Triage & Emergency Services Flashcards
What is triage?
process of sorting injured people based on their need for immediate medical treatment as compared to their chance of benefiting from such care
Where is triage done?
emergency rooms, disasters, and wars, when limited medical resources must be allocated to maximize the number of survivors
Dentists in the military or disaster control are often used to…
triage thus freeing the medics to work critical care
What are white tags?
(dismiss) are given to those with minor injuries for whom a doctor’s care is not required
What are green tags?
(wait) are reserved for the “walking wounded” who will need medical care at some point, after more critical injuries have been treated
What are yellow tags?
(observation) for those who require observation (and possible later re-triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances
What are red tags?
(immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival
What are black tags?
(Expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available
dentists are used to identify burned or other unidentifiable bodies for…
identification/legal purposes
It would be ideal to have every patient in your practice pursuing a strict & planned…
comprehensive dental program
Sometimes people are simply in NEED of ________
HELP
Why do you need to triage patients and remember more serious lifethreatening issues?
What IF they are actually having a Heart
attack, Diabetic crisis, Asthma attack etc. and only THINK they have a toothache ???
True/false
You COULD refer them to someone less busy; you don’t have to do it all. Just provide a path
true
How can you help someone who is in pain and wants results now?
- You MUST START with a HEALTH HISTORY.
- You MUST START with a thorough & appropriate EXAMINATION/STUDIES
- You MUST PERFORM appropriate CLINICAL TESTING/RADIOGRAPHS
- You MUST develop an accurate DIAGNOSIS
- You MUST envision an appropriate TREATMENT PLAN (with OPTIONS)
Don’t FORGET to appraise the PATIENT of THEIR Responsibilities such as…
- Costs required for each option
- Time required for each option (availability of TX and # of visits, etc.)
- Maintenance required for each option
- Expected Prognosis and Longevity for each option
The patient drives the bus, and they must be fully _________ and then they must make their decision regarding which option they wish for their TREATMENT
informed
What are complications to think about with patient’s consenting to treatment?
- The patient MUST UNDERSTAND
(or no permission for Tx exists) - The patient MUST HAVE reasonable expectations
- The treatments must be professionally reasonable
The Professional must be ____________ to avoid untoward/unreasonable options in presenting to the patient
responsible
The Professional must be responsible to avoid untoward or unreasonable options in presenting to the patient by asking what questions?
- is the tooth strategic and functional?
- is the tooth reasonably restorable?
- is there a periodontal situation which is compromsing?
- are there other questionable involvements?
- is the treatment reasonably available?
Is the tooth strategic and functional?
nah because there is no opposing teeth
Is the tooth strategic and functional?
yes because it allows for chewing surfaces and serves a big function
Is the tooth reasonably restorable?
there are fractures so extract
Is there a compromsing periodontal situtaion?
perforations and bone loss
Are there other questionable involvements?
fracture across the crown
What should you consider for considering if the treatment reasonably available?
- Has to be done in Advanced Endo
—$ + Wait? - Must have crown lengthening + post and build-up and crown
- Patient leaving the country soon
- Patient has to travel 200 miles to get here
- Patient can’t get off work or has no $
When the emergency TX is complete and patient is comfortable what can you do?
THEN YOU CAN LECTURE TO THEM ABOUT THE BENEFITS OF COMPREHENSIVE DENTAL CARE & MAYBE THEY WILL CHOOSE TO BECOME YOUR REGULAR PATIENT & MAYBE THEY WILL CHOOSE TO WAIT FOR THE NEXT EMERGENCY TO OCCUR. OR NOT. YOU CANNOT FORCE THEM
WE DO HAVE MORAL, ETHICAL AND PROFESSIONAL OBLIGATIONS to…
- We may NOT begin treatment and then fail to complete same & we may NOT propose to offer to provide any treatment for which we are not qualified. Nor may we refer the patient to anyone whom we do not know to be qualified.
- We may NOT refuse to provide treatment to the patient for any reason covered by a federally “protected group”.
- We MAY refuse treatment to any patient for any reason not covered as a federally “protected group” as long as we have not begun any treatment
How CAN we help the patient effectively & efficiently in an emergency?
- Patient having Symptomatic Irreversible Pulpitis but no PA sensitivity no PARL and no swelling no fever.
- PULP EXPOSURES
- Patient having Symptomatic Irreversible Pulpitis (or AIP or Necrotic Pulp) WITH PA sensitivity, PARL, and swelling or fever.
ANY Tooth with Irreversible Pulpitis or PA Pathology of Endodontic Origin is
Best Treated by…
TOTAL Pulpectomy and RCT
“EMERGENCY” TX means…
Do the best we can the time -until we have time to do the complete RCT
Can you do a pulpotomy on a necrotic pulp?
important
NO
Patient with Symptomatic Irreversible Pulpitis butno PA involvement, no PARL & no swelling nor fever. (NOT sens. to PERCUSSION)
- What is the treatment?
Vital Coronal Pulpotomy
Patient with Symptomatic Irreversible Pulpitis butno PA involvement, no PARL & no swelling nor fever. (NOT sens. to PERCUSSION)
- What is the expected outcome from treatment (vital coronal pulpotomy)?
- Absence of presenting pulpal pain
- Should remain comfortable for a short period of time until canals become necrotic
- Make appointment in Endo (Undergrad or Advanced) prn
- Will require RCT & Crown at
a later date
Asymptomatic Vital Pulp Exposure (without Pain)… what is the treatment?
USE Dycal
- Do all clinical testing & record (test at least 3 teeth as “baseline”)
- fill out endo. Diagnosis form (before o&r if pulp exposure may occur)
- isolate tooth in question with dental dam
- remove all caries & unsupported enamel (if pulp is exposed)
- disinfect with 8.3 % naocl and arrest hemorrhage, pulpcap exposure with dycal & place temporary restoration such as paracore or irm
- after restoration, take 2 radiographs (straight-on and 20 degree shift shot)
- contact any endo faculty on exchange e-mail
Asymptomatic NON-Vital Pulp Exposure (without Pain)… what is the treatment
NO DYCAL
- Do all clinical testing & record (test at least 3 teeth as “baseline”)
- fill out endo. Diagnosis form (before o&r if pulp exposure may occur)
- isolate tooth in question with dental dam
- remove all caries & unsupported enamel (if pulp is exposed)
- disinfect with 8.3 % naocl and arrest hemorrhage & place temporary restoration such as paracore or irm
- after restoration, take 2 radiographs (straight-on and 20 degree shift shot)
- contact any endo faculty on exchange e-mail
SymptomaticVital or Non-VITALPulp Exposure (with Pain)… what treatment?
- Remove all caries & unsupported enamel
-Disinfect & arrest any hemorrhage with NaOCl - Possible Pulpotomy or Pulpectomy inE-Chair (RESTORATION AS REQUIRED)
- Make appointment in Endo. (Undergrad or Advanced) as indicated BY FACULTY IN E CHAIR OR TEAM
Symptomatic Apical Periodontitis
(with or without Symptomatic Irreversible Pulpitis)… what treatment?
Emergency Tx will only complete pulpal extirpation (pulpectomy) be effective with and that RCT is indicated for this tooth in the near future
Symptomatic Apical Periodontitis
(with or without Symptomatic Irreversible Pulpitis)… what is the expected outcome after pulpectomy and future RCT?
- Immediate cessation of pulpal pain
- Tooth will remain sensitive to percussion and biting for up to 3 days
- Make appointment in Endo (Undergrad or Advanced) prn
- Will require RCT & Crown
What is the emergency pulpectomy technique?
don’t have to know this
- Gain Adequate Anesthesia & Isolate tooth
- Access and locate canals
- Use apex locator and #10 file to find patency
- Enlarge 1mm. Short of patency with a #15 file
- Enlarge 2mm. Short of patency with a #20 file
- Enlarge 3mm. Short of patency with a #25 file
- Irrigate copiously between each instrument with 8.3% NaOCl
- Dry with paper points and place CaOH2 in all canals, cotton and IRM.
- patient obtain appointment in Pre-doc endo or Advanced endo as indicated.
What are the benefits of emergency pulpectomy technique?
- removal of irritants, toxins and substrate
- path to patency obtained & retained
- allows NaOCl to WORK
- provides space for CaOH
If the patients are really sensivite to biting and swallowing what can you do?
important!
Reduce the occlusion BEFORE you put the dam on and before you get working length
How MUCH of these procedures are YOU willing & able to do?
- Do YOU want to ASSUME the RESPONSIBILITY?
- Do YOU want to ASSUME the LIABILITY?
- Do you have the Training & Skills?
- Do you have the Facilities & Instruments/Supplies?
- Do you have TIME?
- WHAT IS BEST FOR THE PATIENT?
- What is BEST for Your Practice?
- Can you make $ doing it?
True/false
Patient’s pain will be greatly reduced
by these easy treatments (emergency treatments) and RCT can later proceed as usual
True
If the swelling is fluctuant; it may be prudent to incise the most dependent portion of the swelling
THIS WILL OFTEN GAIN IMMEDIATE RELIEF FROM THE SEVERE PAIN
If you open into the pulp, you may be greeted by a fountain of pus followed by blood and finally serous fluid. Following pulpectomy and shaping, You should then…
dry the canals and close with CaOH, cotton and temp. filling.
True/false
NEVER try to diagnose from the radiograph alone
True
- You MUST EXAMINE the patient!
Can we treat this?
- You are NOT TRAINED to treat this extremely acute problem which is life-threatening.
- Call your oral surgeon friend or ER and get this patient admitted to the Hospital at once.
“Ludwig’s Angina” and shows the 3 drains necessary to treat the 3 fascial spaces involved which are…
important!
Submandibular space
Sublingual space
Submental space
What teeth do you need to be vigilant for Ludwig’s Angina?
Be especially vigilant with infections of mandibular molars (especially 2nd & 3rd Molars)
- Molars often are located with their root apices located inferior to the mylohyoid M. Therefore, allowing ready access for infection to enter the submandibular space encouraging cellulitis to occur in that space and also in associated fascial spaces
How are chronic apical abscesses diagnosed?
Identified by DST: Patient is generally comfortable and pain medication and antibiotics are NOT indicated for the healthy patient
How do you treat deep caries?
You MUST do your Sensibility Testing to determine if you are dealing with reversible pulpitis, irreversible pulpitis or necrosis
- Rev. Pulpitis: Symptomatic Treatment
- IRREV. PULPITIS: RCT or T.E.
- Necrotic Pulp: RCT or T.E.
