16. Behavior in emergency situations in the maxillofacial and oral surgery. Flashcards
Syncope, and its main characteristics
- Transient loss of consciousness and postural tone=>
- Spontaneous recovery without neurological deficit
Most common cause of unconsciousness in a dental office setting
Vasovagal syncope
Psychogenic and non-psychogenic causes of vasovagal syncope
- Psychogenic=>
* Fright
* Anxiety - Non-psychogenic=>
* Prolonged standing and dehydration
What surgeon should consider when a patient experiences syncope
- Usually a benign, self-limiting event=>
- Rule out other more serious etiologies of unconsciousness
Cardiac causes of syncope
Obstructive outflow diseases such as aortic stenosis
Neurogenic causes of syncope
Seizures, transient ischemic attack, migraines
How orthostatic hypotension can lead to syncope
- Patients with depleted intravascular volume=>
- Side effect of drugs=> antidepressants and antihypertensives
- Patients with autonomic instability=>
- Diabetes mellitus
Hypoglycemia relation to syncope
Rare cause of syncope
Patients in which vasovagal or vasodepressor syncope generally the etiology
Young, healthy patients
Stages of syncope and the symptoms
- Presyncopal Stage:
* Blood pressure and heart rate drop - Syncope Stage:
* Irregular breathing
* Pulse thready, blood pressure can drop to extremely low levels
* Unconsciousness can last from seconds to several minutes after placement in the supine position - Postsyncope Stage:
* Rapid recovery
* Pallor, nausea, disorientation may persist
Management steps for syncope in an emergency situation
- Stop the procedure immediately
- Trendelenburg position and administer oxygen
- If unconsciousness =>,basic life support protocol: call for help, assess airway, breathing, and circulation
- Chin lift or jaw thrust to open the airway.
- If breathing and circulation present=> crush an ampule of ammonia under the patient’s nose to hasten recovery
- Call emergency medical services if unconsciousness lasts beyond 10-15 minutes.
Failure to lay the syncopal patient flat can result in brain damage or death.
Most frequent triggers for asthma
- Viral or bacterial respiratory infections
- Exposure to cold, allergens, irritants=>
- Smoke, and exercise
- Emotional distress and medications=>
- Aspirin, NSAIDs
How oral and maxillofacial surgeon prepares for an asthmatic emergency
- Careful history and conducting a physical examination=>
- Extent of the patient’s asthma
- Baseline peak flow rate
- Usage of inhaled agents
- History of emergency care or intubation
Measures that can help prevent asthma attacks during dental procedures
- Reduce emotional distress in fearful patients.
- Anesthetic drugs such as opioids and barbiturates cautiously=> as they can induce bronchospasm=>
- Histamine release
How a typical asthma attack presents
- Chest congestion or tightness
- Nonproductive cough
- Inspiratory and expiratory wheezing
Signs of a severe asthma attack
- Increased dyspnea
- Use of accessory respiratory muscles
- Hypoxia is a late sign=>
- Immediate treatment.
Steps taken if a patient is suspected of having an asthma attack during a surgical procedure
- Stop the surgical procedure immediately
- Administer oxygen and a beta-2 agonist like albuterol via a metered dose inhaler (MDI).
- No response to bronchodilators=>
- Medical emergency (status asthmaticus) and alert EMS
- Subcutaneous epinephrine and parenteral glucocorticoids for severe attacks
Recommended dosage for albuterol during an asthma attack
- Six puffs of albuterol MDI (90 µg/puff)
- Can be repeated every 20 minutes as needed
Status asthmaticus, and how it is managed
- Severe asthma attack that does not respond to bronchodilators
- Requires immediate EMS intervention=>
- Subcutaneous epinephrine and parenteral glucocorticoids
How epinephrine administered during a severe asthma attack
- Subcutaneously at a dose of 0.3 ml of 1:1000 dilution
- Every 20-30 minutes for up to three doses
Role of glucocorticoids in managing severe asthma attacks
- Relieve airway inflammation
- Benefits after 3-6 hours, early
- 125 mg of methylprednisolone
Complications that can occur in diabetic patients in the surgical office setting
- Hypoglycemia
- Diabetic ketoacidosis
- Hyperosmolar non-ketotic coma
Why hypoglycemia particularly concerning in the outpatient setting
- Acute condition requiring immediate attention=>
- Severe complications
How hypoglycemia defined in adults and children
- Blood glucose levels less than 50 mg/dl in adults
- Less than 40 mg/dl in children
Relationship between intensive glucose control therapy and hypoglycemia in diabetes management
- Helps prevent microvascular complications of diabetes mellitus=>
- But increases the incidence of symptomatic hypoglycemia
Normal physiological response to hypoglycemia
- CNS response=> release of glucagon, cortisol, and epinephrine=>
- Increase glycogenolysis and gluconeogenesis
- Inhibit insulin-dependent glucose uptake
- Process can be disrupted by drugs or disease states=> impaired recovery from hypoglycemia
The brain relies on a continuous glucose supply as it cannot store glucose.
How diabetes and certain medications impair the body’s response to hypoglycemia
- E.g exogenous insulin and beta-blockers can impair the counter-regulatory response to hypoglycemia=>
- Reduce the body’s ability to recover from low blood glucose levels
Why diabetic patients undergoing surgery at increased risk for hypoglycemia
- Patients to fast (NPO status), necessitating adjustments in insulin or oral hypoglycemic doses
- Surgeries can alter eating habits=>
- Increased risk of hypoglycemia
Initial symptoms of hypoglycemia
- Sweating, anxiety, palpitations
- Hunger, and tremor=>
- Blood glucose levels below 60 mg/dl
- Mild cognitive dysfunction around 50-55 mg/dl.
How hypoglycemia affects older patients compared to younger patients
- More likely to experience cognitive impairment
- Less likely to exhibit other warning symptoms of hypoglycemia
Severe symptoms that can occur with progressive hypoglycemia
- Severe neurologic symptoms include lethargy and obtundation at 45-50 mg/dl
- Coma can occur at 30 mg/dl
- Convulsions and death below 20 mg/dl
Initial steps taken to manage hypoglycemia in a surgical office setting
- Obtain an initial blood glucose level to document hypoglycemia
- Do not delay glucose administration if clinical suspicion is high
Appropriate treatment for a conscious patient experiencing hypoglycemia
- Oral glucose via glucose=>
- Tablets, fluids, candy, or food
- Reasonable initial dose is 20 g of glucose
Done if patient is unable or unwilling to take oral glucose
- Intravenous dextrose=>
- Initial dose of 25 g
- Unconscious patients,=> dextrose while managing airway, breathing, and circulation
Glucagon used in managing hypoglycemia, and its limitations
- Administered intravenously (1 mg doses),
- Subcutaneously
- Intramuscularly (1-2 mg)
- Effective except in cases of hypoglycemia secondary to ethanol due to depleted glycogen stores
What clinicians should be aware of regarding the treatment of hypoglycemia with glucose or glucagon
- Raise plasma glucose concentrations only transiently
- Monitoring of the patient’s glucose concentration and clinical status essential after treatment
Monitoring required for a conscious patient who only needed oral carbohydrates to treat hypoglycemia
- One hour before allowing them to leave the office=>
- To ensure stable blood glucose levels and recovery
Monitoring required for an initially unresponsive patient treated for hypoglycemia
- Monitor vital signs and blood glucose levels at least every five minutes=>
- Until medical assistance arrive
Why offices that provide medications, especially parenteral ones, should be prepared for anaphylaxis
- Life-threatening medical emergency occuring unexpectedly
Anaphylaxis and how does it occurs
- Type I hypersensitivity reaction=> antigen binds to IgE antibodies on mast cells and basophils=>
- Systemic release of immunologic mediators
Common clinical presentations of anaphylaxis
- Urticaria (hives) and/or angioedema (swelling)
- Respiratory compromise and cardiovascular collapse=>
- Usual causes of death in anaphylaxis
Common causes of anaphylaxis in a surgical practice
- Drugs such as penicillin and aspirin
- Exposure to latex
Conditions that must be differentiated from anaphylaxis
- Vasodepressor syncope
- Local anesthetic overdose
- Panic attack, cardiac arrest, foreign body aspiration
How initial signs and symptoms of anaphylaxis be managed
- Procedure stopped immediately
- Airway, breathing, circulation, and consciousness level assessed,
- Epinephrine should be administered without delay
Role of epinephrine in managing anaphylaxis, and how it should be administered
- Intramuscularly or subcutaneously at a 1:1000 dilution (0.2–0.5 ml in adults or 0.01 mg/kg in children)
- Injected into the lateral thigh, upper arm, or sublingually=.
- Dose repeatable every 5 minutes as needed
Position patient placed in during anaphylaxis and why
- Trendelenburg position (lying flat with feet elevated)
- Maximize cerebral blood flow
Additional treatments that should be considered after initial epinephrine administration in anaphylaxis
- Antihistamines (such as diphenhydramine) intramuscularly or intravenously at 1–2 mg/kg (up to 50 mg).
- Albuterol for bronchospasm
- Corticosteroids (such as hydrocortisone prevent recurrent or protracted anaphylaxis
Why its important for all patients with anaphylaxis to be taken to an emergency department
Can recur
Seizures
- Excessive activation of neurons=>
- Abnormal neurological functioning
Two main classifications of seizures
- Partial=>
- Simple partial (consciousness maintained) and complex partial (consciousness lost)
- Generalized seizures=>
- Involve activity in both cerebral hemispheres
- Absence, myoclonic, and tonic-clonic (grand mal) seizures
Differentiates primary from secondary seizures
- Primary seizures =>no known etiology
- Secondary seizures=> injury or illness affecting CNS
How a seizure managed in a medical office setting
- Confirm it is a seizure and not syncope
- Patient should be reclined to a supine position to minimize injury
- Basic life support initiated=>
- Airway is clear and administering oxygen
- Objects should be moved away
- Pulse should be checked to rule out cerebral hypoxia
Tonic-clonic seizures last less than 2 minutes and do not require anticonvulsants, but postictal monitoring and support are crucial
Status epilepticus and why is it considered a true medical emergency
- Seizures lasting longer than 5–10 minutes
- or frequent seizures without a return to baseline between ictal states=>
- Significant morbidity and mortality
Initial treatment steps taken for a patient experiencing status epilepticus
- Call EMS immediately
- Basic life support, and secure intravenous access.
- Ampule of 50% dextrose IV to rule out hypoglycemia
- First-line treatment=> benzodiazepines- lorazepam (0.02–0.03 mg/kg IV),
Second-line treatment options if benzodiazepines do not terminate a seizure
- Phenytoin (20 mg/kg IV infusion at 25–50 mg/min)
- Phosphenytoin (15–20 mg/kg IV infusion at 100–150 mg/min) intramuscularly
- Monitor vital signs closely due to potential hypotensive effects
