medical emergencies in the dental officewestliberty.edu/health-sciences/files/2014/02/...medical...
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Cindy Kleiman, RDH, BS
Oral Care Consultant and Speaker
West Liberty UniversitySarah Whitaker Glass School of Dental Hygiene
April 11, 2014
Medical Emergencies
in the Dental Office:“Vital Signs” for the
Dental Professional
Many thanks to my sponsor:
P Position
A Airway
B Breathing
C Circulation
D Definitive CareDiagnosis
Drugs
Emergency Management
Non-Cardiac Arrest
H
P Position
C Circulation
A Airway
B Breathing
D Defibrillation
New CPR Guidelines 2010
Cardiac Arrest Only
H
Circulation
If conscious and responding,
assisted circulation not necessary
If unconscious:
Assess carotid pulse for max 10 seconds -deemphasized
Chest compressions if pulse not definite
P A B C D P C A B D
H
Airway
If conscious and speaking, airway is open
If unconscious:
Assess airway
Maintain airway as needed
(Head tilt – Chin lift)
P A C B D P C A B D
H
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Breathing
If conscious and speaking, breathing is adequate
If unconscious:
Assess breathing - deemphasized
Chest compressions ASAP
Ventilations as per CPR guidelines
P A C B D P C A B D
H
Definitive Treatment
Diagnosis
Drugs
Defibrillation
P A B C D P C A B D
H
Basic Emergency Kit
Injectables: Epinephrine
Histamine blocker
Non-injectables: Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)Bronchodilator
Ammonia Inhalant
Equipment: O2, BP Cuff, Barrier Mask, AED
H
Homework!
Contact me within 2 weeks with
your changes and accomplishments:
H
Chest Pain
Causes Of Chest Pain
Cardiac Related Non-Cardiac
Angina pectoris Muscle strain
Myocardial infarction Esophageal reflux
Hiatal hernia
Indigestion
Gas pain
H
Indigestion is similar to the pain of
angina or MI and should not be
ignored. Seek medical assistance if
chest pain persists for 2 minutes or
longer, if episode is the first.
H
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Angina Pectoris
A transient chest pain caused by
insufficient supply of oxygenated
blood to the heart
Often brought on by exertion or
emotion
Relieved by rest or nitroglycerin
H
Medical History Interview
How frequently do you suffer angina attacks?
How long do the attacks last?
What precipitates your attacks?
How quickly does nitroglycerin relieve your attacks?
When was your last attack?
* Phone patients day prior to treatment
requesting them to bring their nitroglycerinH
Angina Pectoris
Management
P Comfortable, usually upright
A
B
C
D Nitroglycerin
Oxygen
Usually not needed
H
Vasodilator
Nitroglycerin
Nitrostat tablets
Sublingual 0.4 mg
Nitrolingual spray
Translingual
application
0.4 mg/spray
H
Basic Emergency Kit
Injectables: Epinephrine
Histamine blocker
Non-injectables: Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)Bronchodilator
Ammonia Inhalant
Equipment: O2, BP Cuff, Barrier Mask, AED
H
Consider Myocardial Infarction
if…
No prior history of chest pain
Patient with history of angina
Pain more intense than usual
Nitroglycerin x 3 fails to alleviate pain
Nitroglycerin resolves pain… then pain returns
H
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Myocardial InfarctionSymptoms
Pain
Severe to intolerable
Crushing, choking
Radiates: L arm,
hand, shoulders,
neck, jaw
Nausea, weakness,
dizziness
Palpitations
Cold perspiration
Sense of impending
doom
Signs
Restlessness
Acute distress
Skin
Cool, pale, moist
Heart rate
Bradycardia to tachycardia
H
Women’s Signs and Symptoms
Shortness of Breath
Weakness
Unusual fatigue
Indigestion
Disturbed Sleep
50% of women have no chest pain
H
Myocardial Infarction
Management
P Comfortable
A
B
C
D Call 911
Nitrous Oxide
Oxygen
Nitroglycerin
Aspirin (4 Baby, chewed)
As Needed
H
Vasodilator
Nitroglycerin
Nitrostat tablets
Sublingual 0.4 mg
Nitrolingual spray
Translingual
application
0.4 mg/spray
H
Thrombolytic (Clot buster)
Aspirin
Tablets, 325 mg
4 Baby CHEWED
Administer if MI is
considered
Contraindicated if allergic
H
Cardiac Arrest:
Basic Life Support - CPR
P Position
C Circulation
A Airway
B Breathing
D Defibrillation
H
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Medical Alert Bracelet
Michael Holzberg
universalmedicaldata.comH H
Basic Emergency Kit
Injectables: Epinephrine
Histamine blocker
Non-injectables: Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)Bronchodilator
Ammonia Inhalant
Equipment: O2, BP Cuff, Barrier Mask, AED
H
Diabetes Mellitus
A metabolic disease that occurs as
either a deficiency or a complete
lack of insulin in the body
H
Diabetes Mellitus
Hypoglycemia
Hypoglycemia occurs when the body's blood sugar, or glucose, is abnormally low. The term insulin shock is used to describe severe hypoglycemia that may result in unconsciousness.
H
Diabetic Emergency:
Hypoglycemia
Causes
Too much insulin
Too little food
Signs and Symptoms
Shaking
Sweating
Anxiety
Palpitations
Restlessness
Mental Confusion
H
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Medical History Interview
Do you use oral medication or insulin?
How well controlled is your diabetes?
What was your last blood sugar and how long ago was it taken?
(Fasting: 80-110 normal)
What is your A1C reading?H
When did you last eat and when are you due for your next snack or meal?
Do you have a sugar source readily available; if so, could you please get it out?
Are you feeling okay at this time for treatment? (If they are unsure, ask them to please check their blood sugar before you proceed.)
What signs do you exhibit with a low blood sugar? H
Hypoglycemia Management Conscious
P Comfortable
A
B
C
D Administer “sugar”
As Needed
Glucose gel
Fruit juices (Orange preferred by many)
Hard candy
Soft drinks (non-diet)H
Hypoglycemia Management Unconscious
P Supine
A
B
C
D Call 911
Absorbable sugar (gel)―Under lips, canine to canine ?
Sugar IV by EMS
As Needed
H
Anti-hypoglycemic
Management of hypoglycemia
Orange juice
Soft drink
No contraindications
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Final Word
All insulin diabetic patients should
monitor their blood glucose levels
at the end of each dental
appointment prior to driving.
H
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Basic Emergency Kit
Injectables: Epinephrine
Histamine blocker
Non-injectables: Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)Bronchodilator
Ammonia Inhalant
Equipment: O2, BP Cuff, Barrier Mask, AED
H
The Asthma Attack
This leads to one or more of the following symptoms
Tightness in the chest
Shortness of breath
A chronic or recurring cough
Wheezing, particularly when trying to exhale
Anxiety
Constriction of the airways and formation of
thick mucus makes it progressively more
difficult to inhale and exhale
H
Medical History Interview
What brings on an attack?
How often do you get an attack and how long does it typically last?
What drugs do you use to prevent acute episodes?
What is the usual number of doses needed?
Have you ever been hospitalized for your asthma?
Do you have your inhaler with you?
When was your last attack?
*Call asthmatic patients prior to day of treatment,requesting them to bring bronchodilator H
P Upright
A
B
C
D Inhaler
Oxygen
Epinephrine if critical
Usually not needed
Asthma Attack
Management
H
Bronchodilator for Asthma
Albuterol rescue inhaler
No contraindications
H
Asthma Attack Management
Summon EMS if…
Patient requests
Episode is continuing with
2 doses of bronchodilator
(Status Asthmaticus)
H
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Basic Emergency Kit
Injectables: Epinephrine
Histamine blocker
Non-injectables: Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)Bronchodilator
Ammonia Inhalant
Equipment: O2, BP Cuff, Barrier Mask, AED
H
Syncope: Predisposing Factors
Psychogenic Factors
Fright/Anxiety
Extraction
Injections
Pain, especially of a sudden
and unexpected nature
The sight of blood or of
surgical or other dental
instruments (such as a local
anesthetic syringe)
Non-psychogenic Factors
Sitting upright or standing
Hunger
Exhaustion
Hot, humid, crowded
environment
Male sex
Age between 16 and 35 years
H
Syncope Management
P Supine, slight elevation of legs
A
B
C
D
Ammonia inhalant
Oxygen
As needed
H
Ammonia Inhalant
No contraindications
H
Recovery
May continue to be light-headed, weak, pale
May be disoriented/confused
Pulse & blood pressure should return to normal
Takes 24 hours to completely recover
Discharge in custody of responsible adult
H
Basic Emergency Kit
Injectables: Epinephrine
Histamine blocker
Non-injectables: Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)Bronchodilator
Ammonia Inhalant
Equipment: O2, BP Cuff, Barrier Mask, AED
H
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Allergy
An overreaction by the body’s
immune system to a foreign
substance
H
Allergy Facts
The faster the onset of signs and symptoms after exposure to the allergen, the more severe the reaction
Allergy involving only skin is NOT life-threatening and requires milder, less aggressive management
Allergy involving difficulty with breathing IS life-threatening, requiring immediate, aggressive management
H
Allergic Reactions
What to look for:
Sneezing, coughing, or wheezing
Shortness of breath
Tightness and swelling in the throat,
face, tongue, or chest
Itching, burning, or rash
Dizziness and weakness
Nausea and vomiting
H
Allergy ManagementDelayed Onset Skin Reaction
P Comfortable
A
B
C
D Oral histamine blocker
Continue for 2-3 days prn
Usually not needed
H
H
Anaphylaxis
A severe, and sometimes fatal, allergic
reaction characterized by respiratory distress and hypotension, leading to cardiovascular collapse
H
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Usual Progression of Anaphylaxis
Skin
Eyes, nose, GI
Respiratory System
Cardiovascular System
H
Anaphylaxis Management
P Based upon primary complaint:
“Can’t breathe” – upright
“Feel faint” – supine, feet elevated
A
B
C
As Needed
H
Anaphylaxis Management
D Call 911
Oxygen
Epinephrine
−Every 5 minutes or until EMS arrives
−Multiple doses usually required
Histamine blocker IM
H
Epinephrine
Adrenalin
Anaphylaxis
Life-threatening allergy
No contraindications
Preloaded syringe
(EpiPen)
H
Why Epinephrine?
Reverses 2 components of anaphylaxis which lead to death Bronchospasm – epinephrine is
bronchodilator
Hypotension – epinephrine is vasopressor (BP↑)
Works quickly IM top of thigh (EpiPenÜ), works in 1-2
minutes
H H
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Causes of Seizures
Epileptic patients
Stress induces seizures
Cerebral anoxia
Neonatal injury
CVA (stroke, ‘brain attack’)
Tumor
Previous head injury
Idiopathic
H
Tonic-Clonic Generalized Seizure
Is self-limiting
Lasts not more than 2 - 5 minutes
Usually does not require IV
anticonvulsant therapy
Usually does not result in injury
H
Medical History Interview
What type of seizure do you have?
How often do you have seizures?
What is your aura?
How long do your seizures last?
Did you take your medicine today?
H
Tonic-Clonic Seizure Management
H
P – SupineProtect victim:
Rescuer 1: arms – gently!
Rescuer 2: legs – gently!
A
B As needed
C
D – Call 911
Remove “pillow” or “donut” from headrest of chair
Do not put anything into the mouth
Post-Ictal Phase
ABC as needed
Patient is disoriented, sleeping
Position
Turn on side, if possible
― Aids in airway maintenance
Dental Chair
―Maintain supine, maintain airway as needed
H
Remember:
The Common Sense Approach to
preventing medical emergencies
requires preparation
Preparation creates the ability to
recognize a problem BEFORE
it becomes an emergency
H
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Medical Emergency Kits and AED
Health First
www.healthfirst.com
H
Mark Spearman - [email protected]
www.physio-control.com
Physio-Control AED
Thank you!
Cindy Kleiman, RDH, BSOral Care Consultant and Speaker
480-342-9655
www.cindyspeaking.com