Sedation/medical emergencies questions Flashcards
Why is written consent is gained prior to sedation?
- To allow patient sufficient time to consider information provided
- Patient might be amnesic on the day of sedation and forget that they consented
- the consent should also be confirmed verbally at the day of sedation
In what circumstances consent for sedation is not gained in a separate appointment?
- If patient is in acute pain and needs treatment ASAP
What drug is used for IV sedation and what is the preparation for it ?
Midazolam 2mg bolus in 1mg/ml increments every 60 seconds with dose varying from 2-10mg
7.5 mg recommended
What vital signs would you monitor before, during and after sedation?
- heart rate
- blood pressure
- oxygen saturation
- breathing rate
what is the weight cut off for sedation?
BMI 35
What drug is used to reverse the effect of midazolam?
- Flumazenil
What advice would you give to patient after sedation? (5)
- no operating machinery or driving
- Stay off social media
- No physical activity for the next 24h
- No involvement in business or signing legal documents
- No important decision making
What is postural hypotension
It is an excessive fall in blood pressure when an upright position is assumed caused by a failure of the auto regulatory systems which normally maintain blood pressure on standing
What is the order of the regulatory systems in postural hypotension? (5)
1 - venous pooling in the legs
2- poor venous return
3- fall in stroke volume
4 - fall in cardiac output
5- patient continues to lose consciousness
What are the risk factors in the elderly for postural hypotension?
- lifestyle - such as sedentary lifestyle
- Medications - polypharmacy
- Cardiovascular disease - medications
- Diabetes
What would you do differently for a patient with postural hypotension? (4)
- Allow the dental chair to sit up gradually over a period of couple minutes
- Let the patient take their time while standing and guide them
- Allow the patient to take deep breaths while standing
- Schedule appointments 30-60 mins after eating and taking medication
What may have caused the patient to lose consciousness after standing up from the dental chair due to postural hypotension?
- Fainting/syncope
- Fear anxiety or emotional trauma
- Diabetic emergency - hypoglycaemic shock or ketacidosis
- Hyper ventilation
- Dehydration
- Standing up too quickly
What is ABCDE ?
A - airway
B - breathing
C - circulation
D - disability
E - exposure (AVPU)
How to assess airway?
- check mouth for any obstruction if patient cannot speak
- Jaw thrust
- Oropharyngeal adjuncts ( measure from incisors to angle of mandible)
How to assess breathing?
Put ear close to mouth and and look at chest movement and sound of breathing
* RR 12-15 breaths per minute
* abnormal sounds : wheezing, strider, snoring
How to assess circulation?
Check carotid pulse by fingers and assess quality, rhythm , rate and patient colour and temperature
How to assess disability?
Using AVPU
Alert = consious
Verbal = check vocals
Pain = respond to painful stimulus
U = unresponsive to any stimulus
How to check exposure?
- Look around for any clinical signs on the body, for example rash
What are the indications for inhalation sedation?
- Medical - conditions worsened by stress such as epilepsy, hypertension, IHD , asthma
- Social - phobia, dental anxiety, severe gag reflex
- Dental - traumatic or complex procedures
What are the contraindications of inhalation sedation (3)
- unable to nose breath :
^blocked nasal airway
^common cold or flu
^tonsilitis
^poor cooperation to nose/mouth breathe - must be able to coordinate nasal breathing with mouth open - 1st trimester of pregnancy
- severe COPD
What are the indications of intravenous sedation?
- Medical
^ conditions worsened by stress
^ conditions affecting cooperation such as mental/physical illness = Parkinson’s - Social - phobias, anxiety, severe gag reflex and fainting
- Long, complex and traumatic dental procedures
What are the contraindications of intravenous sedation? (9)
- Severe systematic disease or special needs
- intracranial pathologies
- Severe COPD
- Myasthenia gravis
- Hepatic insufficiency
- pregnancy and lactation
- uncooperation
- unaccompanied (very old or very young)
- procedure too long for IV sedation (more than 50 minutes)
What safety features are in the Quantiflex MDM machine present when giving inhalation sedation? (9)
- Oxygen flush button
- Reservoir bag
- Scavenger system
- Coloured cylinders - black for O2 and blue for NO
- minimum oxygen delivery at 30%
- Pin index to prevent gas mixture
- one way expiratory valve
- Oxygen monitor built-n
- NO stops when oxygen stops
What is the advantages of using inhalation sedation over midazolam? (8)
- Quicker onset
- Rapid recovery
- Flexible duration of use
- Not metabolised = safer
- less post op side effects
- no needles required
- no amnesia
- can be used in children under the age of 10
What medications are in the dental emergency kit including quantities and uses ? (7)
- Adrenaline IM injections = 1:1000 , 0.5mg/ml = anaphylactic shock
- Aspirin dispersions = 300mg = suspected MI
- Glucagon IM injection = 1mg = hypoglycaemic shock
- Glyceryl Trinitrate (GTN) spray = 400 microg = angina
- Salbutamol 100 microgram per puff = asthma attack
- Midazolam 10mg (buccal) = more than 5 minutes epileptic seizure
When might a referral for GA be made? (7)
- medical history contraindicates sedation
- uncooperative with phobia of needles
- uncooperative children under the age of 12
- medically compromised patients
- extensive and long dental treatment
- children requiring complete comprehensive treatment
- benefits of GA outweigh the risks
What are the stages of anaesthesia? (4)
- Induction
- Excitement
- Surgical anaesthesia
- Respiratory paralysis / overdose
What needs to be included in a GA referral letter (for a child)? (7)
- Patient details
- Guardian details
- GMP and GDP contact details
- Medical history
- Dental history and justification of GA
- Radiographs to back up justification
- Treatment plan for during GA
What is the definition of conscious sedation?
- A technique in which a drug is used to induce central nervous system depression to enable treatment to be carried out but with verbal consent maintained with the patient throughout the period of sedation
- the drugs used should not lead to loss of consciousness
- patient should remain conscious, retain protective reflexes and is able to understand and respond to verbal commands
What is GABA and what is it’s function?
*Gamma-amino butyric acid is an amino acid which acts a neurotransmitter in the central nervous system
*Inhibits nerve transmission in the brain
* calming the nervous activity
How does benzodiazepines act in the CNS?
- act on receptors in the CNS to enhance the effect of GABA in the cerebral cortex and motor circuits
- thus inhibiting CNS nuerotransmitters
What is the half life of midazolam?
- 90 - 150 minutes
- metabolised in the liver
- which means it have a fast recovery time
What should you assess before IV sedation? (8)
- Heart rate
- Oxygen saturation
- Blood pressure
- Weight and height for BMI
- ASA classification
- medical history and medication list
- Cooperation level
- Fitness, baseline and screening tool
What is the ASA classification mean?
It is a physical status classification system for assessing the fitness of patients before surgery from the American society of anaesthesia
What is ASA class 1
normal healthy patient
What is ASA class 2
mild systemic disease - well controlled
* Asthma
* Epilepsy
What is ASA class 3
severe systemic disease
* stable angina
* COPD
What is ASA class 4
Severe systemic disease that is a constant threat to life
* Severe COPD
* Unstable angina
What is ASA class 5
moribund patient who is not expected to survive without the operation
What is ASA class 6
declared brain dead patient who’s organs are being removed for donor purposes
What is the time interval for monitoring vital signs of a sedation patient?
every 5 minutes
On what ASA class is it safe to carry dental treatment?
ASA1
* ASA 2 and 3 care should be given while treatment
