Recognition and Management in Dental Practice
Daniel E. Becker, DDS
Associate Director of Education
Miami Valley Hospital
debecker@mvh [email protected]
BLS for all Personnel
Designated Responsibilities
Mock Simulations
EMS Access
Attention to Medical Evaluation Practice Stress Reduction:
• Psychological Interventions• Pharmacological Interventions
Medical HistoryPhysical
AssessmentASA Physical Class
Medications BP & Pulse Based on disease severity and limitationsAllergies SpO2 (?)
Disease by system Appearance Medical Consultation (prn)
Hospitalizations Mentation Condition(s) of Concern
Treatment Plan (including drugs and anticipated doses)
Anesthetic Experience Exercise tolerance
Preoperative Assessment“Never Treat a Stranger !”
ASA Physical Status
1 Healthy patient
2 Mild systemic disease. No significant impact on daily activity.
3 Significant or severe systemic disease. Significant impact on daily activity.
4 Severe disease that is a constant threat to life. Serious limitation of daily activity.
Activity Points
Run short distance 8Swim, singles tennis, basketball, ski 7.5Golf, bowling, dancing, doubles tennis 6Climb a flight of stairs 5.5Sexual relations 5.25Yard work: raking, weeding, mowing 4.5Moderate work: vacuuming, sweeping 3.5Personal care (dress, eat, bath, toilet) 2.75Walk 1-2 blocks (level ground) 2.75Light work: dusting, wash dishes 2.7Walk around in house 1.75
Overall Functional CapacityExcellent >7 Moderate 4-7 Poor <4
The overall functional capacity of a patient is estimated based on a point scale derived using metabolic equivalents (MET) calculated as 1 MET=3.5 mL/kg/min oxygen utilization.
Hlatky MA, Boineau RE, et. al. Am J Cardiol 1989;64:651-54.Modified by: Hollenberg SM. Chest 1999;115:51s-57s.
Duke Activity Status Index
Primary Assessment Simultaneous Assessment by Team
If Apneic: EMS + BVM Ventilation Q 6-8 sec
If Pulseless: EMS + CPR
A irway Assessment• Must assure patency
• Head tilt-chin lift / Jaw thrust
B reathing• Look, listen and feel
• Note rate and depth
• Maintain patency
Doctor’s Job !
Becker DE. Medical Emergencies 1
Oxygen Source and Regulator
Oxygen Supplementation• Nasal Cannula (4-6 L/Min):
• FIO2 = 20+(4 x L/Min)• Nonrebreathing mask (6-10 L/Min)
• FIO2 = 60+ 5 for each L/Min above 6.
If COPD, supplement to SpO2 >90
OxygenationAuxiliary’s Job !
Increased Oxygen Concentration in FRC Greater Time From Apnea to Hypoxemia
Oxygen Supplementation
Why Oxygen ?
Time to Hb Desaturation
Benumof JL, et al. Anesthesiology 1997;87:979-82
Preoxygenated (~FaO2 = 0.87)
Analysis of 7 Studies
Must Ventilate if Not Breathing• BVM with Reservoir
• Highest Flow Rate (10-15 L/Min)
• FIO2 = 75-90
Oropharyngeal Airway (?)
Ventilation
Prepare Index Card
Cannula: 4 L/Min NRB Mask: 10 L/Min BVM or Pocket Mask: Maximum L/Min
Turn on Oxygen BEFORE applying device !
If BP Difficult:
• SBP ~ 80 if Radial Pulse
• SBP ~70 if Brachial Pulse
• SBP ~ 60 if Carotid Pulse
Is Perfusion Adequate ?• Orientation x 3 (Time, Place, Person)
Assessing Circulation:BP & Pulse
Auxiliary’s Job !
Becker DE. Medical Emergencies 2
Comfort Level of Practitioner EMS Response Times Preparations
• Amps• Vials• Prefilled Syringes
Routes• IV• IM• SC• SLI
Drug TherapyEmergency Drugs
Drug Formulation Action Indication Dosage
Epinephrine1:1000
(1 mg/mL)Alpha/beta
agonistAnaphylaxis /
Asthma0.3 mg IM
Diphenhydramine 50 mg/mL Antihistaminic Minor allergy 25-50 mg IM
Atropine 1mg/mL Anticholinergic bradycardia0.5mg SLI
Q5M to 2mg
Ephedrine 50 mg/mLAlpha/beta
agonist Hypotension20-30 mg SLI Q5M to 50mg
Nitroglycerin 0.4 mg tabs Venodilator Angina/HTN1 tab SL Q5M
x 3
Aspirin 81 mg tabs Antiplatelet MI4 tabs: chew and swallow
Additional Options: Albuterol and Concentrated Glucose
How Many Do You Need?
Baggy for Each Event
Drugs and Syringes for Event
Card with Instructions that YOU Prepared & Understand!
Flowchart ?
Bulleted List ?
Complete Primary Assessment If Major Reaction: EMS
Epinephrine: Tuberculin Syringe 0.3 mg (0.3 mL) IM If Minor Reaction:
Benadryl: 3 mL Syringe 50 mg (1 mL) IM
Vasovagal Syncope
Pain
Fear / Anxiety
Cardiac Mechanoreceptors
Arterial baroreceptors
Bladder / bowel strain
Enhanced vagal discharge
Vasodilator output
“The only difference between syncope and sudden death is that in one you wake up.” Engel GL. Ann Intern Med 1978;89:403-412
A transient and abrupt loss of consciousness due to inadequate cerebral blood flow.
Vasomotor Center
(Neurocardiogenic Syncope)
SBP DBP
MAP
Rate Stroke Volume
Preload
Contractility
Afterload
Arterial Resistance
-
**
* High MVO2
‘Bainbridge’‘Frank-Starling’
Arterial Blood Pressure
Ach = ↓ Rate
Beta1 = ↑ Rate and Force
Alpha = Vasoconstriction
Beta2 = Vasodilation
Ach = Bronchoconstriction
Beta2 = Bronchodilation
1
2
Autonomic Receptors
Ach
2Ach
Parasympathetic (Ach) Sympathetic ( Alpha, Beta)
Becker DE. Medical Emergencies 3
Drugs for Hypotension Atropine
• Anticholinergic Action Blocks Vagal Slowing of Heart Rate
• 1 mg/mL SDV
Ephedrine• Mixed Action: Alpha and Beta Agonist &
Stimulates Release of Norepinephrine• 50 mg/mL SDV
If Symptomatic, Administer DrugIf Symptomatic, Administer Drug
If Hypotension, Confirm HR
If Hypotension, Confirm HR
Primary Assessment
Primary Assessment
Airway Breathing
Supplemental Oxygen
Pulse Blood Pressure
HR <60
Atropine0.5 mg SLI
Q5M x 4
HR >60
Ephedrine20-30 mg SLI
Q5M x 2
Hypotension Algorithm
Tuberculin Syringe1 mL Total
0.1 mL Increments
JNC 7 JAMA 2003; 289:2560-72
Use Highest Reading
Classifications SBP DBP
Normal < 120 < 80
Pre-hypertension 120-139 80-89
Stage 1 140-159 90-99
Stage 2 160 100
Stage 3 >180 >110
Stage 4 >210 >120
Stage 1 and 2 (Up to: SBP 180 / DBP 110)
• Generally OK to treat
Stage 3 (SBP >180 / DBP >110)
• Must consider other medical conditions
• Delay if significant diabetes, CAD or CHF
Stage 4 (Formerly SBP 210 / DBP 120)
• Immediate referralFleisher LA. JAMA 2002;287(16):2043-6
Hypertension Classifications
Hypertensive Crisis Urgency if No Symptoms
• Rarely Require Treatment• Address Possible Causes for Sudden
Elevation Emergency if Symptoms
• Headache, Paresthesia, Chest Pain• EMS Transport
“The most sensible approach to the patient in the ED found to have very high blood pressure, without evidence of acute end organ damage, is referral for outpatient management of serious disease that needs to be treated; not urgently, but for life. Focusing on the height of the column of mercury in the sphygmomanometer confers no demonstrable benefit on the patient and risks doing harm.”
Gallagher EJ. Ann Emerg Med 2003;41:530-31
Treatment Options
Treatment Options
Significant Increase in BP?
Symptomatic?
Significant Increase in BP?
Symptomatic?
Primary Assessment
Primary Assessment
Airway Breathing
Supplemental Oxygen
Pulse Blood Pressure
Asymptomatic:Urgency
Time Out!R/O Cause
Symptomatic: Emergency
EMSNTG 0.4 mg SL
Q5M x 3
Hypertensive Crisis Algorithm
Abrams, J. N Engl J Med 2005;352:2524-2533
Coronary Artery Disease
“An imbalance between myocardial oxygen supply and myocardial oxygen demand.”
Heart RateWall Tension, eg, BP
↑ Demand ↓ Supply
( Ischemic Heart Disease )
Becker DE. Medical Emergencies 4
Vulnerable Plaque
Physical Exertion
Mechanical Stress
• Contractility
• Pulse Rate
• Blood Pressure
• Vasospasm
Factors in Plaque Rupture
Yeghiazarians Y, et al. NEJM 2000; 342(2) 101-14.
Chest Pain…What’s Happening?
Coronary Stenosis
Atherosclerosis
Vasospasm
Symptoms
Angina or
(Silent)
Thrombosis
Occlusion
Myocardial Infarction
ArrestNon-Arrest Continued Angina
AV Blocks
Valve Prolapse
Pump Failure
Wall Rupture
Fibrillation
Chest Pain (Angina)
ACS
Myocardial Infarction
STEMI NSTEMI
Unstable Angina
At Rest New Onset
Stable Angina
On Exertion
Previous Occurrence
+ Serum Markers - Serum Markers
Acute Coronary Syndrome
Nitroglycerin Vasodilation (Veins > Arteries) Reduces MVO2 (preload & SBP) Chest pain / Hypertension
• 0.4 mg tabs (1 tab Q5M x 3)
Aspirin if Suspected AMI
160-300mg provides complete platelet cyclooxygenase inhibition < 1 Hr
Inhibition maintained at ~ 75 mg/day
Collins R., et al. NEJM 1997; 336(12):847-60
Angina / MI Algorithm
Current Guidelines suggest 3 doses NTG for stable but only 1 dose for unstable before alerting EMS. But how do you know?
Pollack CV, Braunwald E. Ann Emerg Med 2008;51:591-606
Chest Pain Persists
Chest Pain Persists
Primary Assessment
Airway Breathing
Supplemental Oxygen
Pulse Blood Pressure
If Provoked:Nitroglycerin
1 Tab SL
EMSNTG Q5M; SBP >90
ASA 300 mg
If Unprovoked, New Onset, or Unsure: EMS
Cardiac Arrest
Various ECG Patterns• V. Tach and V. Fib Most Common
• Asystole/PEA Worst Prognosis
CPR and Defibrillation are Key!• 30:2 Ratio for one and two-person
• 15:2 for HCP 2-Person child
Epinephrine Improves Coronary Perfusion, but must be administered IV
Becker DE. Medical Emergencies 5
When in cardiac cycle and WHY?
What drives perfusion ?
CoronaryPerfusion
BLS Sequence
ACLS Sequence Stroke Pathogenesis
Sensory DeficitVisual
Paresthesia
Motor DeficitAphasia
Dysarthria
Ischemic / HemorrhagicInsult
Ischemic Stroke - (~80%)• Thrombosis vs Embolism• TIA vs CVA• Ischemic Penumbra
Hemorrhagic Stroke – (~20%) • Often Fatal• Leads to Compression
If Positive, Suspect Stroke
If Positive, Suspect Stroke
Aphasia, Paresthesia, Paralysis ?
Aphasia, Paresthesia, Paralysis ?
Primary Assessment
Primary Assessment
Airway Breathing
Supplemental Oxygen
Pulse Blood Pressure
Stroke Scale:
Raise Both Arms
Smile, Speak
EMSConsider Glucose
Do Not Tx. Hypertension
Stroke Algorithm Allergic Reactions
Autacoid ReleaseAutacoid Release
CutaneousCutaneous
Urticaria, Rash, PruritusUrticaria, Rash, Pruritus
SystemicSystemic
Laryngeal Edema, Bronchospasm,
Hypotension
Laryngeal Edema, Bronchospasm,
Hypotension
PG’s & LeukotrienesHistamine
IgE
Allergy
Non-IgE
Pseudo-Allergy
[Histamine, PGs, LTEs]
Minor vs
Major Mast Cells Basophils
Becker DE. Medical Emergencies 6
Epinephrine
AlphaHypotension
Laryngeal Edema
Beta-1Hypotension
Beta-2Bronchospasm
Concentration Dose / Volume Route
1:1000 (1 mg/mL) 0.3 mg/0.3 mL IM
1:10,000 (0.1mg/mL) 0.1 mg / 1 mL IV
Antagonist at H1 receptors counters histamine
Pruritus, urticaria, nausea• 50 mg/mL amp or SDV
• 50 mg IM
Diphenhydramine
TreatmentTreatment
Allergy Symptoms
Allergy Symptoms
Primary Assessment
Primary Assessment
Airway Breathing
Supplemental Oxygen
Pulse Blood Pressure
CutaneousPruritus, Rash, Hives
Benadryl50 mg PO, IM
AirwaySwelling: mouth or throat / Wheezing
EMSEpinephrine
0.3 mg IM
Allergic Reaction Algorithm
Additional Agents
Albuterol (and Spacer ?)
Glucocorticoids• Influence delayed 6-12 hours
Aminophylline• Questionable efficacy; complex
administration
IV Fluids• Definite efficacy if hypotension Primary
Genetic, UnknownSecondaryTumor, Trauma
ReactiveStress, Fever,
Drugs
Focal CorticalDischarge
ConvulsiveAbsence
Seizure Pathogenesis
Status Epilepticus Definition based on duration until
injury to CNS neurons• Uninterrupted for 20-30 minutes
• Repeated without full recovery
Operational Definition• Continuous for 5 minutes
• Two or more seizures without complete recovery
Lowenstein, Alldredge. NEJM 1998;338:970-76
Airway Considerations• Despite periods of apnea and cyanosis,
most patients breath adequately provided airway maintained
• Administer supplemental oxygen
Protect Patient
< 5 minutes
Primary Assessment
> 5 minutes
EMSRebreathing MaskMidazolam (Versed)
IM/Intranasal
Seizure Algorithm
Age Dose
1-4 YO 2.5 mg/ 0.5 mL
5-10 YO 5 mg / 1 mL
>10 YO 10 mg / 2 mL
Intranasal: ½ volume in each nostril (~ dose based on 0.2 mg/kg)
Holsti, M, et al. Pediatr Emerg Care. 2007 Mar; 23(3)148-53.
MucosalAtomizationDevice
Becker DE. Medical Emergencies 7
Emergency Drugs
Drug Cost
Epinephrine 1:1000 (1 mg/mL) 1mL SDV $1.99
Diphenhydramine 50 mg/mL 1mL SDV $1.99
Ephedrine 50 mg/mL 1mL SDV $6.99
Atropine 1.0 mg/mL 1mL SDV $1.99
Glucose GEL 37.5 Gm (3/PACK) $15.99
Nitroglycerin 0.4 mg Tab (25/BTL) $13.99
Albuterol 60-Dose Inhaler $26.00
Medical Purchasing SolutionsPhone: 602-476-1595www.medicalpurchasingsolutions.com
Emergency Supplies
Sedation ResourcePhone: 800 753 6376
www.sedationresource.com
Order # Item Cost
10-002-03 O2 Regulator 69.95
1-001-04 / -05 BVM adult/Pedo 29.95 / 34.95
10-000-50 Nasal Cannulas 32.50 (50/case)
10-102-02 NRB 3.49
1-101-6 Oral Airways 7.50 (5/set)
6-301-01 1 mL TB Syringes (25G x 5/8”) 9.95 (100/box)
6-403-22 3 mL 22G x 1 ½” 11.50 (100/box)
6-199-00 Nasal Atomizer/3 mL syringe 3.79
Also Available: Monitors, AEDs, Manual BP Devices
Becker DE. Medical Emergencies 8