11 - Management of Medical Emergencies in the Dental Office

Medical Emergencies Commonly Provoked by Anxiety

• Angina pectoris

• Myocardial infarction

• Asthmatic bronchospasm

• Adrenal insufficiency (acute)

• Hyperventilation

• Epilepsy/seizures

Supplies for establishment and maintenance of IV access:

• Plastic indwelling (Jelco)

• Metal indwelling (Butterfly)

• IV tubing with flow valve

• Tourniquet

• 1-inch-wide plastic tape

• Crystalloid solution (normal

saline, lactated ringers, D5W)

Supplies for high-volume suction:

• Large-diameter suction tip

• Tonsillar suction tip

• Extension tubing

• Connectors to adapt tubing to office suction

Supplies for drug administration:

• Plastic syringes ( 5- and 10-mL sizes)

• Needles (18 and 21 gauge)

Supplies for oxygen administration

• Clear face mask

• Resuscitation bag (AMBU)

• Extension oxygen tubing (with and without nasal cannula)

• Oxygen cylinder with flow valve

• Oral and nasal airways

• Lubricating jelly

Parenteral Preparations

Anticonvulsant

Diazepam, midazolam

Parenteral Preparations

Antihistamine

Diphenhydramine (Benadryl)

Parenteral Preparations

Antihypoglycemic

50% dextrose in water(D50), glucagon

Parenteral Preparations

Corticosteroid

Methylprednisolone (Solu-Cortef), Hydrocortisone

Parenteral Preparations

Narcotic antagonist

Naloxone (Narcan)

Parenteral Preparations

Symphathomimetic

Epinephrine

Parenteral Preparations

Vagolytic

Atropine

Oral Preparations

Antihistamine

Diphenhydramine (Benadryl)

Oral Preparations

Antihypoglycemic

Candy, fruit juice, sugar tablet, glucose gel

Oral Preparations

Vasodilator

Nitroglycerin (Nitrostat, Nitrolingual)

Inhaled Preparations

Bronchodilator

Albuterol (Proventil, Ventolin)

short-acting B2 agonist

Inhaled Preparations

Respiratory stimulant

aromatic ammonia

Inhaled Preparations

Analgesic/Sedative

Nitrous Oxide

Basic Life Support (BLS) ABCs

A- Airway

B- Breathing

C- Circulation

Basic Life Support (BLS) Certification

1. Extending head at the neck by tilting _____ back with one hand and ____ neck up with other hand

forehead

lifting

Basic Life Support (BLS) Certification

2. Pushing mandible forward by pressure on the ____ ____

mandibular angles

Basic Life Support (BLS) Certification

3. Pulling mandible forward by pulling on _____ mandible

anterior

Basic Life Support (BLS) Certification

4. Pulling tongue forward using ____ material or instrument to grasp anterior tongue

suture

Basic Life Support (BLS) Certification

Breathing provided by one of the following:

1. Mouth-to-mouth or mouth-to-mask ventilation

2. Resuscitation bag ventilation

Basic Life Support (BLS) Certification

Circulation provided by external _____ ____

cardiac compressions

Emergencies of Altered Consciousness

• Syncope

• Hypoglycemia

• Seizure

• Stroke

A sudden, transient loss of consciousness that is usually secondary to a period of cerebral ischemia

syncope

Synonyms of Syncope

• Atrial bradycardia

• Faint

• Neurogenic syncope

• Psychogenic syncope

• Swoon

• Vasodepressor syncope

• Vasovagal syncope

_____ is probably most common systemic complication seen in the dental office

Syncope

Syncope Predisposing Psychogenic Factors:

• Fright (sight of blood/local anesthetic syringe and needle)

• Anxiety

• Emotional Stress

• Pain – acute and unexpecte

Syncope Predisposing Non-Psychogenic Factors:

• Moving from a supine position to sitting in an upright

position or standing

• Hunger from dieting or a missed meal (hypoglycemia)

• Exhaustion

• Poor physical condition

• Hot, humid environment

• Age between 16 and 40

Best Method of Management for Syncope is Prevention

Try to eliminate all predisposing ______ and ______ factors

psychogenic

non-psychogenic

Best Method of Management for Syncope is Prevention

Remember- the injection of ____ ____ is the dentalprocedure that most often precipitates a syncopal episode.

local anesthesia

what position should we place the patient in before giving anesthetic

semi-supine

Pre-syncopal Clinical Manifestations - Early

• Feeling of warmth

• “Don’t feel well”

• Nausea

• Loss of color- ashen-gray

• Perspiration

• Blood pressure- about baseline

• Tachycardia

Pre-syncopal Clinical Manifestations - Late

- Pupillary dilation

• Coldness in hands/feet

• Hypotension

• Bradycardia

• Visual disturbance

• Dizziness

• Loss of consciousness

Clinical Manifestations During Syncope:

• Respiration is irregular/shallow

• Pupillary dilation

• Muscular twitching of extremities/face

• Bradycardia- pulse < 60

• Hypotension < 90/60

• Loss of consciousness

• Muscular relaxation- incontinence

Unconsciousness due to syncope may last from ____ to several ____

seconds

minutes

Complete clinical recovery from syncope should occur in ____ minutes.

15-20

Syncope Roadmap - Image

Manifestations of Acute Hypoglycemia

Mild hypoglycemia range

60-70mg/dl

Manifestations of Acute Hypoglycemia - Mild

60-70

Hunger

Nausea

Mood change

Weakness

Lethargic

Manifestations of Acute Hypoglycemia

Moderate hypoglycemia range

50-60 mg/dl

Manifestations of Acute Hypoglycemia - Moderate

Moderate (50-60)

Tachycardia

Perspiration

Pallor

Anxiety

Behavioral change:

• Belligerence

• Confusion

• Uncooperativeness

Manifestations of Acute Hypoglycemia

Severe hypoglycemia range

<50 mg/dl

Manifestations of Acute Hypoglycemia - Severe

Severe <50

Hypotension

Unconsciousness

Seizures

Iatrogenic Hypoglycemia (Insulin Shock) - Risk Factors

• Skipped or insufficient meals

• Excessive physical exertion

• Inappropriate insulin or oral hypoglycemic therapy

• Alcohol ingestion (while liver enzymes metabolize alcohol the liver may

not release stored glucose)

Alcohol can cause Iatrogenic hypoglycemia because while liver enzymes metabolize alcohol the liver may not release stored ____

glucose

Management of Acute Hypoglycemia

_____ all dental treatment. Check blood _____ with glucomete

Terminate

glucose

Signs and symptoms of mild hypoglycemia

1. Administer ____ ___ for mild symptoms ____ grams of carbohydrates

oral glucose

10-15

(ex. ½ cup of orange juice or regular soda; 3 glucose tablets, etc.)

Signs and symptoms of mild hypoglycemia

2. Monitor vital signs

3. Consult ____ if unsure of why hypoglycemia occurred before further dental care

physician

Signs and symptoms of moderate hypoglycemia

1. Administer _____ source such as sugar or fruit juice orally

2. Monitor vital signs

glucose

with hypoglycemia we want to achieve blood glucose of ____ mg/dl or greater

100

With hypoglycemia, if symptoms do not improve within ___ minutes, treat with an additional ___ grams of carbohydrate

15

10-15

Signs and symptoms of severe hypoglycemia

1. Administer ___ ml of 50% dextrose IV or _ mg glucagon IM, IV or intranasal

2. Have someone summon ____ ____

50

1

medical assistance

Signs and symptoms of severe hypoglycemia

3. Monitor vital signs

4. Administer _____

5. Transport to _____ ____ facility

oxygen

emergency care

Manifestations/Kinds of Acute Seizures

Isolated, brief seizure

Tonic-clonic movements of trunk extremities, loss of consciousness, vomiting, airway obstruction, loss of urinary and anal sphincter control

Acute Management of Seizures

1. ____ all dental treatment

2. Place in ____ position

3. Protect from nearby objects and gently _____ patient

Terminate

supine

restrain

After Seizure - Patient Unconscious

1. Have someone summon medical assistance

2. Place on side and suction airway

3. Monitor vital signs

4. Initiate BLS (if necessary)

5. Administer oxygen

6. Transport to emergency care facility

After Seizure - Patient Conscious

1. Suction airway if necessary

2. Monitor vital signs

3. Administer oxygen

4. Consult physician

5. Observe in office for 1 hour

6. Have patient escorted home

Repeated or sustained seizure >5 mins (status epilepticus)

1. Diazepam ___ mg/min IV up to ___ mg or midazolam ___ mg/min IV or IM up to ___

mg titrated until seizure stops. Or use of nasal _____ (Nayzilam)

2. Have someone summon medical assistance

3. Protect from nearby objects

5

10

3

6

versed

_____ is the third leading cause of death in the United States

Stroke

what are the 2 types of strokes

Hemorrhagic vs. occlusive (ischemic)

____ diagnosis is important with strokes

rapid

Early treatment with ____ agents significantly improves outcomes with strokes

thrombolytic

Especially within the first 90 mins of symptom onset

Stroke Manifestations:

Airway, breathing, and circulation are usually ____

normal

Stroke manifestations

• Headache- can range from mild to the worst the patient ever experienced

• Slurring of speech or inability to speak (aphasic)

• Difficulty swallowing

• Confusion

• Weakness or paralysis of extremities and/or facial muscles unilaterally, drooping of face

• Asymmetry in grip strength

• Visual disturbance, blurred vision

• Loss of smell

• Dizziness, loss of balance

• Seizures

• Partial or total loss of consciousness

Management of Stroke in Progress

1. Terminate all dental treatment

2. Have someone summon medical assistance

3. Position patient in _____ position with head slightly raised. Want to avoid increasing _____ ____

supine

intracranial pressure (ICP)

Management of Stroke in Progress

4. Place patient on ____ and institute BLS if necessary

5. Transport to ____ ___ facility ASAP

oxygen

emergency care

It is estimated that 85% of all strokes are of the _____ nature.

occlusive

_____ drugs must be given within 3-4 hours of symptoms in order to be

effective for stroked

Thrombolytic

i.e., TPA, Streptokinase

Emergencies of Respiratory Distress

• Hyperventilation

• Asthmatic bronchospasm

• Airway obstruction

hyperventilation

systolic BP ____, diastolic BP ____, and HR _____

increases x3

hyperventilation

respiratory rate ____ and depth of respiration ______

increases

increases or decreases

normal respiratory rate vs hyperventilation

normal 12-16

can increase up to 30

With hyperventilation, excessive “blowing off” of CO2 leads to a respiratory _____

alkalosis

high pH

in hyperventilation, blood ph can increase up to ____

7.55 (normal is 7.35-7.45)

Respiratory alkalosis may decrease level of ionized _____ in the blood which causes neuromuscular irritability leading to ____.

calcium

tetany

Carpopedal Tetany- _____ muscle contractions, spasm of fingers and toes

sustained

Manifestations of Hyperventilation Syndrome - Image

Management of Hyperventilation Syndrome

1. Terminate all dental treatment and remove foreign bodies from mouth

2. Position patient in chair in almost full ____ position

3. Attempt to ____ calm patient

upright

verbally

Management of Hyperventilation Syndrome

4. Have patient breathe ___-enriched air

5. If symptoms persist or worsen, administer:

______ - 5-10 mg IV, titrate slowly, until anxiety relieved

OR

______- 4-5 mg IM or intravenously titrate slowly, until anxiety relieved

CO2 (breathe into cupped hands)

Diazepam

Midazolam

Management of Hyperventilation Syndrome

6. Monitor vital signs

7. Perform all further dental surgery using _____-_____ measures

anxiety-reducing

Mild to Moderate Asthmatic Symptoms

• Coughing

• Anxiety

• Tachycardia

• Wheezing (audible with or without stethoscope)

• Dyspnea (labored breathing)

Severe Asthmatic Symptoms

• Extreme anxiety

• Flushing of face

• Perspiration

• Intense dyspnea with flaring of nostrils and use of accessory muscles for respiration

• Cyanosis of mucous membranes and nailbeds

• Minimal breath sounds on auscultation

• Mental confusion

Management of Acute Asthma Episode Occurring During Dental Surgery

1. Terminate all dental treatment

2. Position patient in fully ____ posture

3. Administer short-acting ____ by spray (albuterol)

4. Administer _____

5. Monitor vital signs

sitting

bronchodilator

oxygen

Management of Acute Asthma Episode Occurring During Dental Surgery

Signs and symptoms relieved

Monitor during recovery in office

Management of Acute Asthma Episode Occurring During Dental Surgery

Signs and symptoms continue

1. Give epinephrine 0.3 ml of 1:1,000 IM or SQ

2. Monitor vital signs during recovery

Management of Acute Asthma Episode Occurring During Dental Surgery

Signs and symptoms not relieved

1. Call for medical assistance

2. Prepare for transport to emergency care facility

Airway Obstruction

Patients with an effective cough should be left alone with the hope that they can forcibly ____ and _____ the offending foreign body.

cough

remove

Management of Airway Obstruction

Heimlich Maneuver (abdominal thrusts)

Airway Obstruction Management

If patient becomes unconcious

call 911

Airway Obstruction Management:

1. Place patient in _____ position.

2. Tongue- jaw lift maneuver.

3. _____ ____ of mouth if obstruction seen.

4. If not seen, ___ chest compressions at _____beats/min.

supine

Finger sweep

30, 100-120

Airway Obstruction Management

5. After 30 chest compressions, open mouth and look for foreign object. If seen, try to retrieve it.

6. If not seen, head tilt- chin lift, give __ rescue breaths.

7. If chest does not rise, reposition head and try 2 breaths again.

8. If chest does not rise, repeat cycle of __ chest compressions.

2

30

Allergy - skin signs and symptoms

• Pruritis- itching (often the first sign)

• Rash- red patches of skin

• Urticaria- smooth elevated patches of skin (wheals, hives)

• Angioedema- localized swelling

*Frequently involves face, hands, feet, genitalia. Also may involve lips, tongue, pharynx, larynx

Allergic Rxn - image

Allergic Reaction - Angioedema image

Signs and Symptoms - Bronchospasm

• Respiratory distress (constriction of bronchial airways)

• Increased anxiety

• Tachycardia

• Flushing of the face and neck

• Perspiration

• Wheezing

• Cyanosis- oral mucosa, nail beds

• Use of accessory muscles of respiration

Allergy Generalized Anaphylaxis- multiple organ systems

• Skin reactions

• Smooth muscle spasm of GI (nausea, cramping)

• Smooth muscle spasm of GU (loss of bladder control/incontinence,

genital angioedema)

• Smooth muscle spasm of respiratory tract (bronchospasm)

• Respiratory distress

• Cardiovascular collapse- vasodilation, hypotension

Generalized Anaphylaxis

____ ____ and ______ release histamine and leukotrienes into the blood stream.

Mast cells

basophils