Medical Emergencies in the dental office

Question 1

Emergency

Answer 1

An unforeseen combination of circumstances that call for immediate action. Low frequency high impact events

Question 2

Minor: Simple faint

Answer 2

Elevate feet and monitor if they come back

Question 3

Intermediate emergency

Answer 3

O2 + Repositioning - start CPR

Question 4

Major emergency

Answer 4

Call 911, referral to MD or ER. Ex: Diabetes, infection, hypertension - too high BP

Question 5

Prevention of medical emergencies

Answer 5

Vital signs to be taken - BP (120/80), Heart rate & rhythm (60-110), Respiratory rate (16-18 breaths), height, weight

Question 6

Determining medical risks

Answer 6

Medical history questionnaire, physical eval, dialogue history, medical consultation, ASA classification

Question 7

ASA physical status classifications

Answer 7

1 - healthy patient, no systemic disease
2 - mild systemic disease
3 - severe systemic disease limiting activity
4 - incapacitating systemic disease that is a constant threat to life
Do not see anyone below a 4
5 - Moribund patient not expected to survive 24 hours with/out an operation
6 - brain dead, organ harvest for donation
E: “Emergency operation” added to patients physical status classification

Question 8

Levels of consciousness

Answer 8

Awake
Altered - pre-syncope, TIA, slurred words
Unconscious - syncope, orthostatic hypotension
Seizures - hyperventilation, syncope, epilepsy

Question 9

Airway - breathing

Answer 9

Obstruction, hyperventilation, asthma, COPD, emphysema

Question 10

Management of cardiac emergencies

Answer 10

Given the increase in human life expectancy resulting from improvement in medical care, dental practitioners are now more likely to encounter cardiovascular emergencies in an outpatient setting

Question 11

Cardiovascular

Answer 11

Angina - chest pain, Hypo/Hypertension, dysrhythmia - bradycardia, tachycardia, myocardial infarction, cardiac arrest

Question 12

Drug related emergencies

Answer 12

Overdose: local anesthetics, sedatives

Reaction to drugs: allergy (rash, itching, airway)

Question 13

Goals of physical evaluation

Answer 13

ability to psychologically tolerate stress
ability to physically tolerate treatment
is treatment modification indicated
is psychosedation indicated
which sedation technique is indicated
any contraindication to premedication used

Question 14

Recognition of anxiety

Answer 14

increased BP and pulse
trembling
diaphoresis
restlessness
hyperventilation
dilated pupils

Question 15

Stress reduction protocol

Answer 15

oral sedation - pm and am 
intraoperative sedation - IV or N2O
Effective pain control - local anesthesia 
Am appointment
Time factor - short appts
Hot and humid weather
Post-op Rc prn
Post-op phone call

Question 16

Treatment modifications

Answer 16

Intra-op oxygen
Sedation - oral, N2O, IV
Patient position - can they withstand?
Antibiotic premedication 
cardiac pacemaker or defibrillator
anticoagulant

Question 17

Fainting

Answer 17

Vasodepressor syncope

Question 18

Syncope

Answer 18

is considered a transient loss of consciousness due to hypoerfusion of the brain and is characterized by rapid onset and spontaneous resolution
Can be caused by pallor, nausea, sweating, bradycardia, and rapid fall in BP - > when below a critical level, results in loss of consciousness due to generalized cerebral ischemia
Usually evoked by emotional stress associated with fear or pain

Question 19

Orthostatic hypotension

Answer 19

A decrease in systolic BP or 20mmHG or a decrease in diastolic BP of 10 mmHG within 3 mins of standing when compared with baseline BP
Increased with age

Question 20

Psychogenic factors

Answer 20

Fright or anxiety, pain, emotional stress, sight of blood, sight of dental instruments, unwelcome news

Question 21

Non-psychogenic factors

Answer 21

upright or standing position, hungers exhaustion, poor physical condition, hot, humid, crowded environment, male sex, age btw 16-35

Question 22

Vasovagal syncope

Answer 22

sudden, rapid drop in heart rate and BP which leads to fainting. Most common cause of syncope - about 32%. most patients experience their first episode as a teenager or adolescent

Question 23

syncope manifestations

Answer 23

warmth, loss of color, sweating, feels bad, nausea, BP at baseline, tachycardia

Question 24

syncope episodes

Answer 24

usually triggered by a sudden, temporary drop in blood flow to the brain, which leads to loss of consciousness and muscle control
the person then falls down or over, which allows blood flow to return to the brain
returning blood flow allows the person to regain consciousness

Question 25

late syncope manifestations

Answer 25

yawning, difficult breathing, pupillary dilation, cold hands and feet, dizziness, loss of consciousness, hypotension and bradycardia

Question 26

Treatment syncope

Answer 26

``` position patient - horizontal airway and breathing circulation - vital signs oxygen cool compress on wrist & forehead aromatic spirits of ammonia loosen clothing reassurance ```

Question 27

Hyperventilation - prevention

Answer 27

medical history physical exam recognize signs of anxiety stress reduction protocol

Question 28

Hyperventilation

Answer 28

to breathe at an abnormally rapid rate, so increasing the rate of loss of CO2 rate of removal of CO2 from the blood is increased as the partial pressure of CO2 in the blood decreases, respiratory alkalosis ensues

Question 29

Hyperventilation - symptoms

Answer 29

``` tightness in chest - suffocation rapid respiration - rapid pulse light headedness - apprehension Lump in throat - precordial pain Might think their having a heart attack ```

Question 30

Hyperventilation: signs and symptoms

Answer 30

rapid and shallow breathing, confusion, dizziness, cold hands, carpal-pedal spasms; can lead to seizures, tingling or numbness of hands or lips, carpopedal spasm, patients are usually btw 15-40, color good

Question 31

Hyperventilation - managment

Answer 31

Terminate procedure, position comfortably - usually upright, reassure patient, no oxygen, breathe into paper bag or headrest over, count to ten btw breaths, valium 5mg IM or IV for severe cases