L9 Medical Emergencies Flashcards
What are the most common causes of medical emergencies
- Stress & anxiety
- Extreme age
- Improper pt assessment
- Longer dental appt
- Unhealthy, unfriendly enviornment
Other risk factors for med emergencies?
- OSA
- Obesity
- Higher mallampati score
- Increased drug administration
- Multipharma pt’s
- Addict patients
When do most medical emergencies happen?
55% LA 39% extraction 27% pupal extirpation 22% ensuing dental tx 2% in the waiting room
What do you have to be concerned about that is stress related?
Syncope Acute angina Acute asthma Stroke Seizures HV (hyperventilation) syndrome
Non stress related
Allergy Hypoglycemia Drug overdosage & LA toxicity Postural hypotension Airway obstruction
PABCD of BLS
What does BLS stand for?
Positioning
Airway
Breathing
Circulation
Definitive tx: diagnosis, drugs, defibrillation
Basic life saving = dentist certification
General emergency drugs that are INJECTABLE for dental office
- epi
- histamine-blocker
- antihypoglycemic
Use of epi in office
1: 1000 IM
1: 10 000 IV
Anaphylaxis
Histamine-blocker aka benadryl emergency injection
Non life threatening allergy - rash, hives, itching
Antihypoglycemic emergency injection
50% dextrose in water
glucagon 1mg/IM
Non-injectable & inhalational drugs
- O2 - almost all emergency
- Glucose - hypoglycemia
- Nitroglycerin - acute angina
- Salbutamol (2 puffs) - acute asthma
- Aspirin (chewable) - chest pain, suspected MI
- Aromatic ammonia - respiratory stimulant
Parental (non oral) drugs
- Analgesic - ex morphine, fentanyl
- Anticonvulsant - diazepam, midazolam
- Antihistamine - Benadryl
- Antihypoglycemic - dextrose + glucagon
- Corticosteroid - methylprednisolone
- Narcotic antagonist - Naloxone
- Benzo antagonist - flumazenil
- Vasopressor - epi
- Vagolytic - atropine, glycopyrolate
Vasovagal Syncope
Syncope is a sudden loss of consciousness due to transient brain schema
What type of patients do vasovagal responses occur in?
Otherwise healthy people
What causes the vasovagal response?
Psychic, smelling, hearing, panic, anxiety, acute pain
What is the mechanism of vagal responses?
Vagal stimulation –> slow HR –> decreased CO –> decreased BP and brain schema –> transient LOC
Max dose for LA with and without epi
500 –> 5 um/ml in blood
300 mg
How to prevent systemic toxicity from LA’s?
- Slow injection
- Aspirate
- Small divided doses
- Ask about symptoms
- Know your max doses
How you manage systemic toxicity from LA’s?
- Stop injecting
- Call for help - start lipid emulsion therapy?
- Airway mgmt - give 100% oxygen, avoiding HV
- Treat seizure - valium?
- Treat hypotension and bradycardia
- Pulseless - start CPR
Manifestations of sedative and GA overdose
- Medullary depression
- Reduced RR and HR
- Lower O2 sat, higher CO2 sat
- Cyanosis
- Heart and resp failure
Management of sedative and GA overdose
- Stop injecting drug
- Call for help, call 911
- O2, fluids, vasopressor
- Reversal drug
- Consider admission
What if patient hasn’t woken up after from fainting after 5 mins? they are breathing
- Administer O2
- Crush ammonia ampoule under nose
- Monitor vitals
- Assess pt - good and awake
- Get pt escorted home
- Plan for anxiety control measures for future dental care
What if patient hasn’t woken up after from fainting after 5 mins? they are not breathing
- Start BLS
- Call for help, call EMS
- Consider possible non vasovagal syncope - hypoglycemia, seizure etc.
What are skin manifestations of allergic rx?
- Urticaria
- Angioedema
- Pruritus
- Erythema
- Rashes
What are the respiratory manifestations of an allergic rx?
- Wheezing
2. Dyspnoea (laboured breathing)
Management of an allergic reaction?
- Stop administration of all drugs presently in use
- Call for help
- Administer epinephrine (0.3 – 0.5 mg SC/ IM) (if respiratory signs)
- Give oxygen (6 L/Min) by face mask or nasally
- Monitor vital signs frequently
- Establish IV access
- Administer antihistamine, Benadryl 50 mg
- Consult patient’s physician or emergency room physician
- Observe in office at least 1 hr
- Prescribe antihistamine 25-50 mg tabs 4-6 h.
Manifestations of anaphylaxis?
Malaise Wheezing Moderate to severe dyspnea Stridor Cyanosis Tachycardia Hypotension Dysrhythmias Cardiac arrest
What are 4 possible causes of chest pain?
- Cardiac - angina, MI
- GI - esophagitis, ulcer, heart burn, hernia
- Skeletomucle - spasm
- Psychological - hyperventilation
What relieves angina?
- nitroglycerine
- Oxygen
- rest
What are common causes of chest pain?
- exertion
- Large meal
- anxiety
Management of chest pain in dental chair
- Stop dental tx
- Put patient in semi-reclined position
- Give nitroglycerin
- Give aspirin
- Give oxygen
- check pulse and BP
If relieved: assume angina
- slowly taper oxygen
- Modify dental tx to prevent recurrence
- hospital referral
If not relived: assume MI
- give morphine for pain
- call EMS
MGMT of basic asthma attack
- Terminate all dental treatment
- Position patient in fully sitting posture
- Administer bronchodilator by spray (Salbutamole, isoproterenol, epinephrine)
- Administer oxygen
- monitor vital signs
Symptoms of hyperventilation
Anxiety Tetany Hyperpnea Light headedness Tingling extremities Circumoral numbness
Mgmt of hyperventilation
- Terminate all dental treatment and remove foreign bodies from mouth
- Position patient in chair in almost fully upright position
- Attempt to verbally calm patient
- Have patient breathe CO2 enriched air, such as in and out of a small bag
- if symptoms persist, administer diazepam 10 mg IM (midazolam 5 gm IM)
- Monitor vital signs
- Use anxiety control/ Sedation in future
What are mild symptoms of hypoglycemia?
Nausea
Hunger
Weakness
What are moderate symptoms of hypoglycemia?
Tachycardia Perspiration Pallor Anxiety Behavioural changes - confusion, uncooperative
What are severe symptoms of hypoglycemia?
Unconsciousness
Seizure
Hypotension
Symptoms of pt in seizure
Rigid
Cyanosis
Cheek/tongue biting
Loss of consciousness
Symptoms post seizure
Guilt
Desire to sleep
Confused, disoriented
Tx of conscious pt in seizure
1, protect from harm 2. suction airway if need be 3. monitor vitals 4. give oxygen 5. call dr 6 observe for 1 hour 7. escort home
Tx of unconscious pt in seizure
- call for help
- protect from harm
- place on side and suction airway
- monitor vitals
- start BLS
- oxygen if needed
- Transport ot emerg
