Medical Emergencies in Dental Practice James G. Green, M.D., D.D.S., F.A.C.D. Dept. of Oral and...

Medical Emergencies in Dental Practice

James G. Green, M.D., D.D.S., F.A.C.D.

Dept. of Oral and Maxillofacial Surgery

University of Florida

College of Dentistry

Medical Emergencies

When you prepare for emergencies, they cease to exist!

Malamed

Medical Emergencies

You have to have seen it to recognize it.

Green’s Rule

Medical Emergencies

In case of an office emergency, the first procedure is to take your own pulse.

House of God Rule #3(modified)

Medical Emergencies in the Dental Office

Hyperventilation 29%

Seizures 20%

Hypoglycemia 14%

Vasodepressor syncope 11%

Postural hypotension 7%

Asthma 7%

Angina 5%

Allergy 5%

Medical Emergencies

Office preparation– Emergency procedure manual

• Define each individual’s responsibilities• Standardize equipment and train employees

on location, set-up, function and use• Establish a regular maintenance schedule

and equipment checks

Medical Emergencies

Office preparation– Practice emergency procedures

• Identify problems• Demonstrates capabilities• Set-up and use of equipment• Improve performance• Determine additional needs

Medical Emergencies

Office preparation– Post emergency numbers on or around

each telephone

Medical Emergencies

Office preparation – Determine equipment needs

• Dependent upon:– Training– Skills– Patient base– Practice type– Types of emergencies frequently seen

Medical Emergencies

Emergency protocols– Develop treatment protocols for each

common dental office emergency– Post where easily retrieved– Write in simple and easily followed step-

by-step instructions

Airway Management

It is essential that every practitioner be able to:

1. Maintain an airway

2. Manage an upper airway obstruction

Main purpose is to estimate the risk or probability of a patient having an emergency during treatment

Physical Evaluation

Airway Evaluation

Body habitus– Size of Neck

• Short, muscular neck– Height and weight

Status of dentition– Full dentition vs. edentulous– Protruding central incisors

Retrognathia

Airway Evaluation

High arched palate with long narrow mouth

Trismus or TMJ disease

Cervical mobility

Distance from chin to thyroid cartilage

Mallampati Airway Classification

Airway Angles

Airway Obstruction

Most common cause – Tongue

• Treat by jaw thrust or chin lift - head tilt maneuver

Tongue Obstruction

Head Tilt - Open Airway

Airway Obstruction

Other causes– Foreign bodies

• Treat by retrieving foreign body– Finger sweep– Heimlich maneuver– Chest thrust

Darwin Award Nominee - 1998

Phillipsburg, NJ

An unidentified 29 year old man choked to death on a sequined pastie he orally removed from an exotic dancer. The dancer referred to only as “Ginger” said, “She didn’t know he was going to eat it.”

Airway Obstruction

Other causes– Laryngospasm

• Suction hypopharynx• Positive pressure ventilation• Succinylcholine (if experienced)• Cricothyroidotomy (if experienced)

Airway Obstruction

If unable to clear obstruction by standard measures within 4-5 minutes:– Emergent cricothyroidotomy

Neck - Topographical Anatomy

Anterior Neck Anatomy

Cricothyroid Membrane

Airway Adjuncts

Oropharyngeal airways

Nasopharyngeal airways

Mask-to-mouth airway

Bag valve mask with reservoir

Airway Adjuncts

Nasopharyngeal airways

Airway Management

Nasopharyngeal airways– Length - nose to tragus of ear– Size - little finger (guide)– Insertion

• Lubrication• Insertion• Position

Surgilube

Nasopharyngeal Airway

Airway Adjuncts

Oropharyngeal airways

Airway Management

Oropharyngeal airways– Unconscious patients only!!– Correct size

• Age

– Insertion– Position

Oropharyngeal Airway

Mouth-to-Mask Airway

Bag Valve Mask

Bag Valve Mask Reservoir

Bag Valve Mask

Airway Management

Ambu bag– Experience – Practice– Volume– How many dentists does it take to use

an Ambu bag?

Airway Adjuncts

Oxygen– All patients with medical

emergencies need oxygen• No distress – 2 L/m via nasal cannula• Mild distress – 5-6 L/m via face mask• Moderate to severe distress – 10 L/m via

face mask with reservoir• Unconscious – 100% via intubation

Oxygen

Oxygen Masks

Nasal cannula– 1-6 L/m 24-44% oxygen

Face mask– 8-10 L/m 40-60% oxygen

Face mask with reservoir– 10 L/m ~100% oxygen

Venturi mask– 24, 28, 35, 40% oxygen

Airway Management

Nasal cannula– Readily accepted

Mask with reservoir

–Poorer acceptance

Mask-to-mouth device–Separate provider from patient–Oxygen inlet valve–Clear mask–Seal

Airway Adjunct

Paper bag

Airway Adjuncts

Yankauer Suction

Resuscitation

ABCs– Airway– Breathing

• Assess for airway obstruction• Assess for respiratory arrest

– Circulation• Assess for cardiac arrest

Resuscitation

CPR– BLS designed to maintain circulation of

oxygenated blood to the heart and brain until definitive medical treatment can restore normal or sufficient heart and

ventilatory function– Rapid EMS response with early ACLS required

for best chances of survival

Resuscitation

Most cardiac arrest victims have ventricular fibrillation– Supports early use of automated external

defibrillators (AEDs) or manual defibrillators

Resuscitation

Ventricular fibrillation– Only treatment is defibrillation– 90% of patients with V-fib survive

neurologically intact if treated with defibrillation within 1-2 minutes

– Success of resuscitation decreases linearly with each minute (50% - 4-5 minutes, <10% - 9 minutes)

– Converts to asystole in minutes

Resuscitation

Survival of other cardiac arrest rhythms poor (~ 85 % die)

Case Scenario

An 14 year old female presents for routine restorative dentistry. She has never had a cavity diagnosed until today. She is in your office and will need two simple Class I restorations.

Case Scenario

Past Medical History– Medications: None

– Allergies: None

– PSH: None

– ROS: Noncontributory

Case Scenario

Prior to the injections you note she is sighing frequently.

During the injections, she yells that it hurts and starts crying. She becomes panicky and inconsolable.

Two minutes later she starts complaining of midsternal chest pain.

Case Scenario

What is your diagnosis?

Case Scenario

Five minutes after the injections, she becomes unconscious.

Hyperventilation

Causes of Hyperventilation

Anxiety– Most common

Metabolic conditions– Pain– Metabolic acidosis– Drug intoxication– Hypercapnia– CNS disorders

Predisposing Factors

Anxiety– Most common

Age– 15 - 40 years of age– No sex difference

May develop with other medical conditions

Case Scenario

What is the pathophysiology of this “minor” emergency?

Pathophysiology

Increased respiratory rate causes:– Acute decrease in PaCO2 and rise in blood pH

• Cerebral vessels constrict Unconscious• Decreased PaCO2 depresses Apnea respiratory

drive

– When PaCO2 rises and pH decreases, the patient will begin breathing again

• May repeat cycle

Case Scenario

What other physical signs and symptoms assist in making the diagnosis?

Hyperventilation

Signs– Tachypnea– Tachycardia– Unconsciousness

Symptoms– Dizziness– Lightheadedness– Chest pain– Palpitations– Numbness

• Lips, extremities

– SOB– Nausea / Pain

Case Scenario

How do you treat it?

Management

Terminate procedure

Position patient

Calm patient

Rebreathing bag

Sedation

Case Scenario

A 25 year old male construction worker presents for removal of his third molars. He has 4 erupted thirds which you feel you can remove without difficulty or sedation. He has come from a job site. The outside temperature today was 103 F. He passed up his usual beers after work with his buddies.

Case Scenario

PMH:– Meds: None– Allergies: None– Illnesses: None– PSH: ORIF of left femur fracture from a

motorcycle accident– ROS: Noncontributory

Case Scenario

During administration of local anesthesia, he becomes jittery, pale and diaphoretic. He appears anxious and disoriented.

Case Scenario

What is your differential diagnosis?– Be specific!

What would you do first?

What is your treatment?

Case Scenario

Vital signs– BP - 80/40– P – 80 regular– R – 14

Case Scenario

After your treatment, he recovers sufficiently to allow you to do the extractions. The case goes well and after the procedure, the assistant sits him up and he again becomes faint and dizzy. A half hour later, you need to go home. You put him in a wheelchair and your assistant takes him to his car.

Case Scenario

His girlfriend who met him at your office will drive him home. When he stands up to get into the car, he passes out.

Case Scenario

What is your differential diagnosis?– Be specific!

How does treatment for this differ from your previous treatment?

How can you differentiate clinically between these two types?

Syncope

Syncope

Syncope and death are the same – except that in one you wake up.

Anonymous

Syncope

The sudden transient loss of consciousness– Usually < 1 minute

Syncope

Incidence– Presyncope - Universal– Syncope - 50%

Syncope accounts for ~ 3% of all ER visits and may account for up to 6% of hospital admissions

Syncope

Definitive diagnosis of syncope is made in only about 50% of case.

ER physicians can make a definitive diagnosis in only ~ 25% of cases

25% of all patients referred to cardiologist for cardiac work-up have syncope and not cardiac disease

Pathophysiology of Syncope

Lack of oxygen and blood to the brain– Nonspecific with multiple causes

Lack of glucose to the brain

Seizure activity

Causes of Syncope

Cardiac

Peripheral vascular

Cerebrovascular

Hyperventilation

Hypoglycemia

Seizures

Seizures and Syncope

Difficulty is determining whether the seizure caused the faint or the faint caused the seizure– Generalized clonic jerks result from cerebral

anoxia– Can’t rely on tongue-biting and urination

Seizures and Syncope

– Evaluate by history• Abrupt loss of consciousness with simultaneous

tonic-clonic seizure activity with a slow recovery phase

– Suggests seizure

• Syncope – rapid recovery

Cardiac Events and Seizures

Most remediable cause of seizures

Most lethal cause of seizures

3 broad catagories:– Rhythm disturbances– Ventricular outflow obstruction– Myocardial ischemia

Arrhythmias and Syncope

Often difficult to prove

Usually requires a heart rate of >150 or <40 beats per minute

Ventricular Outflow and Syncope

Aortic stenosis– Prevalvular– Postvalvular

Mitral stenosis

Tumors (rare)

Vasovagal Syncope

Most commonly observed potentially life-threatening emergency seen in the dental office

Vasovagal Syncope

Synonyms– Simple faint– Swoon– Vasodepressor syncope– Psychogenic syncope– Neurogenic syncope

Precipitating Factors

Psychogenic– Fright– Anxiety– Emotional stress– Pain– Site of Blood

Precipitating Factors

Nonpsychogenic – Prolonged sitting or standing– Hunger – Exhaustion– Poor physical condition– Hot humid crowded environment

Early Signs

Feeling of warmthLoss of color (pale)SweatingNauseaFaintTachycardiaNormal BP

Late Signs

YawningColdDizzinessRapid breathing Pupillary dilationHypotensionBradycardiaLoss of consciousness

Stages

Presyncope

Syncope

Postsyncope

Presyncopal Management

Terminate treatment

Protect patient from falling

Trendelenberg position

Oxygen if necessary

Syncopal Management

Trendelenberg position

Protect the airway

Monitor vital signs

Oxygen

Postsyncopal Management

Discontinue treatment

Determine cause of event– Treat appropriately

Arrange for patient to be taken home by relative or friend when stable or to hospital

Recurrent Syncope

Look for other causes– Orthostatic – Seizures– Cardiac– TIA– Hypoglycemia– Hyperventilation

May need hospitalization

Case Scenario

A 55 year old female presents for

dental implants with IV sedation.

Case Scenario

PMH:– Medications: None– Allergies: None– Illnesses: None– PSH: None

Case Scenario

An IV is started and she is given Versed and Fentanyl initially. She receives 1 g of Kefsol IV as antibiotic prophylaxis and 2 minutes later complains of itchy skin, develops a diffuse patchy rash, watery eyes and a runny nose. She feels nauseated and complains of stomach cramps.

Case Scenario

What is your diagnosis?

Allergy

Allergy

Hypersensitivity state– Requires exposure to antigen– Body develops antibodies to antigen– Re-exposure to antigen elicits reaction

Allergy

Variable reactions– Dermatological (most common)– Respiratory

• Nasal / Pulmonary

– CNS– CV– Generalized anaphylaxis (rare)

Type I Reaction

IgE-mediated

Immediate response

Affects 10% population

Inherited tendency

Type I - Antigens

Drugs most commonly associated with allergic reactions– PCN – Sulfa derivatives– Narcotics– ASA– NSAIDS

Case Scenario

What are some of the common dermatological manifestations of allergic reactions?

Dermatological Reactions

– Urticaria – Wheal and flare– Pruritis– Angioedema– Conjunctivitis– Rhinitis

• Rarely life-threatening if sole reaction• May be first indication of a more

generalized reaction to follow

Case Scenario

What are the available treatments for

dermatological signs of allergic

reactions?

Treatment

Dermatological reactions– Delayed (> 1 hour)

• Benadryl 50 mg PO q 6 h for 3-4 days

– Immediate (< 1 hour)• Epinephrine 0.3 mg IM or SC• Benadryl 50 mg IM• Transfer to ER• Benadryl 50 mg PO q 6 h for 3-4 days

Case Scenario

You give the patient Benadryl 50 mg

IV and 20 minutes later she starts to

wheeze and complain of shortness of

breath. Her blood pressure is slowly

decreasing. What should you do

now?

Bronchospasm Treatment

– Terminate therapy– Position patient to comfort– Oxygen 5-6 liters/minute via cannula or

mask– Epinephrine 0.3 mg IM or SC or

Medihaler-epi q 5 minutes as required– Benadryl 50 mg po q 6 h for 3-4 days– Start an IV (if capable) and give NS– Call 911

Respiratory Reactions

Bronchospasm• Dyspnea, wheezing, flushing, cyanosis,

diaphoresis, tachycardia, anxiety, accessory muscle use

Laryngeal edema• Stridor or crowing

– May be indication of a developing generalized reaction

Laryngeal Edema Tx

– Epinephrine 0.3 mg IM or SC q 5 minutes prn

– Maintain airway– Oxygen 5-6 liters/minute by face mask– Start IV (if capable) with NS– Benadryl 50 mg IM or IV– Solucortef 100 mg IM or IV– Cricothyroidotomy (if necessary)

Case Scenario

You can’t find your emergency drug kit. The patient is now confused and uncooperative. His BP is 70/0 and his HR is 140. What should you do?

Generalized Anaphylaxis

BLS

Epinephrine 0.3 mg IM or IV q 5

minutes prn

Oxygen

Monitor VS q 5 minutes

Generalized Anaphylaxis

Usually rapid onset (5 to 30

minutes, occasionally delayed for

hours)Respiratory and cardiovascular problems predominate and occur early in the reactionDeath can occur in minutes

Local Anesthetics

Esters >>> Amides– Overall incidence very, very low– No esters available in dental cartridges

Antigenic components– Parabens - PABA, Methylparabens– Metabisulfite– Bisulfites

Local Anesthetics

Allergy History– Must try to differentiate between true

allergy, overdose, intravascular injection, vasoconstrictor reaction or idiosyncratic reaction

• Requires good dialogue history with patient

– If questionable history, refer to allergist

Penicillin

2.5 million people allergic

Allergic reaction reported in 5-10% of patients receiving penicillin

Fatal reaction in 1 per 100,000

Most frequent cause of generalized anaphylaxis in dental practice

Chest Pain

Chest Pain

Origin – Cardiac– Pulmonary– Musculoskeletal

• Neck, thorax, shoulder

– Upper abdominal viscera

Chest Pain

Classification– Recurrent

• Mild to moderate intensity

– Severe• Prolonged pain

Recurrent Chest Pain

Angina pectoris– Most important but not the most frequent cause

of recurrent chest pain– Secondary to transcient myocardial ischemia

(imbalance between oxygen supply and tissue oxygen demands)

Musculoskeletal– Responsible for the majority of recurrent chest

pain


Other causes– Anxiety states– Reflux esophagitis +/- hiatal hernia

• Associated with large meals, alcohol, highly seasoned food, chocolates, coffee

• Nocturnal and associated with recumbancy• Relieved by nitroglycerin

– Diffuse esophageal spasms• Associated with meals• Relieved by nitroglycerin

Musculoskeletal Pain

Characteristics– Neck, shoulder and thorax most common locations– Tends to occur at night– Precipitated or intensified by fatigue, posture, movement,

coughing, sneezing– Long duration of pain (often hours)– Pain dull, aching with sharp twinges– Relief characterized by rest, heat, postural exercises and

analgesics

Angina Pectoris

Causes:– Coronary artery atherosclerosis– Coronary artery spasm– Coronary artery thrombosis– Multiple other cardiac and pulmonary etiologies:

• Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection

Angina Pectoris

May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X)

Uncommon in males less than 40

Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia

Angina Pectoris

Clinical characteristics– Poorly localized pain

• Usually retrosternal but may occur anywhere from lower jaw to umbilicus

– Brief duration• 2-10 minutes

– Moderate intensity pain described as squeezing, oppressive, burning or heavy

Angina Pectoris

Clinical characteristics– Precipitated by:

• Emotional distress • Physical exertion• Heavy meals• Cold• Walking up stairs or hills

– Exacerbated by:• Recumbency

Angina Pectoris

Clinical characteristics– Excluded if:

• Pain localized with one finger• Lasts less than 30 seconds or longer than 30 minutes• Pain described as sticking, jabbing, throbbing or

constantly severe

Angina Pectoris

Types of angina pectoris– Stable

• Pain pattern repeatable for frequency, intensity, duration, provocation and response to nitroglycerin and rest

– Unstable• Pain pattern changed in one or more characteristics

(frequency, intensity, duration, provocation, response to nitroglycerin or cessation of activity)

• May occur at night or rest

Angina Pectoris

Unstable angina pectoris– Indicative of progressive coronary artery disease– Indistinguishable from MI– Requires admission to “rule out” MI

• Enzymes - CPK-MB, LDH, Troponin I and T• Serial EKGs• Clinical history

Angina Pectoris

Dialogue history– Determine:

• Angina description– Classical, atypical or equivalent angina

• Frequency• Duration of pain• Precipitating factors

– Activity level– Stressors

• Treatment– Medications

Angina Pectoris

Dialogue history– Risk factors

• Smoking• Hyperlipidemia• Obesity• Sedentary life style• Alcohol consumption• Hypertension• Diabetes mellitus

Angina Pectoris


• Sex– Male– Postmenopausal female

• Age• Genetics

– Family history• Race

– Blacks > Caucasians

Angina Pectoris

Treatment– Stop procedure– Position patient to comfort– Oxygen 2-3 L per NC or face mask – Nitroglycerin 0.4 mg SL

• Repeat q 5 minutes x 3 total doses• If no response, assume MI or unstable angina• Activate EMS and transfer to ER

Angina Pectoris

Diagnostic approach– Nitroglycerin

• Normally relieves pain in 3 minutes or less• Failure to relieve pain after 10 minutes evidence

against angina• Failure to relieve pain indicates either unstable

angina or myocardial infarction

Angina Pectoris

Function of nitroglycerin– Dilates coronary arteries to increase blood flow

and improve oxygen delivery to cardiac tissue– Platelet disaggregation

Angina Pectoris

Dental treatment– Early AM appointments– Short appointments– Consider oxygen and prophylactic nitroglycerin– Stress reduction protocols

• Good local anesthesia• Nitrous oxide• PO or IV sedation

Myocardial Infarction


Cardiac ischemia which results in myocardial necrosis


Pain more intense and longer in duration than angina pectorisPain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectorisNot relieved by SL nitroglycerin or cessation of activity

MI Signs and Symptoms

Symptoms– Pain– Nausea/Indigestion– Weakness/Fatigue– Dizziness– Palpitations– Sense of impending

doom– SOB– Lightheadedness

Signs– Restlessness– Acute distress– Vomiting– Diaphoresis– Cardiac arrhythmia– Pallor– Cyanosis– Dyspnea– Wheezing


Dialogue history– History of angina pectoris– Changes in angina pectoris– Previous MI

• When, Treatment, Outcome, Current status

– Medications– Risk factors

Management of Acute MI

Recognition

BLS– Airway– Breathing – Circulation– Activate EMS

Oxygen - 4-5 L by NC or face mask


Monitor VS

Position to comfort

Pain relief– Morphine sulfate 2-5 mg IM/IV q 5-15 minutes prn

• Controls pain and reduces anxiety

Prepare to perform CPR or provide ACLS (if properly trained)


Transfer to ER

Chest Pain

Chest Pain

Origin – Cardiac– Pulmonary– Musculoskeletal

• Neck, thorax, shoulder

– Upper abdominal viscera

Chest Pain

Classification– Recurrent

• Mild to moderate intensity

– Severe• Prolonged pain


Angina pectoris– Most important but not the most frequent cause

of recurrent chest pain– Secondary to transcient myocardial ischemia

(imbalance between oxygen supply and tissue oxygen demands)

Musculoskeletal– Responsible for the majority of recurrent chest

pain