management of emergencies Flashcards
T/F most ARD’s are not life threatening
true - most adverse drug reactions are not life threatening
ARD’s are usually due to what three things
- dentists are at fault
- some events may be RANDOM
- some events may be a REASONABLE RISK OF TX - example- if patient faints - neither the dentist or the patient is responsible - sncope is merely unavoidable complication of injections that everyone must accept
most common in sedation
overdose
- toxic reaction
clinical manifestations of an overdose are related directly to the NORMAL PHARMOCOLGICAL actions of the agent
- example - sedatives = sleep = more sleep = deeper level of sleep or more duration of sleep
barbs have greatest potential
opioid analgesics are involved with the greater number because opioids are more widely used than barbs
ingested vs injected
injected has faster route of transmission
which permit tirtration
inhalation and IV routes
altering amount of drug given based on weight
vs. pill = get a pill
more erratic absorption seen with
intranasal (IN), intramuscular (IM), and oral
if presence of drug sensitivity?
lower than average doses should be administered or diff drug categories substituted
cardiac arrest
resp distress most often reason
moderate to deep sedation affects
hypothalamis and RAS
GA effects
cortex – unconsciousness with progressive respiratory and cardio depression
respiratory arrest occurs where
medulla
diagnostic clues of overdose reaction
recent administrtion of a ssedative hypnotic drug
lack of response
resp depresision - rapid rate but shallow
ataxia
slurred speech
general steps after overdose
step1 - terminate tx
step 2 - position the patient - unconscious = supine and legs slightly elevated
step 3 - airway breathing circulation
ABC ***
look listen and feel for breathe
head tilt and chin lift
step 4 - definitive care
- oxygen, monitor, establish IV line, manage
- definitive management of sedative hypntoic overdose produced by a barbiturate is based on MAINTENANCE of a patent airway and adequacy of ventilation until the patient recovers
step 5 - recovery and discharge
flumazenil
benzo antagonist - ,2 mg in 15 seconds waiting 45
NO discharge if
patient is alone or if not adequately recovered
needto be standing and walking without assistance
therapeutic dosed of meperidine?
what is this
an opioid
analgesia, sedation, euphoris, and a degree of resp depression
diagnostic clues of overdose of opioids
altered consciousness
resp depression - slow rate
miosis - contraction / pinpoint pupils
not reported allergy
- nitrous oxide
2. oxygen
barbs allergy in who?
manifests as?
more seen with past history of asthma, uticaria, and angioedema
manifests as skin lesions, such as hives, and uticaria
meperidine with allergies?
can release histamine locally but this is NOT AN ALLERGIC RXN
along path of vein
ANAPHYLACTIC when
type i response
if hypotension is also a clinical component – this term can be applies
can take up to even 60 minutes to cause reaction
- if take longer to develop - more mild response usually
four main syndromes with anaphylaxis
- skin
- smooth muscle spasms
- resp distress
- cardio collapse
typical generalized anaphylaxis - go through a range of these progressively
fatal anaphylaxis– resp and cardio distrubances predominate
manage immediate skin rxn?
delayed?
epi 1:10,000
IM 1:1000 or subcutaneous .3mg
histamine blocker - diphenydramine
delayed
IM or IV histamine blocker - diphenhydramine 40 mg
prescription for histamine blocker - oral benedryl 50 mg for 3-5 days
bronchospasm is? manage?
resp reaction
wheezing and using accessory muscles to breathe
P-A-B-C
bronchodilator
- ALBUTEROL or epinephrine
IM or subcutaneous 3 ml of 1:1000 dilution for adults or IV .1ml of 1:10000 every 15 to 30
histamine blocker - diphenhydramine - 50 mg intramuscullary or 2mg/kg IM or IV (children
caviate to using epi for bronchodilation
does NOT releive bronchospasm produced by leukotrienes
laryngeal edema
endpoint must know if not fixed?
when little or no air movement can be heard or felt through the mouth and nose DESPITE exaggereated spontaneous respiratory efforts by patient
high pitched crowing and sound of stridor - partially obstructed in presence of respiratory movements
LOSES CONSCIOUSNESS DUE TO HYPOXIA, ANOXIA
- lack of oxygen to brain?
management of laryngeal edema
PABC
definitve
- give epi
maintain airway
administer oxygen
additional - diphenhydramine 50 mg for adults and 25 for children
corticosteroid
cricothyrotomy
hypotension
systolic bp of 90 mmHg in an ASA I adult (might not require tx)
- but same blood pressure in an elderly hypertensive patient may be life threatening
causes of hypotension
exceessive premedicattion
other drugs like steroids. anti HTN, tranquilizers
overdose of sedatives/ anesthetics
reflexes
vascular absorption of LA
hemorrage
theres a very long list
signs of hypotension
chest pain dyspnea systolic below 90 heart failure ischemia
WIDE RANGE – depends on the system it is affecting
like could have adverse skin reacions / cold / clammy
management of hypotension
directed to its cause
PABC
if using inhlation anesthetic like NO2 - decrease concentration
if opioids or benzo
- naloxone or flumazenil
if barbs - no antagonist so basic ife support
can give fluids – 5% dextrose and water, physiiologic saline
administer vasopressors like dopamine – reserved for hypotension that is more severe
hypertensive - overview
can be normal or common due to level of pain or anxiety control is inadequate – can try to prevent by readministration of local anesthesia
if sustained or significant elevation - must be treated aggressively
causes of high blood pressure
light anesthesia or sedation
pain
hypercabia - more Co2
hypoxia
(both these cause catecholamine release)
emergence delirium
fluid overload - over hydraton
hyperthermia
pre existing cardiac problems
hypertensive crisis level
most common in?
Systolic 250 mm Hg or greater
diastolic - is 130 mm Hg or greater
most common / likely to occur in patients with chronic, stable hypertension
definitive care of hypertensive crisis
adinsiter fluids
IV
titrate NITROPRUSSIDE – nipride at an infusion rate of 5 mg/kg/min until the blood pressure is lowered
therapeutic range is 5-10 mg/kg/min
IV nitro - 50 mg bolus - followed by infusion of 10-20 mg / min
- potent vasodilator
IV diazoxide - hyperstat - in doses of 1 to 3 mg/kg up to 150 mg
cardiac dysrhythmias
detectable with monitoring
most common intraoperative complication
ranging from 4% to 60% incidence in preoperative dysrhthmias under GA
even during extraction of bicuspids - patients receiving local anesthesia and sedation levels can be at 24%
(happening but probably under reported))
DeRango’s observations
- majority who are monitored with ECG will demonstrate some dys-rhythmia
- incidence higher in paitents with a past heart history
- higher in trachea intubated patients
- more frequent in surgeries lasting more than 3 hours
- patients receiving digitalis preop (like digoxin) have higher incidence
precipitating factors for dysthrhthmias
anestesia like HALOTHANE
elevated levels of Co2
pain
vagal responses
intubation
anoxia
duration of procedure
management of dysrhythmias
ensuring adequate ventilation
increasing / decreasing level of anesthesia or sedation and providing adequate pain control
continuous ECG monitoring
angina and MI
stable angina
- thoracic pain, usually substernal
- tightness
- heavy weight on chest
result of mild inadequacy of the coronary circulation
- vasodilator drugs and rest can relieve it
significance of chest pain for LONGER DURATION
more likely to lead to a presumptive MI than angina
status of patients who get an MI
51% are at REST when MI occurs – where as onset of angina - usually occuring with increased myocardial activity
management if NO history of angina
activate EMS
administer O2 and nitro
management if history of angina
administer O2 – if pain resolves – make modifications in tx next time
if pain does not resolve – activate EMS - administer aspirin and monitor
MONA morphine oxygen nitroglyxerine aspirin
airway obstruction
important to recognize?
if it is chest pain or not (cardiac origin or not)
airway obstruction due to
most common cause during sedation or GA is POSTERIOR DISPLACMENT OF THE TONGUE – into the pharynx as muscle tonus is lost as a result of the CNS depression
presence of foreign object in airway - produces partial airway obstruction - rather than total obstruction
fluids blood saliva and water / or vomit can produce obstruction
signs of NORMAL UNOBSTRUCTED AIRFLOW
LOW WHOOSING SOUND –
through the mouth and nose has a very distinctive low whoosing sound
movement of the chest during respiration is minimal and looks “smooth”
signs of complete obstruction of airway
absence of sound!!! but observed respiratory movements appear exaggerated with evvident suprclavicular and intercostal soft tissue retraction
partial airway obstruction sound
resulting from tongue posteriorly displaced
SNORING SOUND - that is often heard by all persons in the tx room
wheezing sound
cause?
manage?
bronchospams
administer a bronchodilator
gurgling sound
cause?
manage?
fluid in airway
pharyngeal sunction
snoring sound
cause?
manage?
soft tissue / tongue - displaced in pharynx
- head tilt
- anterior displacement of tongue with hemostat or gauze
no sound bt exxaggerated resp
cause?
manage?
complete obstruction
- head tilt chin lift
- anterior displacement of tongue
- pharyngeal suctioning
- adbominal thrusts
- cricothyrotomy
no sound / no resp
cause?
manage?
apnea
control the ventilation efforts
laryngospasm
protective reflex - maintain integrity of airway
partial = high pitch sounds
complete = no sound with exggerated respiration
management
- supine position
- administer 100 % oxygen and non stop nitrous
- positive pressure with oxygen to maintain airway and break the laryngospasm
muscle relaxant like succinylcholine 10 mg
emesis and aspiratio of foreign material
(vomitting) and possible aspiration of this into airway is one of MOST FRIGHTENING of potential emergencies arising during GA and deep sedation
lower pH of material aspirated – morbidity and death more likely
if go into trachea – potential for disaster
three common factors in incidents in dental offices with relatio to morbidity
- improper preoperative evalutation of the patient
- lack of knowledge of drug pharm by the dentist
- lack of adequate monitoring during the procedure
monitoring for CNS? Resp?
Cardio?
CNS
- direct verbal contact with patient
Resp
- pulse oximetry
- pretracheal stethescope
cardio
- continuous of vitals
- ECG
physician desk reference
compilation of prescribing info on rx drugs
provides with mandated info for prescriing
chemical info
function / action
indications and contra
trial research, side effects, warnings
widely available
