Side effects • Dry mouth • Blurred vision • Aggravates blindness in patients with glaucoma • Difficulty in urination with older males • Contraindications • Atrial flutter or fibrillation with rapid ventricular response • Patients with closed angle glaucoma • Tachycardia

40. Emergency Drugs and Equipments • Diazepam • Actions • Minor tranquilizer • CNS Depressant • Anticonvulsant • Muscle relaxant • Indications • Status epilepticus • Hysteria/anxiety • Dosage • 2 to 15 mg slowly IV(5mg/min maximum in larger veins) • Given in small doses initially • May give more if patient’s condition requires • Side effects • Respiratory depression • Sleepiness • Hypotension • CNS depression • Dysrhythmias • Contraindications • Hypotension • Ventilatory insufficiency • Pregnancy • Alcohol intoxication • Narrow angle glaucoma

41. Emergency Drugs and Equipments • Diphenhydramine HCI • Actions • Antihistamine – binds to histamine receptor sites to prevent further action • Antiemetic • Mild central nervous system depressant • Reverses actions of phenothiazines • Indications • Anaphylaxis • Preferred before encountering allergen to keep reaction from occurring • Will not reverse effects of histamine once histamine is active in system, but will keep from further histamine effects • Delayed hypersensitivity reactions • Dosage • 25 to 50 mg IM or IV • Side effects • Drowsiness • Blurring of vision • Respiratory depression • Dry mouth • Wheezing • Urinary retention • Hypotension • Contraindications • Hypotension • Alcohol intoxication • Closed angle glaucoma • Ulcer disease with GI obstruction • Pregnancy

42. Emergency Drugs and Equipments • Epinephrine • Action – alpha and beta sympathomimetic drug • Increases heart rate • Increases contractile state of heart • Bronchodilates • Vasoconstricts • Increases blood pressure • Indications • Cardiac arrest • Ventricular fibrillation • Asystole • Asthma • Anaphylaxis • Dosage • Cardiac arrest • 0.5 to 1.0 mg of a 1:10,000 concentration IV • May be repeated every 5 to 10 minutes • Asthma • 0.3 to 0.5 mg of a 1:1,000 concentration SQ • May be repeated every 10 minutes as necessary • Anaphylaxis • 0.5 mg of a 1:1,000 concentration SQ • May be repeated as required • Side effects • Ventricular dysrhythmias • Angina • Hypertension • Ectopic beats • Nausea • Dilated pupils • Contraindications • Angina • Hypertension • Hyperthyroidism • No contraindications for patients in cardiac arrest or anaphylaxis

43. Emergency Drugs and Equipments • Morphine Sulfate • Actions • Analgesic • Vasodilator • Reduces preload • Reduces afterload • Stimulates parasympathetic nervous system • Indications • To reduce pain and anxiety associated with acute myocardial infraction • Pulmonary edema from congestive heart failure • Dosage • 2.0 to 5.0 mg IV bolus • Side effects • Respiratory depression or arrest • Hypotension • Sleepiness • Bradycardia • Increased intracranial pressure • Contraindications • Respiratory depression • Head injuries • Trauma to chest or abdomen • Uncontrolled bleeding • Alcohol intoxication • Use with caution when giving to patients with inferior or posterior wall myocardial infarction as morphine may cause bradycardia

44. Emergency Drugs and Equipments • Naloxone • Actions • Narcotic antagonist; blocks the effects of narcotics on the central nervous system • Indications • Overdose of opiate and opioid drugs Common opiates and opioids: Morphine Heroine Codeine Darvon Lomotil Percodan Methadone • Dosage • 0.4 to 2.0 mg initially given only to point of stimulating patient’s respiratory rate • Side effects • May precipitate withdrawal in patients who are addicted to narcotics • When it wears off, patient may lapse back into coma • Contraindications • None

45. Emergency Drugs and Equipments • Nitroglycerin • Actions • Vasodilator – dilates both arteries and veins • Reduces cardiac workload • Reduces preload • Reduces afterload • Reduces oxygen demand by myocardium • Indication • Angina • Acute myocardial infarction • Congestive heart failure with pulmonary edema • Dosage • 0.3 mg given SL, and may be repeated at 5 minute intervals three times • Side effects • Headache • Burning under the tongue • Hypotension • Weakness • Dizziness • Contraindications • Myocardial infarction with hypotension • Hypotension • Increased intracranial pressure • Glaucoma

46. Emergency Drugs and Equipments • Nitrous Oxide • Actions • Analgesic • Indications • Pain related to acute myocardial infarction • Dosage • Mixture of 50% nitrous oxide and 50% oxygen • Patient self-administers to prevent overdose • Side effects • Light-headedness • Drowsiness • Nausea and vomiting • Contraindications • Head injuries • COPD • Pulmonary edema • Abdominal distention • Shock

47. Emergency Drugs and Equipments • Oxygen • Actions • Increased arterial oxygen tension • Increased hemoglobin saturation • Increased oxygen delivery to tissues • Indications • Hypoxemia of any cause • Acute myocardial infarction • Trauma • Shock • Cardiopulmonary arrest • Dosage • Nasal cannula – 2 to 6 liters per minute • Simple mask – not less than 6 liters per minute • Reservoir mask – 10-15 liters per minute • Side effects • Decreased rate and depth of ventilations if patient has COPD • No side effects when given in high concentrations over short periods of time • Drying of mucous membranes if not humidified • Contraindications • None

48. REFERENCES • Medical Emergencies: Prepare Your Team for A Quick Response. Fast, T.B. Dental Management. Jan. 1987, 32-6. • Managing Emergencies in the Dental Office. Terezhlamy, G.T. • When the Patient’s Life in Your Hands. Dental Management. Aug. 1976. • Medical Emergencies: The Team Approach. Malamed, S.F. Alpha Omega. Fall 1984, 29-36. • Medical Emergencies in Dental Practice Part I – Preparation. Gobetti, J.P., et al. Journal of Michigan Dental Assoc. Vol. 61, Feb. 1979. • Emergency Preparedness: A Survey of Dental Practitioners. Fast, T.B., et al. JADA. Vol. 112, Apr. 1986, 499-501. • Emergency Kits for the Dental Practitioner. Jastak, J.T. J. Oreg. Dentl. Assoc. Winter 1983/84. • Medical Emergencies in Dental Practice Part III – Cardiovascular Emergencies. Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979. • Medical Emergencies in Dental Practice Part V: Miscellaneous Medical Emergencies. Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979. • Office Emergencies: An Outline of Causes, Symptoms, and Treatment. Freeman, N.S. et al. JADA. Vol. 94, Jan. 1977, 91-96. • Emergency Medical Therapy. Eisenberg and Copass. W.B. Saunders 2nd Ed. 1982. • Medical Emergencies in Dental Practice Part IV: The Dyspenic Patient. Dworin, A.M. and Gobetti, J.P. J. of Michigan Dental Assoc. Vol. 61, July-Aug. 1979.