contraindications, emergencies Flashcards
If someone on bisphopshantes, what to do if have to have it extracted. Do you need prophylaxis?
-ideally avoid extraction, do RCT
-discuss risks and benefits
-if need extraction, no need for antiobitc prophylaxis unless required for another reason. follow-up after 8 weeks then refer to secondary care if it was not healing
What is the platelet count below where you avoid extraction
<100 x 10^9 per litre
-if so, refer to secondary care
<50 delay elective procedures
What is first line for fungal angular chelitis
miconazole ointment, but avoid in hepatitis or if on warfarin
How osteoradionecrosis is caused and why extraction needs to be avoided. What to do if need extraction
-caused by radiotherapy of head and neck region. It obliterates arteries, impairing blood supply. So if have extraction, then poor healing so avoided.
-if need extraction, send to secondary care where they will need to make it as atraumatic as possible and not use vasoconstrictor in LA. Pre and post op co-amoxicillin is advised
What to do if someone has swelling around the ear and parotid, likely due to mumps
recommend paracetamol, tell them to isolate, go see GP to confirm it is mumps
If someone has prothetic heart valves and has had previous IE, that needs RSD, what do you do before hand
they are high risk for IE and it is an invasive procedure so consult the cardiologist regarding prophylaxis
which antifungals to avoid or reduce with warfarin & hepatitis. which one can you use
-lower dose of fluconazole
-avoid miconazole
-can use nystatin
Which antibiotics to avoid with warfarin. and therefore which is used for abscess
-avoid penicillins, metranizadole, erythromycin, rifampicin
-clindamycin is used
If someone comes in with vesicles on mouth due to herpes that has been there for a day, what to do
=gingivostomatitits and risk of herpetic whitlow
-send them away, advise to take fluids and paracetamol rest
Recommend getting topical acyclovir, only systemic acyclovir if immunocompromised
Which LA to avoid in liver disease.
Avoid amides (lidocaine, prilocaine, articaine.) as they are broken down in liver
So ideally give esters (Benzocaine, procaine)
-but if ester allergy, give prilocaine or articaine reduced to 2 cartridges as less broken down in liver
What to do if 1-2 sprays of GTN sublingual spray doesn’t work
-repeat every 3-5 mins. Max 3 times
-100% oxygen 15l/min
-If no working could be MI so 300mg aspirin, call 999
-could be MI
Which antibiotics to avoid if pregnant, breastfeeding or risk of preterm
-Breastfeeding: clindamycin caution
-Pre-term: co-amoxiclav and metranidazole avoid
-Pregnacy: metronidazole, tetracycline
When is best to treat a pregnant woman
-Ideally delay until after. Although best carried out in 2nd trimester as 1st= foetus more susceptible to teratogenic influences. and 3rd= risk of syncope due to pressure on IVC when supine
Which antibiotics to avoid if liver disease. which is safest
penicillins safest
-avoid tetracyclines, clindamycin, erythromycin
-reduce metronidazole or avoid
Which antibiotics to avoid or reduce dose if kidney disease
-Avoid=tetracyclines
-Reduce= erythromycin, amoxicillin
When must INR be checked before treatment, if stable and unstable with warfarin. What values it needs to be.
-take INR within 72hrs if stable, within 24hr if unstable
-INR <4 can be treated
What to do if warfarin patient has INR >4 and need extraction
-Inform GP, delay treatment until it is below 4. May need vitamin K and prothrombin
-Once <4, use local measures to achieve haemostasis
When someone would need to stop their DOAC before a dental procedure
-don’t need to stop treatment for 1-3 simple extractions and other low risk procedures
- if high risk procedure (surgical etc.) advise to miss morning dose dabigatran/apixaban, and delay rivaroxiban. And take >4 hours after haemostasis
-But never interrupt it if DVT or PE in last 3 months, or on med for cardioversion, stent, prosthetic heart valve
What to give a hypoglycaemic patient. what if uncooperative. What to do if unconscious in dental setting
-give oral glucose tablet or drink
-buccal hypostop for uncooperative
-inconscious = IM glucagon 1mg
Steroid cover for adrenal insufficiency (Addison’s) for minor and major procedures
-Minor surgery under LA – no change to steroid dose
-Major surgery eg. XLA with LA or GA -double dose hydrocortisone 24hrs before & after.
OR 100-200mg hydrocortisone IM 30 mins before, or IV instantly
What to give if bacterial angular chelitis
2% fusidic acid
What angular chelitis looks like and causes
-soreness, erythema, fissuring in corners of mouth
-assoicated with iron deficiency, dentures, reduced OVD, HIV, crohn’s
-either bacterial or fungal
What to do in acute adrenal crisis
-hypotensive, hypoglycaemia, hyponatraemic
lay flat, ABCDE, IV electrolytes and glucose. 200mg hydrocortisone IV
Management and medication for cardiac arrest with 1) no heart beat and 2) chaotic rhythm
with no heart beat= not shockable. 1mg IV adrenaline
With chaotic rhythm: DC shock. If fails, Adrenaline + amiodarone. Lidocaine. Atropine
What pain killers to give to liver and kidney disease patients
-kidney = avoid NSAIDs. Paracetamol fine
-liver = NSAIDs fine, reduce paracetamol
Contraindications for NSAIDs (aspirin and ibuprofen)
Gastric ulcers, kidney disease, asthmatics
aspirin= avoid warfarin
What to prescribe for ANUG
1st line=metronidazole (400mg for 3 days TDS)
2nd line= amoxicillin (500mg for 5 days TDS)
What meds can cause xerostomia, potentially causing angular chelitis. what to do
B blockers, diuretics, ACE inhibitors, Ca blockers, anti-parkinonians, anxiolytics, antidepressants, carbamazepine, atropine
liase with GP to ask for potential alternative drugs
What drugs can cause lichenoid reactions
- ibuprofen
- β-blockers
- Diuretics (indapamide)
- Oral hypoglycaemics
- Statins
- Antimalarials
- Sulphonamides
3 causes of angioedema. management
- C1 esterase deficiency (genetic)
- Drug induced= ACEI, nicorandil (anti-anginal)
- Allergy
-Management – change medication. If lots of tongue odema, patient should be admitted to hospital and intubated until swelling gone down
Can you treat someone after recent CABG, stent, angioplasty, valve surgery
-Procedures do not pose any contraindication
-Avoid immediate postoperative period until suture line reendothelialises
-Always check if patient’s symptoms may have abated after their surgery
-monitor high risk patients with signs, symptoms, BP, ECG, pulse oximetry
What dental treatment to avoid with pacemaker patients
-Don’t use diathermy or electrosurgical units, unless know safe to do so
-Ultrasonic scalers may interact – use hand scalers
-Sudden defibrillation: risk of injury
Do you give dental treatment to someone with acute MI, unstable angina, cardiac failure
-Acute MI: postpone elective treatment till 3-6 months later. If urgent, refer patient to dental hospital or maxfax unit
-Unstable angina: dental care in suitable facilities/postpone (don’t treat in general practice)
-Cardiac failure: dyspnoea= difficulty breathing (do not lie flat) So maybe refer too
Use of LA in CVD patients
-Patients with mild to moderate CVS disease can have LA containing adrenaline. As there is a risk of it being more painful (as vasoconstricts so keeps it localised)= not good for heart
-Severe CVS disease (unstable angina, recent MI, dysrythmias) may be considered relative contraindications to LA
How to distinguish the different causes of chest pain
-angina: central crushing pain on exertion, relieved by GTN
-MI: central crushing pain at rest, not relieved by GTN
-gastro-osophageal reflux disease: burning due to regurgitation. GTN can releive causing misdiagnosis
-pleuritic pain: when breathing
-pulmonary embolism: sharp pain, associated with calf pain due to DVT
-musculoskeletal
-referred pain from abdomen
Prevention of inhaled foreign bodies. signs of mild choking and severe obstruction
-prevention= rubber dam, mouth sponges, instrument chains
-Mild=ask if they are choking, they respond and can speak, breath, cough
-severe= no response, unable to breath, silent cough, unconscious, clutching neck
How to treat someone who has choked and it is: mild, severe and conscious, and severe and unconscious
-if mild and can reply: encourage coughing, lean forward, monitor dislodged object
-conscious= 5 back blows between shoulder bladed, 5 abdominal thrusts (if <1 year old do chest thrusts)
-unconscious= call 999, CPR, cricothyroidectomy if trained
[indications for CPR= No breathing or limited breathing. Or No Pulse]
How long to dentally treat someone after an MI
at least 6 months, otherwise they are at high risk of another MI
-although there are no set guidelines as depends on the individual. Consider how stable and well they are
How to treat opioid addiction. and overdose
-addiction= methadone
-overdose= oxygen, naloxone
explain ABCDE
A=airways: head tilt chin lift. Or jaw thirst if worried about cervical spine. Finger sweep. Suction. Guedel airways as adjuncts
B=breathing: look listen and feel for 10s
C-circulation: only check carotid pulse if competent. Not essential as not breathing is the reason for CPR
D-disability: ask if they can hear you to check if they are conscious. ACVPU, GCS
E-exposure: examine for rash/ application of defibrillator paddles, extent of injuries
How to position patient if 1) lose consciousness 2) struggling to breath 3)anaphylaxis 4)unconscious and pregnant
- lie flat and raise legs to return circulation to brain
- keep patient sitting or leaning forward
- Need to lie flat
4.. Left lateral position to prevent IVC obstruction - recovery position on left hand side
List drugs that should be in emergency drug box in a dental surgery [checked every week]
-adrenaline epipen (1:1000) [anaphylaxis]
aspirin (300mg) [MI, stoke]
-glucagon 1mg [hypoglycaemia]
-GTN tabs or spray (400ug) [angina]
-oxygen cylinder 15l/minute [cardiac arrest, acute asthma attack, acute coronary artery syndrome, epilepsy, faint, hypoglycaemia, stroke]
-salbutamol inhaler [asthma attack]
-10mg midazolam buccal liquid or injection [epilepsy]
-oral glucose: 15-20g
Symptoms of vast-vagal syncope. How to manage
-feels faint, dizzy, light-headed, pale, sweating, nausea
-initially fast pulse, then slow
-lie flat, open window, raise legs, loosen tight clothing, assess ABCDE
-most recover quickly. If not, ABCDE and consider other causes. Perhaps hypoglycaemia
Symptoms of anaphylaxis. Management
-urticaria’s, erythema, rhinitis, conjunctivitis, abdominal pain, vomitting, diarrhoea, flushing
-vasodilation leading to hypovolaemia
-stridor, wheeze, hoarnseess, struggling to breath, airway swelling, faint, pale, clammy, cyanotic, confusion = call 999, lay flat, 0.5ml adrenaline 1:1000 IM on lateral thigh for 10s, oxygen
-prevents respiratory arrest then cardiac arrest
-can also use salbutamol inhaler and antihistamines (chlorphenamine)
Symptoms and management of panic attack
-ABCDE to avoid mistaking for anaphylaxis
-hyperventilation =breathing out too much CO2, becoming ankylotic
-anxiety, weak, dizzy, palpitations, paraesthesias, anxiety rash, carp-pedal spasms
-rebreathing same air, using paper bag of spacer device with hand covering other end
Signs and management of an acute asthma attack
A- Inability to complete sentences in one breath
B- Respiratory rate > 25 per minute
C- Tachycardia (pulse> 110 beats per minute)
-sit up
-2 puffs of beta agonist inhaler (salbutamol in spacer device). Repeat if no rapid response using spacer, every 10 mins, up to 10 puffs
-ABCDE if no response. call 999
worrying sings= cyanosis, resp rate <8 per min, bradycardia, confusion, exhaustion, reduced consciousness
Management of angina attack
ABCDE
GTN spray - 2 puffs, repeat after 5 mins, up to 3 times
Oxygen
Aspirin if not working= MI
entonox (nitorus oxide) can be helpful
999 as possibly MI
Management of epilepsy seizure lasting >5 mins
-could be mistaken for hypoglycaemia
-ABCDE
-10mg buccal midazolam
-In children, rectal diazepam
Difference in ABCDE and CPR in infant or child
-For opening airway, don’t overextend cervical spine in infants and young children as this can obstruct the airway so put in neutral position
-expect higher normal respiration rates and HR
-Initial ventilation = 5 rescue breaths before compressions (usually airway origin rather than cardiac) Then 15:2
-for compressions use 2 fingers in infant, 1 or 2 hands in child
-usually don’t need AED as due to airway problems so un-shockable type of arrest
Managing choking in infants and children
-Adult guidelines suitable for children over 1 year of age (5 back blows, 5 abdominal thrusts)
-Chest thrusts instead of abdominal thrusts for infants <1
=Put infant across lap with head under, lower than chest. 5 sharp inter-scapular blows. If fails try 5 chest thrusts with patient supine (but head lower than chest), one every 3 seconds. Repeat. Call 999 early. If unconscious, start CPR.
Shockable and un-shokable arrhythmias
-shockable= ventricular fibrillation, pulseless ventricular tachycardia
-non-shockable= asystole (flat line), PEA (pulseless electrical activity)
What are the reversible aetiology factors in a pulseless electrical activity (PEA) arrest (4 Hs, 4 Ts)
Hypoxia
Hypovolaemia
Hyper/hypokalaemia/metabolic
Hypothermia
Tension pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis (coronary or pulmonary)
Signs of cardiac arrest
loss of consciousness
absence of normal breathing
loss of pulse
dilation of pupils
Who on bisphosphantes are considered low and high risk
-low: taken orally or IV for <5 years, with no systemic glucocorticoids
-high: >5 years, or for any time with systemic glucocorticoids. or have had previous MRONJ
Early management of Bell’s palsy
-paralysis or weakness in one side of face
-eye-patch to protect eye, eye lubricants, prednisolone
Initial management of osteonecrosis
-recommend analgesia
-recommend rinse mouth with chlorhexidine
-if recent onset get them to seek urgent care. If chronic get them to seek non-urgent care
Early management of peri-implantitis
-recommend analgesics, and good OH
-advise patient to seek non-urgent care, or urgent if analgesia not effective
Symptoms and management of sepsis
-Slurred speech
Extreme shivering or muscle pain
Passing no urine (in 24hr period)
Severe breathlessness, high HR, low BP, high lactate, low oxygen saturation
It feels like you’re going to die (impending sense of doom)
Skin mottled or discoloured
-O2 (15L/min) to keep sats >94%
Give IV antibiotics
Give a fluid challenge - IV
Take blood cultures (full blood count)
Measure lactate
Measure urine output
Early management of stroke
-Urgent assessment in a hospital - neurological assessment, ECG, bloods
-CT to asses if ischamic or haemorrhagic
-Haemorrhagic= stop any anticoagulants, control BP
-Ischamic= IV Thrombolysis within 4.5hrs. Then aspirin and clopidogrel
-Close monitoring
Explain the medical risk assessment categories (ASA I to VI)
ASAI= Healthy
ASAII= Mild systemic disease (function ok). eg. controlled asthma, angina, diabetes, epilepsy etc. Drug allergy. Smoker, alcoholic, pregnant. Or >60 years old. BMI 30-40. BP <160/95
ASAIII= Severe systemic disease
(definite functional limitation) - uncontrolled. BMI>40
ASA IV - Severe disease (constant threat) - sepsis. 3 months post MIA/CVA/TIA/stents
ASA V -Moribund. Risk of death if no surgery in 24 hours
ASA VI - Brain dead (organ donor)
ACVPU system is used to assess a patient’s neurological condition in a medical emergency. What are you assessing. (It is the disability part of ABCDE)
A - Alert
C - confusion
V- Voice (verbal response)
P - Pain response
U - Unresponsive
=assessing how conscious they are
What pre, peri and post extraction treatment is given to severe type A or B haemophilia patients.
Prophylaxis treatment for mild A
-Must treat in collaboration with haematologist
-pre: blood test. Transfusion of factor concentrates (8/9) then measure plasma levels
-peri: avoid IDB due to deep tissue injury. PDL or intraosseous better. Articaine better for mandibular infiltrations. Surgicel packing and sutures
-post: tranexamic acid mouth rinse, gauze, post-op instructions. Keep patient for 30 mins before discharging. post-op monitoring
-mild A: given DDAVP 30-60 mins before which raises factor 8 and wWF
