OMS rotation pearls Flashcards
normal hb1ac
below 4 is good
5-6 pre diabetic
over that is diabetes
maximum dose of epi per visit in adult with HTN
0.04 mg
if pt has hx of HTN what must be done before and after procedure?
take BP and pulse before AND after
document it prior to procedure and prior to discharge
Following any oral surgery procedure in a patient with cardiac or HTN history or an abnormal pre-operative value, a BP and Pulse check must be documented after completion of procedure, prior to discharge
how to manage patient with stage 2 HTN?
what is the BP in these patients?
systolic is over 140
diastolic is 90+
- Retake and confirm blood pressure and consider other risks factors for the high BP.
- Monitor blood pressure during the appointment.
- Proceed with the elective dental treatment, avoid pain and intravascular epinephrine
- Systolic =180, diastolic >90 ≤99 with a true dental emergency, may be OK to
proceed with caution
definition of severe HTN and how to manage?
systolic 180+ and diastolic 120+
- Retake and confirm blood pressure with an alternate device, such as a mercury manometer–type sphygmomanometer.
- If the blood pressure is unchanged, consider referring the patient to his/her
physician or emergency room for evaluation if any symptoms of Hypertensive Emergency. - Typically, no treatment of any type should be undertaken.
**MEDICAL CONSULT VS EMERGENT/ URGENT REFERRAL
** HTN patient rules in the U M OMS clinic
for urgent / emergent tx?
for elective tx?
for urgent / emergent tx
- BP must be below 199/114 to be preformed in UMSOD clinic and only in select circumstances
for elective treatment
- BP systolic must be below 160 and diastolic below 100 and ASYMPTOMATIC (not light headed/dizzy/ lethargic)
patient presents with hx if MI.
What questions will you ask?
when would you defer txx?
defer tx if MI occurred within the last 2-3 months
more than 3 but less than 6 - typically defer elective tc
over 6 months - typically OK for elective tx BUT must have had a follow up with cardiologist prior
ASA if MI less than 3 months? more than 3 months?
more than 3 = ASA III
less than 3 motnhs automatic ASA IV
patient presents with agina
what to ask?
how to manage?
when to defer?
When does s/he feel the chest pain
At rest ?
On exertion?
How often does s/he feel the chest pain
How does the chest pain resolve?
-Spontaneously or with medications (nitroglycerin, aspirin, etc)
Does the patient have the medication for the chest pain relieve? Is it present? Has it expired?
When was the last episode?
if episode is in last week or occurs often then needs a med consult if not under active care from cardiologist or unstable
patient presents with CHF
questions to ask and
how to manage?
what do you have to request in a med consult?
Ask patient how active he/she is.
Flights of stairs without shortness of breaths? Exercise tolerance? Sleeps flat or upright?
- usually will require a med consult to request the following
1. is it systolic or diastolic failure - note the EJECTION FRACTION in systolic failure will be decreased
determine the drugs being used and the dosages
requests recommendations from cardiologist for procedures and plan to avoid epinephrine
no more than 0.04 mg
ejection fraction in terms of systolic vs diastolic heart failure
formula for EF and SV?
EF = stroke volume / EDV (end diastolic volume)
this determines how efficient the ventricle is at emptying itself or % of EDV that is moved out of ventricle
SV = EDV - ESV (ESV is approximately 50 mL and EDV is approximately 120mL, giving a difference of 70 mL for the stroke volume.)
in systolic heart failure — the ejection fraction
Heart failure with reduced ejection fraction (HFrEF), also called systolic failure: The left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
Heart failure with preserved ejection fraction (HFpEF), also called diastolic failure (or diastolic dysfunction): The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can’t properly fill with blood during the resting period between each beat.
patient presents with aFib?
questions and management
continue or discontinue drug?
include PT/ INR levels
ask if pt is taking a blood thinner
- if not ask why that is at it is likely a problem
DO NOT DISCONTINUE IF the blood thinner if it is not patients physician recommendation
warfarin need to request 24-48 hours ma prior to the surgery
get PT/ INR
PT/INR below 3.5 = can usually proceed with extraction of up to 3 teeth
normal PT, PTT and INR values
PT= 10-12 seconds PTT = 20-45 seconds
PT/ INR for warfarin patients is usually 2-3
general management tips for active cardiovascular patients
- use anxiety reducing protocol
- consider nitrous oxide
- consider no epi use or the smallest amount of epi needed for profound anesthesia (max 0.04 mg/ epi/adult/ day)
- aspirate before injecting
- ensure profound anesthesia
no extraction if active cardio disease if?
- MI less than 2 months
- decompensated CHF
- acute coronary syndromes
- systolic over 180 and diastolic over 110
- severe valvular disease
- severe arrythmia
- INr over 3.5
major basic difference between 1:50,000 epi and 1:200,000 epi?
1: 50,000 epi has MORE concentration of epi in 1.7 mL of lidocaine
1: 200,000 epi has LESS concentration of epi
amount of epi in?
1 carpules of 1:50
1:100
1:200?
1: 50
0. 034 mg epi
1: 100
0. 017 mg
1: 200
0. 0085 mg
amount of epi in?
2 carpules of 1:50
1:100
1:200?
1:50
.068
1: 100
0. 034
1: 200
0. 017
amount of epi in?
4 carpules of 1:50
1:100
1:200?
1:50
.136 epi
1:100
.068 mg epi
1: 200
0. 034
when does patient have to use antibiotic prophylaxis
- artificial / prosthetic heart valve
- hx of infective endocarditis
- crdio valvulopathy with regurg
- patient have serious heart condition present from birth (congenital) including
- unrepaired or incompletely repaired
cyanotic congenital heart disease, including those with palliative shunts and
conduits
a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months
after the procedure
any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
antibiotic prohy with mitral valve prolapse?
if invasive and confirmed murmer = yes
if presence not determined but need for procedure is urgent = yes
(lack of significant mitral regurgitation makes prophylaxis unnecessary )
when to take the antiobotic prophylaxis?
30-60 minutes before procedure
antibiotic if able to take oral med?
dose in adult?
child?
amoxicillin
adult 2g
so 250-500 mg qid
child 50 mg/ kg
patient cant take oral meds? rx for prophy?
ampicillin
2g IM / IV
child = 50mg/kg IM IV
OR
cefazolin/ ceftrixone
1g IM/IV
child = 50 mg IM/ IV
medication and dose if patient allergic to penicillin?
dose for prophylaxis adult and child
clindamycin
600 mg
child
20 mg/kg
OR azithromycin or clarithromycin 500 mg
child = 15 mg/kg
questions to ask patient with pulmonary diseases?
Frequency & severity When was last attack? When was the last hospitalization? Current Medications Ask for response to pain medications
asthma LA contraindicated? nitrous?
No, nitrous not contraindicated for mild and moderate asthma
COPD LA contraindicated? nitrous?
LA no contraindication
nitrous – No for unknown status or severe COPD due to risk of pneumothorax
Use semi-supine position or upright position
always take initial Sp)@ as a reference of severity of COPD
caution with oxygen administration and keep SpO2 between 88-92% and use only if necessary
pulmonary emphysema
considerations
Oxygen dependent – use wall-oxygen during the procedure
Upright or semi-supine position
SpO2 levels
above 95% considered normal
suspect kidney disease if?
med consult for?
if patient has long term uncontrolled hypertension and diabetes
med consult for creatine clearance and medication dose adjustment
