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OS and Pain Management 2 > Medically compromised patient > Flashcards

Medically compromised patient Flashcards

1
Q

CONSIDERATIONS
(5)

A
  • Thorough up to date medical history
  • Appropriate physical exam
  • 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
  • Thorough up to date medical history
    (1)
A
  • At consultation and each follow-up visit
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3
Q
  • Appropriate physical exam
    (2)
A
  • Full exam performed on consultation examination
  • Updated on new visits, and depending on new medical history
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4
Q

WHY MORE RELEVANT TODAY?
* We have the ability to perform

A

more complicated and lengthy dental procedures
* “The aging of America”
* Polypharmacy

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5
Q
  • “The aging of America”
    (2)
A
  • Growing geriatric population
  • Increased medical risk patients
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6
Q

HYPERTENSION (HTN)
* New BP guidelines from ACC
* — recordings at separate visits

A

Two

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7
Q

New Guidelines: Normal
Systolic BP
Diastolic BP

A

Less than 120
Less than 80

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8
Q

New Guidelines: Elevated BP
Systolic BP
Diastolic BP

A

120-129
Less than 80

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9
Q

New Guidelines: Hypertension (Stage I)
Systolic BP
Diastolic BP

A

130-139
80-89

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10
Q

New Guidelines: Hypertension (Stage II)
Systolic BP
Diastolic BP

A

≥ 140
≥ 90

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11
Q

HYPERTENSION
* Treatments available:
(5)

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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12
Q

HYPERTENSION
* Primary (essential)
(2)

A
  • Greatest % of hypertensive pts
  • > 95% idiopathic
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13
Q

HYPERTENSION
* Secondary

A
  • 5% with underlying condition: renal/endocrine disorders
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14
Q

HYPERTENSION
* Risk Factors

A
  • Obesity, Smoking, EtOH, hypercholesterolemia, DM, LVH
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15
Q

Hypertensive URGENCY vs Hypertensive EMERGENCY
* Not all patients with elevated BP need to go to the

A

Emergency Department

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16
Q

BP —- IS ABSOLUTE CUTOFF VALUE for elective procedures
* Emergency procedures would be case by case basis

A

> 180 mmHg or DBP > 110 mmHg

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17
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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18
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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19
Q

ANTI-HYPERTENSIVES
* Beta Blockers
(3)

A
  • Atenolol, propranolol, metoprolol
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20
Q

ANTI-HYPERTENSIVES
* Ca+ channel blockers
(2)

A
  • Verapamil, Amlodipine
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21
Q

ANTI-HYPERTENSIVES
* ACE-Inhibitors
(2)

A
  • Lisinopril, Captopril
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22
Q

ANTI-HYPERTENSIVES
* Diuretics
(2)

A
  • HCTZ, Furosemide
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23
Q

ISCHEMIC HEART DISEASE
* Decreased oxygenated blood to myocardium
* Due to

A

narrowing or incomplete blockage of coronary artery(ies)

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24
Q

ISCHEMIC HEART DISEASE
NO — DAMAGE

A

MYOCARDIAL

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25
Q

ISCHEMIC HEART DISEASE
Rx: (4)

A

stent, angioplasty, CABG, meds

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26
Q

ISCHEMIC HEART DISEASE
If patient has NO restrictions and NORMAL EKG after above procedure, then patient
can be categorized as

A

ASA II

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27
Q

PROGRESSION OF IHD
(3)

A
  • Stable Angina
  • Unstable Angina
  • Myocardial Infarction
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28
Q

ANGINA
* Symptom of IHD due to

A

discrepancy of myocardial oxygen demand and the ability of the
coronary arteries to supply oxygenated blood

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29
Q

Angina
Causes:
(2)

A
  • Narrowing of coronary arteries (LAD a. = “widow-maker”)
  • Spasm of coronary arterial wall (Prinzmetals angina)
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30
Q

Angina
Symptoms:
(3)

A
  • Chest pain w/ radiation
  • Nausea, sweating, dyspnea, HTN
  • Bradycardia, Impending sense of doom
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31
Q

ANGINA
* Question the patient thoroughly concerning:
(4)

A
  • Precipitating events
  • Frequency
  • Duration
  • Severity
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32
Q

Angina
What alleviates pain?
(2)

A
  • Medication, what?
  • Rest
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33
Q

ANGINA
STABLE
(5)

A
  • Pain on exertion
  • Infrequent episodes
  • One nitro tab controls pain
  • ASA III
  • Medical Consultation prior to treatment
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34
Q

ANGINA
UNSTABLE
(5)

A
  • Pain at rest
  • Frequent episodes
  • Increasing nitro for pain relief
  • ASA IV
  • Likely requires inpatient care
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35
Q
  • Stable vs Unstable
  • Practitioner’s must differentiate
  • Guidelines for management:
    (5)
A
  • 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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36
Q

CARDIAC DOSE OF EPI
*— mg per 30 mins (in OMS clinic we limit — mg in one appointment)
* 1:1,000 →— mg/mL
* 1:10,000 →— mg/mL
* 1:100,000 →— mg/mL

A

0.04, 0.04
1
0.1
0.01

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37
Q

In 1.7 mL cartridge, of 1:100,000 epi →0.017 mg epi per cartridge
* 1.7 mL cartridge of 2% lidocaine →– mg lidocaine
* 1% solution →– mg/mL
* 2% solution →– mg/mL

A

34
10
20

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38
Q

NITROGLYCERIN
* Potent vasodilator:
* Low doses →
* High dose →

A

reduces myocardial oxygen demand
VENO-dilator
VENO-dilator plus ARTERIO-dilator

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39
Q

NITROGLYCERIN
Dosage:
* — mg metered dose spray (oral/sublingual)
* — mg/tab, bottle of 25, light protected
* Give every 3-5 min, no more than — doses
* Watch the blood pressure!

A

0.4
0.4
3

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40
Q

ANXIETY REDUCTION PROTOCOL
* Pre-operative
(3)

A
  • Sedative
  • AM appts
  • Nitro
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41
Q

ANXIETY REDUCTION PROTOCOL
* Intra-operative
(2)

A
  • Non-pharm →VERBAL ASSURANCE
  • Pharmacologic →profound LA and Nitrous
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42
Q

ANXIETY REDUCTION PROTOCOL
* Post-operative
(2)

A
  • Analgesics
  • Post-operative instructions and reassurance
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43
Q

MANAGEMENT: HISTORY OF MI
* Defer elective procedures for — months after infarction
* Controversy today:
(2)

A

6

  • With advent of neovascularization procedures
  • If patient has NO restrictions and NORMAL EKG after above procedure, dental work can resume after 2
    months
44
Q

ALWAYS Consult Cardiologist
* Patient are usually placed on anticoagulants/antiplatelets →drug holiday required?

  • Potential problems post-MI:
    (3)
A
  • Ventricular fibrillation →due to increased myocardial excitability
  • Re-infarction
  • CHF
45
Q

Rate of Re-infarction:
* Within 3 months = —%
* 3-6 months = —%
* After 6 months = —%

46
Q

WHAT TO DO FOR EMERGENCIES IN PATIENTS
WITH HISTORY OF HEART ATTACK

A
  • 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
47
Q

HEART FAILURE
* Congestive heart failure is the

A

failure of the heart as a basic pump

48
Q

HEART FAILURE
Symptoms:
(5)

A
  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Weakness/fatigue
  • Extremity edema
49
Q

RIGHT VENTRICULAR FAILURE
(3)

A
  • Jugular venous distention (JVD)
  • Peripheral edema
  • Hepatomegaly
50
Q

LEFT VENTRICULAR FAILURE
(3)

A
  • Pulmonary edema
  • Dyspnea
  • Paroxysmal nocturnal dyspnea
51
Q

HEART FAILURE
* If patient has NO symptoms, and is well controlled medically (antihypertensives,
diuretics) the patient is

A

SAFE for ambulatory outpatient surgery

52
Q

HEART FAILURE
Take precautions:
(3)

A
  • Supplemental low-flows Oxygen
  • Patient UPRIGHT!!!! Position
  • Anxiety reduction protocol
53
Q

STROKE SYMPTOMS
(4)

A
  • NUMBNESS/WEAKNESS of face/arm/leg
  • Unilateral
  • Trouble walking or loss of balance
  • CONFUSION, speaking or understanding
  • VISION CHANGES
  • SEVERE HEADACHE
54
Q

TRANSIENT ISCHEMIC ATTACK
(3)

A
  • TIA
  • Symptoms < 24 hours
  • With return to normal functioning
55
Q

CEREBROVASCULAR ACCIDENT
(5)

A
  • CVA
  • Symptoms > 24 hours
  • Limited return to “normal” functioning
  • Ischemic (80%)
  • Hemorrhagic (20%)
56
Q
  • Ischemic (80%)
    (2)
  • Hemorrhagic (20%)
    (2)
A
  • Embolic and Thrombotic
  • Aneurysm and/or vascular malformation
57
Q

STROKE
* Deferral of treatment for — months post-stroke due to increased incidence of recurrence
* Always send medical consultation to
* Call PCP/Neurologist that day for —
* Check medical list:
(2)
* Monitor —
* — reduction

A

6
PCP/Neurologist regarding elective care
emergent procedures
* Anticoagulants
* Antiplatelets
BP
Anxiety

58
Q

COPD
(3)

A

asthma
emphysema
chronic bronchitis

59
Q

ASTHMA
(3)

A
  • Onset usually early
  • Associated with allergens, cold air,
    anxiety, exercise
  • A reversible process
60
Q

asthma
* First line tx:

A
  • Inhaled short-acting beta agonist
    (Albuterol)
61
Q

COPD
(3)

A
  • Onset usually 4th decade and up
  • H/o smoking or chronic respiratory infections
  • An irreversible process
62
Q

COPD
First line tx:
(3)

A
  • Bronchodilators
  • β2-adrenergic agonist (Salbutamol, salmeterol)
  • Anticholinergic (Ipraropium, tiotropium)
63
Q

ASTHMA PATIENT MANAGEMENT
* Usual no problems if the patient has GOOD control
* Thorough medical history review:
(4)

A
  • Frequency of attacks
  • Hospitalizations from asthma attack
  • Intubations from asthma attack
  • Current medications
64
Q

ASTHMA PATIENT MANAGEMENT
(4)

A
  • Anxiety reduction
  • Okay to give nitrous oxide
  • Keep beta-agonist inhaler (albuterol) at chair side
  • Avoid NSAIDs, ASA, PCN in susceptible patients
65
Q

If STATUS ASTHMATICUS (severe attack not responsive to standard medication)
* Epinephrine:
* Supplemental oxygen:

A

0.3 mg SubQ Q15 - 20 min x 3 doses
1-3 L/min

66
Q

EMPHYSEMA
(4)

A
  • Barrel chested
  • Exertional dyspnea
  • Non-productive cough
  • Thin body habitus
67
Q

BRONCHITIS
(4)

A
  • Cyanotic
  • Frequent respiratory infections
  • Chronic PRODUCTIVE cough
  • Obese body habitus
68
Q

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

A
  • 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)
69
Q

COPD MANAGEMENT
* Avoid respiratory —
* If patient has own oxygen with them, continue
* If patient is not on oxygen, consult physician prior to starting oxygen therapy
* Respiratory drive is a —
* Keep patient inclined, until confident patient can lay — in chair with no dyspnea
* Keep — at chairside
* Closely monitor respiratory and heart rates
* — appointments preferred

A

depressors (opioids)
same flow rate throughout procedure
HYPOXIC DRIVE (low Oxygen saturation)
supine
bronchodilator
PM

70
Q

DIABETIC PATIENT
* If not well controlled there are significant potential difficulties in treatment
(4)

A
  • Prone to infection
  • Hyperglycemia adversely affects WBC diapedesis and demarginalization
  • Delayed in wound healing, possible chronic wound
  • Hyperglycemia
  • Hypoglycemia
  • More problematic if it occurs
71
Q

DIABETIC PATIENT
* Balancing post-operative caloric intake with their — requirement
* No change in insulin — for local anesthesia
* If NPO (for intravenous sedation)

A

insulin
pre-operatively

continue normal nighttime dose but decrease AM dose
by 50%
* Alternate: hold AM dose, and half nighttime dose

72
Q

DIABETIC PATIENT MANAGEMENT
* — appointments best
* Take pre-operative blood — on every diabetic patient
* Long term control of blood glucose determined by —

A

AM
glucose
Hb A1c

73
Q

Long term control of blood glucose determined by Hb A1C
* Red Blood Cell’s life span is ~ — days
* Glucose irreversibly binds to — molecule in RBCs
* So the glycated hemoglobin level is a —-month average of blood glucose control
* Want level to be below —%

A

120
hemoglobin
three

74
Q

SICKLE CELL DISEASE
* Substituted — for — on Hb molecule
* Hb — converted to Hb —
* Autosomal — inheritance pattern

A

Valine, Glutamate
A, S
recessive

75
Q
  • Sickle Cell Trait:
  • Sickle Cell Anemia:
A

no treatment modifications
concern is the prevention of acute crises

76
Q
  • Hemolysis of RBCs →
  • Splenic sequestration of RBCs →
A

anemia

splenomegaly, anemia →asplenia
* Increased risk of infection by encapsulated organisms

77
Q

PREVENTION OF CRISES
* Supplemental Oxygen throughout procedure to prevent —
* Warming blanket to prevent —
* Profound local anesthesia to decrease —
* Adequate fluid intake (PO or IV) to prevent —
* Adequate Post-operative —
* Consultation with PCP regarding — as patients traditionally are already on high dose
— medication daily
* Treat infection aggressively

A

hypoxia
hypothermia
stress
dehydration
analgesics
narcotics

78
Q

PATIENTS ON STEROIDS
* Increased risk of complications due to:

A
  • 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
79
Q

Steroids
Long term side effects:
(4)

A
  • HTN
  • DM
  • Delayed healing
  • Infection
80
Q

STEROID PATIENT MANAGEMENT
* Do we need to give patient stress dosing of steroids pre-operatively, to prevent this patient from crashing?
DEPENDS ON
(4)

A
  • How invasive is the surgery?
  • 20 mg/day of Prednisone equivalent for 3 weeks
  • If this dosing for this long, consider stress-dosing
  • Usually all dental procedures are minor surgery and do not require pre-operative prophylaxis
81
Q

THYROID DISEASE
* Defer surgery until thyroid dysfunction is well controlled
* Lab values of note from PCP:
* Thyroid panel →
* If treated and limited control obtained:
(2)

A

T3, T4, thyroid binding globulin, thyroid stimulating hormone (TSH)

  • Limit epi
  • Do not give atropine
82
Q

HYPOTHYROIDISM
* Progressive destruction of thyroid tissue
(3)

A
  • Autoimmune (Hashimoto’s thyroiditis)
  • Surgically (removed thyroid tissue to treat hyperthyroidism)
  • Medically (lithium, propylthiouracil (PTU), radioactive iodine, methimazole)
83
Q

HYPOTHYROIDISM
Symptoms:
(5)

A
  • Fatigue, unintended weight gain, cold intolerance, constipation, AMS
84
Q

Myxedema:
(3)

A
  • Emergency, can be caused by infection, meds, stress
  • Altered mental status, seizures, coma, hypotension
  • Tx: immediate IV levothyroxine and corticosteroids
85
Q

HYPERTHYROIDISM

A
  • Increased presence in thyroid stimulating antibodies
  • Graves disease
86
Q

Thyroid storm:
(3)

A
  • 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
87
Q

LIVER DISEASE
* Know the risk factors for liver disease:
(6)

A
  • IV drug use, EtOH, promiscuity, overuse of medications, viral infections, hereditary disorders
88
Q

LIVER DISEASE
Associated symptoms:

A
  • Jaundice, itching, easy bruising, ascites, gynecomastia, hepatic encephalopathy, spider
    telangiectasia, palmar erythema
89
Q

LIVER DISEASE
Lab values from PCP:
(4)

A
  • Alanine aminotransferase (ALT),
    Aspartate Aminotransferase (AST),
    coagulation panel,
    hepatitis panel with viral load
90
Q

LIVER DISEASE
* Major implications:
(3)

A
  • Viral contagion of dentist and other patients
  • Increased risk of bleeding
  • Altered metabolism of drugs
  • Can cause toxicity or no effect from drug
91
Q

LIVER DISEASE
* Strict adherence to

A

sterile technique
* THIS SHOULD BE DONE FOR ALL PATIENTS NO MATTER IF DISEASED OR NOT DISEASED

92
Q
  • Pre-op tests as mentioned earlier to determine
A

extend of liver damage as well as infectivity
(viral load)

93
Q

Liver disease
Avoid drugs primarily excreted in

A

liver
* May need to discuss post-op pain management with PCP prior to procedures

94
Q

RENAL INSUFFICIENCY
* Patients can’t
* Be careful with medications with active
* Avoid

A

excrete normally, thus drug metabolites and filtrate usually excreted
remains in blood serum

metabolites (Demerol, codeine, ASA, valium)

nephrotoxic medications (NSAIDs, Amphotericin B, ACE-Inhib, MTX, acyclovir, B-
lactam antibiotics, etc…)

95
Q

HEMODIALYSIS
(2)

A
  • Replaces the kidneys as the filtration system in body
  • Also can remove excess fluid from system (reducing BP)
96
Q

HEMODIALYSIS
* Due to tortuosity of dialysis machine, the blood is
* Usually requires dialysis shunt for long term dialysis
* Schedule patient on days — Dialysis
* Heparinized blood, clots —
* Consult PCP concerning —

A

HEPARINIZED
* Prevents clotting in machine, and then transfer of clot to venous system
AFTER
poorly
antibiotic prophylaxis

97
Q

ANTICOAGULATION
* Patient on anticoagulation for variety of reasons
* Medical consultation requesting basic coagulation profile
(5)

A
  • 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)
98
Q

ANTICOAGULATION PATIENT MANAGEMENT
* If on Coumadin/Warfarin: INR below — is acceptable to surgery
* INR:

A

3
International Normalized Ratio

99
Q

ANTICOAGULATION PATIENT MANAGEMENT
drug holiday (4)

A
  • Medical consultation regarding safety of drug holiday prior to procedures
  • Patients may be at too high of risk to stop medication
  • Big, full mouth extractions might require drug holiday
  • Single teeth, or a couple in one quad may not require drug holiday
100
Q

ANTICOAGULATION PATIENT MANAGEMENT
* Augment clotting during surgery with use of
* Monitor wound for an — to ensure good initial clot
* Avoid (2)

A

pro-coagulant substances, sutures, and well
placed pressure packs
hour
NSAIDs and ASA

101
Q

PREGNANCY
* Elective procedures best to perform after delivery or in

A

2nd trimester
* 1st trimester fetus formation susceptibility
* 3rd trimester, premature delivery of fetus →not in my office!!!

  • Lead apron for radiographs
  • Medication adjustments prior to delivery, after delivery,
    and related to breastfeeding
102
Q

PREGNANT PATIENT
* Avoid
* Lay patient on — side if prolonged appointment
* Allow frequent bathroom breaks

A

teratogenic medications
* Tetracycline, corticosteroids, aminoglycosides
left
* Prevents occlusion of inferior vena cava

103
Q

FDA DRUG CATEGORIES
* Category A:
* Category B:
* Category C:
* Category D:

A

no fetal harm
no fetal risk in animal studies, no human studies
* Lidocaine, B-lactam abx, Tylenol, NSAIDs (not in 3rd trimester), short round fentanyl/oxycodone
risk in animal studies but no human studies
* Codeine, hydrocodone, tramadol, mepivicaine, bupivacaine
positive evidence of human fetal risks
* Aspirin, all NSAIDs in 3rd trimester, long term opioid use

104
Q

LACTATION
SAFE
(7)

A
  • Tylenol
  • Antihistamines
  • Cephalexin
  • Codeine
  • Erythromycin
  • Fluoride
  • Lidocaine
105
Q

LACTATION
HARMFUL
(6)

A
  • Aspirin
  • Atropine
  • Steroids
  • Valium
  • Metronidazole
  • PCN

OS and Pain Management 2 (10 decks)

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