Patient and Practioner Optimization · the public domain •Discuss some example “made up cases” •Preventing common emergencies •Managing common emergencies •Office drills

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Medical Emergencies in the Dental Office

Robert G. McNeill, DDS, MD

Diplomate, American Board of Oral & Maxillofacial Surgery

Who am I?• Grew up in Canada

• Oral and maxillofacial surgeon in North Garland

• Fellowship, Integrative Medicine from the University of Arizona School of Medicine

• Former staff dentist, TSBDE

• Former member, Blue Ribbon Panel on anesthesia safety

• Board member, TSBDE

Conflicts of interest

• No conflicts with any products I will be speaking about today

• I am not here in my official capacity as a representative of the TSBDE

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Other disclaimers

• I might come across like I have it all figured out

• I don’t…….I just have a different set of experiences

• I don’t know many of the questions let alone the answers

•What you do in your office will be dependent upon your training, experience and preferences

What is our game plan?

• Discuss actual cases that exist in the public domain

• Discuss some example “made up cases”

• Preventing common emergencies

• Managing common emergencies

• Office drills

• Customize an emergency plan

•My intent is to have this be a different type of lecture

• I hope to help you to evaluate how prepared you are for an emergency in your office

•We will go through scenarios and discuss drills for your office

• I will try to use my experiences to hopefully have you look at this process a little differently

We are going to talk about stress

•How stress contributes to emergencies in your office

•How to control stress to hopefully prevent and best manage emergencies

•My hope is also to look at the issue more globally from case selection/patient management (what is their PMH and what and how you are going to do it)

•Discuss legal/state board issues

•Management of emergencies

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Who are you?

Dentists?

Hygienists?

Dental assistants?

•How many of you feel very well prepared to manage a medical emergency in your office?

•How many of you provide sedation?

•How many of you treat a fair number of ASA III or IV patients?

•Why are we not talking more about the actual prevention of medical emergencies in

our dental offices?

Preventing emergencies

• Let’s try to prevent them from happening in the first place

•Case selection

•Not doing too much at one time

•Will you request to modify or not modify their medical management?

•How are you going to manage their stress (and yours)?

We are in the Perfect Storm

• Sugar consumption with increased caries in young children• Increased obesity causing poor airways• Increased rates of depression and anxiety for all ages• Increased drug use• Increased rates of ADHD and Autism • People are living longer and how is that going to change

your decision making?•Medically compromised patients• Everyone is on a blood thinner

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•Young people have lost their grit and they are much harder to manage and often require much higher levels of

sedation when used

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•Prompt implementation of basic emergency management protocol can significantly

increase the likelihood of a successful result when medical emergencies occur in the

dental office

What is a basic emergency protocol?

• Position

• Airway

• Breathing

• Circulation

• BLS

• Keep them alive until someone better trained in emergency management takes over or the patient recovers

•Keep them alive until someone better trained in emergency management takes

over or the patient recovers

Push for more state dental board envolement

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Let’s look at a clinical scenario

Let’s look at this situation

• Doctor/staff communication: how did they do?• Very poor

• Medical emergency plan: how did that work for them?• Did not appear to have one and staff and dentist not

coordinated on who does what

• Patient vital signs: ?• None taken and no emergency treatment record to document

vitals as well as interventions

• Portable oxygen: Did they have it?• It does not appear that they did• Every office (including you orthodontists) must have portable oxygen

• Emergency kit: Did they have one?• No mention of it

• Calling EMS/9-1-1: How did they do here?• Quicker response could have occurred

• Automated external defibrillator (AED): Did they have one?

• Early defibrillation is critical in these types of cases

The Five Deadly Misconceptions

•Who in this room has participated in a

medical emergency at their office?

Six Links of Survival

•1. Doctor training• BLS

• AED

• Using EpiPen or other form of epi

• Administering oxygen (practice during BLS training)

• Medical emergency training

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•2. Staff training• Trained to recognize the signs and symptoms of medical

emergencies

• They might be the only one with the patient!!!!!• Their quick response to can make the difference between life and

death for a patient• They need to know their role in an emergency

• They need to know where the equipment is


•3. Medical Emergency Plan• Every office needs one

• Everyone should know their roles

• The dentist will be the team leader (if they are available)

• Quickly make decision about calling EMS

• “If in doubt, call EMS out!”


•4. Emergency Drug Kit• What you have in it will be determined by your training and type

of practice

• If you provide sedation you will have more drugs (such as reversal agents) and perhaps different airway devices

• Don’t have something in the kit if you do not know how to use it• Make sure your drugs are not expired (keep and practice with your

expired drugs)

ADA Council on Scientific Affairs

•Oxygen with the ability to administer positive pressure

• Epinephrine

•Benadryl

•Aspirin

•Bronchodilator

•Nitroglycerin (spray or tablets)

•Glucose source


•5. Proper Equipment• Some of this will be determined by your level of training and what

you do in your practice

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•6. Mock drills• None of this matters if you and your staff do not know how to

respond appropriately during an emergency

• How often should you practice?• All staff should participate

Avoiding a medical emergency in the office:

•Know when not to treat

When is the blood pressure too high?

•64 year old patient presents for crown on #19. Pt. is without pain.

•PMH: elevated cholesterol

•PE: BP: 220/120

•What do you do?

•Retake BP: 222/121

•Do you treat them that day?

•45 year old male presents for RCT #7. Pt. is without pain but has severe dental phobia.

•PHM: reports nothing on health history questionnaire and has not seen his MD in 5 years

•PE: Height:5’10’’ Weight: 310 P: 122 BP: 182/112 (lowest of several readings)

What are you going to do?

• 45 year old male presents for RCT #7. Pt. is without pain but has severe dental phobia.• PHM: reports nothing on

health history questionnaire but has not seen his MD in 5 years• PE: Height:5’10’’ Weight:

310 P: 122 BP: 182/112 (lowest of several readings)

• Defer tx and get him to MD?• What would you do if BP came

down to 170/105 after you helped him to relax?

• How would your management change?

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Is it easy then to say when tx should be deferred?

• Everything is fine until it isn’t

•PMH of patient (history of heart disease or stroke)

•Age and physical condition of patient

• Is the patient in pain?

•Can you provide something to help relax them

• Is it a long procedure?

•Do you re-check blood pressure?

Let’s go back to this patient

• 64 year old patient presents for crown on #19. Pt. is without pain.

• PMH: elevated cholesterol• PE: BP: 220/120• What do you do?• Retake BP: 222/121

• Other retake after your assistant calms the patient down and you start nitrous is 165/92

• Now what do you do?

• If you proceed will you use epinephrine in your local anesthesia?

• Pt. starts to get SOB• You start oxygen• Patient develops chest pain• You give ASA and call 911• EMS arrives and transports pt. to the hospital• Patient had an MI and is released from the hospital after 4 days

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Reporting cases to the dental board Board process

• Investigators will gather information from your records, EMS and the hospital based on your self-report

• In a case such as this the information will likely be reviewed by the Dental Review Panel (DRP)

• The first DRP dentist will make a report to opine if standard of care was followed (SOC) as it relates to your patient management, treatment, records and other factors as it relates to the dental board rules

•A second DRP dentist will then look at the case and the first report

• If they can not agree on SOC issues then it goes to a third DRP member to break the tie

•What would a reasonable and prudent dentist do in a similar circumstance?•Did you defer care to get them to MD?•Did you flood them with 1:100,000 epi?•Were rules followed?•Did you take blood pressure or was EMS the first

person to take BP?•How quickly did you activate EMS?

• If there is no SOC violation then the case is dismissed

• If there is an SOC violation then the respondent (dentist/hygienist/dental assistant) may need to go to Austin for an informal settlement conference (ISC)

• This is their chance to discuss the case details with a board member

• The board member will then offer to dismiss the case or recommend a remedy (warning, fine, CE, suspension)

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Dental board rule: 108.8

• (1) Patients name;

• (2) Date of visit;

• (3) Reason for visit;

• (4) Vital signs, including but not limited to blood pressure and heart rate when applicable in accordance with §108.7 of this title.

• (5) If not recorded, an explanation why vital signs were not obtained.

• (c) Further, records must include documentation of the following when services are rendered:

• (1) Written review of medical history and limited physical evaluation;

• (2) Findings and charting of clinical and radiographic oral examination:

•

• (A) Documentation of radiographs taken and findings deduced from them, including radiograph films or digital reproductions.

• (B) Use of radiographs, at a minimum, should be in accordance with ADA guidelines.

• (C) Documentation of the findings of a tactile and visual examination of the soft and hard tissues of the oral cavity;

• (3) Diagnosis(es);

• (4) Treatment plan, recommendation, and options;

• (5) Treatment provided;

• (6) Medication and dosages given to patient;

• (7) Complications;

• (8) Written informed consent that meets the provisions of §108.7(7) of this title;

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Rules

• For good or bad there are rules in place

• Following and being mindful of the rules can help protect you and your patient • Equipment you need to have available for emergencies

• Monitors for different levels of sedation

• Mandated emergency drills

• Continuing education for sedation for pediatrics or high risk patients


•Know when to stop

• Is it okay to fail

•Are we giving local anesthesia enough time to work?

•Doctors, listen to your assistants

• Encourage your team to feel comfortable speaking out


•What are you learning from the physical exam and patient interview?

•Auscultation

•Are they short of breath walking in your office?

•Pre-tibial edema

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•Are there concerns about their PMH?•Cardiac issues•Blood thinners•Anxiety issues•Respiratory issues• Sleep apnea


•When do they need to see their physician?

•Medical issues versus legal issues

Cardiac issues

•Get a good cardiac history•Angina

• how often do they take Nitro? • what are they doing when it happens?

•Congestive heart failure • when did you last see your doctor?• ask if you can see their pre-tibial area and press on it (fluid

retention)• are they huffing and puffing getting in and out of the chair

Cardiac issues

•Heart attack•When did they have it, how many?•When are you going to treat? 3 months, 6 months•Pain or infection?

• Is it safe to give epinephrine and how much?•Are you going to stop the blood thinner?

Cardiac issues

• Remember that many cardiac patients do not know they have heart problems and therefore you do not know they have heart problems

• Should you manage a patient as though they have cardiac issues?

• Comorbidities: smoking, obesity, diabetes, physical activity, cholesterol meds, hypertension, age

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Cardiac issues

•Do you reach out to the patient’s physician/cardiologist?

• Is their heart condition optimized?

•Does it make sense legally to get a consult?

•Are you trying to take them off blood thinners?

• Is a pre-op work up prudent for more involved procedures?


•Can the patient tolerate a lengthy procedure?

•Does it make sense to break things up into smaller procedures?

• Looked at 3,817,113 patients having major non-cardiac surgery

• Looked at three risk factors

• Currently smoking

• Treatment for hypertension

• Treatment for diabetes

Risk Factors

•42% had none of the RF

•40% had one RF

•17% had two RF’s

•1.2% had all three RF’s

• They found that the incidence of an acute MI or death within 30 days climbed in a stepwise fashion

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ASA classifications

•Do you know the ASA classifications?

ASA classification

Healthy 30 year old male with no known medical problems

1

ASA classification

Well controlled diabetes

2

ASA classification

Alcohol dependence or abuse

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3

ASA classification

Pacemaker

3

ASA classification

Kidney failure (ESRD) and undergoing regular dialysis

3

ASA classification

Smoker

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2

ASA classification

MI 2 months ago

ASA classification

4

ASA classification

Morbid obesity (BMI >= 40)

3

ASA classification

MI > 3 months ago

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3

Very important ones to know

•MI (heart attack)

•CVA (stroke)

• TIA (mini-stroke)

•CAD with stents

•If any of these are recent (<3 months) then this makes it an ASA 4

Why is ASA classification important?

•A mechanism for risk stratification

• If you don’t get the classification right it might effect your patient management

• You might run into legal/state board problems

How are you going to treat this patient?

Time for audience involvement

•Would you treat this patient?

•Would you contact physician about the treatment if performing this with local anesthesia and nitrous oxide?

• Would you ask for patient to stop Coumadin or Aspirin?

• How many would stop Coumadin only?

• How many would stop Aspirin only?

•What INR number is too high to remove this tooth?

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American College of Chest Physicians American College of Chest Physicians

• Tannins: tannic acid is an astringent that is present in many plant leaves and bark

• Used since ancient times for clotting

• Has anti-microbial, anti-oxidative and anti-inflammatory activity

• Soltani R, et.al. Evaluation of the Effect of Green Tea Extract on the Prevention of Gingival Bleeding after Posterior Mandibular Teeth Extraction: A Randomized Controlled Trial. Evidence-based Complementary and Alternative Medicine : eCAM. 2014

Avoiding medical emergencies

• Limit epinephrine with older patients

•Use appropriate local anesthesia

•Keep on current medications when possible, including blood thinners

• 86 y.o. female• 2 fractured teeth with

discomfort• Vitals stable• PHM:

• DM• CAD on coumadin• Osteopenia• COPD

• Would you get a medical clearance?

• Chest X-ray• Atherosclerotic calcification of aortic arch

• EKG: LBBB, cardiac ischemia with old infarction

• Medical consult showed:

• Intermediate risk for non-cardiac surgery

• Plan: Nitrous oxide, local, local measures, stay on coumadin

• Limit epi (no epi versus 4 carps 1:200,000 at a maximum)

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Blood thinners

•Continue when possible if benefits > risks

•Coming off the blood thinner puts the patient at risk whilst sitting in your chair

•Be careful with Rx of meds when patients are taking Coumadin (antibiotics and antifungals)

Blood thinners

• Local hemostatic agents?• Do you need them?• Legal protection?

•Hemostatic rinses?

•How do you deal with bleeding in the office?

•What works well in your hands?

•Are you going to follow MD advice?

Can Integrative Medicine make things safer in the dental office?

• Integrative Medicine (IM) is healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies.

Stress•1) patient stress

increases the risk for an emergency in your office

•2) how can you decrease your stress during an emergency?

Differentiate yourself!

•Physicians are not discussing stress with their patients

•We see the consequences of stress and are in a great position to discuss it

•What would it be like if you could help your patients (and yourself) better manage stress?

• Increase empathy

How can you tell if your patient is stressed?

• Eyes

• Forehead

•Hands

• Shoulders/posture

•Heart rate

•Blood pressure

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Psychology versus physiology

•Very often the two are interconnected

•A problem with one causes a problem with the other (e.g. panic attacks)

• Is it safer to maintain baseline physiology during a dental appointment?

• Is it optimal to decrease fear and anxiety during a dental appointment?

Symptoms of anxiety: The mind body effect working against us!

•Racing heart or skipped beats

•Hyperventilation

•Breathing difficulty

•Choking sensation

•Tingling or numbness

•Shaking

•Chest pain, pressure or discomfort

•Perspiration

•Diarrhea

•Nausea or vomiting

Differentiate yourself!

•Physicians are notdiscussing stress with patients

•We see the consequences of stress

• Increase empathy

• “It is very common to be stressed about coming to the dentist. We will talk about some things we can do to make you feel more comfortable.”

Music

•A systemic review found that music can moderately reduce pain and anxiety• Effects before, during and

after surgery•No side effects•Benefits for the staff

Hole J., et.al. Lancet. 2015.

Marconi breathless (YouTube)

Essential oils

• To investigate whether ambient orange fragrance, compared with no fragrance, can reduce patient anxiety before and during surgical removal of an impacted mandibular third molar.

•DAS (dental anxiety scale) used, only those with moderate to high levels of anxiety included•BP, HR, RR taken before,

during and after procedure

• The mean blood pressure, pulse rate, and respiratory rate were significantly lower in the fragrance group during surgery (from sitting in the dental chair to the end of surgery; P < .05).

Hasheminia, Dariush et al. Journal of Oral and Maxillofacial Surgery , Volume 72 , Issue 9 , 1671 - 1676

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How can this work?

•Volatile molecules of the oil reach the nasal mucosa and lungs and rapidly diffuse into the blood, causing brain activation

•Neocortex activation occurs, which has an effect on perception of odors and reaches the limbic system

• Levels of hormone and emotions are then altered

• Salivary cortisol levels and pulse rate decrease

Safer alternatives

• Silexan lavender essential oil 80mg

•Relaxing but does not make them sleepy

•Burping or mild lavender aroma

Smoking

• Increases risks for surgery substantially

•Often related to stress

• “How would your life be different if you stopped smoking?”

Deep breathing

• Significant impact on anxiety and pain perception

• Focused attention

• Stimulation of the parasympathetic chain

• Reduction of sympathetic discharge

•Many different forms such as 4-7-8

• Practice is important

• Use negative cues as a reminder

• Important in an emergency - 911

What is the worst way you can interact with a patient to increase

their sympathetic tone and therefore increase their risk of a medical

emergency in your office?

Communication and word selections

•Patients are terrified of pain

•Don’t use the pain word

• Implant suggestion of some discomfort after the procedure that will be controlled with anti-inflammatories

•Modify how you talk

•Post procedure suggestion

•Post hypnotic suggestion

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Hypnosis

• “A state of consciousness involving focused attention and reduced peripheralawareness characterized by an enhanced capacity for response to suggestion.”

Hypnosis

• State of focused attention with increased suggestibility

•Children are the easiest to place into a trance

•Very useful for a variety of medical conditions as well as procedures

How do I use hypnosis?

•Practice hypnotically (tone, volume, pacing, word selection)

•This helps me to reduce meds given

•I.V. placement

•Post hypnotic suggestion

Why did hypnosis become less popular?

•Anesthesia became better

•Drugs became better

• Stage hypnosis created fear

•Religious views

•Hypnosis is really just effective relaxing communication

•Will safety issues make it more popular?

•Will sedation regulations change?

Clinical Report: Mind-Body Therapies in Children and Youth

• “Research suggests benefits of clinical hypnosis for children and adolescents, particularly for functional abdominal pain, IBS and pain management”

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Mind body connection

• It is very powerful and can be used to either help or hurt the patient’s condition

Patient presents for full mouth extractions

• 59 year old male, farmer

• VS: 138/84 P: 87

• PE: general exam normal

•Oral exam: generalized decay

• A/P: Generalized decay

• Plan to remove all teeth (25) with IV sedation and place immediate dentures

• IV sedation performed:• 5mg Versed (titrated to effect)

• 50 µg of Fentanyl (titrated)

• 2 carpules 0.5% Marcaine with 1:200k epi

• 4 carpules 2% Lidocaine with 1:100K epi

• Nitrous oxide and oxygen

• Vital signs stable during procedure

After the procedure, IV was removed and the patient

complains of right shoulder pain to my assistant

Started MI protocol

• Oxygen started• ASA crushed between two spoons and given orally• 911 activated, re-started IV and gave fentanyl, monitors reapplied• ST segment changes, PVC’s on EKG (change from baseline)• Quickly decompensated, decreased blood pressure (so we

elevated legs and pushed IV fluids)• Stress reduction protocol (including for yourself)• I packed sites with gelfoam in cardiology suite whilst they removed

clots• His wife was thankful

What did I learn?

• Limit epinephrine when possible (use 1:200,000 dosage when possible)

• Use non-epi containing local anesthesia (alone or in combination)

• You don’t know if they have cardiac disease

• Should I have sent him to his MD for a pre-op evaluation?

• Call 911 early

•When something happens, sit down and figure out if you would do anything differently

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Call 911 early!!!

Call 911!

•When should you call for help?•You get that gut feeling•You don’t know what to do

•Not doing something might be as important as doing something

•Do not do an intervention if you are unsure and especially if it is a high risk intervention!

• Sometimes that is the most difficult thing to do

What are our obligations as doctors

in an emergency?

Keep the patient alive until they get better

Keep the patient alive until someone comes who is better trained

& takes over

Basic Life Support: Always do this first!

Position: Lay flat or head slightly

down and elevate legs (asthma or cardiac patients may want to sit

up)

Airway: Head tilt, chin lift (place

oxygen)

Breathing: Get close and listen/feel

Circulation: Check pulse

• You are going to be in for a very long 10-15 seconds

• Stay as calm as you can

• Call for help when you don’t know what to do

• If you are not sure, don’t give a drug

• Give oxygen (unless hyperventilating)

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Emergency protocol sheet

•An emergency protocol sheet will help you to methodically go through an assessment and intervene as needed

•Use the sheet that you and your staff have been practicing with

Time for a break

•Survey of 4,300 dentists with 30,000 emergencies,

Stanley Malamed, DDS

•Most emergencies occur when the patient’s stress level is highest

• Increased stress, increased epinephrine/norepinephrine

•55% during the injection

•25% during treatment (majority being extractions and endodontic access)

If you can decrease the patient’s stress then you can reduce the

chances of them having an emergency at your office

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•Be mindful of fear versus pain stress and manage both

•Get good at a stress reduction protocol (premed sedation, breathing exercises, music, relaxation techniques, hypnotic techniques, nitrous/IV sedation…..)

•Good pain control is crucial

• Let’s look at 95% of the emergencies that you will see

Syncope

• vasovagal reaction: “passed out”

•Reposition them and they recover quickly

•Usually “big tough guys” that are trying to hide their fear

• Try to avoid this with a stress reduction protocol

•Act quickly when you see the early signs

•Do you call 911?

• Should they drive home?

• Place patient in reclining position and elevate the legs

•Maintain the airway

•Oxygen and support respirations if needed

• Take vital signs

• Cold compress to forehead and back of neck

• Consider spirits of ammonia

• Consider IV atropine if bradycardia present and persists (and you feel comfortable doing so)

Remember

Often the hardest thing is to do no specific intervention

Postural hypotension

•Get dizzy when they stand up too quickly•Sit them up before you leave the operatory•“Don’t let them bonk their heads!”

•Position the patient with head down and legs up if necessary•Talk in a calm reassuring voice (hypnotic)

Allergic reactions: Mild

• Identify the cause if time permits

•Remove or dilute if possible

•Consider diphenhydramine adult dose 25-50mg PO or 10-50mg IV not to exceed 25mg/minute or 100mg deep intramuscular injection

•Auscultate their lung fields (to listen for wheezing and air exchange)

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Allergic reactions: Severe

• Skin rash

•Watery eyes and nose

• Abdominal cramps

•Wheezing

• Tachycardia

• Hypotension

• This is a patient will have the look of acute distress

• Risk of impending cardiovascular collapse


• Stop the antigen

•Call 911

• Follow the ABC’s• Maintain airway and provide oxygen• Support respiration and breathing

• IV fluids for volume loading

•Consider epinephrine


• IM injector•Adult: 0.3mg epi•Pedo: 0.15mg epi• This may need to be

repeated at 10-20 minute intervals• Should EMS be there

already?


• IM• Adults: titrate 0.2 mg to 0.5 mg to

effect and repeat every 2-5 minutes as needed

• Children: 0.01 mg/kg

• Albuterol inhaler• 4-5 puffs for an adult• 2-4 puffs for a child• auscultation

• Consider diphenhydramine, H2 blocker, steroids

• The patient may need a more advanced airway• Pharyngeal edema and upper airway obstruction can occur

even after epinephrine• The patient may need a vasopressor if fluid volume and

epinephrine are not adequate to sustain blood pressure• Seizures may develop (diazepam or versed for treatment if

able)• Should the patient be hospitalized and observed for 24

hours? Anaphylactic reactions can recur as counteracting drugs wear off

Seizures

• You are not going to like this one

• Patient history is essential• Keep them safe - BLS• It should stop soon, if not

activate EMS• IV/IM/nasal benzodiazepines• Prevent it from happening• Good medical control and

stress reduction

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Angina

• If a patient has a history of angina then they will diagnose it for you•No history of angina, activate 911 immediately•Oxygen•Nitroglycerin if SBP not too low (<90mg HG) or pulse

<50•Chew aspirin (non-coated)• Set up AED and use if chest pain continues

Angina: Let’s prevent it

• Limiting epinephrine (put away your 1:100,000 epinephrine)

• Stress reduction

•Medical evaluation

• Should you modify your treatment plan?

Hyperventilation

• Try to calm them down

• Psychology is causing a physiological problem

• Use a paper bag for rebreathing (recapture inhaled carbon dioxide)

• Have them hold the bag

• Do not use oxygen unless they lose consciousness

Asthma

•The patient will likely diagnose this for you

•Auscultation

•Albuterol inhaler, oxygen

•They might even tell you when to activate EMS

•Prevent it will prophylactic inhaler use and stress reduction

Hypoglycemia

•Check blood sugar (get a glucometer)

•Give oral sugar gel if appropriate

• IV access if able (dextrose/glucagon)

•Prevent with appropriate medical management of diabetes, shorter morning appointments

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“Epinephrine reaction” to injection

•Heart racing with injection

• Slow and easy

• The more white knuckled the patient, inject a very small amount first

•Consider 1:200,000 epi or none at all


•Get good at your injection technique!

Local anesthetic overdose

•Dizziness

• Tachycardia

•Anxiety and agitation with confusion

• Seizures

•Respiratory depression

• Stop before you have to get out the calculator to figure out how much more local anesthesia you can give

• Treatment includes activating EMS, airway and BLS

• Seizures managed with valium or versed

• Fat emulsion may be used at the hospital

The other 5%: MI/cardiac arrest:

•MONA: oxygen, nitro spray, ASA…..probably not going to give morphine

•ACLS protocol if trained

•Don’t give a drug if you are unsure

•Prevent with medical consultation?


•Continue all meds when possible

The other 5%

• True anaphylaxis

•Activate EMS immediately

• IM epi (0.2-0.5 mg) q5 minutes as needed

•Oxygen

• Inhaler, steroids

• Start IV

So what do you need in your emergency kit?This will be different for each of us!

•Oxygen with regular/bag valve mask and oral airway device

• Stethoscope, BP monitor

• 325mg Aspirin (non-enteric coated)

• Nitro spray

• Albuterol

• Glucose source and glucometer

• AED

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Know how to use your equipment

•Do no harm•When you do your BLS take the opportunity to get

familiar with the your equipment•Use your bag valve mask and oral airway•Ask instructor for pointers•Are you ventilating too quickly? Write a reminder on

your bag!•Are you doing the chin tilt/lift?

BRP data for Texas 2011-2015

• Six major sedation events (death/permanent disability)•Child under 8 or adults with high risk factors•A deeper level of sedation than intended occurred

in many cases•Poor pre-op evaluation, drug over dosage, poor

monitoring and poor emergency management

Anesthesia mishaps in the State of Texas 2011-2015

•13 mishaps with 8 involving children under 8 or high risk adults (obese, compromised health or elderly)•Poor pre-operative evaluation •Drug overdose•Premature discharge•Bolus drug administration•Not using required monitors•Poor problem recognition•Poor emergency management

Emergency Failures from BRP Report

• Emergency drugs given at the wrong dose

•Ventilation equipment was available but used ineffectively

•Ventilation equipment was not available

• Supplemental oxygen was available but not administered when indicated

• The provider was slow the activate EMS!!! (most common finding)

What can you do?

• Have an emergency plan and use it for emergency drills with your staff

• Activate 911 early

• Practice using ventilation equipment

• Careful sedation usage

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Limit medications

•Avoid local anesthesia over dosage

•Do you record weight?

•Be careful with 4% solutions

• Is it really a failure of local anesthesia?

•Limit epinephrine when appropriate to 0.04 mg (4 carps of 1:200k versus 2 carps 1:100k)

What is the maximum dose we can use?

What is the minimum dose we can use?

Failure

• It is okay to have your sedation technique fail

• It is okay to say NO to a procedure or abort a procedure

•We do not need to do everything• It is likely not the best thing for you or the patient• Should the patient be managed in a different

environment?

Risk management

How can you be best prepared?

•Have an emergency plan and practice with it

•Customize it to your practice

•Practice the “doctor down” drill

•Be mindful of stress reduction techniques

•Be mindful of dosages of medications (including local anesthesia) that you are using

• Evaluate and document your patient medical evaluation

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Establish a culture of safety

•Make sure all team members are aware of their role in an emergency•Make sure everyone feels

comfortable stopping the doctor if they have a concern• Listen to your staff• Evaluate and discuss near

miss or problems that happen

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How can we prevent/manage an emergency in our office

• Recognize this can happen to you in your office

• Be mindful of case selection

• Learn stress management techniques

• Be cautious with respect to certain health parameters:• Cardiac disease and history of stroke• Smoking, hypertension and diabetes

• Get to know and follow dental board rules

• Have an emergency plan that you and your team use for drills

• Call EMS early

Thank you!

• Full presentation PDF and downloadable word documents for emergency plans are available at:

•Dfwdentalimplants.com• Go to referral doctors section and click on patient safety

Documents

Patient and Practioner Optimization · the public domain •Discuss some example “made up cases” •Preventing common emergencies •Managing common emergencies •Office drills