Dental Office Medical Emergencies

Wendy Moore RDH, EFDA, MSA

Why We Are Here

Every 1.2 minutes someone dies of a sudden cardiac arrest Every 20 seconds someone has a heart attack Every 45 seconds someone has a stroke Every 3.3 minutes someone dies from a stroke Every 3 minutes someone has a seizure for the first time Every 6.6 minutes someone has an anaphylactic reaction

Dental Economics July 2007 Roberson DMD and Rothman DDS

Objectives

Syncope Hyperventilation Asthma Emphysema Airway Obstruction Aspiration

Seizure Diabetes Stroke Angina Pectoris Myocardial Infarction Allergic Reactions

Objectives of Dental Medical Emergencies

Have a understanding of the causes and contributing factors of dental medical emergencies. Recognize the signs and symptoms. Describe initial treatment indicated. Knowledge of techniques of prevention. State stress reduction protocols.

Private Practice Emergencies

Syncope Mild Allergic Reaction Angina Pectoris Postural Hypotension Seizures Asthmatic Attack Hyperventilation Epinephrine Reaction Insulin Shock Hypoglycemia Cardiac Arrest Anaphylactic Reaction Cerebrovascular Accident

15,407 2,583 2,552 2,475 1,595 1,392 1,326 913 890 331 304 68

-J Am Dent Assoc 112:499-501, 1986

Important Information

This course meets the OSDB requirement for dental hygienists to practice without the dentist being physically present. Need: 2 years AND 3000 hours.

PERMISSIBLE PRACTICES DOCUMENTATION FOR DENTAL HYGIENISTS

http://www.dental.ohio.gov/forms.stm Forms (Far Left) http://www.dental.ohio.gov/ Front Page bottom Right Permissible Practices Documentation for Dental Hygienists Form

Oral Health Access Supervision Program Permit Applicant

Dental Hygienists: Copy of your most recent license to practice dental hygiene in the State of Ohio; Evidence of completion of at least two (2) years and 3,000 hours of experience in the clinical practice of dental hygiene; Evidence of completion of at least twenty-four (24) hours of continuing dental hygiene education during the two (2) years immediately preceding submission of the application; Evidence of completion of an eight (8) hour course pertaining to the practice of dental hygiene under the oral health access supervision of a dentist that meets the standards established in Ohio Administrative Code Section 4715-9-06.1; Evidence that in the two (2) years immediately preceding submission of this application, you have successfully completed a course pertaining to the identification and prevention of potential medical emergencies that is the same as the course described in division (C)(2) of Section 4715.22 of the Ohio Revised Code.

Are you prepared?

You have an oxygen tank You have an emergency kit You know CPR What could go wrong?

Why We Are Here

Emergencies do occur in dental offices: a survey of 4,000 dentists revealed an incidence of 7.5 emergencies per dentist over a 10-year period.
http://www.cda-adc.ca/jcda/vol-65/issue-5/284.html

ADA survey of 4000 dentists- 45 deaths were reported

http://www.jefferson.edu/omfs/research/powerpoint/medical_files/frame.htm

Why We Are Here Question

What is the emergency plan in the office? Where is the emergency kit in your office? Do you know how and when to administer oxygen? Is the oxygen readily available? What is in your emergency kit? Are the meds all up to date? What is the emergency plan when the doctor is not there?

Does everybody else in your office?

Minutes Count
Call 911 However, that can take 3-45 minutes! Physiology studies indicate if the brain is deprived of oxygen for: 4-6 minutes- possible brain damage 6-10 minutes- probable brain damage Over 10 minutes- likelihood of irreversible brain damage or death.
Access 11/2006

Minutes Count

EMS/911 response times average more than nine minutes in urban centers and more than 15 minutes in rural areas. Failing to prepare is preparing to fail
United States Secretary of Health Tommy Thompson.
Dental Economics July 2007 Roberson DMD and Rothman DDS

former

Why We Are Here

Ethical Duty to protect and help our patients Standard of Care 7-8% of dentists are sued yearly Good Samaritan statutes help free an office from liability in most states if the dental team renders a patient life-saving treatment in good faith without expecting compensation for the service. But if it is your patient it is your responsibility. GSL covers family members in the waiting room. Jury decides and where does the burden of proof lie?
Malamed 2002, pg 103

There has never been a successful lawsuit against a lay rescuer who attempted to provide CPR for a victim of cardiac arrest.

-American Heart Association 2006

If In Doubt

CALL 911
But this is only PART of the plan.

Calling for 911

1. 2. 3. 4. 5. 6. 7. 8. 9.
10.

Exact location of building with cross streets, landmarks, name of building, and room number The telephone number from which the call is being made The callers name and office name What happened How many people are involved The condition of the victim The care being given The caller should stay on the line until further instructed while another person waits for them outside, if possible. They will want to know blood pressure and medications
Access 11/2006

Prevention Is The Key

90% of all office emergencies are preventable. The medically complex patients arent always the highest concern.

Straight From Wilkins

5-Point Plan to Prevent Emergencies 1. Use careful, routine patient assessment procedures. 2. Document and update accurate, comprehensive patient records. 3. Implement stress reduction protocols. 4. Recognize early signs of emergency distress. 5. Organize team management plan for emergency preparedness.

Develop an Office Plan

Duties of Team Member One Provide BLS as indicated Stay with victim Alert office staff members Duties of Team Member Two Bring emergency kit and Oxygen to emergency site (Check oxygen daily) Check emergency kit weekly Duties of Team Member Three Assist with BLS Monitor vital signs Prepare emergency drugs for administration Activate EMS system Assist as needed Maintain records Forms are available to follow Meet rescue team at building entrance

Standard of Care

Minimal level of care that the patient is entitled to while being treated by a healthcare professional Good Samaritan Statues- differ from state to state Informed consent is to promote the patients best interest
- Manual of Emergency Medical Treatment for the Dental team- Braun, Cutilli

Occurrence of Complication

Immediately before treatment During or after local During treatment After treatment After leaving the office

1.5% 54.9% 22% 15.2% 5.5%

-Medical Emergencies, Malamed 2000

Type of Emergency

65% of all cases developed during 2 types of treatment- Extractions (38.9) and Pulp Extirpations (26.9) Sudden, unexpected pain

-Medical Emergencies, Malamed 2000

Why we are hereCardio and Perio

2003- American Academy of Periodontology declared link Atherosclerosis- Reduction of arteries, reducing blood flow and oxygen to the brain, heart, and other vital organs. MI or stroke is likely

Heart and blood vessel diseases and conditions claim close to 100,000 lives annually. In US, 700,000 strokes occur each year and someone dies of a stroke every 3 minutes. Contemporary Oral Hygiene

Medical History
Use open ended questions What changes have you had to your health since your last appt/ what medications, vitamins, herbals, OTCs do you take? Closed- Have there been in changes to your health since your last visit? Encourage them to keep an updated list with them.

Medical History

Baseline History Medications Past/ current medical conditions- may indicate need for precautions Allergies Need for and results of Medical Consults Pre-Med Vital Signs- baseline then yearly Provides documentation in a legal matter.

Pre-medication needed Used to be for 2 years

minimum for total joint replacement, now new recommendation pre-medication for life. Medical consult: may need to contact orthopedic surgeon

Artificial Heart Valve Previous endocarditis Complex cyanotic congenital heart defect Congenital Heart defect repair for at least 6 months after repair. With residual effects = ALWAYS Heart transplant with valvular dysfunction Surgically constructed systemicpulmonary shunts or conduits

From 2007- ALL Joint Replacements Titanium, Knee, Hip, Shoulder, Elbow, TMJ

Regiment of Premedication

1 hour prior to appointment Not allergic to penicillinAmoxicillin - Adult: 2.0 grams, Children: 50 mg/kg Penicillin allergy: Clindamycin- Adults: 600 mg,
Children: 20 mg/kg

Give a different type if currently on the prescribed antibiotic

When to premed: Extractions Periodontal procedures Placing implants and avulsed teeth Endodontic procedures Orthodontic brackets Intraligamentary injections Prophylaxis Placing antibiotic fibers/ strips

Medical History
Although every dental office has its own medical questionnaire, there are six basic questions that should be asked to detect potential problems:

1. Do you have any allergies? 2. Is there a history of bleeding? 3. Do you have shortness of breath? 4. Do you have or have you had chest pains? 5. Are you taking any medication? 6. Have you previously been admitted to hospital?

A positive answer to any of these questions should be investigated to determine if treatment needs to be modified.
http://www.cda-adc.ca/jcda/vol-65/issue-5/284.html

Medical History

80% of all adults take at least one medication 25% of the population take 5 medications 80% of all seniors have at least one chronic condition 50% of seniors have at least 2 chronic illnesses More than 400 medications cause xerostomia
- Ciancio, J Perio, Vol 76;2005 and Lyle ADHA 2006

Herbal Supplements
Patients dont realize the impact of herbal therapy. Visits to alternative therapist rose 47% in the 90s Herbals are unregulated by the Food and Drug Administration Ones to Watch:

Hyg-10/2003

Echinacea- Numbness of the tongue and breathing difficulty Ginseng- active bleeding, avoid in pregnancy, avoid caffeine Kava- causes sedation, interacts with anti-anxiety meds St. Johns Wart- Drug interactions; Ephedra- Stimulant.

Contemporary Oral

Herbal Supplements
The following pose a risk for increased bleeding:

Garlic, Ginseng, Ginko Biloba, and any other that promotes increased circulation.
Little, J. Oral Surg 2004; 98:137-45

The American Academy of Anesthesiology suggests patients avoid herbal therapy 2 weeks prior to any surgery.

Herbal Supplements

Niacin- increase risk of postural hypotension Kava, Valerian, St. Johns wortinterference with sedative drugs

Ephedrine- hypertension

Herbal Supplements
Side Note: If you take birth control or know someone that does, advice them not to take the following: Black Cohosh (also linked to liver damage) St. Johns Wort

Both are shown to decrease the effectiveness of the birth control.

Drugs that contain aspirin or affect blood clotting

Advil Aleve Alka-Seltzer Bufferin CAMA Dextran Doloxene Echinacea Ephedra Garlic Ginkgo Ginseng

Heparin Ibuprofen Kava Lasix Midol Motrin Nonsteriodal antiinflammatory agents Nuprin Sine-Aid St. Johns Wort Triaminicin Vitamin E * May take Tylenol

- Dr. Avva, M.D, FACS

Vitals
PulseBelow 50 or above 120 is considered serious Irregular or Regular and Full or Weak If less then 50 or greater then 120 it is distress Respiration- Rapid or Shallow, Deep/Labored, Gurgling- Airway Obstruction, SnoringStroke. If less then 10 or greater then 20 it is distress

Vitals
Blood Pressure- 120/80 Great We do not treat 160/100 or over 180/120 is distress Under 90/60 is typically shock

Associated with stroke, heart attack, cong heart failure, end stage renal disease, diabetes, and hyperthyroidism

Hypertension in a Dental School Patient Population: A review of 500 patient records.

-Kellogg, J Dent Ed, 2004

32% of patients were hypertensive 49% were unaware 9% had a BP that required an immediate medical consult Determined that it is crucial that dental providers take BP readings.

Vital signs are key to assessing a patient in trouble.

Respiratory rate, pulse and blood pressure are what need to be measured, nothing more sophisticated than that. If all these vital signs are normal, chances are the patient will be fine. If they are not normal, your goal is to normalize them until the patient can receive appropriate medical attention.

http://www.cda-adc.ca/jcda/vol-65/issue-5/284.html

Answer: If your patient has taken Viagra within the past twenty four hours, you must never administer nitroglycerine. Why? The patient's blood pressure can fall to dangerously low levels. If their systolic blood pressure drops to below 100, the patient could faint or lose consciousness. The treatment would be to place the victim into the Tredelenburg position, administer oxygen, go to your A,B,C, D's, and give aspirin if chest pain develops.
http://www.gotodds.com/updates/index.aspx April 2005

The antibiotic, erythromycin, is no longer recommended for premedication use in dentistry. Why?

This antibiotic can cause an adverse drug reaction (ADR) when taken with the following types of medications: blood pressure meds. (verapamil, diltiazem), antifungal meds. (ketoconazo, fluconazole), antibiotic (clarithromycin), and the antidepressant (nefazodone). If this were to happen, a toxic build up of erythromycin can occur in the bloodstream and the result could be sudden death or a heart arrhythmia .
Excerpt from the " New England Journal of Medicine, Sept. 9, 2004

Medical Classification System

ASA I- A normal healthy patient ASA II- A patient with mild systemic disease ASA III- A patient with severe systemic disease ASA IV- A patient with severe systemic disease that is a constant threat to life

General precautions for patients with questionable health

Limit

amount of local anesthetic and number of injections (e.g., 3 cartridges instead of 5) Consider preoperative sedation Consider afternoon appointment

Never Treat A Stranger

Observe physical appearance (walk slow, medical alert tags). Reveal possible unrecognized/diagnosed medical conditions. Provide insight into emotional, psychological and attitudinal factors- may effect dental needs. Evaluate the patients anxiety level.

Signs of Acute Anxiety

Cold, sweaty palms or forehead Flushed face Altered facial expression Bruxism or clenching Rude demeanor Need to go to the bathroom Unnaturally stiff posture Inability to sitting still, tapping Trembling/ Fiddling
Access- July 2004

White-Knuckle syndrome Crying out, moaning Hyperventilation- No Oxygen Nausea Increased respiration, blood pressure, and heart rate

Stress Reduction
Number one way to prevent an emergency

Minimize waiting time. Present them with a smile. Actively listen to a patient's fears Keep patient informed. Dont give them time to think the worst. Schedule in A.M. Shorter appointments Regular meals Avoid accidents- Pass instruments below chin

Common Observed Changes

Acute changes in demeanor/consciousness Sudden onset of pain anywhere in the body Tight feeling in chest or back Difficulty in breathing Choking Dizziness or feeling faint Numbness or tingling
Dental Office Medical Emergencies, Meiller

Contributing Factors to Emergencies

Increased number of older patients with natural teeth Medical advancements Essential medications: certain prescriptions must be taken on schedule or the patient is at risk for an emergency

Drug interactions- Herbal supplements and medications that interact adversely with drugs used in dentistry. More complex dental procedures require longer appointments Dental diseases that require invasive procedures

The most rapidly growing segment in the US is the 65 and over due to post-World War II baby boomers.
Malamed

70 60

US population over 65 will be over 64 million by 2030.

50 40 30 20 10 0 1790 1900 1980 2030

Procedures for All Emergency Situations

Supine position- Do not move from chair If conscious make them comfortable Reassure the patient Provide Oxygen when not in hyperventilation Check vitals/ maintain open airway Be prepared for the worse

Why Oxygen?

The most important aspect of nearly all medical emergencies in the dental office is to prevent, or correct, insufficient oxygenation of the brain and heart. The management of all medical emergencies should include ensuring that oxygenated blood is being delivered to these critical organs. http://www.pubmedcentral.nih.gov/
articlerender.fcgi?artid=1586863

Oxygen

E cylinder- 3 feet high This is enough oxygen to ventilate a nonbreathing adult for approximately 30 minutes. If it is FULL!
www.ineedce.com

Equipment

Ammonia spirit, Glucose, Epinephrine, Histamine blockers- acute allergic reactions

Fail-safe drug kit- Albuterol,

AED Emergency number call list Oxygen tank- size E Low flow regulator and nasal cannula Bag valve, pocket and nonrebreather masks Syringes

Pen light Blood pressure kits Stopwatch Emergency Report Form First-aid kits

The following is a list of all the ADA recommended contents: 1) epinephrine in 1:1000 dose with 3 empty syringes for loading or preloaded syringe 2) benadryl in 2 pre-dosed syringes 3) aspirin 325mg, 3 packets 4) nitroglycerine spray 5) instant glucose, 2 tubes 6) ambu-bags, 1 adult 7) ammonia inhalants, 3 8) albuterol inhaler 9) CPR disposable masks, 1 adult All of the above items are packaged in a centralized emergency kit.

Albuterol Inhaler

Treats severe asthmatic attack Causes relaxation of the smooth muscle of the bronchioles.

Nitroglycerin

A venous and arteriolar dilator that results in increased cardiac output and reduced left ventricular filling pressure.

Nitroglycerin

If exposed to oxygen/light it is only effective for 12 weeks. Most cases- 6 month shelf life When using it should produce a bitter taste or impart a sting if still effective. The translingual nitro spray has a longer shelf life. (2 years)

Epinephrine 1:1,000 Concentration

For severe allergic reaction and acute asthmatic attacks. Adult Dose: 0.3mg. Delivery: auto-injector Pediatric size auto-injector is available.

Epinephrine 1:1,000 Injection

Use: to reverse hypotension, bronchospasm, and laryngeal edema that result from an acute anaphylactoid type reaction. Also used to reduce bronchospasm resulting from an acute asthmatic episode that is refractory to inhaler therapy. Dose: Supplied in vials, ampules, or pre-loaded syringes in concentration of 1:1000, 1mg/ml. IV give 0.5-2.0mg (0.5ml-2.0ml) depending on severity of hypotension, titrate to effect repeat in 2 minutes if needed. IM give 0.3mg (0.3ml) repeat in 10-20 minutes as needed. Pharmacology: Causes vasoconstriction that in turn increases blood pressure, heart rate, and force of contraction. Reduces histamine release. Adverse Effects Cardiovascular: Tachycardia, Tachyarrhythmias, and hypertension. Central Nervous System: Agitation, headache, and tremors. Endocrine System: Increased blood glucose. Pregnant Female: Can decrease placental blood flow. Drug Interactions: Nasal decongestants, antihistamines, asthma inhalers will increase incidence of adverse effects. Can be ineffective if the patient is taking beta-blockers.

Diphenhydramine (Benedryl) 50mg Injection

Use: To reduce the affects of histamine release that is associated with allergic reactions, anaphylaxis, and acute asthma attack precipitated by exogenous causes. Dose: 50-100mg IM or IV. For mild cases of pruritis, urticaria, or erythema an oral dose of 50mg every 6 hours can be used. Pharmacology: Benedryl is an antihistamine that blocks the release of histamine in the body. It does not prevent the action of the histamine once released and thus must be given quickly. Prevents histamine responses such as bronchospasm, hypotension, rash, and edema. Adverse Effects: Cardiovascular: Tachycardia (Fast heart rate.) Central Nervous System: CNS depression (Sedative effects including drowsiness, lethargy, and mental confusion.) Gastrointestinal: Xerostomia (Dry mouth.) Drug Interactions: Any drugs causing CNS depression will increase the sedative effects of Benedryl. Can also exaggerate this effect in other drugs suck as Atropine, Antipsychotics, Demerol, and Tricyclic Antidepressants.

Patient Positioning

Respiratory difficulty Upright > Cerebral blood flow Upright < Cerebral blood flow Trendelenberg Unconsciousness Trendelenberg Cerebral blood flow indicators: color changes, blood pressure, pulse, respirations, levels of consciousness

If the face is red raise the head. If the face is pale raise the tail!

Supine Position
Figure 14-1 Supine position. Place patient so head is equal to heart level.

Mary Danusis Cooper and Lauri Wiechmann Essentials of Dental Hygiene: Clinical Skills

Copyright 2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Unconsciousness is determined by performing the shake and shout maneuver, gently shaking the shoulders and calling the victims name. Head Tilt Chin Lift Look, Listen and Feel for Breath

Loss of Consciousness
Most Common Syncope Postural Hypotension Hypoglycemia (Insulin shock) Less Common Anaphylactic Shock Stroke Seizure Disorders

Syncope/ Fainting

Syncope/ Fainting

Loss of consciousness caused by a reversible disturbance in cerebral function. Decreased circulation of blood to the brain. Hypotension- decrease of blood pressure

Most common emergency in the office Recovers in seconds to 1-2 minutes

Causes: Anxiety, fear, pain,

hunger, rising fast, exhaustion

Syncope/ Fainting
Possibilities to consider Hypotension Hypoglycemia Cerebral Vascular Accident Seizure Arrhythmias Anaphylaxis Anxiety Attack Hyperventilation Adrenal insufficiency Myocardial infarction

Syncope/ Fainting
Symptoms: Rapid
pulse, decreased pulse rate (below 40 bpm), light headiness, diaphoresis (sweaty/ clammy), nausea, pale (deathlike look), gasping breath

Drugs and Stimulants

Postural Hypotension- At risk drugs: Low BP causing loss of Any that lower BP consciousness Nitroglycerin- so do not administer Cause: Supine position Erectile-dysfunction for more then 15-20 (Viagra- 24 hrs, minutes. Cialis-3 days, Levitra) Niacin supplements (to lower cholesterol)

Postural Hypotension

Prolonged periods of reclining, positioning Late stage pregnancy Advanced age Venous defects in legs-Varicose veins Exhaustion Starvation Nitrous oxide
-Malamed 2000

Syncope/ Fainting
Treatment:

Trendelenburg positionsupine position with feet up, head down. Left side for pregnancy. Maintain an open airway. Give oxygen. Monitor vital signs. Intermittent use of crushed ammonia capsule. Face will get red which is a good sign. Blood is returning.

Cold compress on forehead or back of neck Record all events and time line Activate EMS if patient is unstable or theres a delay in response Comfort patient upon awakening

Syncope/ Fainting
Signs patient is recovering: Patient awakens Vitals are stable Signs patient is deteriorating: Patient does not awaken after one minute Falling BP- unstable vitals Bradycardia * Reevaluate diagnosis- consider hypoglycemia, seizure, cardiac arrest, anaphylaxis, stroke.

Hyperventilation

Hyperventilation

Excessive exhaling of carbon dioxide, blood drops in CO2. Increased ventilation (breathing) in excess of what is required to maintain normal carbon dioxide levels.

Causes: Fear/anxiety (injections), apprehension, panic attacks, overdose of medications, stimulants. Symptoms: Rapid shallow breathing, suffocation feeling, confusion, vertigo (dizziness), paresthesia (numbness of extremities), chest tightness, increased heart rate.

Hyperventilation
Treatment:

Monitor vitals. Position upright or semi-reclined Reassure the patient. (comfortably). Terminate procedure. Talk to them in a slow, quiet and calm voice Tell the patient There will be no more dental treatment today. Do NOT administer oxygen. Have patient hold breath for 10 second intervals (breath into Signs patient is deteriorating: hand to warm up) to enrich Patient loses consciousness, vitals CO2 levels. are unstable

Asthma

Asthma

Spasm and constriction of the bronchi Affects more than 20 million Americans-Cont Oral Hyg
08/2005

Causes:

Extrinsic: Allergic reaction

(younger people),

Intrinsic: Respiratory infection

(after 35, acute episodes) Emotional stress/anxiety

Hyperactivity of the Tracheobronchial tree Bronchial muscles completely or partially contract.

Asthma
Symptoms:

Labored breathing, tightness in chest, coughing spasms, wheezing, anxiety, increased heart rate, vagus nerve stimulation (gagging).

Asthma
Treatment:

Upright position, comfortable. Utilize inhaler (2-4 puffs

initially, repeat in 15 minutes).

Maintain open airway Reduce anxiety Monitor vitals Administer oxygen Activate EMS if normal breathing does not return.

Epinephrine if needed Supplemental cortisone if patient has been on corticosteroid. Signs patient is deteriorating:

Breathing does not improve, Patient is tiring or slows breathing dramatically.

Asthma
Prevention:

Identify history of asthma. Know what a typical attack is like for them Have inhaler accessible Avoid inhalation of irritating agents
Risks

Dry mouth from meds Dental stress

Emphysema

Emphysema

Usually found in older adults Form of chronic obstructive pulmonary disease Patient has decreased respiratory reserve when the body requires more oxygen.

Causes:

Loss of elasticity of the lung tissue, over distention of the lungs, chronic respiratory infections, smoking, pollutants.

Symptoms:

Labored breathing, shortness of breath

Emphysema
Treatment:

Prevention:

Sit slightly upright Encourage proper breathing Utilize inhaler Be cautious of the amount of oxygen given Activate EMS if normal breathing does not return

Identify history of Have inhaler accessible Keep patient slightly upright

Airway Obstruction

Airway Obstruction

Partial or complete obstruction of the airway. Foreign body causing mechanical blockage in the larynx pharynx. Blockage does and not allow adequate air exchange in the lungs.

Causes:

Dental objects (crown, head of mirror, prophy angle, rubber dam clamp, amalgam, etc.), food, balloons, marbles. Choking, gagging, violent expiratory effort, not able to speak, panic, labored breathing, rapid then decreased pulse, respiratory and/or cardiac arrest.

Symptoms:

Airway Obstruction
Treatment:

Supine position if patient becomes consciousness Roll them to the side for head to be lower then the throat Encourage patient to cough Perform foreign body airway maneuver (thrust from behind) Call EMS as soon as unconsciousness occurs Perform abdominal thrusts until unconscious then perform CPR. Attempt to clear airway If partial obstruction let the ER handle it so you do not tear tissues.

Prevention:

Utilize rubber dam Assure all equipment is fastened tightly Keep patient upright for impressions High volume suction Appropriate chair and head position Gauze partition Floss attached when able.

Airway Obstruction

Because total airway obstruction usually occurs during inspiration, there is usually adequate oxygen in the cerebral blood to permit up to two (2) minutes of consciousness.

If foreign body is NOT recovered or passes, refer patient as soon as possible for radiographic localization.

Ingested/ Aspirated Items

Institute emergency assistance as indicated

(Universal sign of choking).

Notify the Doctor/ Other Office Personal to Assist Temporize procedure if applicable. Follow-up radiographs Surgery? Necessary paper work completed.

Acute Bleeding

Intraoral- Evaluate every 2-3 minutes while applying pressure. Consider hemostatic agents and primary wound closure Extraoral- Apply direct pressure, pressure bandage and transport via EMS

Seizure

Seizure

Abnormal brain activity Intermittent disorder of the nervous system Sudden/ excessive neurological discharge Idiosyncratic reaction to a drug. Partial/petit Mal- conscious Tonic-clonic/Grand Malloss of consciousness

Causes:

Epileptic seizure, brain damage, drug reactions, triggers (light, stress, fatigue, hormonal) Aura, tremor followed by clonic-tonic convulsions (tonic= rigid muscles; clonic- convulsions, frothing), excitement, trance-like, confused, sleepy

Symptoms:

Seizure
Things to ask the patient during the medical history interview:

What kind do you have? What happens? How long do they typically last? When was your last one? If within one week, call their physician. Did you take your medications today? What can we do for you if one comes on? Is their someone we should contact if you have one?

Seizure
Treatment:

Leave patient in chair, supine Clear area for safety Loosen clothing Maintain open airway Administer Oxygen Do NOT restrain patient Allow patient to rest following

According to the American Red Cross, summon the EMS when:

seizures occur repeatedly a seizure lasts longer than five minutes the victim appears injured the victim has no history of a seizure the victim is pregnant the victim is diabetic the victim does not regain consciousness immediately after the seizure. if the episode lasts longer than 10-15 minutes

Allergic Reactions

Allergic Reactions
Hypersensitive state caused by an exposure to a particular allergen. Urticaria (red) Pruritus (itching) Rapid onset Causes: Antibiotics (penicillin) Anesthetics Local irritants (latex)

Symptoms: Rash, itch, edema (swelling) Bronchial constriction Treatments: Position comfortably Administer oxygen Monitor vitals Withdraw irritant Administer Benadryl 25-50 mg orally

Anaphylactic Shock

Severe allergic reaction Immediate hypersensitivity Cardiovascular collapse Severe hypotension Life threatening

Symptoms:

Causes: Antibiotics (penicillin) Anesthetics Local irritants (latex) Bee Stings

Itching of nose and hands, flushed face, coughing Sudden hypotension Labored breathing Respiratory and circulatory failure GI upset Shock Cardiovascular distress Swelling of the tongue and oropharynx

Anaphylaxis
Typical progression * Skin reactions Smooth muscle spasms (GI, GU, respiratory) Respiratory distress Cardiovascular collapse *may occur rapidly, with considerable overlap

Anaphylactic Shock
Treatments:

Supine position- basic life support Call EMS immediately- Have medical history to inform EMS Monitor vitals Administer Epinephrine/ epi-pin Initial doses

0.3 to 0.5 mg intramuscularly or 0.1 mg intravenously. Give through clothes.

(.3 ml injection can be given sublingual if licensed) Administer Hydrocortisone (ALS) Administer Oxygen Proceed with basic life support as needed

EpiPen

Preloaded dose of injectable epinephrine Jr strength for 33-66 pounds. Effects last only 15-20 minutes for each dose

Video: www.epipen.com/howtouse.aspx
Access 11/2006

Update: April 21, 2005 For those dentists and dental hygienists either using, recommending, and/ or prescribing the popular mouth rinse, chlorhexidine gluconate 0.12%, you must be aware that the Asian population can be extremely allergic to this product.

The incidence of severe anaphylactic shock with this patient group is immediate and includes upwards of 4% of this population group. If you are using chlorhexedrine as a pre-rinse prior to dental treatment, be aware that the Asian patient population could have a potentially serious reaction while in your office.

Source: Dental Hygiene Conference in Washington D.C. 2005.

Epinephrine Reaction
Symptoms Rapid elevation in blood pressure Increased pulse rate Anxiety Tremor

Treatment Position patient comfortably Administer Oxygen Reassure patient Monitor vitals (could be 20
minutes for return to normal bp)

Activate EMS if further symptoms develop or if elevated BP remains

CLINICAL MANIFESTATIONS of Local OVERDOSE

Clinical Manifestations of Local Anesthetic Overdose (Signs)

Low to Moderate Overdose Levels Confusion Talkativeness Apprehension Excitedness Slurred speech Elevated BP Elevated HR Elevated RR Generalized stutter Twitching

http://www.jefferson.edu/omfs/research/powerpoint/medical_files/frame.htm

Minimal to Moderate
Low to Moderate Overdose Levels Restless Visual disturbances Auditory disturbances Numbness Metallic taste Light-headed and dizzy Drowsy and disoriented Losing consciousness Sensation of twitching (before actual twitching is observed)

Moderate to High
Generalized tonic-clonic seizure activity followed by Generalized CNS depression Depressed BP, heart rate Depressed respiratory rate

MANAGEMENT of Local OVERDOSE

Mild Reaction -slow onset

Reassure patient Administer O2 Monitor vital signs Allow recovery or get medical help Get medical consultation, esp. if possibility of metabolic or renal dysfunction

Severe Reaction - rapid onset

Stop all treatment Place patient in supine position, feet up Establish airway, give O2 (BLS) If convulsions, protect patient Summon emergency medical help Consider anticonvulsant drugs, vasopressors

Management of Allergy Pts.

If the patient gives a history of allergy to local anesthetics - Assume that an allergy exists Elective procedures Postpone until work-up is completed

Management of Reactions
Delayed skin reaction Benadryl - 50 mg stat & Q6H X 3-4 days Immediate skin reaction Epinephrine 0.3 mg IM or SC Benadryl - 50 mg IM Observation, medical consultation Benadryl - 50 mg Q6H X 3-4 days

Management of Reactions
Bronchial constriction Semi-erect position, O2 - 6 L/min Inhaler or Epinephrine 0.3 mg IM or SC Benadryl - 50 mg IM Observation, medical consultation Benadryl - 50 mg Q6H X 3-4 days

Differential Diagnosis
Pyschogenic reaction (Syncope) Overdose reaction Hypoglycemia Stroke (CVA) Acute adrenal insufficiency Cardiac arrest

Diabetes

Diabetic emergencies are the result of diabetes mellitus, a chronic disorder of carbohydrate metabolism in which insufficient insulin is produced or insulin is not used effectively. The emergency conditions associated with diabetes include hypoglycemia, the most acutely lifethreatening, and the slower onset hyperglycemia.

Diabetes Mellitus and Periodontal Disease

More than half of the inflicted population do not know they have diabetes. 1/3 of people with diabetes have severe periodontal disease with loss of attachment measuring 5 mm or more
Give me fever- ADHA 2006, Deborah Lyle, RDH, MS

Effects an estimated 5-10% of all people in the United States. (Over 16 million people) 73% of adults with diabetes have hypertension About 800,000 new cases are diagnosed each year.

Diabetes Mellitus and Periodontal Disease

6th leading cause of death in the US

Assoc., 2004

-Amer Diabetes

Accounts for 1 out of every 10 health care dollars spent In a practice with 2,000 patients, about 3 patients per week will have diabetes
-Periodontalogy 2000, Vol 32;2003

Diabetes Mellitus and Periodontal Disease

The hyperglycemia of uncontrolled diabetes is the basis for most of the vascular, cellular, and immune changes seen in periodontal disease. Uncontrolled diabetes is the most violent to the periodontal structures. Rate of development in uncontrolled subjects is 3 times greater.

Diabetes
Type I, insulin - dependent Type II, non-insulindiabetes mellitus dependent diabetes mellitus Represents about five Mostly seen in adults percent of all cases of diabetes but may occur in some children. It is more common in adolescents, but can occur in adults http://www.adha.org/CE_courses/course2/ In this form virtually additional_emergencies.htm no insulin is produced.

Diabetes mellitus

A medical emergency of diabetes mellitus, is precipitated by factors that increase the body's need for insulin. Dental therapy is a potential threat since stress increases insulin needs, which in turn can precipitate hyperglycemia even in a person who is normally well controlled. Simply having a dental appointment may cause the person to alter normal eating habits that could create an insulin imbalance. Malamed suggests that after extensive dental treatment, the patient should be instructed to check blood glucose levels at least four times a day for several days, and make dosage adjustments.
www.adha.org 2007

Diabetes
Hypoglycemiatoo little glucose in the blood/brain too much insulin in the body Low blood sugar Symptoms: Sudden onset, clammy, pale, nervousness, full/bounding pulse, confusion, drooling, nausea, hunger, numbness, argumentative Causes: Omission of meals, overdose of insulin, alcohol, excessive exercise

Hypoglycemia

A result of exogenous insulin therapy, is an acute life-threatening condition. It can result from an insulin overdose or failure to maintain normal food intake, usually by delaying or omitting meals. It is generally manifested in patients receiving insulin therapy.

Diabetes
Hyperglycemiatoo much glucose in the blood too little insulin in the body Symptoms: Gradual onset, flushed, fatigue, weak/rapid pulse, sweet breath Causes:

Lack of insulin, ignoring disease, obesity, heredity

Diabetes
HypoglycemiaTreatment: Give glucose, carbohydrate (icing, juice) Brain can only survive 5 minutes without glucose Position comfortably, semi-reclining Maintain open airway Administer oxygen Call EMS as soon as unconsciousness occurs HyperglycemiaTreatment: Seek medical advice Administer insulin Prevention: Thorough medical history, Did the patient eat and/or take insulin today?, AM appointments, do not treat uncontrolled diabetes

St. Johns Wort and Type 2

Patients taking rosiglitazone (Avandia) for Type 2 diabetes should not take St. Johns Wart. It has shown to cause the drug to metabolize 35% faster than normal. Other drugs effected are synthetic estrogen, like the pill thus mixing the two can make the pill less effective. Also interacts with antidepressants.
Health.com 11/2008 Health.com 11/2008

Source: www.news.health.ufl.edu

A Two Way Connection Between Diabetes and Periodontal Disease.

The presence of periodontal disease affects glycemic control, making it harder for the diabetic to control their blood sugar levels. One study showed that chronic release of cytokines associated with periodontal disease interferes with the action of insulin, increasing the risk for diabetic complications. Uncontrolled diabetic patients are more susceptible to periodontal disease. Urge the patient to go to their doctor regularly to get their diabetes controlled.

Diabetes Resources

American Diabetes Association/National Diabetes Fact Sheet 2005: www.diabetes.org National Diabetes Education Program: www.ndep.nih.gov Center for Disease Control: www.cdc.gov National Institute for Diabetes, Digestive, Kidney Diseases: www.niddk.nih.gov

Give me fever- ADHA 2006, Deborah Lyle, RDH, MS

Stroke

Stroke

3rd leading cause of death in US Leading cause of brain injury in adults Early recognition and intervention is crucial with our advance therapy Can mirror hypoglycemia or a seizure In any given year 28% of stroke victims are younger than 65.
2006 American Heart Association

Stroke
Cerebrovascular Accident Localized neurological disorder Decreased blood supply to the brain Causes: Uncontrolled hypertension (high blood pressure) Head trauma

Types:

Cerebral embolism- floating blood clot lodges in brain (7%) Cerebral infarction- decreased blood flow to the brain (atherosclerosis 80%) Cerebral hemorrhage- rupture of a cerebral artery (13%) Cerebral thrombosisObstruction of a cerebral artery due to clot formation (80%)

Risk factors for Stroke

Risk factors you cannot change:

High blood pressure Smoking Diabetes: 5 times more likely to suffer stroke Heart disease Carotid artery disease High cholesterol Physical inactivity Obesity Heavy alcohol use

decade

Aging- over 55 risk doubles each Being male however stroke is the

number 3 killer of women LHJ

African-American Ethnicity A family history of stroke A prior stroke or heart attack Sickle cell disease

Risk Factors

New research shows that certain conditions such as smoking, hypertension, or diabetes produce chronic, low levels of inflammation. This inflammation can destabilize cholesterol deposits in coronary arteries, leading to a heart attack or stroke.
-RDH 11/2004

Carbon monoxide generated during smoking reduces the amount of oxygen carried in the blood causing blood platelets to cluster, decreasing clotting time, and increasing blood thickness. -American Heart Association 2006

Stroke
Symptoms:

Headache- intense Confusion Vertigo Dizziness Loss of control on one side (paralysis) Impaired speech Unequal pupils Difficulty breathing and swallowing

Whirling sensation Ears Ringing Tunnel of flashing lights Body veering to one side Chest pain and shortness of breath (more common in women) Blurred or double vision Unilateral tingling around mouth Aura/ Smells

Stroke
Treatment: Terminate procedure Position upright Activate EMS immediately! (Ask if the transport can be to a
hospital with a stroke center)

Manage symptoms Administer oxygen

this type 2 times as much as man)

Do not give aspirin- (If hemorrhagic it is deadly and women have

Stroke

1) Ask the person to smile. 2) Ask the person to raise both arms. 3) Ask the person to speak a simple sentence. 4) Ask the person to stick out his tongue.

Stroke
Prevention: Medication (blood thinners)

Normal prothrombin time:11-15 Recommended International Normalized Ratio (INR) 2-3

Stress reduction Do not treat for 6 months do to healing and risk of re-stroke
(1/4 of patients die within the year from the TIA or a subsequent strokeLHJ 6/06

) Ask if their physician gave any warnings to dental treatment Ask for knowledge of increased bleeding Mid afternoon appt.s- BP lower Use cardiac dose of epi

Angina Pectoris (Chest pain)

Angina Pectoris (Chest pain)

Insufficient blood supply to the cardiac muscle (heart) Pain varies from mild to severe Lack of oxygen to the heart

Causes:

Stress and anxiety Exertion Heredity, age, sex (males 2:1) Smoking, obesity, hypertension Crushing or squeezing pain in chest, Intense Excessive sweating History of angina pain (lasting more then 3-5 minutes but shorter than 20 minutes) Radiating pain to left arm/jaw Feels like indigestion

Symptoms:

Angina Pectoris (Chest pain)

Treatment:

Prevention:

Comfortable semi-upright position Administer oxygen Administer nitroglycerin sublingually (may repeat in 3-5 minute intervals 3 times) Monitor vitals to have baseline If pain lasts longer then 8-10 minutes or is atypical for patient activate EMS immediately. Then administer aspirin 325 mg orally to be chewed. Utilized 20 minutes faster.

Complete medical history Have nitroglycerin pills available (check expiration date) Stress reduction Cardiac dose of local: no more

than 2 carpules of 1:1000,000 epi Pacemaker: keeps heart regular Contraindications Ultrasonic: if unshielded (before 1985)

* If any doubt about the type of attack call 911 for a possible heart attack

Nitroglycerin

Spray is not to be inhaled Spray under the tongue If systolic BP decreases below 100 mm Hg, discontinue administering because it will further decrease.

Nitroglycerin 0.4mg Tablets or 0.4mg Metered Dose Spray

Use: To relieve or eliminate chest pain associated with angina pectoris, to differentiate between angina and a myocardial infarction. Dose: Tablet: 1 tablet sublingually repeat after 2 minutes if no relief up to 3 doses. Metered Dose Spray: 1 spray sublingually repeat after 2 minutes if no relief up to 3 doses. Monitor blood pressure after each dose; do not repeat if systolic BP drops below 100. Average drop in BP is 11-16 mm Hg after one dose. Patient should be sitting or supine when Nitroglycerine is administered. Adverse Effects: Cardiovascular: Rapid heart rate, facial flushing, and orthostatic (Postural) hypotension. Central Nervous System: Dizziness and headache. Drug Interactions: Anti-hypertensive drugs may exaggerate the hypotensive effect of Nitroglycerine.

Angina Pectoris (Chest pain)

Ask patient if they have taken any erectiledysfunction drugs within the last 24 hours. Viagra, Levitra- 3 days, Cialis These drugs+ Nitro= No Blood Pressure

Niacin + Nitro= No Blood Pressure

Simply state if you dont tell me you will die.

Myocardial Infarction

Heart Disease

1 in 4 deaths will occur in persons younger than 65. Single largest killer of both men and women. Stroke and chronic heart disease #1 killer among US women. Research shows unique factor is the influence of their hormonal status (Endogenous Estrogens increase
postmenopausal)

This year approximately 1,200,000 persons will have a new or recurrent heart attack or fatal episode of coronary heart disease. Cigarette smokers have a 2-3 fold greater rate of death of CHD than nonsmokers.
American Heart Association 2006

Myocardial Infarction

35% of all deaths occurring in men between the ages of 35 and 50 years. 27% of men and 44% of women die within 1 year after having a heart attack. 25% do not exhibit obvious clinical symptoms before the onset of death.
-Malamed 5th edition

Myocardial Infarction
Heart Attack Death of a portion of the myocardium Lack of oxygen to the heart caused by a blockage to an artery Coronary artery disease (90%) Occurs at rest (52%) Occurs with modest exertion (18%) Time is critical

Causes:

Stress and anxiety Exertion Heredity, age(50-70?), sex (males?) Smoking, obesity, uncontrolled hypertension

Myocardial Infarction
Symptoms:
Severe crushing or squeezing pain in chest, Sharp Sudden onset, cold sweat Radiating pain to left arm/jaw, back Nausea, vomiting, light headed Women: Fatigue and back pain

Diabetics are more likely to have silent MI.

55% of patients who experience a heart attack can go into cardiac arrest and die within the first 2 hours.
Access 11/2006

Myocardial Infarction
Treatments:

CALL EMS IMMEDIATELY!! Position comfortably Proceed with basic life support as needed Administer oxygen Have the patient chew to crush an aspirin- if not allergic- 325 mg adult dose Administer nitroglycerin Give 50-50 Oxygen and Nitrous oxide to help relieve the acute pain. Monitor vitals- every 5 minutes Accompany patient to hospital

Prevention:

Thorough medical history Stress reduction Appt in late morning/ afternoon better. Research shows highest MI time is during endogenous epinephrine peaks- 8-11 AM Medical clearance Do not treat a pt with history of MI within 6 months prior

Myocardial Infarction

Denial- If a victim starts giving reasons why they couldnt be having a heart attack, that is a signal to us that it is and we should call 911! Many times it isnt just the victim that is in denial.

Sudden Cardiac Arrest

Strikes about 1000 victims per day in US This is the equivalent of 3 full 747s crashing daily. 10% (100 of these) are in people younger than 40.
Dental Economics 10/07

Dental Therapy Considerations in the Patient with a History of MI

Review Changes in Medical History including Medication Doses

Stress Reduction Supplemental Oxygen Sedation Pain Control Minimize duration of Appointment- late morning, early afternoon Only Emergency procedures if MI is within six months medical consultation recommended
http://www.jefferson.edu/omfs/research/powerpoint/medical_files/frame.htm

Cardiovascular Disease and Periodontal Disease

Individuals with periodontitis have nearly twice the risk of having a fatal heart attack than a person without periodontal disease. Periodontics, Neild-Gehrig, Willmann

Oral bacteria may infect blood vessel walls, causing a buildup of deposits inside heart arteries. Oral bacteria can enter the blood causing small blood clots that clog arteries.

Phen-Phen

Over 30% of the past users of Phen-Phen can develop aortic stenosis. This literally means "narrowing of the aorta". What results is the aortic valve starts to lose its flexibility and becomes more rigid. This in turn causes the left ventricle to work harder since the blood will re-enter the ventricle due to the loss of a tight seal by the aortic valve. The left ventricle will start to hypertrophy due to the increased work load. In time, the increased size of the left ventricle can lead to possible strokes, MI's, arrhythmias, and tachycardia. The primary result of aortic stenosis is an aortic valve infection. This will require pre-medication with the appropriate antibiotics! The symptoms of aortic stenosis are: chest pain (angina), fainting, and shortness of breath. One point to realize is that 4% of the patients with aortic stenosis can go to sudden death!
LECTURE AUGUST 21, 2004 SPEAKER: BETSY REYNOLDS, RDH., M.S.

How do you know the difference?

Acute Myocardial Infarction Pain lasts 30 minutes to hours Associated with arrhythmias Pain during exertion or rest Pain is not relieved by rest Pain returns after Nitro Patient may have reduced or normal BP Angina Pectoris Pain lasts 3-5 minutes

Not associated with arrhythmias Pain follows exertion/stress Pain is relieved by rest Pain is relieved by Nitro Pain is uncomfortable not acute

Sudden Cardiac Arrest - Chain Of Survival

Basic Life Support

Are you OK? Call 911 and get the AED Circulation- Check for a pulse in 10 seconds or less Airway Breathing- Get the AED Defibrillation

Remember CABs now

AED- monitors heart rhythm

Year 1947 Claude Beck, defibrillator

Today

http://www.americanaed.com/aed_resources.html

AED stands for Automated External Defibrillator What is a Defibrillator? A machine that administers a controlled electric shock to the chest or heart to correct a critically irregular heartbeat that cannot drive the circulation.

AED

Chances of surviving a cardiac arrest diminishes 10% every minute. Survival rates can exceed 90% if AED is used in the first 1-2 minutes. After 8-10 minutes, the survival probability is near zero. AED saves lives!
Dental Economics 10/07 Dental Economics 10/07

AED- Where are they?

Wal-mart? Giant Eagle? Airplane? Airport? Disney Resort? A cruise ship? In a school? The Bottom of the Grand Canyon? Is the area locked? Is the battery working? Where is it in your office?

AED- Is it the Standard of Care?

Section 64B5-17.015 of the Florida Administrative Code states: As part of the minimum standard of care, every dental office location shall be required to have an automatic external defibrillator by 2/28/2006. Any dentist practicing after this, without an AED on site shall be considered to be practicing below the minimum standard of care.
Dental Economics 10/2007

AED- Automated External Defibrillator

Use AEDs when the victims have the following 3 clinical findings: No response No breathing- Remember
agonal breaths are not effective breaths

If the adult is a drowning victim the rescuer should give 2 minutes of CPR before getting the AED

No Pulse

Do not move or touch the victim while AED is analyzing.

http://www.americanaed.com/aed_resources.html

AED Cautions

Water- remove the victim from water and wipe the chest dry Hairy chest- Press the pads firmly, if prompt to check pads is given then pull off the pads and then apply pads. If hair still remains shave area with a razor form the AED case. Implanted pacemaker- Place pad at least 1 inch from device Medication patch- Remove the patch and wipe clean

http://www.americanaed.com/aedspecial_onsite.html Special Offer: $1250.00

Special Offer : $1395.00

Shopping results for AED prices

AED CR Plus Semi Responder VP - RVP-CRPLUS-S $1,954.00 new Amazon.com DEFIBTECH Lifeline AED Automated External Defibrillator $1,299.99 new Overstock.com Philips HeartStart AED Home Defibrillator + $100 Bonus eGift Card $1,267.00 new Walmart AED 5 Year Business VP (Alarm Cabinet) - BVP-LIFELINE5-A $1,402.16 new Amazon.com ZOLL AED Defibrillator $1,299.00 used DOTmed.com

AED- Automated External Defibrillator

AED can now be used on children. Use children

pads when available. You may use adult pads as long as the pads do not touch. Flipping a child switch or button may be indicated on some units.

If using an AED on a child, perform 2 minutes of CPR prior to attaching and using the AED.

AED- Automated External Defibrillator

To get a program started in your office:

www.redcross.org/services/hss/courses/aed.html

Basic Life Support- Update

One rescuer 30 compressions to 2 breathes CAB from ABC Two rescuer Children and Infants15 to 2 Moving away from the breathing portion

Develop an Office Plan

Every office employee should have a role. Document, Document, Document What is your plan?

If In Doubt

CALL 911

SourcesFrom any questions over material in this course contact: moore.1397@osu.edu

Advanced Protocols for Medical Emergencies- Lewis, McMulln; Lexi-Comp, Inc. Dental Office Medical Emergencies- Meiller, Wynn; Lexi-Comp, Inc. Manual of Emergency Medical Treatment for the Dental team- Braun, Cutilli Medical Emergencies- 5th edition, Malamed- 2000 The Health History, Gurenlian and Pickett- 2005 Dr. Mark Castle, D.D.S. www.gotodds.com-2007 Pocket Guide To Medical Emergencies in the Dental Office. LCDR V.C. , DC, USN 2007 Medical Emergencies- Essentials for the Dental Profession Ellen B. Grimes