CHAPTER 10: MEDICAL EMERGENCIES

sas + ppt + notes

morbidity

a diseased state, disability or poor health due to any cause

mortality

emergencies that may threaten the patient’s life and state of being subject to death

oxygen

primary emergency drug in the dental office

hypoxemia (low oxygen content in the arterial blood) → the final common pathway to morbidity and mortality in the majority of severe pediatric medical emergency situations

oxygen may be delivered through:

• facemask

• positive pressure ventilation (bag-valve-mask device)

• mouth-to-mouth, mouth-to-mask (not ideal, delivers only 17% oxygen)

10 basic emergency drugs

albuterol

aspirin

diphenhydramine

epinephrine

glucose(oral)

midazolam(Versed)

naloxone

nitrogylcerine

oxygen

flumazenil(Romazicon)

albuterol

treatment of bronchospasm in either asthma attack or allergic reaction

aspirin

suspected acute coronary syndrome

diphenhydramine

allergic reactions

epinephrine

anaphylaxis for severe persistent asthma and bronchospasm

midazolam (versed)

anticonvulsant for the management of status epilepticus

naloxone

reverses opoiod medication, narcotic overdose

nitrogylcerine

chest pain as a result of angina or mycardial infarction

oxygen delivery (the primary drug)

minimum E cylinder capable of >90% oxygen at 10L/min for 1hr

must be paired with properly sized bag-valve masks (infant to adult)

• 1st rescuer → uses thumb & index finger to form a C sealing the mask, remaining 3 fingers form an E along the mandible to hold the airway open

• 2nd rescuer → squeezes the bag

high-volume evacuation

a yankauer suction tip connected to the high-volume dental evacuation unit

critical for clearing vomitus to prevent lethal aspiration

defibrillation

automated external defibrillator (AED) with both adult and pediatric pads <25kg

flumazenil (romazicon)

indicated to reverse oversedation and respiratory depression

5 basic steps for management of medical emergencies

position

circulation

airway

breathing

definitive treatment

in order: PCABD

position

supine position → for unconscious patients

benefits:

• minimize work of the heart

• increase vital blood flow to the brain

• increase return of pooled blood from the extremities

circulation

the first assessment step is to determine if the patient has a pulse

carotid pulse → easiest and most accurate in the adult and child patient (located under the sternocleidomastoid muscle in the neck)

agonal breathing / no chest movement → begin with chest compressions immediately

• for adult → carotid

• for pedia → brachial

[di dapat idungan ug palpate ang 2 sides of carotid → may cause reflex bradychardia ]

adult compression

30:2 ratio

1-2mm depth

full recoil, fast

airway

most common cause of airway obstruction is the tongue

when patient is unconscious the musculature supporting the mandible will become relaxed which allows the base of the tongue to fall against the posterior pharyngeal tissues creating an obstruction

preventive measures:

• suction

• oral packing

• chair position

• use of rubber dam

management:

• tilt - chin - lift

• jaw thrust movement

• heimlich maneuver

allergy

penicillin and latex → primary agents employed in pediatric dentistry that provoke allergic reaction

a hypersensitivity response by the immune system to antigens that are recognized as foreign

immediate position:

• recumbent with elevated legs

management:

• mild reaction → diphenhydramine 25-50mg of oral or 1mg/kg for pedia

• rapid onset allergic reactions → diphenhydramine 1mg/kg or up to 50mg IM

severe systemic allergic reactions

• gastrointestinal:

  • abdominal cramps, nausea, vomiting, diarrhea

• skin:

  • flushing, urticarial, angioedema

• respiratory:

  • wheezing, laryngeal edema, respiratory distress

• cardiovascular:

  • hypotension, tachycardia, dizziness, loss of consciousness , cardiovascular collapse

asthma

aka: acute bronchospasm

described as inflammatory disorder of the airway that results in intermittent airflow obstruction

management:

• albuterol (inhaler)

immediate position:

• upright position

symptoms:

• wheezing, dyspnea, tachypnea

• high anxiety, accessory muscle use

2 types:

• extrinsic asthma → common in children, mediated by IgE antibodies (dust, pollen, molds)

• intrinsic asthma → common in adults due to exercise, stress, cold weather, infection

if unresponsive to albuterol treat it as status asthmaticus → managed w epinephrine

diabetic emergencies

management:

• oral glucose tabs 37.5g (can be repeated as necessary)

• sugar dissolved in juice or softdrinks

hyperventilation

anxiety is the most common cause

increase ventilation causes a marked reduction in the blood carbon dioxide

defined as a maladaptive anxiety reaction that primarily occurs in apprehensive patients who attempt to hide their anxiety

decrease in the arterial partial pressure of carbon dioxide (PaCo2) hypocarbia, causes physiologic vasoconstriction of arteries

management:

• early recognition, reassurance, patient rapport

• calmly coaching the patient to breathe slowly

• terminate procedure, position patient (upright)

drug management:

• 10-15mg diazepam or 3-5mg midazolam IV

• do not administer oxygen!

• steps should be taken to increase PaCo2 simply by having the patient rebreathe exhaled CO2-containing air

seizures

aka: status epilepticus

life-threatening emergency causing hyperthermia and brain hypoxia

clinical manifestations of paroxysmal excessive neuronal brain activity

clinical signs:

• tonic-clonic movements lasting >5mins

immediate position:

• supine w legs elevated

management:

• clearing the area

• gentle immobilization (stabilization)

• positioning of the patient to prevent self injury

phases: prodromal → aura → ictal phase (tonic-clonic) → postictal phase

prodromal phase

not clinically visible

subtle early warning signs, days, or hours before

aura phase

focal sensory or experiential warning

neurological experience, no physical manifestation yet

ictal phase

1-3mins uncontrolled electrical CNS discharge causing rigid skeletal contraction followed by rapid jerking

• tonic → skeletal muscle being rigid

• clonic → rapid jerking movements

postictal phase

most critical as it can cause obturdent, hypoglycemia

significant CNS and respiratory depression, confusion, fatigue

hypoglycemia

aka: insulin shock

clinical signs:

• tachycardia, anxiety, ataxia,

• slurred speech, confusion

immediate position:

• upright / position of comfort

syncope

aka: vasodepressor

most common medical emergency in the dental office

clinical signs:

• pallor, presyncope dizziness

• loss of consciousness, bradychardia

management:

• supine position with legs slightly elevated

• administer oxygen

vasopressor syncope (aka: simple faint)

• most common type of syncope

• cause for loss of consciousness in the dental office

cardiac arrest

something wrong in electrical transmission and theres a presence of Q-wave elevation

clinical signs:

• agonal breathing, lack of central pulse

immediate position:

• supine on hard surface

epinephrine 1:1000

0.3mg (adult), 0.15mg (child) IM

action is sympathetic

indicated for anaphylaxis / severe asthma

albuterol

2 puffs or 2.5mg nebulized

action is B2 agonist

indicated for bronchospasm

diphenhydramine

1mg/kg IM/IV (max 50mg)

action is histamine blocker

indicated for mild allergy

glucose (oral)

dose is 37.5g tube

action is it raises blood sugar

indicated for hypoglycemia

midazolam

0.2 mg/kg IM/IN

action is anticonvulsant

indicated for status epilepticus

oxygen

dosage is 8-15 L/min (non-breather)

indicated for hypoxemia

action is increases blood O2

aspirin

324mg chewed

action is antiplatelet

indicated for myocardial infarction

naloxone

0.1mg/kg (pediatric max 2mg)

indicated opioid overdose

action is opioid antagonist

nitroglycerin

0.4mg sublingual

action is vasodilator

indicated for angina pectoris

flumazenil

0.01mg/kg IM/IV

action is benzodiazepine antagonist

indicated benzodiazepine overdose