Med. Emergencies Week 2 - Unconsciousness

unconsciousness

lack of response to sensory stimuli

hypoxia

low oxygen

anoxia

absence or lack of oxygen

consciousness

appropriate response to questions/commands with protective reflexes intact

faint

sudden, transient loss of consciousness

what are some predisposing factors that can lead to unconsciousness

stress, special needs (impaired physical status), drug administration (allergy, overdose, stress)

what are some signs and symptoms of unconsciousness

no response to stimuli, no protective reflex, loss of muscle tone

what does a person lose the ability to do when muscle tone is lost

keep airway open

what 2 things do you do if a patient losses muscle tone (ability to keep airway open)

1. maintain patient open airway to avoid hypoxia/anoxia

2. head tilt chin lift- moves base of tongue to open airway

what is the acronym for the steps for emergency management

R.E.P.A.I.R

What does the R stand for in REPAIR

Recognize signs and symptoms of an emergency

what does the E stand for in REPAIR

Evaluate the patient (level of consciousness...)

what does the P stand for in REPAIR

Position patient

what does the A stand for in REPAIR

Activate CAB's and CPR and monitor vitals (BSL if needed)

What does the I stand for in REPAIR?

Implement appropriate actions of emergency

what does the second R in REPAIR stand for

Refer patient to healthcare professional

list the steps for REPAIR in an unconscious patient

Recognize signs and symptoms

Evaluate patient (shake and shout test)

Position patient in supine position (feet above head)

Activate CAB's and CPR/monitor vitals

Implement appropriate action for emergency (depends of cause)

Refer

what 3 vitals do you check during ACTIVATE

circulation- carotid pulse for 10 sec

airway- head tilt chin lift

assess breathing- is patient breathing normal

syncope definition

abrupt loss of consciousness associated with inability to maintain postural tone

what causes syncope

decreased blood flow to the brain

a lack of WHAT to the brain can lead to syncope

Oxygen and glucose

what is another name for syncope

fainting

what is the number one cause of unconsciousness in the dental clinic

Vasodepressor syncope

what steps (causes) lead to vasodepressor syncope

1. patient becomes excited/nervous/anxious

2. heart rate increases

3. blood pressure decreases

4. blood pools in arms/legs

5. decreased blood to the heart and brain

6. leads to further decrease in BP and pulse

7. patient goes unconscious

what are psychogenic factors that can cause vasodepressor syncope

stress, fear, bad news, poor prognosis, pain

what NON-psychogenic factors can lead to syncope

hunger, poor health, upright position/standing log periods, fatigue, temperature (heat/crowded environment), male, age 16-35

vasodepressor syncope is most common in ____ aged ____

men, 16-35

how can vasodepressor syncope be avoided in a dental setting

1. observation and evaluation

2. decrease stressful situations (cover instrumnets)

3. have an honest, open approach

4. take time to visit with the patient

5. look at medical history

when looking at a patients medical history, what should you all look at when trying to avoid vasodepressor syncope

history of fainting spells, dizziness, medications, anxiety

anxious patients should do what before a stressful appointment

eat

list the signs and symptoms of pre-syncope

1. pale/ashen-grey

2. cold sweat

3. dizziness

4. nausea

5. warm feeling

6. rapid pulse initially

7. BP and pulse drop right before consciousness is lost

what are the signs and symptoms of syncope

1. death-like appearnace

2. irregular breathing (jerky/grasping, quiet/shallow, may temporarily stop)

3. dilated pupils

4. convulsive movements

5. Low BP

6. Slow pulse

a slow pulse during syncope would be < ____

50

what are some signs and symptoms of post-syncope (recovery stage)

1. pale, nausea, sweating, weakness

2. confusion

3. BP returns to normal

4. heart rate returns to normal

5. patient can easily faint again

after a patient faints, they are more likely to faint again, what do you NOT do?

leave them alone

after the patient recovers after vasodepressor syncope, what 3 things should you do

1. raise them up slowly

2. check their vitals

3. get patient a ride home

why does a patient need a ride home after vasodepressor syncope

it takes up to 24 hours to recover fully

what is an orthostatic (postural) syncope

syncope due to sudden drop in blood pressure when a patient is raised from supine to vertical position

what is the second leading cause of unconsciouness in a dental setting

postural syncope

orthostatic (postural) syncope is a drop of at least ___mmHg in systolic or ___mmHg in diastolic BP within ___ minutes after being supine for at least 5 minutes

20, 10, 3

during postural syncope, the body fails to increase ______ _____ ______ needed to maintain _______ when patient is raised ______

peripheral vascular resistance, blood pressure, upright

what are some predisposing factors that can lead to postural syncope

Drug therapy, prolonged recumbency, pregnancy, geriatric population, venous defects in legs

what is the number one cause of postural syncope in the dental setting

drug therapy

why is pregnancy a risk factor for postural syncope

the weight of the fetus affects venous return to the heart

incidents of postural syncope ____ with age

increase

T/F there are psychological factors that can lead to postural syncope

FALSE- it is all physical!!

why is venous defect in legs a risk factor for postural syncope

blood can pool in the legs and not enough returns to the heart

what are some steps that can be taken to prevent postural syncope in dental setting

1. Review medical history

2. bring patient upright in chair slowly and have them sit upright for 5 minutes

what is the purpose of raising the chair slowly and having the patient sit upright before leaving

allows the BP to adjust back to normal

what are the signs and symptoms of postural syncope

no warning signs, BP drops and patient is unconscious

is patient has history of postural syncope episodes they can/cannot drive home

can, once fully recovered

is patient has NO history of postural syncope episodes, you should get them a ____ and contact ____

ride home, physician

Cortisol is a _____

Glucocorticoteroid

cortisol is produced by the ___

adrenal gland

cortisol helps the body adapt to

stress

a lack of cortisol can lead to what 3 things

shock, cardiac arrest, death

what is adrenal insufficiency

when the body does not produce enough cortisol to adapt to stress

what is crushing syndrome

hypersecretion of cortisol

which is more life threatening, adrenal insufficiency or crushing syndrome

adrenal insufficiency

crushing syndrome can cause increased fat deposition in the face/back known as a

buffalo hump

Primary adrenal insufficiency is also know as

Addison's disease

what is the most common cause of Addison's disease

autoimmune destruction to adrenal cortex causing insufficient cortisol production

what is a less common cause of Addison's disease

secondary to chronic infectious diseases like TB or HIV

what is the treatment for Addison's disease

glucocorticosteroid therapy

what causes secondary adrenal insufficiency

a disruption to the pituitary gland

the pituitary gland sends signals where

to the adrenal cortex (tells it to produce cortisol)

what are some causes of secondary adrenal insufficiency

1. tumors, removal or radiation of pituitary gland

2. head trauma

3. lack of response of adrenal gland to pituitary signal

what is tertiary adrenal insufficiency

when patient has a normally functioning adrenal gland, but they have been receiving glucocorticosteroid therapy for another condition

in tertiary adrenal insufficiency, why does the adrenal gland stop producing glucocorticosteroids

they are receiving enough through medication for another condition

in tertiary adrenal insufficiency, what happens to the adrenal cortex

begins to atrophy due to misuse and can no longer produce cortisol during periods of stress

what causes adrenal insufficiency crisis in undiagnosed Addison's disease

patient does not produce enough cortisol to deal with stress

what causes adrenal insufficiency crisis in diagnosed Addison's disease

the patient stops taking meds or does not modify medication dose during stressful times

rule of two's:

____ or more of ____

for ____weeks or more

within in the last ____years of dental treatment

20mg, hydrocortisone, 2,

a patient on long term steroid therapy is a use if

they fall into the rule of twos

how can adrenal insufficiency/crisis be avoided

1. look medical history (steroid meds)

2.consult with patients' physician (may need to administer pre-med)

3. decrease stress for patient

how can you reduce stress for a patient

1. explain procedures

2. cover instruments

3. administer sedative

what are some signs and symptoms of adrenal insufficiency

1. severe hypotension

2. severe mental confusion

3. nausea/vomiting

4. abdominal pain

5. fever

6. shock, coma, death

If pulse O2 drops below then you need to titrate to

90%, 90-98%

What do steriods normally end in

ONE

What are the 3 glucocorticosteriods to know

Hydrocortisone (20mg) Prednisone (5mg), Prednisolone (5mg)

is the most common reason for a medical emergency in a dental setting

Stress