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medically comp pts Flashcards

1
Q

CONSIDERATIONS of med comp pts
* Thorough up to date medical history when?
* Appropriate physical exam?
*consultations sent?
* Be ready to handle?
* Necessary to work together with?

A
  • Thorough up to date medical history: At consultation and each follow-up visit
  • Appropriate physical exam: Full exam performed on consultation examination and Updated on new visits, and depending on new medical history
  • Proper consultations sent
  • Be ready to handle various emergencies
  • Necessary to work together with patient’s PCP to formulate appropriate decisions
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2
Q

HTN stages and diagnosis

A
  • Two recordings at separate visits
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3
Q

HTN txs

A
  • Lifestyle modifications for 2-3 months
  • Diuretics
  • Watch for K loss
  • One drug therapy
  • Multi-drug therapy: Blood Pressure difficult to treat if have to use more than one med
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4
Q

forms of HTN

A
  • Primary (essential) : Greatest % of hypertensive pts
    > 95% idiopathic
  • Secondary: 5% with underlying condition: renal/endocrine disorders
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5
Q

HTN risk factors

A
  • Risk Factors
  • Obesity, Smoking, EtOH, hypercholesterolemia, DM, LVH
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6
Q

cut off value bp for elective procedures

A

180/110

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7
Q

HTN Urgency

A

If BP elevated (can get above 200s systolic and130s diastolic) and patient feels normal →postpone dental treatment AND go see PCP for evaluation and treatment

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8
Q

HTN Emergency

A
  • END ORGAN DAMAGE!! → GET PATIENT TO EMERGENCY DEPARTMENT NOW!!!!
  • Headache, fatigue, blurry vision, numbness, chest pain, dyspnea, anuria
  • Higher risk for stroke and uncontrolled bleeding
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9
Q

ANTI-HYPERTENSIVES

A
  • Beta Blockers: Atenolol, propranolol, metoprolol
  • Ca+ channel blockers: Verapamil, Amlodipine
  • ACE-Inhibitors: Lisinopril, Captopril
  • Diuretics: HCTZ, Furosemide
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10
Q

ISCHEMIC HEART DISEASE
tx?

A
  • Decreased oxygenated blood to myocardium
  • Due to narrowing or incomplete blockage of coronary artery(ies)
  • NO MYOCARDIAL DAMAGE
  • Tx: stent, angioplasty, CABG, meds
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11
Q

IHD pts ASA class with tx and normal EKG

A
  • If patient has NO restrictions and NORMAL EKG after above procedure, then patient can be categorized as ASA II
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12
Q

PROGRESSION OF IHD

A
  • Stable Angina
  • Unstable Angina
  • Myocardial Infarction
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13
Q

ANGINA

A
  • Symptom of IHD due to discrepancy of myocardial oxygen demand and the ability of the coronary arteries to supply oxygenated blood
  • Causes: Narrowing of coronary arteries (LAD a. = “widow-maker”) or Spasm of coronary arterial wall (Prinzmetals angina)
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14
Q

angina symptoms

A
  • Chest pain w/ radiation
  • Nausea, sweating, dyspnea, HTN
  • Bradycardia, Impending sense of doom
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15
Q

ANGINA
* Question the patient thoroughly concerning:

A
  • Precipitating events
  • Frequency
  • Duration
  • Severity
  • What alleviates pain? Medication, what? Rest?
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16
Q

stable angina

A
  • Pain on exertion
  • Infrequent episodes
  • One nitro tab controls pain
  • ASA III
  • Medical Consultation prior to treatment
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17
Q

unstable angina

A
  • Pain at rest
  • Frequent episodes
  • Increasing nitro for pain relief
  • ASA IV
  • Likely requires inpatient care
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18
Q

MANAGEMENT: HISTORY OF ANGINA PECTORIS
what should be available during tx?
LA?
epi dosage?
O2?
anx?

A
  • Stable vs Unstable: Practitioner’s must differentiate
  1. Guidelines for management:
    * Have nitro available
    * Profound LA
    * Cardiac dose of epinephrine (0.04 mg in 30 mins)
    * Use supplemental oxygen (N2O/O2)
    * Anxiety reduction protocol
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19
Q

CARDIAC DOSE OF EPI

A

0.04mg/30min
0.017 mg epi per cartridge (1:100,000)

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20
Q

NITROGLYCERIN

A
  • Potent vasodilator: reduces myocardial oxygen demand
  • Low doses →VENO-dilator
  • High dose →VENO-dilator plus ARTERIO-dilator
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21
Q

NG dosage

A
  • 0.4 mg metered dose spray (oral/sublingual)
  • 0.4 mg/tab, bottle of 25, light protected
  • Give every 3-5 min, no more than 3 doses
  • Watch the blood pressure!
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22
Q

CARDIAC RISK INDEX

A
  • Independent predictors of post-op cardiac complications (all one point each)
  • ≥ 3 = 11% risk
  • 2 = 7% risk
  • 1 = 0.9% risk
  • 0 = 0.4% risk
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23
Q

ANXIETY REDUCTION PROTOCOL pre-op

A
  • Sedative
  • AM appts
  • Nitro
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24
Q

ANXIETY REDUCTION PROTOCOL intra-op

A
  • Non-pharm →VERBAL ASSURANCE
  • Pharmacologic →profound LA and Nitrous
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25
ANXIETY REDUCTION PROTOCOL post-op
* Analgesics * Post-operative instructions and reassurance
26
MANAGEMENT: HISTORY OF MI
* Defer elective procedures for 6 months after infarction * Controversy today: With advent of neovascularization procedures>If patient has NO restrictions and NORMAL EKG after above procedure, dental work can resume after 2 months * ALWAYS Consult Cardiologist * Patient are usually placed on anticoagulants/antiplatelets → drug holiday required?
27
* Potential problems post-MI:
* Ventricular fibrillation →due to increased myocardial excitability * Re-infarction * CHF
28
TIME SINCE MI * Rate of Re-infarction:
* Within 3 months = 28% * 3-6 months = 10% * After 6 months = 5%
29
WHAT TO DO FOR EMERGENCIES IN PATIENTS WITH HISTORY OF HEART ATTACK * epi? * Have what in office and available * Make certain the patient is? * medications prior to dental treatment? * Monitor? * Contact cardiologist when? * Reduce? how? * location?
* Limit Epi (0.04 mg) * Have Nitro in office and available * Make certain the patient is taking medications * More often than should, patients do not take their medications prior to dental treatment * Monitor blood pressure throughout procedure * Contact cardiologist that day prior to procedure, if possible * Reduce anxiety: Walk patient through procedure, Reassure constantly * Change location to hospital setting
30
HEART FAILURE
* Congestive heart failure is the failure of the heart as a basic pump
31
HF symptoms
* Symptoms: * Dyspnea * Orthopnea * Paroxysmal nocturnal dyspnea * Weakness/fatigue * Extremity edema
32
RIGHT VENTRICULAR FAILURE signs
* Jugular venous distention (JVD) * Peripheral edema * Hepatomegaly
33
LEFT VENTRICULAR FAILURE signs
* Pulmonary edema * Dyspnea * Paroxysmal nocturnal dyspnea
34
* If HF patient has NO symptoms, and is well controlled medically can we perform outpt procedures?
* If patient has NO symptoms, and is well controlled medically (antihypertensives, diuretics) the patient is SAFE for ambulatory outpatient surgery
35
Precautions for HF pts supplemental what? position? anxiety?
* Supplemental low-flows Oxygen * Patient UPRIGHT!!!! Position * Anxiety reduction protocol
36
STROKE SYMPTOMS
* NUMBNESS/WEAKNESS of face/arm/leg * Unilateral * Trouble walking or loss of balance * CONFUSION, speaking or understanding * VISION CHANGES * SEVERE HEADACHE
37
TRANSIENT ISCHEMIC ATTACK
* TIA * Symptoms < 24 hours * With return to normal functioning
38
CEREBROVASCULAR ACCIDENT % causes?
* CVA * Symptoms > 24 hours * Limited return to “normal” functioning * Ischemic (80%): Embolic and Thrombotic * Hemorrhagic (20%): Aneurysm and/or vascular malformation
39
STROKE pt management * Deferral of treatment? * PCP/Neurologist involvement? * Call PCP/Neurologist when? * Check medical list for what drugs? * Monitor? * Anxiety?
* Deferral of treatment for 6 months post-stroke due to increased incidence of recurrence * Always send medical consultation to PCP/Neurologist regarding elective care * Call PCP/Neurologist that day for emergent procedures * Check medical list: * Anticoagulants * Antiplatelets * Monitor BP * Anxiety reduction
40
ASTHMA
* Onset usually early * Associated with allergens, cold air, anxiety, exercise * A reversible process * First line tx: * Inhaled short-acting beta agonist (Albuterol)
41
COPD
* Onset usually 4th decade and up * H/o smoking or chronic respiratory infections * An irreversible process * First line tx: Bronchodilators: β2-adrenergic agonist (Salbutamol, salmeterol) Anticholinergic (Ipraropium, tiotropium
42
NO with COPD
contraindicated
43
ASTHMA PATIENT MANAGEMENT * Usual no problems if the patient has? * Thorough medical history review: * Frequency of? * Hospitalizations? * Intubations? * medications?
* Usual no problems if the patient has GOOD control * Thorough medical history review: * Frequency of attacks * Hospitalizations from asthma attack * Intubations from asthma attack * Current medications
44
ASTHMA PATIENT MANAGEMENT * Anxiety? * nitrous oxide? * Keep what at chair side? * Avoid what in susceptible patients?
* Anxiety reduction * Okay to give nitrous oxide * Keep beta-agonist inhaler (albuterol) at chair side * Avoid NSAIDs, ASA, PCN in susceptible patients
45
* If STATUS ASTHMATICUS (severe attack not responsive to standard medication) what to do?
* Epinephrine: 0.3 mg SubQ Q15 - 20 min x 3 doses * Supplemental oxygen: 1-3 L/min
46
EMPHYSEMA signs
* Barrel chested * Exertional dyspnea * Non-productive cough * Thin body habitus
47
BRONCHITIS signs
* Cyanotic * Frequent respiratory infections * Chronic PRODUCTIVE cough * Obese body habitus
48
CHRONIC OBSTRUCTIVE PULMONARY DISEASE common signs
* Easily fatigued * Frequent respiratory infections * Use of accessory muscles to breathe * Chronic cough * Pursed-lip breathing * Digital clubbing * Orthopneic * Wheezing * Barrel chested * Prolonged expiratory time * Thin appearance * Increased sputum (bronchitis)
49
COPD MANAGEMENT * Avoid what drugs? * If patient has own oxygen with them? * If patient is not on oxygen? why? * chair position * Keep what at chairside? * Closely monitor? *timw for appointments preferred?
* Avoid respiratory depressors (opioids) * If patient has own oxygen with them, continue same flow rate throughout procedure * If patient is not on oxygen, consult physician prior to starting oxygen therapy: Respiratory drive is a HYPOXIC DRIVE (low Oxygen saturation) in these pts * Keep patient inclined, until confident patient can lay supine in chair with no dyspnea * Keep bronchodilator at chairside * Closely monitor respiratory and heart rates * PM appointments preferred
50
DIABETIC PATIENT * If not well controlled? * Prone to? * Hyperglycemia adversely affects? * Delayed in? * Hyperglycemia and Hypoglycemia? which worse?
DIABETIC PATIENT * If not well controlled there are significant potential difficulties in treatment * Prone to infection * Hyperglycemia adversely affects WBC diapedesis and demarginalization * Delayed in wound healing, possible chronic wound * Hyperglycemia * Hypoglycemia: More problematic if it occurs
51
DIABETIC PATIENT * Balancing post-operative caloric intake with? * change in insulin pre-operatively for local anesthesia? * If NPO (for intravenous sedation) what is insulin protocol? alternate?
DIABETIC PATIENT * Balancing post-operative caloric intake with their insulin requirement * No change in insulin pre-operatively for local anesthesia * If NPO (for intravenous sedation) continue normal nighttime dose but decrease AM dose by 50%, Alternate: hold AM dose, and half nighttime dose
52
DIABETIC PATIENT MANAGEMENT * what time appointments best? * Take pre-operative blood glucose? * Long term control of blood glucose determined by? * Want level to be below %?
DIABETIC PATIENT MANAGEMENT * AM appointments best * Take pre-operative blood glucose on every diabetic patient * Long term control of blood glucose determined by Hb A1C * Red Blood Cell’s life span is ~ 120 days * Glucose irreversibly binds to hemoglobin molecule in RBCs * So the glycated hemoglobin level is a three-month average of blood glucose control * Want level to be below 6%
53
SICKLE CELL DISEASE
* Substituted Valine for Glutamate on Hb molecule * Hb A converted to Hb S * Autosomal recessive inheritance pattern * Sickle Cell Trait: no treatment modifications * Sickle Cell Anemia: concern is the prevention of acute crises * Hemolysis of RBCs →anemia * Splenic sequestration of RBCs →splenomegaly, anemia →asplenia * Increased risk of infection by encapsulated organisms
54
encapsulated organisms for sickle cell
some stranger killers have pretty nice capsules: Salmonella, Strep Pneumo, Klebsiella, H. influenza, Pseudomonas, Nisseria, Cryptoccocus
55
PREVENTION OF CRISES with sickle cell * Oxygen? * Warming? * LA? * fluid intake? * post op? * Consultation with PCP regarding? * Treat infection?
* Supplemental Oxygen throughout procedure to prevent hypoxia * Warming blanket to prevent hypothermia * Profound local anesthesia to decrease stress * Adequate fluid intake (PO or IV) to prevent dehydration * Adequate Post-operative analgesics * Consultation with PCP regarding narcotics as patients traditionally are already on high dose narcotic medication daily * Treat infection aggressively
56
PATIENTS ON STEROIDS * Increased risk of complications due to:
* Adrenal suppression and inability to cope with stress * Inability to vasoconstrict peripheral vasculature, thus can not respond to stress accordingly * This leads to profound hypotension →LOC
57
* Long term side effects of steroid tx:
* * HTN * DM * Delayed healing * Infection
58
STEROID PATIENT MANAGEMENT: Do we need to give patient stress dosing of steroids pre-operatively, to prevent this patient from crashing? depends on:
* How much and how long on steroids? * How invasive is the surgery?
59
steroid pts and preop prophylaxis
* Usually all dental procedures are minor surgery and do not require pre-operative prophylaxis
60
THYROID DISEASE Defer surgery until? * Lab values of note from PCP: * If treated and limited control obtained limit what and do not give what?
Defer surgery until thyroid dysfunction is well controlled * Lab values of note from PCP: * Thyroid panel →T3, T4, thyroid binding globulin, thyroid stimulating hormone (TSH) * If treated and limited control obtained: Limit epi and Do not give atropine
61
HYPOTHYROIDISM
* Progressive destruction of thyroid tissue * Autoimmune (Hashimoto’s thyroiditis) * Surgically (removed thyroid tissue to treat hyperthyroidism) * Medically (lithium, propylthiouracil (PTU), radioactive iodine, methimazole) * Symptoms: * Fatigue, unintended weight gain, cold intolerance, constipation, AMS
62
* Myxedema:
* Emergency, can be caused by infection, meds, stress * Altered mental status, seizures, coma, hypotension * Tx: immediate IV levothyroxine and corticosteroids
63
HYPERTHYROIDISM
* Increased presence in thyroid stimulating antibodies * Graves disease
64
* Thyroid storm:
* Emergency, can be caused by infection, meds, stress * Fever, tachycardia, tremors, HTN, cardiac arrhythmia, cardiac failure, coma, death * Tx: beta blockers (propranolol), PTU, or iodine
65
risk factors for liver disease:
* IV drug use, EtOH, promiscuity, overuse of medications, viral infections, hereditary disorders
66
Associated symptoms of liver dx
* Jaundice, itching, easy bruising, ascites, gynecomastia, hepatic encephalopathy, spider telangiectasia, palmar erythema
67
Lab values from PCP for liver dx:
* Alanine aminotransferase (ALT), Aspartate Aminotransferase (AST), coagulation panel, hepatitis panel with viral load
68
major implcations of liver dx
* Viral contagion of dentist and other patients * Increased risk of bleeding * Altered metabolism of drugs: Can cause toxicity or no effect from drug
69
LIVER DISEASE * Strict adherence to? * Pre-op tests? * Avoid drugs primarily excreted in? * discuss post-op pain management?
* Strict adherence to sterile technique: THIS SHOULD BE DONE FOR ALL PATIENTS NO MATTER IF DISEASED OR NOT DISEASED * Pre-op tests as mentioned earlier to determine extend of liver damage as well as infectivity (viral load) * Avoid drugs primarily excreted in liver * May need to discuss post-op pain management with PCP prior to procedures
70
RENAL INSUFFICIENCY * Patients can’t? * Be careful with medications with? * Avoid?
* Patients can’t excrete normally, thus drug metabolites and filtrate usually excreted remains in blood serum * Be careful with medications with active metabolites (Demerol, codeine, ASA, valium) * Avoid nephrotoxic medications (NSAIDs, Amphotericin B, ACE-Inhib, MTX, acyclovir, B-lactam antibiotics, etc...)
71
pts with hemodialysis Replaces the kidneys as? *bp? * Due to tortuosity of dialysis machine, the blood is?why? * Usually requires what for long term dialysis? * Schedule patient when reagrding dialysis? why? * Consult PCP concerning?
Replaces the kidneys as the filtration system in body * Also can remove excess fluid from system (reducing BP) * Due to tortuosity of dialysis machine, the blood is HEPARINIZED: Prevents clotting in machine, and then transfer of clot to venous system * Usually requires dialysis shunt for long term dialysis * Schedule patient on days AFTER Dialysis= Heparinized blood, clots poorly * Consult PCP concerning antibiotic prophylaxis
72
ANTICOAGULATION * Medical consultation requesting? * PT? * INR? * PTT? * Platelet count? * Bleeding time?
* Patient on anticoagulation for variety of reasons * Medical consultation requesting basic coagulation profile * PT (10-12 sec) →extrinsic factors * INR (1) →extrinsic factors * PTT (60-70 sec) →intrinsic factors * Platelet count (150k-250k) * Bleeding time (5-7 min)
73
* If on Coumadin/Warfarin: INR below what is acceptable to surgery
* If on Coumadin/Warfarin: INR below 3 is acceptable to surgery
74
anticoag med consults for drug holiday
* Medical consultation regarding safety of drug holiday prior to procedures * Patients may be at too high of risk to stop medication
75
what procedures may/may not req drug holiday
* Big, full mouth extractions might require drug holiday * Single teeth, or a couple in one quad may not require drug holiday
76
ANTICOAGULATION PATIENT MANAGEMENT * Augment clotting during surgery with use of? * Monitor wound? * Avoid?
* Augment clotting during surgery with use of pro-coagulant substances, sutures, and well placed pressure packs * Monitor wound for an hour to ensure good initial clot * Avoid NSAIDs and ASA
77
Elective procedures best to perform when in pregnancy
Elective procedures best to perform after delivery or in 2nd trimester * 1st trimester fetus formation susceptibility * 3rd trimester, premature delivery of fetus →not in my office!!!
78
pregnancy radiographs and med adjustments
* Lead apron for radiographs * Medication adjustments prior to delivery, after delivery, and related to breastfeeding
79
what meds to avoid with pregnant pts
* Avoid teratogenic medications * Tetracycline, corticosteroids, aminoglycosides
80
postioning pregnant pts
* Lay patient on left side if prolonged appointment * Prevents occlusion of inferior vena cava * Allow frequent bathroom breaks
81
FDA DRUG CATEGORIES for pregnant pts
* Category A: no fetal harm * Category B: no fetal risk in animal studies, no human studies * Category C: risk in animal studies but no human studies * Category D: positive evidence of human fetal risks
82
category B drugs for pregnancy
Lidocaine, B-lactam abx, Tylenol, NSAIDs (not in 3rd trimester), short round fentanyl/oxycodone
83
category C drugs for pregnant pts
Codeine, hydrocodone, tramadol, mepivicaine, bupivacaine
84
category D drugs for pregnant pts
Aspirin, all NSAIDs in 3rd trimester, long term opioid use
85
safe Rx during lactation
* Tylenol * Antihistamines * Cephalexin * Codeine * Erythromycin * Fluoride * Lidocaine
86
unsafe drugs during lactation
* Aspirin * Atropine * Steroids * Valium * Metronidazole * PCN

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