Ways to prevent a medical emergency in the dental office

-Nasal Cannula

-O2 with regulator and flow meter

-Non-rebreathing mask with reservoir

-Bag Mask

Epinephrine

Nitroglycerine

Diphenhydramine/Chlorpheneramine

Albuterol

Aspinion

Glucagon (Oral Carbohydrate)

Nasal Cannula Facts:

Rests on patients upper lip

Prongs are inserted into nasal passages & looped around ears

Oxygen flow of 1-6 liters/minute

Turn on prior to placement

Oxygen tank is green

Includes: Cylinder, regulator, flow meter

Size E for dental offices-30 mintues of oxygen

Reservoir attached to provide extra oxygen

Placed over patients nose and mouth

Straps tighten around patients head

Patient to place mask to reduce apprehension

Bag Mask Facts:

Complete oxygen delivery

Difficult to obtain leak proof seal

Use thumb, index and middle fingers to hold mask to patients mandible.

Anaphylaxis

redue hypotension, bronchospasm, laryngeal edema, prevents release of histamine, and other chemical mediators.

Severe asthma attack

Counteracts major physiological events in anaphylaxis

reduce hypotension, laryngeal edema, prevents release of histamine.

Most dramatic life-threatening symptoms of left HF

Decreased ability of lungs to oxygenate blood and inhibits lung expansion

Precipitating Events: Stress, infection, failure to take mediations as prescribed, meal high in sodium

Tablets become impotent if exposed to air or light

Tablet 12 weeks

Spray 2 years

Orally  25-50mg

IM 25-50 mg 

Pediatric 1mg/kg

Orally 10mg

IM 10-20mg

Pediatric 1mg/kg

Mild, non-life threathening allergic reactions 

Moderate allergic reaction with respiratory symptoms

Inhaler

Adult 2 sprays

Pediatric 1 sprays

Repeat PRN

Reduces mortality from MI

IM

Adult 1mg

Pediatric 0.5mg

Pulse 60-80 BPM

Respirations 12-20 RPM

Temp 98.6-+

BP 120/80

# of breaths/minute

rise and fall of chest

40-50 RPM

Quicker than adult

Often seen in syncope

slow rate <12

Measure of heat associated with metabolism of body.

Normal 98.6 -+

Prehypertension

Arrhythmia

Obstructive

Seizures

Orthostatic Hypotension

Situational Occurences

Hyperventilation

Metabolic Disease

Noxious Stimuli

Activation of Sympathic Nervous System

Remove objects from oral cavity

Supine with feet elevated

Open Airwar

Assess circulation

Loosen tight clothing

Monitor vital

EMS
Bradycardia administer 0.6mg Atropine IM

Longer patient in syncope more likley seizure will occur 

Most commom form;

caused by inadequate venous return

MI

Cardiac arrhythmias

Cardiac dysfunction

Results from indirect heart pump failure

leads to decreased cardiac funstion and reduced circulation

Arterial stenosis

pulmonary embolism

cardiac tamponade

Distributive (Vasogenic) Shock

3 types: Anaphylaxis,

Septic, Neurogenic

 Loss of sympathetic nerve activity from brain’s vasomotor center due to an emotional trauma, disease, drug, or traumatic injury to brain or spinal cord. Loss of sympathetic nerve activity causes peripheral dilation leading to reduction in venous return, thus causing decreased cardiac output with hypotension

Normal 10-16RPM

Rarely exceeds 22RPM

 This minor change can have significant physiological effects

 Genetic tendency

Seizure caused by systemic distress/isolated non-recurrent attacks caused by

 Beginning of abnormal changes in focal area of brain

Generalized Tonic-Clonic Seizures (GTCS)

Aura Phase

Psychic, sensory, olfactory, visual, auditory, gustatory

Generalized Tonic-Clonic Seizures (GTCS)

Pre-Ictal Phase

Generalized Tonic-Clonic Seizures (GTCS)

Ictal Phase- Tonic

Muscle have substained contraction-patient appears rigid. Produces loud cry-epileptic cry or crowing.

Dyspnea and cyanosis due to contraction of respiratory muscles

Generalized Tonic-Clonic Seizures (GTCS)

Ictal Phase- Clonic

Muscular contractions and relaxation-rhythmis, jerky movements (convulsions). Heavy Breathing clenched jaw, froth at mouth, blood from biting tongue.

2-5 minutes gradually slow with final flexor jerk

Generalized Tonic-Clonic Seizures (GTCS)

Post- Ictal Phase

Movement stopped, patient remains unconscious. CNS, CVS, and respiratory systems depression. CNS and respiratory may lead to airway obstruction-time when death occur.

Muscle relaxation-urinary and fecal incontinence. Pt awakens-confused, fatigued, and wanting to sleep, amnesia-lasts for several hours

 Most common in children, Genetic tendency

 Rare after age 20

Not usually true seizure

 Risk of developing other seizure disorders later in life

 Place in supine position

 Do not place anything in patient’s mouth

AKA Brain Attack

An Abnormal condition of the brain characterized by occlusion or hemorrhage of blood vessel resulting in lock of oxygen (Ischemia) and leads to cell death

 Factors:  hypertension, anticoagulation, tumor, substance abuse, aneurysm (weakening in blood vessel wall – with added pressure ruptures)

 Vision changes – loss of half the visual field

 Altered level of consciousness – yawning to coma

 Aspirin for intracranial hemorrhage CVA patients also improved outcomes – however not recommended

predictable, reproducable discomfort often brought on by exercise or stress due to narrowing of arteries. Stable angina responds to nitro or rest. Pain left side of chest that lasts 1-15 mins. Stable if no changes in frequence or duration for 60 days.

angina at rest, does not respond to rest, does not respond to usual medications. If plaque ruptures or forms a clot then can be a sudden restriction in blood flow.  If blood flow doesn’t improve goes into a heart attack. Causes: coronary plaque that have undergone repeated phases of destruction and repair, resulting in a reduction in supply of oxygen to myocardium. Receive minimal or emergency dental care only after physician clearance, or in hospital setting.  NO EPI.

caused by spasm in coronary artery whereby the artery narrows causing restricted blood flow and chest pain. If have a known hx no epi. 

 Increased pulse and BP

 Nitro contraindicated in patients that have used drugs to treat ED past 24 hours

 May form rapidly or over a period of time

 MI can lead to cardiac arrest

 Diabetes dramatically increases risk of cardiovascular problems (CHD, angina, MI, atherosclerosis) 

 Women show different symptoms:  atypical discomfort, upper abdominal pain, shortness of breath, fatigue

 If no history of angina, contact EMS immediately

 Monitor vital signs and Assess ABC’s

 If pain diminishes and then returns, most likely AMI

 Manage pain – nitrous oxide if available

 If cardiac arrest occurs, perform CPR with AED

 Weakness, fatigue, pitting edema, anorexia, headaches, abdominal edema

 Often require supplemental oxygen via nasal cannula (if ASA II or IV)

 Loud coarse lung sounds

 ABC’sMonitor vital signs every 5 minutes

 Nitroglycerine 2-3 tablets or sprays every 5  minutes

 If consciousness lost, place in supine position and administer CPR

 Lifespan – 7-10 years

 Monitors heart rate and provide pacing impulses when necessary

Implantable 
Cardiac Defibrillator

Classic:  weakness, dizziness, syncope

Dyspnea, Moist, pale skin,Weakness, Bradycardia or tachycardia, Chest pain, Swelling of extremities, Prolonged hiccoughing, Muscular twitching, Altered mental status

 Greater risk with electromagnetic interference

 —Vasoconstrictors in local anesthetics, use with caution

Most common: 50% of all asthmatics. Inherited allergic predisposition

Triggers from outside of body

 Dental office:  eugenol, impression materials, resins, latex

Second major category: Develops in adults > 35

Triggered by psychological and physiological stress – dental appointments

Caused by NSAIDS

Metabisulfite

Viral infections of respiratory tract most common cause. Frequently seen in children and Treatment of infection reduces symptoms

acute onset, short duration if trigger remove

 10% cause impaction, abscesses, or perforation of GI tract

 More severe form = anaphylaxis

 Tachycardia/arrhythmias/reduced cardiac contractility

 —Place patient in supine position and observe for worsening symptoms

 Symptoms worsening or allergic response begins with severe symptoms:Dyspnea, hypotension, laryngeal edema. 

Contact EMS. Administer epinephrine IM .3 ml 1:1000 in deltoid or quadricep muscle – massage injection site

Leading cause of blindness age 20 – 74. Mild form – increased vascular permeability. Moderate form – vascular closure. Severe form – growth of new blood vessels on retina and posterior surface of vitreous.

Microangiopathic changes where basement membrane of capillaries thicken and cause thrombi leading to impairment of blood flow

Damages small blood vessels in kidneys. Impairs ability to filter impurities from blood. Require transplant or dialysis to cleanse blood. Once occurs 100% morbidity within 10 years

Increased incidence of:

 Candidiasis

 Adjustment in medication needed or referral to MD

Usually some type of insulin. Different types based on time of onset, peak effectiveness, effective duration   and maximal duration (Humalog, Novolog). Need to be refrigerated to lengthen effectiveness

Medication based on cause and severity of condition

 —Glyburide (Micronase, DiaBeta, Glynase)

 30% of diabetics