Management of Sedation Emergencies

1. Management of Sedation Emergencies Patrick D. McCarty, DDS Dentist Anesthesiologist McCarty Anesthesiology, LLC Cambridge, MA 02141 617.913.3363 www.zzzdmd.com mccarty.dental.anesthesia@gmail.com

2. Preventing Emergencies • Thorough medical history • Baseline vital signs • Continuous monitoring • PRECORDIAL stethoscope • Local anesthesia: aspiration & slow injection • BLS/CPR training - all office personnel

3. Biographical data Chief complaint History of present illness Past medical history Family history Social history Medications Allergies Review of systems Physical exam Laboratory values Assessment/plan Medical History

4. Assessment Call for help Position Airway Breathing Circulation Cardiopulmonaryresuscitation Basic Life Support Principles

5. Syncope(Hypotension) • DEFINITION: massive peripheral vasodilation leading to low cardiac output resulting in decreased cerebral blood flow which often results in transient loss of consciousness • Most common emergency

6. Syncope Causes: • Fear and anxiety • Orthostatic/postural hypotension • Cardiac conduction defects

7. Syncope Prevention: • Medical history • Stress reduction protocol • Patient position • Oxygen

8. Syncope Symptoms: • Pale ashen-gray appearance • Sweaty • Nausea • Eyes dilate • Convulsive movements

9. Syncope Treatment: • POSITION SUPINE with FEET ELEVATED • Administer 100% OXYGEN • MONITOR VITALS: respiration, pulse, blood pressure, and oxygen saturation • Loosen tight clothing

10. Syncope Treatment: (continued) • Cool, moist towel to patients forehead (provides stimulation) • AMMONIA (if unconscious) • If hypotension persists, EPINEPHRINE (1:10,000) 0.01 mg/kg IV/IM • If bradycardia, ATROPINE 0.01 mg IV/IM

11. Hyperventilation Syndrome • DEFINITION: anxiety induced increased ventilation resulting in a reduction of the carbon dioxide tension of the blood, may typically result in Carpopedal spasm

12. Hyperventilation Syndrome Cause: • Fear and anxiety • Most common in women between the ages of 15 and 40

13. Hyperventilation Syndrome Prevention: • Past hyperventilation history • Recognition and management of anxiety • Stress reduction protocol

14. Symptoms: Feeling of suffocation Tightness in chest Fast respiration Giddy Light-headedness Tingling or paresthesia Color usually good Trembling Carpopedal spasm Hyperventilation Syndrome

15. Hyperventilation Syndrome Treatment: • POSITION comfortably • DO NOT GIVE OXYGEN !!!!!!! • Reassure patient

16. Hyperventilation Syndrome • Rebreathing in paper bag, head rest cover or your hands • VERSED 1-2 mg IV/IM (only in most severe cases. Titrate to relaxation)

17. Airway Obstruction • DEFINITION: partial or complete obstruction of the airway. Frequently caused by object falling into the oral pharynx. Most serious are objects entering the larynx or trachea.

18. Airway Obstruction Causes: • Dental objects (head of handpiece, mouth mirror, endodontic file, crown, extracted tooth, amalgam, or calculus)

19. Airway Obstruction Prevention: • Use rubber dam for restorative and endodontic procedures • Use "loose" throat screen for extraction or seating crowns (4x4 gauze)

20. Airway Obstruction Symptoms: • Noisy breathing is partial obstruction • Victim gasping for breath with great effort

21. Airway Obstruction • Retraction of suprasternal notch and/or intercostal regions during attempted inspiration (complete obstruction) • Patient unable to speak (universal sign hand at throat)

22. Airway Obstruction Treatment: (HEIMLICH maneuver) • POSITION (if conscious) behind patient, wrap your arms around their abdomen, one fist placed into abdomen (thumb side first) other hand over fist.

23. Airway Obstruction • Administer ABDOMINAL THRUSTS brisk inward and upward delivery back blows are no longer recommended in adults or children older than one year of age • Remove foreign body (use finger, suction, etc.)

24. Airway Obstruction TREATMENT: (continued) • Airway maneuver: A) head-tilted B) displace mandible forward C) retract lower lip to allow breathing between lips D) attempt to ventilate

25. Aspiration of Vomitus • DEFINITION: aspiration of vomitus into pulmonary tract while protective reflexes are not intact (unconscious) • Sixty-two percent mortality

26. Aspiration of Vomitus Diagnosis: • High index of suspicion (vomiting while patient has altered protective reflexes) • Auscultation of chest • X-ray examination • Arterial blood gases • Elevated temperature within 12 hours

27. Aspiration of Vomitus Prevention: • Keep patient CONSCIOUS • Include anti-emetic in sedation medications • NPO for at least 6 hours (gen anesth) • High volume suction (especially for sedation or general anesthesia)

28. Aspiration of Vomitus Treatment: • Position TRENDELENBURG • Roll onto RIGHT SIDE (helps confine aspirate to right lung) • Suction VOMITUS • Administer 100% OXYGEN • DEXAMETHASONE 10 mg IV / IM or SOLU-CORTEF 50 mg IV • Transport to emergency care facility

29. Bradycardia • DEFINITION: heart rate slower than 60/min, from unexplained cause (Must understand heart rate is age dependent)

30. Bradycardia Causes: • Increased Vagal tone as in sinus bradycardia. (Pressure on eyes or pulling on tongue can also be cause of increased Vagal tone) • Block in the cardiac conduction system

31. Bradycardia Prevention: • Medical history • Stress reduction protocol

32. Bradycardia Treatment: • Position comfortable • Reassure patient • Give 100% OXYGEN via loose mask or nasal cannula • Atropine 0.02 mg/kg IV/IM (Max 0.5 - 1 mg) • Use basic life support if unconscious

33. Seizure • DEFINITION: convulsions resulting from excessive neuronal discharge which spreads throughout the brain

34. Seizure Causes: • Spontaneously occurring (i.e. Epilepsy) • Toxic effect of medications on the CNS (i.e. lidocaine) • Metabolic disorders (i.e. Hypoglycemia)

35. Seizure Prevention: • Medical history • Stress reduction protocol

36. Seizure Treatment: • Position supine • Prevent injury: use padded tongue blade as mouth prop (some will disagree) • Administer 100% OXYGEN • Reassure patient

37. Seizure • If seizure recurs: VERSED 1-2 mg IV/IM, May repeat in 2 min one time • If seizure not controlled, call 911 • DISCONTINUE all further dental treatment for that day

38. Stress Reduction Protocol • Patient should sleep well the night before the appointment • Use pre-op medication • Use intraoperative sedation if indicated (PO / IM / IV / INHALATIONAL)

39. Stress Reduction Protocol • Consider morning appointment (functional reserve is usually highest in the morning) • Consider limiting the length of the treatment to avoid exceeding the patients level of physical or emotional tolerance

40. Stress Reduction Protocol • Consider post-op control of pain and anxiety • Schedule appointment when the DOCTOR will be available on call for post-op problems • Telephone the patient in the evening after the appointment to provide emotional support (great practice builder, too!)