Dental Office Medical Emergencies – Comprehensive Bullet-Point Study Notes

Asthma & Bronchospasm

• Pathophysiology
  • Acute episode = spasm of smooth muscle around bronchi/bronchioles → marked luminal narrowing.
  • Consequence: inadequate O₂ in / CO₂ out → potential fatal hypoxia / hypercarbia.

• Pre-appointment history checklist
  • "What type of asthma do you have?" – \text{Allergic} vs \text{Non-allergic}.
  • Non-allergic often precipitated by fear / anxiety / inadequate pain control.
  • Ask: "What are you allergic to?" (aspirin common trigger).
  • Current meds: rescue bronchodilator (e.g., albuterol) ± daily inhaled corticosteroid.
  • Frequency & triggers of attacks; recent attacks in dental chairs? fear of dentistry = red flag.
  • History of attacks that "did not stop" or hospitalization → determines need to pre-alert 911.

• Preventive office strategies
  • Advise pt during confirmation call to bring own inhaler (rescue med).
  • Consider prophylactic sedation if stress-induced attacks likely.

• In-office management of an attack
  • Immediately sit pt upright (easier diaphragmatic excursion).
  • Encourage self-administration of rescue inhaler placed on bracket tray.
  • Typical dose: 2 puffs; reassess after 5 min; may repeat.
  • If pt, provider, or situation remains uncomfortable → terminate procedure, reschedule, treat underlying fear before resuming care.
  • Office backup: own bronchodilator if pt’s fails.

Airway Obstruction (Choking)

• Most common cause: food; pt initially conscious but mute; universal choking sign.
• Critical window: if airway not reopened within 15–20 s → loss of consciousness.
• Management sequence
  • Abdominal thrusts (Heimlich) on conscious pt.
  • Activate EMS, assess need for medical evaluation even after object expelled.
• Dental-specific prevention
  • Tie dental floss to any small object placed intra-orally (rubber dam clamp, implant screw, cotton roll etc.) – "little things save lives".

Allergic Reactions & Anaphylaxis

• Immunology crash-course
  • Allergen binds to sensitized mast-cell receptors → degranulation → release of chemical mediators (primarily histamine).
  • Histamine actions: itching, urticaria, rash, bronchospasm, vasodilation, edema.
  • Severity depends on speed + site of mediator release:
  – Skin-only = pruritus / rash (non-life-threatening).
  – Lungs = bronchospasm.
  – CVS = vasodilation ↓BP + edema → anaphylaxis.

• Classification by onset
  • Late (delayed) onset: signs ≥ 1 h post-exposure; usually cutaneous; e.g., pt who took prophylactic penicillin developed mild rash.
  • Immediate onset: seconds–minutes; involves skin + airway and/or CVS = true anaphylaxis.

• Management algorithm (PABCD)
  • P – Position: unconscious → supine; conscious → whatever eases breathing.
  • A/B/C – assess, support airway, breathing, circulation; instruct staff to call 911.
  • D – Definitive drug: Epinephrine 0.3–0.5 mg IM mid-thigh ASAP; repeat q 5 min until recovery or ALS arrives.
  – Benefits: potent bronchodilation + vasopressor (restores BP).
  – No absolute contraindication when anaphylaxis suspected.
  • After epi & once pt stable → administer antihistamine (e.g., diphenhydramine) to blunt residual histamine.

Local Anesthetic (LA) Overdose

• Error chain
  • Wrong treatment plan: four-quadrant dentistry in one visit on child.
  • Wrong drug: long-acting LA w/ vasoconstrictor when short-acting sufficient.
  • Injecting every quadrant sequentially.
  • Using full cartridge 1.8\,\text{mL} per site when fraction would suffice.

• Toxicity timeline
  • Peak blood level ≈ 5 min post-injection; first manifestation often generalized seizure <60 s.
  • If airway not maintained post-seizure → hypoxia + hypercarbia ↓ seizure threshold → second, longer seizure 2–3 min later.

• Management
  • Secure airway, deliver \ge 5\,\text{L/min} O₂.
  • Prevent hypoxia / hypercarbia to avoid recurrence.
  • Monitor vitals until drug redistributes & pt recovers.

Oral / Inhalation Sedatives & Monitoring

• Premed given ≈ 60 min pre-procedure; pt must remain under continuous observation.
• Once in chair:
  • Apply pulse oximeter – real-time SpO₂ & HR.
  • Low-SpO₂ alarm → immediate airway check, reposition, supplemental O₂, consider reversal agents if narcotics/benzodiazepines involved.

Coronary Artery Disease (CAD) & Acute Coronary Syndromes

• Pathogenesis
  • Atherosclerotic plaque buildup in coronary walls → chronic inflammation → luminal narrowing.
  • Stress/effort ↑ myocardial O₂ demand; narrowed lumen can’t augment supply → ischemia.

• Angina Pectoris
  • Ischemic chest discomfort: tight/heavy; pt may clench fist over sternum (Levine sign).
  • Usually known dx; relieved by vasodilator (nitroglycerin).

• Myocardial Infarction (MI)
  • Plaque rupture → platelet aggregation → thrombus occludes artery → downstream myocardium ischemic → necrosis.
  • Ischemic tissue electrically unstable → arrhythmias → sudden cardiac arrest.
  • "Golden window": reperfusion (balloon angioplasty or thrombolytics) within 2 h → minimal damage.

• Chair-side differentiation & first aid
  • Persistent pain after 3 doses nitro (q 5 min) OR first-ever chest pain → treat as MI.
  • Immediate steps (MONA):
  – Morphine IV (or 50\% N₂O/O₂ mix if available) for pain & anxiety.
  – Oxygen 5 L/min via mask or cannula.
  – Nitroglycerin sub-lingual or spray up to 3 doses unless hypotensive.
  – Aspirin 325 mg chew & swallow if no contraindication (allergy, GI bleed, anticoag tx).
  • Always activate EMS early.
  • Typical MI pain scale: 10/10; may radiate to epigastrium, L-arm (pinky tingling), L-neck, L-mandible; pt pale, diaphoretic, anxious but conscious.

Cardiac Arrest, CPR & AED

• Only signs: sudden unresponsiveness + apnea + no carotid pulse.
• Provider sequence
  • Stop dental work; shout for help.
  • Check responsiveness; call/name; no response.
  • Open airway (head-tilt/chin-lift), look–listen–feel; if no breathing → 2 rescue breaths with O₂.
  • Palpate carotid 10 s; if pulseless start high-quality chest compressions.
  • Delegate: "Activate 911, bring emergency kit & AED!"
  • Continue CPR at 100–120 compressions/min, depth \approx 2 in (adult) with minimal interruptions.
  • Apply AED ASAP; follow prompts – defibrillate if advised.
• Complications
  • Rib fractures common, especially elderly / osteoporotic – legally acceptable outcome when CPR done correctly.
  • Multiple shocks cause skin burns; continue care until ROSC or ALS arrival.

Infection-Control Nuggets Identified in Video

• Observed lapses: contaminated gloves touching cabinets/phones, jewelry under gloves, etc.
• Reminder: maintain high standards (hand hygiene, PPE removal before touching non-clinical surfaces, no jewelry) – clinical reality often falls short; vigilance protects patients & providers.