Mel Hawkins Medical Emergencies in the Dental Office, Medical … · 2019. 4. 26. · C.V.A. 68 Emergencies Martin & Ellis JADA 112:499 -501, Malamed JADA 124:4-53 >30,000 events

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Medical Emergencies in the Dental Office, Medical Emergencies in LIFE!

Mel Hawkins, DDS, BScD AN, FADSA, DADBA

DISCLOSURE

Mel Hawkins

has no relevant financial relationship with any company or organization to disclose with respect to this continuing dental education program

The Ontario Dental Association’s

152nd Annual Spring Meeting

May 10th, 2019

Almost Always Almost Never

Reality of Dental Emergencies“With Great Power comes

Great Responsibility”

How can we as health

professionals, who are

supposed to have higher

skills, be expected to treat an

emergency situation in the

office or in life when they

NEVER (well, almost never)

occur?

What today is NOT:

A myriad of different emergency

situations involving as many

different medical scenarios which

you and I may never have heard of

let alone memorized, which drug

to use, where to give it, IV? IM? IL?

dose in mg., how often must you

repeat it? side effects? Then,

which drugs can combat the side

effects? etc…etc…

Are we facing an . . . .

INCONVENIENCE?

URGENCY?

EMERGENCY?

RARITY?

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Inconveniences

Syncope 15,407

Mild Allergy 2,583

Postural Hypotension 2,475

Bronchospasm (asthma) 1,392

Hyperventilation 1,326

Epinephrine Reaction 913

“Emergency” n=30,608

Martin & Ellis JADA 112:499-501, Malamed JADA 124:4-53 >30,000 events

Syncope 15,407


Syncope 15,407


Syncope 15,407


Urgencies

Syncope 15,407

Angina 2,552

Seizure 1,595


Epinephrine Reaction 913

Insulin Shock (conscious) 890



Syncope 15,407

Angina 2,552

Seizure 1,595


Myocardial Infarction 289

Local Anaesthetic Overdose 204


C.V.A. 68

Emergencies


Rarity (“Non” Events)

Acute Pulmonary Edema 141

Diabetic Coma 105

Adrenal Insufficiency 25

Thyroid Storm 4

Martin & Ellis JADA 112:499-501, 1986, Malamed S JADA 124:4-53, 1993



“What’s Really Important?”

Syncope 15,407

Angina 2,552

Myocardial Infarction 289

Cardiac Arrest ???

Asthma, Severe Allergy

Bronchospasm1,392


SUMMARY:

Sycope occurs more times than all the other conditions

COMBINED i.e. > 50%

CONCLUSION:

If you can treat syncope by Position, A. B. C.’s and O2 +

sugar, then you can treat over 50 % of

unconscious victims or patients AND...

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FURTHERMORE:

By knowing this syncope protocol a health

professional or member of the public or both can

initiate treatment of the other 50 % of

emergencies

WITHOUT MAKING or NEEDING A DIAGNOSIS

Supportive care and CPR or BLS fundamentals

including (rarely) chest compressions will maintain

life until consciousness returns or EMS arrives.

Everything Else Has Time!

Diabetic Coma/Insulin Shock Sugar

Epilepsy/Seizure/ConvulsionsAirway

Protect

Hyperventilation - O2 Sat? 100%

Mild Allergy Itchiness/Rash Wait

Local Anaesthetic/Epinephrine Blockers

2

Protocols,

Age/Risk

Pharmaco-

dynamics

Defib,

Drugs

and

Diagnosis

WHAT TODAY IS:

Airway +

a few good

adjuncts,

Oxygen,

Vasocon-

strictors

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▪ Protocols,

▪ Age/Risk

▪ Pharmacodynamics

1

Emergency Protocol

IT DEPENDS on:

• What,

• When, and

• Where the problem is!

Is 911 a false sense of security?

Emergency Protocols

911 is a solution.YES

What to do in the

meantime???Problem

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Communication

• Front Desk

• Office Manager

“What is your Emergency?”

The 3 U’s

Unconscious

Unresponsive

Unable to find

a pulse

RESPONSIBILITIES

Attending person 911“I HAVE AN UNRESPONSIVE CHILD

WITHOUT A PULSE”.

123 Home Street.

Hawkins residence.

Front door.

“I will meet you there”

RESPONSIBILITIES

Front Desk 911“WE HAVE A PATIENT IN CARDIAC ARREST

WITH CPR IN PROGRESS”

91 Rylander Blvd.

Dr. Hawkins office.

Front parking lot.

“I will meet you there”

All the staff must know the location of:

• Portable oxygen with masks/cannulas

• Bag-Valve-Mask with airways

• Automatic External Defibrillator

• Emergency drug kit

• Portable suction

• Emergency lighting source

Staff Training

• Current BLS training

• Task designation: 2 groups,

action + support

• Mock simulations:

shorter time (15 min.)

higher frequency (2 mo.)

repetition, repetition, repetition

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Staff Training

Recommendation:

Can you discover, privately,

without embarrassment who is

and who may not be prepared

for an assigned duty before

an event, not during.

Every 2 Months:Syncope

for 15 Minutes:Syncope

Mock Simulations 2019

Syncope Algorithm

Position, ABC’s

Time, Time, Time

Always!

O2 by nasal

cannula

4 litres/minute

+ Glucose

Syncope Algorithm

But the Nasal Cannula

is an open and therefore a dilutable

system

So how much

enriched % oxygen

can actually be

administered?

Syncope Algorithm

Room air has ~ 21 % oxygen

The percentage O2 approximates:

20 + 4 X litre flow of O2 = % oxygen received

3 litres/min = 32 %

4 litres/min = 36 %

5 litres/min = 40 %

6 litres/min = 44 %

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Medical Consultation

B-r-r-r-ing

B-r-r-r-ing

B-r-r-r-ing

B-r-r-r-ing

MUST HAVE A GAME PLAN!

1. Dental treatment risk/benefit

2. Contemplated medications in

mg. or g.

MD scrawling: BP is 240/120

but “OK for dental treatment”

is NOT a mandate!

RESPONSIBILITY? OURS!

EMERGENCY KITS

Acme Dental / Medical Kit

Ready

made?

Self

assembled?

IN OLD

DAYS:

nice

suitcase

and color

coded

micro-

print

SENIOR CITIZEN

“AVER-AGE” PATIENT

PEDIATRIC

CONSIDERATIONS

Pharmacodynamics: Age/RiskPhysical Classifications - ASA

ASA I – normal, healthy

ASA II – mild systemic disease

ASA III – severe multiple systems, medication

ASA IV – severe disease, threat to life

ASA V – won’t survive without operation

ASA VI – brain dead, alive organ transplant

E – operation modification e.g. ASA III-E

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The Senior Citizen

Although inaccurate, a “senior” in our society is usually < or = 65 years old

A “bad day” will usually happen because of an attack of a pre-existing condition

Senior’s Considerations

• Physiology

• Age of 65 is arbitrary.

How often do we see a 65 year old

who looks 50 and vice versa?

Hepatic metabolism and renal

clearance can be reduced by 50%

in patients over the age of 65.Becker DE Mod Curric Moder Sed, Miami Valley Hosp. Dayton OH


Fear Factors:• Loss of independence

• Institutionalization and isolation

• Disability

• Death


•C.N.S:

• Loss of Neurons

•C.V.S:

• Systolic B.P. with age

• Rate due to parasympathetic

activity


• Pulmonary:

• Loss of alveolar septa

• elasticity of lungs

• Impact of smoking


COMMUNICATION

DIFFICULTIES

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The “Aver-age” Patient

ASA I or II are generally very

safe sedation patients.

ASA III is a judgment call.

A “heart” patient is safer with

sedation than without it.

A “bad day” will usually

happen because of lack of

attention to the rules - doses,

lack of good L.A. or “point of

no return” feelings.

Why does

Morbidity –

Mortality

“target”

CHILDREN?

Although inaccurate, a

“child” in our society

is usually defined as

≤ 12 years old.

A “bad day” will

usually happen

because of lack of

respect of their

airway...

Children

Pediatric Considerations

High

MYOCARDIAL

O2 Consumption

High BRAIN

O2 Consumption

The 2 MOST

IMPORTANT

Physiological

Considerations in

PEDIATRIC

RESCUE are:

C.V.S / C.N.S:


C.N.S:

The CPR / BLS guideline of:

“3 – 6 minutes until permanent brain

damage begins” is for the adult

without an O2 debt and does NOT

apply in pediatric life.”

IT’S MORE IN THE ORDER OF

1 MINUTE!

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Drug (local anaesthetic) impact:

• Unpredictable

• Blood Brain Barrier is immature

• Metabolism due to immature liver


COMMUNICATION

DIFFICULTIES

??

??

?

?Questions

▪ Airway,

▪ A Few Good Adjuncts,

▪ Oxygen and

▪ Vasoconstrictors

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MANAGEMENT OF AIRWAY

Actions & Armamentarium

•

Airway Obstructions:The ConsciousVictim

Airway

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I like to put EVERYTHING in my mouth…my toes…your toes,

everything!

Airway

• Know Each Patient’s Airway

• Always Maintain Patency

• Head Position

• Clear Debris

• Use Throat Partitions

• Use Rubber Dam When Possible

It would be ideal to be able

to use emergency

armamentaria in day-to-day

dentistry too, for cost

efficiency, familiarity and for

practice!

Equipment Management Adjuncts

Airway -“Mouth Rester”… not a prop

Disposable Laryngoscope

“A tongue depressor

with a light on it”

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Magill Forceps

Serated, circular tips,

double lumen

➔

Disposable “long saliva ejector”

…with a screen tip that

doesn’t

come off

•

Airway Obstructions:The UnconsciousVictim

AirwayOral Pharyngeal Airway

Size? Angle of Mandible to Corner of Mouth

Airway closed Airway open

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Old and New Ideas

CRICOTHYROTOMY

CRICOTHYROTOMY What is it?

A mechanical opening of the airway at the

1st tracheal ring – the cricothyroid membrane

Done below a blockage of the plugged

(food) OR constricted laryngeal vocal cords

(laryngospasm) due to an irritant, resulting

in little or no air exchange to the lungs

Accompanied by panic, inability to speak

and strained, contracted accessory neck

muscles

Follows multiple, unsuccessful Heimlich

manoevers

CRICOTHYROTOMY Where is it?

At the 1st tracheal ring – the cricothyroid

membrane

Done below the Adam’s Apple, just above the

1st tracheal cartilage)

If respiratory effort is still present, an ingress of

air will follow

This allows time to try to physically remove the

obstruction

If not, a bag to tracheal tube or opening(?) must

somehow do AR part of CPR.

CricothyroidMembrane Puncture

for Tracheal Access

CRICOTHYROTOMY Obstructions?

Seaweed

Food bolus

Laryngospasm with coughing

air is being exchanged – leave them alone

Laryngospasm without air exchange ( cannot

cough).

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CRICOTHYROTOMY Actions?

Trocar needle within a 13 ga. Or 10 ga. Metal

tube inserted inward and downward

Horizontal scalpel incision. Reverse blunt end

inserted at 90 degrees

Broken Bic® pen

Fishing knife

If not available, a “mouth to opening” must

somehow do the AR portion of BLS/CPR.

Cricothyrotomy

What you really need to

know about old and new

ideas of cricothyrotomy

is…

MANAGEMENT OF BREATHING


Oxygen Sources

•Portable tanks

(Stem & Wrenches)

•Central tanks

• Regulators and Components

• Flow meters

Flow meter:

0-15 litres/min Full:

2000

PSI

Nasal Cannula - Disposable

O2

4 l/min

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VIDEO - Oxygen.wmv

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Non-rebreathing Mask (NRB)

O2

6-10 l/min Bag-valve-mask

Systems (B.V.M.)

Bag Valve Mask (BVM)

Inflatable Mask

(use 10 cc. syringe – air)

One way valve- once

sealed no need to lift

edge of mask for

exhalation

Supplemental O2 with

reservoir at 10-15

liters/minute

2-3 l. bag

Can be

used IF

breathing

Transparent mask –

can see regurgitation

These 3

fingers pull up

These 2 digits

press

Demand Valve

NOT Recommended

??

??

?

?Questions

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Video MedE - Oxygen.pptx

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MANAGEMENT OF CIRCULATION


Vasoconstrictor Considerations

VASOCONSTRICTOR

“ISSUES”or

Truths, Lies and

Consequences

A. Use is based on vasoconstrictivealpha receptor agonists

1. Delays absorption, reducing toxicity and prolonging duration

No Advantage With Concentrations > 1:200,000

2. Reduces haemorrhage at surgical site

(CONCENTRATION IS ADVANTAGEOUS IN THIS CASE)



Deep

Arteries

Adrenergic alpha receptor functions and vascular distribution

Vasoconstriction

2Vasodilation +Bronchial dilation

1 Cardio-tropic

Veins and

Submucosal

Arteries

2

With most heart conditions, the most

serious medical-dental risk for dental

treatment is the vasoconstrictor.

or FalseTrue

Vasoconstrictors

A. Epinephrine is not safe

for the hypertensive

patient

True or False?

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Selecting a Vasopressor

• Epinephrine for Hypertensive Patients

• Levonordefrin if Tachycardia is Concern

• Both Increase Myocardial Oxygen Demand

Epinephrine Heart Rate

Levonordefrin Blood Pressure

Vasoconstrictors

B. When anaesthetizing

children – do not use

epinephrine. Use a plain

non-epi containing

solution

True or False?

Parents are

responsible

for lip /

tongue biting

Dentists are responsible for

safety!

Vasoconstrictors

Why?

Epinephrine delays

absorption, reduces

toxicity and safely

allows for 1 ½ X

maximum dose!

75 mg

400 mg

300 mg

300 mg

300 mg

No Vasoconstrictor

150mgBupiva 0.5%

600 mgPrilocaine 4%

500 mgMepiva 3%

500 mgLidocaine 2%

500 mgArticaine 4%

VasoconstrictorDRUG

“MRD” or Maximum Recommended Doses

* For healthy 70 Kg adult –must adjust for age and weight

Hawkins, M - various sources, 2017

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Maximum Doses

78 mg/kg (up to 500

mg)Prilocaine 4%

9*7 mg/kg (up to 400

mg)Mepivac 3%

13 ? 10 ?7 mg/kg (up to 500

mg)Lidocaine 2%

102 mg/kg ( up to 200

mg)Bupiva .5%

77 mg/kg (up to 500

mg)Articaine 4%

Drug Maximum Dose # “Carps”

Hawkins, JM: various sources compiled 2012Hawkins, M - various sources, 2017

Vasoconstrictors

C. Epinephrine and

antidepressants do not

interact (except POSSIBLY

with tricyclics?)

True or False?

ANTIDEPRESSANTS

CLASS: MONOAMINE OXIDASE INHIBITOR

GENERIC NAME TRADE NAME

Phenelzine sulfate Nardil®

Tranyleypromine sulfate Parnate®

Local Anaesthetic/Vasoconstrictor Precautions:None, since both epinephrine and neocobefrin are

metabolized by COMT, not MAO

ANTIDEPRESSANTS

CLASS: TRICYCLICS


Maprotiline hydrochloride Ludiomil® Novo-Maprotilinel®

Trimipramine maleateApo-Trimip® NovoTripramine® NuTrimipramine® Rhotrimine®, Surmontil®

Local Anaesthetic/Vasoconstrictor Precautions:Use with caution; epinephrine and levonordefin have been

shown to have an increased pressor response in combination with tricyclics. Clinically may only be seen in higher doses.

ANTIDEPRESSANTS

CLASS: SELECTIVE SEROTONIN REUPTAKE INHIBITORS


Fluoxetine hydrochloride Prozac®

Fluvoxamine maleate Luvox®

Paroxentine hydrochloride Paxil®

Sertratine Zoloft®

Local Anaesthetic/Vasoconstrictor Precautions: No interactions reported with vasoconstrictors

ANTIDEPRESSANTS

CLASS: MISCELLANEOUS


Nefazadone hydrochloride Serzone®

Venlafaxine hydrochloride Effexor®

Buspirone hydrochloride BuSpar®

Local Anaesthetic/Vasoconstrictor Precautions:No precautions appear necessary

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Vasoconstrictors

D. Non-selective -blocked

patients are a relative

precaution only. All

other -blocker

categories are fine

True or False?


Deep

Arteries

Adrenergic alpha receptor functions and

non-selective blockade (e.g. Inderal®)

Vasoconstriction

2 Vasodilation +Bronchial dilation

1 Cardio-tropic

Veins and

Submucosal

Arteries

2

BETA-ADRENERGIC SympathomimeticsBLOCKERS epinephrine

(a) Cardioselective

Atenolol Tenormin®

Metoprolol Betaloc® Lopressor®

(b) Noncardioselective

Nandolol Corgard®

Propranolol Inderal®

Sotalol Sotacor®

(c) Noncardioselective and alpha blocker

Labetalol Trandate®

“alright” 1 blocked only

“beware” 1,2 both blocked

“cool”all blocked

43 year old female, Candace, 1 hour hygiene appt.

Propranolol 40 mg. b.i.d. for migraine headaches, but no

CVD, BP 128/86 HR 88

IV sedation - 4 mg. midazolam with RN Nancy

Local anesthesia: 4% articaine

1:100K epi 6.8 ml. – 4 cartridges

Q 2 minutes: 152/94 92

Q 3 168/98 78

Q 4 190/104 64

Q 5 minutes: 158/98 78

Case Report

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Case Report

1. IF ANY SYMPTOM ➔ Activate EMS

2. Position, ABC’s, O2

3. Lower Blood Pressure – Nitroglycerine

spray + support

4. ASA? NO!

ER protocol, Miami Valley Hosp Becker DE Dayton OH

NOW WHAT?

Managing Beta Blocked Patients

No issue with cardioselective agents,

(a) category BUT

Propranolol and others in the non-

selective, (b) category

WHAT TO DEFINITELY DO!

1. Look it up on line

2. Wait 5 minutes after each cartridge and

reassess vitals

Managing Beta Blocked Patients

WHAT TO POSSIBLY DO?

3. Avoid using a vasopressor if (b)

category

4. Consult physician regarding

discontinuing (b) beta blocker or

changing it to a cardioselective (a)

beta blocker

Hypertension Algorithm

Syncope Protocol

Reassess BP / Perfusion

Nitroglycerin Nifedipine

EMS transport if symptomatic

Vasoconstrictor Summary:

A. Epinephrine is safe for the hypertensive

patient

B. When anesthetizing children - use

epinephrine. It delays absorption,

reducing toxicity

C. Non-selective -blocked patients are a

relative precaution only

D. Epinephrine and antidepressants do not

interact (tricyclics?)

??

??

?

?Questions

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Looking at the “Drug”

Local

Anaesthetic

DOSAGES

Any “%” solution

needs to be expressed

as:

mg/cc (ml)

POSOLOGY

In 2 % lidocaine, for example:

2 %, add 0 = 20 mg /cca cartridge of 1.8 cc

= 36 mg

POSOLOGY Maximum Doses

78 mg/kg (up to 500 mg)Prilocaine 4%

9*

7 mg/kg (up to 400 mg)Mepivac 3%

13 ? 10 ?7 mg/kg (up to 500 mg)Lidocaine 2%

102 mg/kg ( up to 200 mg)Bupiva .5%

77 mg/kg (up to 500 mg)Articaine 4%

Drug Maximum Dose # “Carps”

Hawkins, JM: various sources compiled 2017

* For healthy 70 Kg adult –must adjust for age and weight

75 mg

400 mg

300 mg

300 mg

300 mg

No Vasoconstrictor

150mgBupiva 0.5%

600 mgPrilocaine 4%

500 mgMepiva 3%

500 mgLidocaine 2%

500 mgArticaine 4%

VasoconstrictorDRUG

“MRD” or Maximum Recommended DosesFactors:

Physiology of a child affects the M.R.D.

3% mepivacaine PLAIN

Adult: 7 mg./kg = 490 mg. = 9 cartridges

Age 12-18 yrs: 6 mg./kg = 330 mg. = 6

Age 6-12 yrs: 5 mg./kg = 200 mg = 3.5

Age < 6 yrs: 4 mg./kg = 100 mg = < 2

Hawkins, JM: various sources compiled 2012Hawkins, JM: various sources compiled 2017

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Factors:

Physiology of a child affects the M.R.D.

2% lidocaine 1:100,000 epi

Adult: 7 mg./kg = 490 mg. = 13 cartridges

Age 12-18 yrs: 6 mg./kg = 330 mg. = 8.5

Age 6-12 yrs: 5 mg./kg = 200 mg = 5.5

Age < 6 yrs: 4 mg./kg = 100 mg = 3

Hawkins, JM: various sources compiled 2012Hawkins, JM: various sources compiled 2017

Scenario:

1. Good child J

2. Financial

3. L.A. is just

“water”

4. Bell curveDr. Norman Treiger, DDS, MD Montefiore Hospital, the Bronx, NY

CASE REPORT

Case: @ 55 lb 7 y.o. (25 k.g.)

Administered:

11 CART 2% LIDO 1:100,000 EPI

or

@ 400 mg!

How …..

Does This Happen???

Dr. Norman Treiger, DDS, MD Montefiore Hospital, the Bronx, NY

Factors:

1. Size: 1/3 of adult2. Physiology of a child vs. adult3. M.R.Dose = 133 mg.

or no more than ~ 3.5 cartridges!

4. BUT adjust for physiology to 4 mg./kg. So…M.R.D. = 100 mg. or < 3 cartridges


RESULTS:

Patient died

No dentist or assistant CPR (BLS) certificationNo resuscitative equipment, including no oxygenDefense: Medicaid case. “Had to do as

much dentistry as possible”

Involuntary manslaughter, jail term


Toronto, ON

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Miami, Florida Airport

The 3 R’s:

Racketball…

Readiness?..

and

Rescue

Attempt…

VictimMust BeOn “Firm”Surface ???

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Resusitation: FloorResusci-Anne (n = 50)

Hawkins, M JODA. Jul/Aug Vol 6:28

Dental Chair ResusitationResusci-Anne (n = 50)

Hawkins, M JODA. Jul/Aug Vol 6:28

Defibrillation,

Drugs and

Diagnosis

3

Defibrillation

3

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A.E.Ds

One-Touch

$1245.00CPR Savers and First

Aid Supply®

AED + ECG

Simple but

Sophisticated

$1999.00CPR Savers and

First Aid

Supply®

A.E.D. State Standards and Philosophy

• If you are regulated to have

one, then get one!

•FL, NY, TX (future) ?

Automatic External Defibrillators or A.E.D.s

• Increasingly common placement in

malls, airports, golf courses,

exercise facilities and office

buildings

• They DO save lives when used by

trained individuals

Roccia WD, Modic PE, Cuddy MA: Automated external defibrillators use

among the general population. J Dent Educ 67:1355-1361

D


• How adequately do untrained persons

perform in an emergency?

• Does lack of training influence patient

outcomes?

• Can a lay person successfully operate

an AED to deliver the shock needed in v-

fib or pulseless v-tach?

Roccia WD, Modic PE, Cuddy MA: Automated external defibrillators

use among the general population. J Dent Educ 67:1355-1361

D


FAILURE RATES:

General population: 80%

1st year dental students: 60%

3rd year dentsl students: 30%

Dental professionals/RN’s: 20%

Anaesthesiologists/OMFS: 10%

REASONS for FAILURE (n=50):

Failure to remove chest covering clothing: 52.4%

Incorrect placement of pads 28.6%

Operator touching patient

or not saying, “CLEAR, CLEAR, CLEAR” 14.3%

Roccia WD, Modic PE, Cuddy MA: Automated external defibrillators use among the

general population. J Dent Educ 67:1355-1361

D

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Let’s Do

Drugs

3

What do you need?

DO NOT

even THINK of using a

drug you know nothing

about!

Guidelines

Emergency MedicationsResponsible Auxiliary:

• Check kit every two months (on mock simulation day) to assure drugs are not expired or broken. Replace as needed.

• Review correct method for preparation in emergency periodically.

OXYGEN

Epinephrine

Various injectors available for anaphylaxis

(severe allergy; bee stings, peanuts) and

bronchospasm

CHILD / ADULT:

Packs of 1 or 2 vary in price

child: 0.15 mg.

adult: 0.3 mg.

*until you can draw up from an amp.

Epinephrine

Equi-potent doses: (1ml 1:1000 amps)

by route of administration:

• SC - 0.5 mg

• IM - 0.3 mg.

• IL - 0.2 mg.

• IV - 0.1 mg. - must dilute 1:10,000

If patient has air exchange: ß-2 inhaler: albuterol

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VIDEO - Drawing Drugs.wmv

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Epinephrine

EPIPEN®* for anaphylaxis (severe allergy;

bee stings, peanuts) and bronchospasm

CHILD / ADULT: EpiPen 2-Pak®:

child: 0.15 mg….. $279.06

adult: 0.3 mg…. $ 279.06

*until you can draw up from an amp.

Nitroglycerin

Action is unclear: SL administration vasodilation result in a reduced venous return, or preload reduction, lowering myocardial O2

consumption.

Indications: Ischemic chest pain - 1 tab Q5M x 3

Symptomatic hypertensive episodes

• Dose: 0.3-0.6 SL mg. tabs / 0.4-0.8 SL spray

Warning: do not give another “nitro” if SBP < 90

$9.00 / 100

Expiration date

must be

“Sharpied” to

8-10 weeks from

“today’s

seal breaking”

$32.00

Nitrolingual®

Pumpspraybut . . .

. . . expiry date IS the expiry

date

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27

ASA

Giving the maximum

as a 325 mg. tablet

is OK but…

325 mg. = peak effect

It’s best via 4X baby

ASA (81 mg.) chewed,

aside from, and over and

above prophylactic

use

ASA (for MI)

325 mg. = peak effect

Action: Keeps # of platelets

from increasing, which could

lead to further coronary

artery blockage

or if cerebral blockage,

STROKE!

ASA (for MI)Solbutamol-Bronchodilator

Salbutamol - β2 agonist

Inhaler: Inhale 1 to 2 puffs of

Salbutamol up to 4 times daily.

More than 8 inhalations per day is

not recommended.

Salbutamol -Ventolin® -

β2 agonist

Diphenhydramine

• Action and effect based on blocking

histamine release

• Indications / Dose: (50mg/ml amp or SDV)

• pruritus / urticaria / nausea

• 50mg IM followed by 50mg TID P.O.

• medical follow up to anaphylaxis

• THINK FIRST! Can they get a ride?

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VIDEO - IM Injection.wmv

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28

Glucose Source

ALL dental offices have a

massive sugar availability in

house!

?

?

??

?Questions

Diagnosis DependentTreatments

Syncope

• Sudden, transient loss of

consciousness

• Common immediately pre- or post

injection

• Most common procedure – extraction

• Often recovery before advanced

treatment can be implemented

Syncope Profile - Prevalence

• Male » Female

• Never in children

• Average age? 35 years old

• Scenario:

Male, 35 y.o., anxious,

“macho” guy,

“needlephobic”

Syncope Signs/Symptoms

• Pallor

• Nausea

• Disorientation

• Loss of Consciousness

• Blood pressure

• Pulse thready, may arrest 30-45 sec.

• Low blood sugar

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165 166

167 168

VIDEO - IM Injection.wmv

Video MedE - Algorithms.pptx

4/18/2019

29

Syncope Causes

• Anxiety, Pain

• Sit up too fast

• Inject too fast

• Intraosseous injections

• Hypoglycemia (prolonged NPO)

Syncope Algorithm

Position, ABC’s

Time, Time, Time

Always!O2 by nasal

cannula

4 litres/minute

+ Glucose

Nausea /Vomiting

…associated with syncope

Hyperventilation

Signs / Symptoms:

• Rapid, shallow breaths, “air hunger”

• Impaired inspiration / expiration

• Sense of panic

• Disorientation

• O2 saturation = 100%

Hyperventilation

Showtime?

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171 172

173 174

Video MedE - Algorithms.pptx

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30

Hyperventilation Treatment

• Rebreathe from paper bag?

• Do nothing and leave room?

*Nobody has ever died from a

100% oxygen saturation!

Angina

• Pallor, chest pain in “waves”

• “Indigestion?”

• Denial

• Midsternal pain, left arm, left mandible

• Nausea, diaphoresis

• Rapid, shallow breathing,

• Rx 1 nitroglycerine tablet or 2 sprays

Myocardial Infarction

• Female: “weight on chest” /

indigestion?

• mild shortness of breath (SOB), nausea

• Male: chest pain, sharp, severe, left arm

• SOB, BP (pain)

• Panic, fear, but denial

• Rapid, shallow breathing

Angina / MI Algorithm

Syncope Protocol

Nitroglycerin q. 5 min x 3

Assume MI / Call EMS

Cardiac Arrest

• Marked hypotension

• Rapid, shallow breathing LOC

• Apnea cyanosis = respiratory

arrest

• Fibrillation = no pulse

• AED gives diagnosis and action

Cardiac Arrest Algorithm

Syncope Protocol

CPR

100% Oxygen

➔ 1 - 2 mg epinephrine

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31

Asthma

Asthma and Severe Allergy

Signs/Symptoms

Bronchospasm Algorithm

ABC’s & Position

Oxygen

B-2 inhaler

BUT if not exchanging air:

epinephrine 0.3 mg

Seizures / Convulsions

DEFINITIONS:

•Seizure: “Fibrillation of the CNS”

•Convulsion: “Fibrillation of the CNS”

with Motor Nerve activity added

Protect Patient,Protect Yourselves!

Syncope ProtocolFollowing Seizure

Seizure Algorithm

If status seizure: EMS/PPV

Seizure Algorithm

Not practical

Flumazenil

Anexate®

Romazicon®

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• Primary assessment is in front of you or in the history

• Activate EMS, 911

• Assign, Designate

In The Dental Office or

Witnessed at home

It is still A, B, C

• Primary assessment

• Call for HELP, get to a phone even if it’s youthat has to leave

• No medical history, no relatives, no knowledgeable friends

Unexplained, Unwitnessed,

Unconscious

Cardiac arrest NOW

C, A, B

IN LIFE…triple “U”

• Look for MEDIC ALERT bracelet or

necklace

• Read allergies, medical conditions

• Phone emergency hot line # on MEDICAL ALERT tag,

• Quote victim’s ID #

• Medical history will be given 24 / 7 by phone

QUESTIONS?

Pregnancy

Local Anesthetic News:

Dental Treatment Safety with Local Anesthetics during Pregnancy 572

Cover Story:

Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A,

JADA 146(8) Aug 2015

JADA ® AUG. 2015 146(8)

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33

Pregnancy SafetyLocal Anaesthetics

➢ A prospective, comparative observational

study by the Israeli Teratology Information

Services (TIS), 1999 – 2005

➢ 210 pregnant patients were exposed to

dental treatment including local

anaesthetics - 112 (53%) in 1st trimester

vs. control group = 794 pregnant patients

who were not exposed to any dental

treatment or local anaesthetics

Hagai A et al, Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment:

A prospective comparative cohort study, JADA 146(8), Aug 2015


The rate of major

anomalies was not

significant between the

two groups.

There was no difference in

the rate of miscarriages,

gestational age at

delivery, or birth weight.


A prospective comparative cohort study, JADA 146(8), Aug 2015


Safest local anaesthetics during pregnancy

and breast-feeding:

➢ Lidocaine and prilocaine (Citanest ® brand)???

are B (FDA 2012)

➢ All others, even mepivacaine plain (Carbocaine®

brand, Carestream Dental) are C (FDA 2012)

➢ Risk of methemoglobinemia with topicals

(especially esters: benzocaine, tetracaine)

➢ Epinephrine is OK


Donaldson M & Goodchild JH, Pregnancy, breast-feeding and

drugs used in dentistry, J Am Dent Assoc, 143(8), August 2012




Epinephrine is a catecholamine,

which normally is present in the

body, with no clear evidence of

increased risk of malformation

when used during pregnancy with

local anaesthetics

Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A, ADA 146(8) Aug 2015




In Canada and adopting an ADA position paper:

Epinephrine is safe, including these

Local anaesthetics that contain epinephrine:

0.5% bupivacaine, Marcaine® 1:200K epi

2% lidocaine, Xylocaine ® 1:100K epi

3% mepivacaine, Carbocaine ®

In fact there is no evidence of increased risk of

malformation with the use of ANY local

anaesthetic.Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A ADA 146(8) Aug 2015

ADA Updated reaffirmation published Feb 6 2019

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34




2% lidocaine, 1:100,000 epinephrine

...is the ONLY local anaesthetic +

epinephrine composition that is

OK’d on all NIH, ADA and FDA

guideline lists

Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A ADA 146(8) Aug 2015

ADA Updated reaffirmation published Feb 6 2019


143(8), August 2012

Conclusions:

The use of local

anaesthetics as

well as dental

treatment during

pregnancy, does

not represent a

teratogenic risk.

Hagai A et al, Pregnancy outcome after in utero exposure to local anesthetics as part of

dental treatment: A prospective comparative cohort study, JADA 146(8), Aug 2015


Despite the reassuring considerations…

Dentists are still reluctant to perform dental

treatment for pregnant patients and

Women are still reluctant to receive dental

treatment during pregnan


A prospective comparative cohort study, JADA 146(8) , Aug 2015

QUESTIONS?

Toronto, Ontario Canada

Friday, May 10th, 2019

Medical Emergencies in the

Dental Office, Medical Emergencies in Life !

Mel Hawkins, DDS BScD AN

Dentist/Dentist Anesthesiologist

Toronto, ON Canada



1 2 3

Product

Issues

Dentist

Issues

CONSULTING DILEMMAS

Patient

Issues

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35

CASE REPORT

PRODUCT

COMPLAINT:

3% MEPIVACAINE (PLAIN)Common local anesthetic administered

COMPLAINT:7 patients 'stroke-like' reactions to

3% mepivacaine (plain)DOCTOR’S INTERVIEW

INFORMATION

Background

•Dentist with 34 years

experience

•Practices general dentistry

•High need for exodontia

•Holistic component to

practice

“Nobody’s

going to die

on my

watch”

“This last

patient might

sue me” “I know stroke

when I see it”“It must be the

mepivacaine”

Quotes

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36

EMS 911CALLED 7 TIMES

in past year

due to

"stroke-like

symptoms"

Common History: “Hypertension”

• Dentist did not define her personal interpretation of hypertension

• No baseline vital signs on record

• No intra operative vital signs taken

• Multiple tooth extractions common

• 3% mepivacaine plain used for these stated “hypertension” case histories

Patient Signs & Symptoms

Anxiety,

anxiousness,

restlessness

DIFFERENTIAL

DIAGNOSIS

?

?

?

?

?

ALLERGY TO 3% MEPIVACAINE?

ALLERGY?

• No scientific evidence of allergy

• No itching, urticaria or airway

compromise

• No documented Ag-Ab in

literature

• Mepivacaine molecule is a non-

allergen

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37

Option

A

Option

A

“COULD IT BE THE

PRESERVATIVE IN THE LOCAL

ANESTHETIC?"

PRESERVATIVE?

3% mepivacaine does

NOT contain a

preservative

ALLERGY TO LATEX?

LATEX ALLERGY?

Doctor states it is a

latex-free office

MYOCARDIAL EVENT?

MYOCARDIAL?

• No scientific evidence

• No angina

• No signs or symptoms of

infarction

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38

PATIENT SELF-MEDICATION?

SELF-MEDICATED?

Unknown

IATROGENIC?

IATROGENIC?

•Dental office environment

•Dentist treatment?

•Other in-office factors during

procedure

•Was the local anaesthetic

ineffective?

CEREBRAL VASCULAR ACCIDENT - STROKE?

•Headache, dizziness, impaired

vision, mental clouding

•Hemiplegia, unilateral weakness

•Nausea, diaphoresis

•Facial “Bells Palsy” appearance

•Speech impairment

•Fear

SIGNS, SYMPTOMS OF STROKE

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39

• No scientific evidence, symptoms

not consistent with stroke

• No vital signs available

• Assumption: paramedics/ER took

vitals

• Doctor does not know actual

systolic/diastolic/rate results

• Doctor did not accompany to ER

CVA - STROKE?

WHAT’S

YOUR DIAGNOSIS, DOCTOR?







Toronto, ON Canada



1 2 3

Product

Issues

Dentist

Issues

CONSULTING DILEMMAS

Patient

Issues

CASE REPORT

Patient

Issue:

First appointment:

Product titrated slowly

IV 30 mg. 0.1% midazolam

Versed® brand in 1 ½ hours

Second appointment approach?

BACKGROUNDINFORMATION

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40

Dentist student with no IV

training getting case

experience during 95 hour

MCMS Program

CASE FACTS - CLINICAL

Hawkins JM, Director Mod Curr Moder Sed,

U of A Fac Med Dent, 2011

•Male 32 y.o. 6’ 145 lbs. ASA “1”

•Personal drug history held

back?

•Baseline vital signs on record:

BP 128/88, P. 110

PATIENT HISTORY

PRE OP:

• Anxiety, anxiousness, restlessness

• Pupils not really constricted but not

assessed initially

PER OP:

•

PATIENT SIGNS & SYMPTOMS –1st APPOINTMENT

30 mg. midazolam over 1 ½ h.

• Intra operative vital signs stable

• Pulse oximeter within normal

limits throughout

“When are

you going to

start?”“Are you going

to give me any

drugs soon?”“I’m not

asleep”“This sucks”

Quotes:

SECOND APPOINTMENT Dilemma –

PATIENT DRUG TOLERANCE?

• Based on last appointment tolerance i.e.

total dose, dentist/student asks

permission to “push” 3 mg. midazolam

IV

• Request denied, 1 mg. given slowly IV

• Patient goes to level 4-5 very difficult

to wake

PATIENT SIGNS, SYMPTOMS –2nd APPOINTMENT

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41

DIFFERENTIAL

DIAGNOSIS

?

?

?

?

?

SYNCOPE?

•Symptoms not consistent with

vasovagal syncope

•No panic attack

•No hyperventilation

•Not needle phobic

•Hypoglycemia could be a factor

SYNCOPE ?Option

A

Option

A

MIDAZOLAM

OVERDOSE?

Were other drugs possibly

on board?

What drugs could they be?

MIDAZOLAM O.D?

Only 1 mg...after a previous

appointment with 30 mg.?

ALLERGIC REACTION TO MIDAZOLAM?

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42

ALLERGIC REACTION ?

• No evidence of allergy

• No itching, urticaria or airway

compromise

• No documented Ag-Ab in

literature

• Midazolam molecule is not a

known allergen

CEREBRAL VASCULAR ACCIDENT (CVA)?

No evidence of common

symptoms

CVA – STROKE?

MYOCARDIAL EVENT?

• No scientific evidence

• No angina

• No signs or symptoms of

infarction

MYOCARDIAL SOURCE?

IATROGENIC?

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43

•Dental office environment

•Other in-office factors during

procedure

Unknown

IATROGENIC ?Option

A

Option

A

PATIENT SELF-

MEDICATION

SELF-MEDICATION?

SELF-MEDICATION “I’m afraid of not getting

enough”

Unknown but

Highly Suspect!

SELF-MEDICATION?

becomes a

Primary Diagnosis

SHOULD EMS HAVE BEEN CALLED?

MANAGEMENT

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44

Always! Syncope Protocol

Position, ABC’s

Time, Time, Time

Always!

O2 by nasal

cannula

4 litres/minute

+ Glucose

• Male 32 y.o. 6’ 145 lbs. (too tall for his

weight-cocaine?) ASA “1” ?

• Personal drug history held back?

• Baseline vital signs on record:

BP 128/88, (not sycope-too high and not

cardiac-too low) P. 110 (cocaine?)

• Pupils constricted (narcotic?) but

unnoticed

MANAGEMENT – IT’S EASIER TO GO BACK…

• Call EMS? Support? Wait?

• Reverse midazolam with 0.1 – 0.2 mg.

flumazenil?

• “Guess” at a self administered narcotic

and give 0.4 mg. Narcan® ?

• All of the above?

• Would you treat him again?

NOW WHAT?

• Call EMS? Support? Wait?

• Reverse midazolam with 0.1 – 0.2 mg.

flumazenil?

• “Guess” at a self administered narcotic

and give 0.4 mg. Narcan® ?

• All of the above?

• Would you treat him again?

WHAT EVOLVED?

FINAL OBSERVATIONS

• You just never know!

• Don’t assume anything

• Always titrate any medication slowly

• Treat each appointment like it is the first

appointment.

• Students now not permitted to see

previous appointment sedation record

• Don’t be surprised to be surprised!

FINAL OBSERVATIONS

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45

• Liability claims experience

repeatedly characterized by poor

record keeping

• Dentists often do not attend CDE

programs

• Abandonment and lack of follow up

is most incriminating

FINAL OBSERVATIONS FINAL OBSERVATIONS

•Court almost always empathizes

with patient, facts aside

•Plaintiff’s lawyer knows the

dentist has liability insurance

•Company is hardly ever targeted

Final Observations

•Never offer financial

compensation directly to a

patient - viewed as admission of

guilt

•Bring in a “friendly” expert

•Legal release mandatory

ANY

LAST

QUES-

TIONS

?







Toronto, ON Canada



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Documents

Mel Hawkins Medical Emergencies in the Dental Office, Medical … · 2019. 4. 26. · C.V.A. 68 Emergencies Martin & Ellis JADA 112:499 -501, Malamed JADA 124:4-53 >30,000 events