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
2
Q
- Thorough up to date medical history
(1)
A
- At consultation and each follow-up visit
3
Q
- Appropriate physical exam
(2)
A
- Full exam performed on consultation examination
- Updated on new visits, and depending on new medical history
4
Q
WHY MORE RELEVANT TODAY?
* We have the ability to perform
A
more complicated and lengthy dental procedures
* “The aging of America”
* Polypharmacy
5
Q
- “The aging of America”
(2)
A
- Growing geriatric population
- Increased medical risk patients
6
Q
HYPERTENSION (HTN)
* New BP guidelines from ACC
* — recordings at separate visits
A
Two
7
Q
New Guidelines: Normal
Systolic BP
Diastolic BP
A
Less than 120
Less than 80
8
Q
New Guidelines: Elevated BP
Systolic BP
Diastolic BP
A
120-129
Less than 80
9
Q
New Guidelines: Hypertension (Stage I)
Systolic BP
Diastolic BP
A
130-139
80-89
10
Q
New Guidelines: Hypertension (Stage II)
Systolic BP
Diastolic BP
A
≥ 140
≥ 90
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)
12
Q
HYPERTENSION
* Primary (essential)
(2)
A
- Greatest % of hypertensive pts
- > 95% idiopathic
13
Q
HYPERTENSION
* Secondary
A
- 5% with underlying condition: renal/endocrine disorders
14
Q
HYPERTENSION
* Risk Factors
A
- Obesity, Smoking, EtOH, hypercholesterolemia, DM, LVH
15
Q
Hypertensive URGENCY vs Hypertensive EMERGENCY
* Not all patients with elevated BP need to go to the
A
Emergency Department
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
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
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
19
Q
ANTI-HYPERTENSIVES
* Beta Blockers
(3)
A
- Atenolol, propranolol, metoprolol
20
Q
ANTI-HYPERTENSIVES
* Ca+ channel blockers
(2)
A
- Verapamil, Amlodipine
21
Q
ANTI-HYPERTENSIVES
* ACE-Inhibitors
(2)
A
- Lisinopril, Captopril
22
Q
ANTI-HYPERTENSIVES
* Diuretics
(2)
A
- HCTZ, Furosemide
23
Q
ISCHEMIC HEART DISEASE
* Decreased oxygenated blood to myocardium
* Due to
A
narrowing or incomplete blockage of coronary artery(ies)
24
Q
ISCHEMIC HEART DISEASE
NO — DAMAGE
A
MYOCARDIAL
25
ISCHEMIC HEART DISEASE
Rx: (4)
stent, angioplasty, CABG, meds
26
ISCHEMIC HEART DISEASE
If patient has NO restrictions and NORMAL EKG after above procedure, then patient
can be categorized as
ASA II
27
PROGRESSION OF IHD
(3)
* Stable Angina
* Unstable Angina
* Myocardial Infarction
28
ANGINA
* Symptom of IHD due to
discrepancy of myocardial oxygen demand and the ability of the
coronary arteries to supply oxygenated blood
29
Angina
Causes:
(2)
* Narrowing of coronary arteries (LAD a. = “widow-maker”)
* Spasm of coronary arterial wall (Prinzmetals angina)
30
Angina
Symptoms:
(3)
* Chest pain w/ radiation
* Nausea, sweating, dyspnea, HTN
* Bradycardia, Impending sense of doom
31
ANGINA
* Question the patient thoroughly concerning:
(4)
* Precipitating events
* Frequency
* Duration
* Severity
32
Angina
What alleviates pain?
(2)
* Medication, what?
* Rest
33
ANGINA
STABLE
(5)
* Pain on exertion
* Infrequent episodes
* One nitro tab controls pain
* ASA III
* Medical Consultation prior to treatment
34
ANGINA
UNSTABLE
(5)
* Pain at rest
* Frequent episodes
* Increasing nitro for pain relief
* ASA IV
* Likely requires inpatient care
35
* Stable vs Unstable
* Practitioner's must differentiate
* Guidelines for management:
(5)
* Have nitro available
* Profound LA
* Cardiac dose of epinephrine (0.04 mg in 30 mins)
* Use supplemental oxygen (N2O/O2)
* Anxiety reduction protocol
36
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
0.04, 0.04
1
0.1
0.01
37
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
34
10
20
38
NITROGLYCERIN
* Potent vasodilator:
* Low doses →
* High dose →
reduces myocardial oxygen demand
VENO-dilator
VENO-dilator plus ARTERIO-dilator
39
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!
0.4
0.4
3
40
ANXIETY REDUCTION PROTOCOL
* Pre-operative
(3)
* Sedative
* AM appts
* Nitro
41
ANXIETY REDUCTION PROTOCOL
* Intra-operative
(2)
* Non-pharm →VERBAL ASSURANCE
* Pharmacologic →profound LA and Nitrous
42
ANXIETY REDUCTION PROTOCOL
* Post-operative
(2)
* Analgesics
* Post-operative instructions and reassurance
43
MANAGEMENT: HISTORY OF MI
* Defer elective procedures for --- months after infarction
* Controversy today:
(2)
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
ALWAYS Consult Cardiologist
* Patient are usually placed on anticoagulants/antiplatelets →drug holiday required?
* Potential problems post-MI:
(3)
* Ventricular fibrillation →due to increased myocardial excitability
* Re-infarction
* CHF
45
Rate of Re-infarction:
* Within 3 months = ---%
* 3-6 months = ---%
* After 6 months = ---%
28
10
5
46
WHAT TO DO FOR EMERGENCIES IN PATIENTS
WITH HISTORY OF HEART ATTACK
* 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
HEART FAILURE
* Congestive heart failure is the
failure of the heart as a basic pump
48
HEART FAILURE
Symptoms:
(5)
* Dyspnea
* Orthopnea
* Paroxysmal nocturnal dyspnea
* Weakness/fatigue
* Extremity edema
49
RIGHT VENTRICULAR FAILURE
(3)
* Jugular venous distention (JVD)
* Peripheral edema
* Hepatomegaly
50
LEFT VENTRICULAR FAILURE
(3)
* Pulmonary edema
* Dyspnea
* Paroxysmal nocturnal dyspnea
51
HEART FAILURE
* If patient has NO symptoms, and is well controlled medically (antihypertensives,
diuretics) the patient is
SAFE for ambulatory outpatient surgery
52
HEART FAILURE
Take precautions:
(3)
* Supplemental low-flows Oxygen
* Patient UPRIGHT!!!! Position
* Anxiety reduction protocol
53
STROKE SYMPTOMS
(4)
* NUMBNESS/WEAKNESS of face/arm/leg
- Unilateral
- Trouble walking or loss of balance
* CONFUSION, speaking or understanding
* VISION CHANGES
* SEVERE HEADACHE
54
TRANSIENT ISCHEMIC ATTACK
(3)
* TIA
* Symptoms < 24 hours
* With return to normal functioning
55
CEREBROVASCULAR ACCIDENT
(5)
* CVA
* Symptoms > 24 hours
* Limited return to “normal” functioning
* Ischemic (80%)
* Hemorrhagic (20%)
56
* Ischemic (80%)
(2)
* Hemorrhagic (20%)
(2)
* Embolic and Thrombotic
* Aneurysm and/or vascular malformation
57
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
6
PCP/Neurologist regarding elective care
emergent procedures
* Anticoagulants
* Antiplatelets
BP
Anxiety
58
COPD
(3)
asthma
emphysema
chronic bronchitis
59
ASTHMA
(3)
* Onset usually early
* Associated with allergens, cold air,
anxiety, exercise
* A reversible process
60
asthma
* First line tx:
* Inhaled short-acting beta agonist
(Albuterol)
61
COPD
(3)
* Onset usually 4th decade and up
* H/o smoking or chronic respiratory infections
* An irreversible process
62
COPD
First line tx:
(3)
* Bronchodilators
- β2-adrenergic agonist (Salbutamol, salmeterol)
- Anticholinergic (Ipraropium, tiotropium)
63
ASTHMA PATIENT MANAGEMENT
* Usual no problems if the patient has GOOD control
* Thorough medical history review:
(4)
* Frequency of attacks
* Hospitalizations from asthma attack
* Intubations from asthma attack
* Current medications
64
ASTHMA PATIENT MANAGEMENT
(4)
* Anxiety reduction
* Okay to give nitrous oxide
* Keep beta-agonist inhaler (albuterol) at chair side
* Avoid NSAIDs, ASA, PCN in susceptible patients
65
If STATUS ASTHMATICUS (severe attack not responsive to standard medication)
* Epinephrine:
* Supplemental oxygen:
0.3 mg SubQ Q15 - 20 min x 3 doses
1-3 L/min
66
EMPHYSEMA
(4)
* Barrel chested
* Exertional dyspnea
* Non-productive cough
* Thin body habitus
67
BRONCHITIS
(4)
* Cyanotic
* Frequent respiratory infections
* Chronic PRODUCTIVE cough
* Obese body habitus
68
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
* 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
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
depressors (opioids)
same flow rate throughout procedure
HYPOXIC DRIVE (low Oxygen saturation)
supine
bronchodilator
PM
70
DIABETIC PATIENT
* If not well controlled there are significant potential difficulties in treatment
(4)
* 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
DIABETIC PATIENT
* Balancing post-operative caloric intake with their --- requirement
* No change in insulin --- for local anesthesia
* If NPO (for intravenous sedation)
insulin
pre-operatively
continue normal nighttime dose but decrease AM dose
by 50%
* Alternate: hold AM dose, and half nighttime dose
72
DIABETIC PATIENT MANAGEMENT
* --- appointments best
* Take pre-operative blood --- on every diabetic patient
* Long term control of blood glucose determined by ---
AM
glucose
Hb A1c
73
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 ---%
120
hemoglobin
three
74
SICKLE CELL DISEASE
* Substituted --- for --- on Hb molecule
* Hb --- converted to Hb ---
* Autosomal --- inheritance pattern
Valine, Glutamate
A, S
recessive
75
* Sickle Cell Trait:
* Sickle Cell Anemia:
no treatment modifications
concern is the prevention of acute crises
76
* Hemolysis of RBCs →
* Splenic sequestration of RBCs →
anemia
splenomegaly, anemia →asplenia
* Increased risk of infection by encapsulated organisms
77
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
hypoxia
hypothermia
stress
dehydration
analgesics
narcotics
78
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
79
Steroids
Long term side effects:
(4)
* HTN
* DM
* Delayed healing
* Infection
80
STEROID PATIENT MANAGEMENT
* Do we need to give patient stress dosing of steroids pre-operatively, to prevent this patient from crashing?
DEPENDS ON
(4)
* 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
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)
T3, T4, thyroid binding globulin, thyroid stimulating hormone (TSH)
* Limit epi
* Do not give atropine
82
HYPOTHYROIDISM
* Progressive destruction of thyroid tissue
(3)
* Autoimmune (Hashimoto’s thyroiditis)
* Surgically (removed thyroid tissue to treat hyperthyroidism)
* Medically (lithium, propylthiouracil (PTU), radioactive iodine, methimazole)
83
HYPOTHYROIDISM
Symptoms:
(5)
* Fatigue, unintended weight gain, cold intolerance, constipation, AMS
84
Myxedema:
(3)
* Emergency, can be caused by infection, meds, stress
* Altered mental status, seizures, coma, hypotension
* Tx: immediate IV levothyroxine and corticosteroids
85
HYPERTHYROIDISM
* Increased presence in thyroid stimulating antibodies
* Graves disease
86
Thyroid storm:
(3)
* 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
LIVER DISEASE
* Know the risk factors for liver disease:
(6)
* IV drug use, EtOH, promiscuity, overuse of medications, viral infections, hereditary disorders
88
LIVER DISEASE
Associated symptoms:
* Jaundice, itching, easy bruising, ascites, gynecomastia, hepatic encephalopathy, spider
telangiectasia, palmar erythema
89
LIVER DISEASE
Lab values from PCP:
(4)
* Alanine aminotransferase (ALT),
Aspartate Aminotransferase (AST),
coagulation panel,
hepatitis panel with viral load
90
LIVER DISEASE
* Major implications:
(3)
* Viral contagion of dentist and other patients
* Increased risk of bleeding
* Altered metabolism of drugs
- Can cause toxicity or no effect from drug
91
LIVER DISEASE
* Strict adherence to
sterile technique
* THIS SHOULD BE DONE FOR ALL PATIENTS NO MATTER IF DISEASED OR NOT DISEASED
92
* Pre-op tests as mentioned earlier to determine
extend of liver damage as well as infectivity
(viral load)
93
Liver disease
Avoid drugs primarily excreted in
liver
* May need to discuss post-op pain management with PCP prior to procedures
94
RENAL INSUFFICIENCY
* Patients can’t
* Be careful with medications with active
* Avoid
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
HEMODIALYSIS
(2)
* Replaces the kidneys as the filtration system in body
* Also can remove excess fluid from system (reducing BP)
96
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 ---
HEPARINIZED
* Prevents clotting in machine, and then transfer of clot to venous system
AFTER
poorly
antibiotic prophylaxis
97
ANTICOAGULATION
* Patient on anticoagulation for variety of reasons
* Medical consultation requesting basic coagulation profile
(5)
* 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
ANTICOAGULATION PATIENT MANAGEMENT
* If on Coumadin/Warfarin: INR below --- is acceptable to surgery
* INR:
3
International Normalized Ratio
99
ANTICOAGULATION PATIENT MANAGEMENT
drug holiday (4)
* 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
ANTICOAGULATION PATIENT MANAGEMENT
* Augment clotting during surgery with use of
* Monitor wound for an --- to ensure good initial clot
* Avoid (2)
pro-coagulant substances, sutures, and well
placed pressure packs
hour
NSAIDs and ASA
101
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!!!
* Lead apron for radiographs
* Medication adjustments prior to delivery, after delivery,
and related to breastfeeding
102
PREGNANT PATIENT
* Avoid
* Lay patient on --- side if prolonged appointment
* Allow frequent bathroom breaks
teratogenic medications
* Tetracycline, corticosteroids, aminoglycosides
left
* Prevents occlusion of inferior vena cava
103
FDA DRUG CATEGORIES
* Category A:
* Category B:
* Category C:
* Category D:
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
LACTATION
SAFE
(7)
* Tylenol
* Antihistamines
* Cephalexin
* Codeine
* Erythromycin
* Fluoride
* Lidocaine
105
LACTATION
HARMFUL
(6)
* Aspirin
* Atropine
* Steroids
* Valium
* Metronidazole
* PCN
