7 - Behavior Management and Medical Emergencies

Question 1

What is the functional inquiry you can ask to get a sense of the patient’s cooperation?

Answer 1

The functional inquiry consists of the following questions:

1. How do you think your child has reacted to past medical procedures?
2. How would you rate your own anxiety (fear, nervousness) at this moment?
3. Does your child think there is anything wrong with his or her teeth, such as a chipped tooth, decayed tooth, gum boil?
4. How do you expect your child to react in the dental chair?

Question 2

What are the initial communication techniques for anxious patients?

Answer 2

1. Child should be welcomed in to a child friendly environment.
2. There is a triangular relationship between the dentist, the child and the family.
3. Functional inquiry should be part of the history form: negative response to more than one question increases the chance of encountering a behavior problem.

Question 3

How do you accomplish tell-show-do?

Answer 3

1. Tell the pt what is going to be done
2. Show/demonstrate the action
3. Do/perform the procedure and simultaneously explain it

Question 4

What are the advantages and disadvantages of having a parent in the operatory?

Answer 4

1. Communication advantages of having the parent in the operatory:
   - Parent can see firsthand how the child behaves.
   - Parent may be able to facilitate communication, especially with a special needs child or when language is an issue.
   - Very young children may not separate easily from the parent.
2. Communication disadvantages of having the parent in the operatory:
   - Parent can interfere with communication between the dentist and the child.
   - The child may divide her attention between the dentist and the parent.
   - The child may be less willing to cooperate with the dentist when the parent is present.

Question 5

What ASA classification pts are routinely accepted as appropriate candidates for in-office moderate sedation?

Answer 5

ASA I

Question 6

What ASA classification require consultation with the pt’s primary care provider to identify any concerns regarding the administration of sedation medications?

Answer 6

ASA II or III

Question 7

What ASA classification is typically treated in the hospital setting with anesthesiologists to manage potential complications?

Answer 7

ASA III

Question 8

According to the AAPD, what are the goals of sedation for children undergoing diagnostic and therapeutic procedures?

Answer 8

1. Ensure the pt’s safety and welfare
2. Minimize discomfort and pain
3. Control anxiety and minimize psychological trauma
4. Maximize amnesia
5. Control behavior or patient movement so the procedure can be completed safely
6. Return the pt to the pre-sedation level to allow for safe discharge from medical supervision

Question 9

What is the Brodsky scale?

Answer 9

The Brodsky scale indicates how much space the tonsillar tissue occupies in the pharyngeal area.

Question 10

What Brodsky scale number indicates the pt is at increased risk for developing airway obstruction? How should these pts be treated?

Answer 10

Patients with a Brodsky of +3 (meaning the tonsillar tissues takes up more than 50% of the pharyngeal space).

Patients with a Brodsky of +3 or greater should be considered for alternative pharmacologic management, i.e., general anesthesia or no sedation to maintain a patent airway.

Question 11

What are the AAPD guidelines for monitoring during sedation?

Answer 11

1. Continuous monitoring of oxygen saturation and heart rate, and intermittent recording of respiratory rate and blood pressure that should be recorded on a time-based record.
2. Frequent checking of restraint devices to prevent airway obstruction or chest restriction.
3. Frequent checking of the pt’s head position to ensure airway patency.
4. Presence of a functioning suction apparatus.
5. Monitoring requirements depend on the level of sedation. Minimal, moderate, and deep sedation all have different monitoring guidelines.

Question 12

For painful procedures what medication can you select for the sedation procedure?

Answer 12

For painful procedures, include an analgesic such as an opioid like Meperidine.

Question 13

For non-painful procedures what medication can you select for the sedation procedure?

Answer 13

For non-painful procedures, a sedative can be used, such as a benzodiazepine like Midazolam (Versed). A sedative hypnotic also can be used, such as chloral hydrate.

Question 14

For procedures that require both sedation and analgesia, what medication can you select for the procedure?

Answer 14

For procedures that require both sedation and analgesia, choose either single agents with both sedative/analgesic properties, or combination drug therapy.

Question 15

What can happen when sedation drugs are mixed?

Answer 15

The more drugs that are mixed, the greater the chance of adverse events such as hypoventilation, apnea or airway obstruction.

Question 16

What drugs are commonly used as amnestics in the outpatient sedation of children?

Answer 16

Benzodiazepines

Question 17

How do benzodiazepines work?

Answer 17

Benzodiazepines enhance the binding of GABA, the primary inhibitory neurotransmitter of the CNS.

Question 18

What are the effects of benzodiazepines?

Answer 18

Benzodiazepines produce sedation, anxiolysis, amnesia, and suppression of seizure activity.

Question 19

What will typically happen at moderate doses of benzodiazepines?

Answer 19

At moderate doses, pts who have received benzodiazepines will be conscious, yet sedated, and will not remember the procedure.

Question 20

What will typically happen at high doses of benzodiazepines?

Answer 20

At high doses, the benzodiazepines will result in unconsciousness and loss of protective airway reflexes.

Question 21

What do you have to consider when you combine benzodiazepines with narcotics?

Answer 21

When combined with narcotics, the respiratory depressant effects are synergistic.

Question 22

What cardiac effects are produced with benzodiazepines?

Answer 22

Benzodiazepines produce little direct cardiovascular effect.

Question 23

What are the main opioid receptors? What are the effects of each opioid receptors?

Answer 23

The main receptors are Mu1 and Mu2 receptors.

Analgesia occurs through Mu1 receptors.

Respiratory depression, bradycardia, and euphoria occur through Mu2 receptors.

Question 24

What is meperidine commonly combined with for outpatient sedation of children?

Answer 24

Meperidine is commonly used in the outpatient sedation of children, usually in combination with Versed or Chloral Hydrate.

Question 25

What is the chemical structure of Chloral Hydrate similar to?

Answer 25

Alcohol.

Question 26

What are the advantages of Chloral Hydrate?

Answer 26

Commonly used, inexpensive, well absorbed by mouth, minimal effects on respiration, sedation in about 30 to 45 minutes.

Question 27

What are the disadvantages of Chloral Hydrate?

Answer 27

It is NOT an analgesic, sedation can result in airway obstruction especially in the presence of large tonsils, tastes bad, can cause nausea and vomiting.

Question 28

Why is it important to monitor children as they recover from sedation?

Answer 28

Do not be fooled by thinking that just bc the dentistry is done, the child is recovered. With the loss of surgical stimuli, the child may actually become more sedated.

Question 29

When are children ready to be discharged from sedation?

Answer 29

Children are ready to be discharged if at least the following criteria are met:

1. Pre-sedation level of consciousness is attained.
2. Respiratory rate and rhythm, heart rate, and oxygen saturation are within normal limits.
3. Pre-sedation level of ambulation is attained.
4. Pt can swallow oral fluids; demonstrates return of gag reflex or cough.
5. Pt has no nausea, vomiting, dizziness.

Question 30

When are longer periods of supervised recovery required after sedation?

Answer 30

Medications with a longer half life may require longer periods of supervised recovery due to possibility of resedation.

Pts who have received reversal agents also require a longer period of supervised recovery bc the sedative medication tends to last longer than the reversal agent, posing a potential for resedation.

Question 31

What important history and physical observations are required before administrating sedative medications to a pt?

Answer 31

The pre-sedation history and physical should include information regarding:

1. Allergies to foods or medicines
2. Current prescription or over-the-counter medications
3. Medical disease processes
4. Previous hospitalizations and surgeries
5. Review of body systems
6. Weight in kilograms
7. History of anesthesia or sedation and any complications
8. Vital signs
9. Airway evaluation
10. ASA class
11. NPO status

Question 32

What are the requirements of a safe environment for in-office administration of sedation?

Answer 32

1. Appropriate educational training.
2. Support personnel trained in monitoring the pt.
3. Adequate rescue equipment and personnel who know how to use it.

• Everybody should be competent in basic life support techniques.
• The primary provider should be trained in pediatric advanced airway skills.

Question 33

What are some of the potential complications of sedation in the office that the provider should be prepared to handle?

Answer 33

1. Hypoventilation
2. Airway obstruction
3. Allergic reactions
4. Apnea
5. Laryngospasm
6. Aspiration
7. Cardiopulmonary impairment

Question 34

How can the discomfort of local anesthesia administration be lessoned?

Answer 34

1. Use of topical aesthetics: available in gels and sprays.
2. Counter irritation: application of vibratory stimulation or moderate pressure at the site of injection.
3. Distraction: maintain constant communication to keep attention away from syringe.
4. Slow rate of administration: administration of a cartridge of anesthetic should take at least one minute.

Question 35

What is the maximum doses of the local anesthetics in children?

Answer 35

Articaine: 7.0 mg/kg, 3.2 mg/lb, 500 mg total
Lidocaine: 4.4 mg/kg, 2 mg/lb, 300 mg total
Mepivicaine: 4.4 mg/kg, 2 mg/lb, 300 mg total
Prilocaine: 6 mg/kg, 2.7 mg/lb, 400 mg total
Bupivicaine: 2 mg/kg, 0.9 mg/lb, 90 mg total
Etidocaine: 8 mg/kg, 3.6 mg/lb, 400 mg total

Question 36

What is paresthesia from local anesthesia and what causes it?

Answer 36

Defined as persistent anesthesia beyond the expected duration.

Caused by trauma to the nerve or “electric shock” on injection.

Question 37

What is the difference in risk for paresthesia in different local anesthetics?

Answer 37

Risk is 1:1,200,000 for 0.5%, 2%, and 3% local anesthetics.

Risk is 1:500,000 for 4% local anesthetics.

Question 38

How long does it take for paresthesia from local anesthesia to resolve?

Answer 38

Most cases resolve in eight weeks.

Question 39

Does a bilateral mandibular block increase the risk of soft tissue trauma (e.g., lip biting) when compared to unilateral mandibular block?

Answer 39

No.

Question 40

What can you do to help prevent soft tissue trauma after administration of local anesthesia?

Answer 40

If possible, have the child bite on cotton rolls until the soft tissue anesthesia has worn off.

Question 41

What are the signs of local anesthetic toxicity (overdose)?

Answer 41

Early signs (CNS excitatory phase): dizziness, anxiety, confusion, tachycardia, increased blood pressure

Later signs (depression of the CNS): seizure activity, bradycardia, cardiac arrest

Question 42

What is an anatomical difference between children and adults with respect to administration of the inferior alveolar nerve block?

Answer 42

The mandibular foramen is lower than the occlusal plane in children, so the injection should be made lower and slightly more posterior in children.

Question 43

What is the mechanism of action of local anesthetics?

Answer 43

Local anesthetics act by interfering with the entry of sodium ions in sodium channels of the nerve cell membrane.

Question 44

What are the indications for general anesthesia in pediatric dentistry?

Answer 44

1. Certain physical, mental or medically compromising conditions.
2. Ineffective local anesthesia due to acute infection, anatomic variations of allergy.
3. Extremely uncooperative, fearful, anxious, physically resistant or uncommunicative child or adolescent in whom there is no expectations that the behavior will soon improve.
4. Extensive orofacial/dental trauma.
5. Patients with immediate needs who would not otherwise receive comprehensive care.
6. Patients in whom use of general anesthesia may protect the developing psyche or reduce medical risks.

Question 45

What are the contraindications for general anesthesia?

Answer 45

1. Unsuitable general anesthesia risk.
2. Respiratory infection.
3. Acute systemic disease with elevated temperature.
4. No-food-by-mouth (NPO) guidelines violated.
5. Healthy cooperative patient with minimal dental needs.

Question 46

What alternative treatment plan can be provided to the parent who does not want to use sedative agents or general anesthesia?

Answer 46

If the parent did not want to use sedative agents or general anesthesia, attempts could be made to place interim restorations while trying to reduce the pt’s anxiety with short, easy visits.

Question 47

What are the NPO pre-anesthetic feeding guidelines for general anesthesia?

Answer 47

1. Clear liquids up to two hours prior to the procedure.
2. Breast milk up to four hours prior to the procedure.
3. Infant formula and non-human milk up to six hours prior to the procedure.
4. Light meal up to six hours prior to the procedure.

Question 48

What information do you need to have prior to scheduling a pt for general anesthesia?

Answer 48

1. Pre-anesthetic assessment of the medical history.
2. Explanation of the procedure along with the risks/benefits and options for alternative treatment and informed consent.

Question 49

What are the advantages and disadvantages that general anesthesia provide in dental care to children?

Answer 49

Advantages:

1. All of the child’s dental needs can be met in one visit.
2. Quality care can be provided.
3. The child’s developing psyche is protected.

Disadvantages:

1. Higher cost.
2. The risk of a general anesthetic.
3. The inability for the child to learn coping skills.

Question 50

What type of training is needed for a dentist to treat children under general anesthesia?

Answer 50

A dentist who treats children under general anesthesia should be trained in:

1. Hospital protocol
2. Operating room procedures
3. Pre-operative assessment
4. Management of post-operative complications

Question 51

What does the Mallampati score evaluate?

Answer 51

The Mallampati score assesses the degree to which the practitioner can visualize the uvula during voluntary tongue protrusion. It is sometimes difficult to obtain on an uncooperative child.

Question 52

What does the Brodsky scale evaluate?

Answer 52

The Brodsky scale is used to evaluate the size of the tonsils and the degree to which they may obstruct the airway.

Question 53

What can make laryngoscopy at risk for damaging the maxillary incisors?

Answer 53

Prominent labial inclination of the maxillary incisors can make laryngoscopy difficult without damaging the incisors.

Question 54

What are the indicators of a potentially difficult mask ventilation or laryngoscopy and intubation?

Answer 54

1. Micrognathia
2. Large tongue
3. Short neck
4. Limited cervical spine or TMJ mobility

Question 55

What difficulties can children with high BMI or obesity have in airway management?

Answer 55

Children with a high BMI or obesity can have:

1. Difficult airway.
2. Upper airway obstruction in the post-anesthetic care unit.
3. May require longer post-operative recovery times.
4. May need more antiemetics.

Question 56

What is the follow-up care following full mouth dental rehabilitation under general anesthesia?

Answer 56

1. Supervised recovery period after extubation.
2. Instructions for parenteral monitoring of pt’s status at home on the surgical day.
3. Post-op phone call at 24 to 48 hours.
4. Follow up visit in two weeks, then three month recall visits.
5. Space management as needed due to multiple extractions.
6. Implement aggressive prevention plan.

Question 57

What are the post-op instructions for the parent following full mouth dental rehabilitation under general anesthesia?

Answer 57

1. Minimize vigorous activity for the pt.
2. Pay attention to lip numbing while the pt attempts to eat.
3. Maintain a bland and soft diet for the day.
4. Follow up with a visit in two weeks.
5. Establish a dental home.
6. Implement an aggressive caries prevention plan.
7. Recall visits at least every six months.

Question 58

If you have to administer supplemental oxygen in an acute situation, what else must you be ready to do?

Answer 58

Assist or provide ventilation.

Question 59

What are the ways in which oxygen can be delivered?

Answer 59

1. Nasal cannula
2. Face mask
3. Blow-by or face tent
4. An invasive, secured airway such as an an endotracheal tube

Question 60

How do you decide which oxygen delivery instrument to use?

Answer 60

The least invasive yet maximally effective route should be chosen first to minimize increasing the child’s anxiety, which will only serve to increase oxygen demand.

Question 61

How much oxygen is delivered in a:

1. Low-flow simple mask
2. Partial rebreathing mask
3. Nonrebreathing mask
4. High flow Venturi mask
5. Nasal cannula

Answer 61

1. Low-flow, simple mask delivers 35% to 60% oxygen
2. Partial rebreathing mask delivers 50% to 60% oxygen
3. Nonrebreathing mask delivers 95% to 100% oxygen
4. High-flow, Venturi mask delivers 25% to 60% oxygen
5. Nasal cannula delivers 32% oxygen

Question 62

How do you determine the appropriate size of the bag-valve-mask?

Answer 62

It should fit over the bridge of the nose (avoiding pressure on the eyes) and around the mouth.

Question 63

How do you use the bag-valve-mask?

Answer 63

Use:

1. Hold the mask with the left hand.
2. Gently deliver a tidal volume with your right hand squeezing the bag.
3. Watch for chest rise. Don’t overinflate.

Gentle repositioning of the head and neck may be required to find the best position for ventilation.

Do not compress the soft tissue of the young pt’s airway with remaining fingers while creating a seal between the face and the mask.

Question 64

What is the most common cause of obstruction in the unconscious or sedated pediatric patient? Why?

Answer 64

The tongue:

1. In the child, the tongue is bigger in relation to the oral cavity.
2. The larger occiput of the child tends to flex the child’s neck, contributing more to obstruction.
3. To manage this type of obstruction, use the head-tilt-chin-lift maneuver.

Question 65

Why is correct finger placement under the chin important during rescue of a pt during airway management?

Answer 65

Children have soft tissue that can easily be compressed by the rescuer’s incorrect finger placement under the chin. Be sure your fingers are on the bony part of the jaw, not the soft tissue, bc this will exacerbate any airway obstruction.

Question 66

Compare the narrowest part of the child and adult airway?

Answer 66

The cricoid is the narrowest part of the child’s airway.
The glottic opening is the narrowest part of the adult’s airway.

This necessitates the use of uncuffed endotracheal tube in children.

Question 67

What do you do if a pt has spontaneous respirations but signs and symptoms of a partial airway obstruction?

Answer 67

Gentle application of approximately 5 to 10cm of continuous positive airway pressure (CPAP). This is generally accomplished by obtaining and maintaining a good seal with the face mask and a breathing circuit that will allow CPAP to be provided.

Question 68

What is a common complication that can occur during assisted or controlled ventilation with a face mask?

Answer 68

Insufflation of the stomach can occur, especially if the practitioner is attempting to ventilate around a partial obstruction. This is a common complication that could result in aspiration or regurgitation of gastric contents.

Question 69

In an unconscious pediatric patient with no spontaneous respirations, what is the best airway adjunct choice for initial airway management to provide ventilation and oxygenation?

Answer 69

The bag-valve-mask device, connected to oxygen, used by either one or two rescuers.

Question 70

In a conscious pediatric patient exhibiting signs of respiratory distress, what is the first airway adjunct that should be attempted?

Answer 70

The least invasive yet maximally effective adjunct should be chosen first to minimize increasing the child’s anxiety.

Start with an oxygen cannula or simple face mask, call 911 and continually assess the child’s respiratory pattern to determine the need for more invasive airway support requirements.

Question 71

Is an oral airway an appropriate airway adjunct to use in an awake child exhibiting signs of respiratory distress?

Answer 71

No, an oral airway in any awake patient will only stimulate the gag reflex and possibly cause laryngospasm.

Question 72

How much oxygen can a non-rebreather mask be expected to delivery if connected appropriately to an oxygen delivery source?

Answer 72

A non-rebreather mask will delivery nearly 100% oxygen if connected correctly to an oxygen source delivery 10 to 15 LPM of oxygen to a patient who is breathing spontaneously.

Question 73

How is a child with a partial airway obstruction managed?

Answer 73

To manage a child with a partial airway obstruction, first make sure the airway is positioned correctly. Obtain a good seal with the face mask by pulling the child’s face into the mask, and creating a seal with the index finger and thumb. Be sure to stay off the soft tissue under the mandible and provide supplemental oxygen. Do not use an oral airway in a child who is conscious.

Question 74

What food allergies can suggest a possible latex allergy?

Answer 74

Food allergies to bananas, mangos, avocado, kiwi and passion fruit.

Question 75

In children, what kind of history may indicate latex sensitivity?

Answer 75

1. Chronic exposure to latex and a history of atopy (an immediate reaction) increases the risk of sensitization.
2. History of multiple surgeries or frequent exposure to urinary catheters are possibly at risk for latex allergy.
3. In children, lip swelling or itching upon exposure to balloons can be an indication of latex sensitivity.

Question 76

What is the process of latex allergy?

Answer 76

Most serious latex reactions involve a direct immunoglobulin E–mediated response to the polypeptides found in natural latex.

Question 77

What are common causes of allergies?

Answer 77

1. Certain foods
2. Medications
3. Animals
4. Insect venom
5. Cosmetics
6. Perfumes
7. Latex

Question 78

Describe the types of allergic reactions?

Answer 78

1. Type I, or immediate, hypersensitivity reactions involve antigens cross-linking with immunoglobulin E antibodies. This cross-link triggers mast cells to release inflammatory mediators. Severe allergic reactions, or anaphylaxis, can result.
2. Type II, or cytotoxic, hypersensitivity reactions involve immunoglobulin G (IgG) antibodies, which bind with antigens on cell surfaces. This IgG binding causes cell lysis, i.e., hemolytic transfusion reactions.
3. Type III, or immune complex, hypersensitivity reactions occur when antigen-antibody complexes are deposited into tissues. After the complex is deposited, neutrophils are activated and cause tissue injury from the release of lysosomal enzymes and other toxic products.
4. Type IV, or delayed/cell-mediated, hypersensitivity reactions are mediated by T lymphocytes that have been exposed to the antigen before. Re-exposure to the antigen causes the production of lymphokines that activate inflammatory cells over about 48 to 72 hours, i.e., contact dermatitis.

Question 79

What are mild symptoms of allergic reactions?

Answer 79

Mild symptoms include watery, itchy eyes with a rash and possibly nose and/or chest congestion.

Question 80

What are moderate symptoms of allergic reactions?

Answer 80

Moderate reactions can include mild symptoms, but also display itchiness and/or difficulty breathing.

Question 81

What are severe symptoms of allergic reactions?

Answer 81

Severe allergic reactions, or anaphylaxis, result in differing degrees of angioedema (swelling) that can make it difficult for the patient to swallow or breathe. Other symptoms include:

1. Abdominal pain, vomiting
2. Cramps, diarrhea
3. Mental confusion and/or dizziness

Question 82

What are some other clinical signs and symptoms of allergic reactions?

Answer 82

Other clinical signs and symptoms of allergic reactions include:

1. Tachycardia, hypotension, arrhythmias
2. Cough, bronchospasm, laryngeal edema, hypoxia
3. Facial edema, pruritis generalized itching.

Question 83

What is anaphylaxis?

Answer 83

Anaphylaxis is an IgE-mediated allergic reaction. The body produces antibodies to a substance on first exposure. On second exposure, the body releases the antibodies and huge amounts of histamine. This can be potentially life threatening without immediate intervention. Symptoms appear quickly and can include increased heart rate, extreme shortness of breath, sudden weakness, a drop in blood pressure, shock, unconsciousness and death.

Question 84

What is the treatment for allergic reactions?

Answer 84

1. Discontinue all sources of the allergy-causing substance.

2. Administer diphenydramine. Children: 1mg/kg po qid, 0.5 to 1 mg/kg IV. Adults: 25 to 50mg PO qid.

Question 85

What is the treatment for anaphylactic reactions?

Answer 85

Recognize a true medical emergency:

1. Call 911
2. Administer epinephrine (IM or sq), 0.01 mg/kg q 5 minutes.
3. Administer supplemental oxygen
4. Monitor vital signs
5. Provide airway support as required.

Question 86

What do you ask about the medical history of the pt that has asthma?

Answer 86

1. The severity of the asthma, and how well it is controlled (medications).
2. Frequency of attacks, what causes/precipitated/exacerbates the attacks.
3. ED visits, what treatment was done in the ED.
4. Limitations or restrictions on activities.

Question 87

Describe the different types of asthma?

Answer 87

1. Mild intermittent asthma
   –Symptoms 2 times a week or less.
   –Nighttime symptoms 2 times a month or less.
   –Brief exacerbations of varying intensity.
2. Mild persistent asthma
   –Symptoms more than 2 times a week but less than once/day.
   –Nighttime symptoms more than 2 times a month.
   –Exacerbations may affect activity.
3. Moderate persistent asthma
   –Daily symptoms with daily use of inhaled B2 agonists.
   Nighttime symptoms more than once/week.
   –Exacerbations affect activity and occur 2 times a week or more. Exacerbations could last for days.
4. Severe persistent asthma
   –Continual symptoms with frequent exacerbations and nighttime symptoms.
   –Limited physical activity.

Question 88

What can trigger asthma attacks?

Answer 88

Asthma attacks can be triggered by:

1. Environmental irritants (dust, smoke, pollen)
2. Strenuous exercise or increased stress
3. Weather (cold air or increased humidity)
4. Upper respiratory infections

Question 89

What oral findings are in asthma?

Answer 89

1. Xerostomia (caused by asthma medications)

2. Increased levels of gingivitis

Question 90

What can be done to help patients with asthma with oral problems?

Answer 90

1. Xerostomia - consider water-based chlorhexidine to reduce gingivitis. Discuss with parents options for reducing dry mouth.
2. Increased risk of caries - develop oral hygiene routine, try to keep the mouth moist with sugarless candies and beverages, rinse several times a day with a solution of salt and baking soda to help buffer the acidic environment.

Question 91

What are the signs of an asthma attack?

Answer 91

1. Audible expiratory wheezing with restlessness and apprehension
2. Hacking, non-productive cough
3. Dyspnea
4. Nasal flaring and intercostal retraction
5. Cyanosis; look around the lips and the nailbeds
6. Coarse rhonchi
7. Tachycardia

Question 92

What is a bad sign in an asthma attack?

Answer 92

In an asthma attack, the loss of the wheezing sound is a BAD sign: the airways are totally collapsed and a respiratory arrest is likely.

Question 93

What is the treatment of an asthma attack?

Answer 93

1. Call 911 if it is an in-office emergency.
2. Help pt into a position of comfort, usually sitting.
3. Give airway support as needed - supplemental oxygen and ventilation support as needed with a bag-valve-mask. Only people with advanced airway training should attempt an intubation.
4. Administer appropriate medication if adequately trained:
   - -B2 agonists - inhaled medications such as albuterol inhalers or nebulized breathing treatments. Subcutaneous injections of epinephrine or terbutaline.
   - -Anticholinergics - inhaled Atrovent
   - -Corticosteroids - oral prednisone

Question 94

What determines the classification of asthma?

Answer 94

1. Frequency of symptoms in a week’s time
2. Frequency of nighttime symptoms.
3. Frequency of exacerbations and their impact on activity.
4. Medications required to manage asthma.
5. Peak expiratory flow.
6. Forced expiratory volume.