Prevenire e trattare le emergenze mediche in odontostomatologia

Claudio MelloniAnestesista libero professionista.

Feck A.Preparing for medical emergencies in the dental office. 12.2012 dentaleconomics.com e

Feck A.Preparing for medical emergencies in the dental office. 12.2012 dentaleconomics.com

66%

Feck A.Preparing for medical emergencies in the dental office. 12.2012 dentaleconomics.com

Medical Emergencies in the Dental Office, 6e by Stanley F. Malamed

407422 visite!!8 anni e 5 mesi,101 mesiThe Nature and Frequency of Medical Emergencies Among Patients in a Dental School Setting

Patrick L. Ander, Robin L. Comeau, Michael Hatton, Mirdza E. Neiders..J.Dental Education,2010;74;390-396.

< 1/mese University at Buffalo School of Dental Medicine

Non pazienti!!! The Nature and Frequency of Medical Emergencies Among Patients in a Dental School Setting

Patrick L. Ander, Robin L. Comeau, Michael Hatton, Mirdza E. Neiders..J.Dental Education,2010;74;390-396.

Quindi tra pazienti e non pazienti circa 1/mese!!

University at Buffalo School of Dental Medicine

University dental hospital of Manchester

• 183 staff;dentists,assistants,radiographers.• A survey of medical emergencies at the

University Dental Hospital of Manchester:• 1.8 /anno• Fainting the commmonest

Dentists survey over 12 months • Germany,620 dentists • 57% had encountered up to 3emergencies• 36 %had encountered up to 10

emergencies • • Vasovagal episode was the most

common reported emergency – average 2 per dentist

• 42 (7%) had encountered an epileptic fit • • 24 (4%) had encountered an asthma

attack • 5 dentists (0.8%) had encountered choking • • 7 dentists (1.1%) had encountered

anaphylaxis • •2 dentists (0.3%) had encountered a

cardiopulmonary arrest.• Müller MP, Hänsel M, Stehr SN, Weber S, Koch T. A state-wide survey of

medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J. 2008; 25: 296-300

• Ma solo 620/2998 risposte

• UK ,300 dentists

• Vasovagal syncope (63%) – 596 patients affected

• Angina (12%) – 53 patients affected• • Hypoglycaemia (10%) – 54 patients

affected• • Epileptic fit (10%) – 42 patients

affected• • Choking (5%) – 27 patients affected • • Asthma (5%) – 20 patients affected• • Cardiac arrest (0.3%) – one patient

affected • Girdler NM, Smith DG. Prevalence of emergency events in British

dental practice and emergency management skills of British dentists. Resuscitation. 1999; 41:159-67

The Resuscitation Council (UK)’s statement Medical emergencies and resuscitation standards for clinical practice and training for dental

practitioners and dental care professionals in general dental practice• RESUSCITATION COUNCIL (UK) STATEMENT • provides guidance and recommendations concerning medical emergencies that may occur in the dental

practice. It was revised in June 2011 to incorporate the new resuscitation guidelines as well as other best practice. It has been endorsed by the General Dental Council.

• Key recommendations

• • Every dental practice should have a procedure in place for medical risk assessment of their patients

• • All dental practitioners and dental care professionals should follow the systematic ‘ABCDE’ approach when assessing an acutely sick patient

• • Specific emergency drugs and items of emergency medical equipment should be immediately available in every dental practice (this should be standardised throughout the UK)

• • Every clinical area should have immediate access to an automated external defibrillator (AED)

• • Dental practitioners and dental care professionals should receive training in cardiopulmonary resuscitation (CPR), including basic airway management and the use of an AED, with annual updates

• • Regular simulated emergency scenarios take place in the dental practice • • Dental practices should have a protocol in place for calling medical assistance in an

emergency (this will usually be calling 999 for an ambulance) • • All medical emergencies should be audited.

Perchè parlare di emergenze in odonto?

• Avanzamenti della medicina• Sopravvivenza più lunga:sempre più

anziani....sempre più comorbidità• Polifarmacia• Sedute più lunghe...chirurgia implantare....• Pressione economica

AUSTRALIAN DENTAL ASSOCIATION INC.GUIDELINES FOR GOOD PRACTICE ONEMERGENCIES IN DENTAL PRACTICE

• FIVE STEPS IN THE PREPARATION FOR EMERGENCIES.

• Step 1. Medical History.• Step 2. Assessment of patient/Recognition of

cause of emergency• Step 3. Resuscitation - knowledge, training and

practice.• Step 4. Emergency Drugs and Devices.• Step 5. Calling for Medical Assistance

L’importanza di essere preparati

• Avere le cose giuste:attrezzature e farmaci• Fare le cose giuste:– training;dentista e assistenti• Contenuto,tecnica,frequenza

• Pratica!!!routine + scenari• Organizzazione:protocolli con compiti precisi

– Simulearn via Gobetti,Bo,Fipes,CEPOSS pd.,SMO Roma ....

Trattamento delle emergenze mediche

Riconoscimento

prevenzione

Preparazione

BLS

CPR

Emergenze mediche specifiche

Valutazione di un paziente in emergenza

• È cosciente?• Sta respirando?• Ha un polso?

•RICONOSCERE IL Distress del paziente !!!

Prevenzione

AnamnesiAnamnesi

Esame fisico

Segni vitali

Ripetizione della storia clinica,aggiornamenti,farmaci,consulto....

Valutazione del rischio medico.ASA PS,altre scale.....

Riduzione dello stress

ASA PS CLASSIFICATION ADATTAMENTO(SUGGERITO) ALLA PRATICA ODONTO...

ASA I

• Un paziente sano,senza malattie sistemiche

• Può tollerare lo stress del trattamento

• Non esiste rischio aggiuntivo di complicanze serie

Modificazioni del trattamento non sono in genere necessarie

ASA II

Un paziente con malattia sistemica lieve

ES::

-diabete ben controllato

-asma ben controllata

Rappresenta un rischio minimo durante il trattamento

Trattamento routinario con minime modificazioni:

Appuntamenti brevi,mattina presto(??) --profilassi antibiotica-Sedazione

ASA III

Un paziente con malattia sistemica severa ma non invalidante

Es:

- angina stabile

- 6 mesi post MI

- 6 mesi dopo ictus con ripresa funzionale

- COPD

Il trattamento di elezione non è controindicato

Meglio modificare l’approccio: - Ridurre lo Stress

- Sedazione- appuntamenti

brevi

ASA IV

un paziente con malattia sistemica invalidante che è un costante pericolo per la vita

Es:

- Angina instabile

- M I entro i 6 mesi

- Ictus entro 6 mesi

- PA> 200/115

- Diabete non controllato

• Trattamenti elettivi devono essere rimandati

• Solo cure di emergenza:

– Rx di controllo– Terapia antidolorifica

e antinfiammatoria – Altre terapie in

ospedale:incisione e drenaggio,estrazioni...

ASA V

Un paziente gravemente ammalato che non ci si aspetta sopravviva

Es:

- mal.renale terminale

- mal.epatica terminale

- Ca terminale

- Mal. Infettive terminali

Il trattamento elettivo eè controindicato

Terapia solo in emergenza per il sollievo del dolore.

Il rischio.......• C.M.,64,kg 100,cm 180• Cammina molto,va a caccia in collina e montagna• Chir.pregressa:erniorrafia e appendicetomia• Lab:BAV 1,PA 140/105….creat 2,06…• Fisicamente ;uomo forte • Tuttavia:3 anni prima MI + TIA senza complicazioni • farmaci:cardicor(bisoprolol),cardioasp,lasix,novonorm(repaglinide)

,Lescol(fluvastatina),senikar(olmesartan+ amlodipina),zyloric• Intervento lungo:7 hrs:rialzo di seno,impianti multipli sopra e sotto • Il giorno dopo ,dopo avere lavorato in giardino......

• stroke!

Rino M.,paz di dott.MV

• Ascesso dentario!• Maschio,bianco, 88 a, 74 kg,cm 178 • ASA 4 ;Met 2• EF 25% ;CHF,PM, AAA,IRC ,basse piastrine • Polifarmacologia : …………………….• Premed:midaz4;chirurgia dopo 25 min,midaz

0,5+fent 40 microgr ;2 episodi SaO2 <90%;O2 1 lt/min.Per il resto stabile (PA 108/65),

• Durata chir:50 min.

Rosa V-paz dott G”J”P.

• Femmina , 70 a, 60 kg, 160 cm,• ASA 4 (cardiomiop dilat ,diabete)• Anesth stand by con monitoraggio !!! • Segni vitali stabili:BP 149 /73 • Durata chir :90 min.

R- T.,paz dott PP

• 87 a.,50 kg,155 cm.• Alzheimer• Estrazioni multiple ;25 min.• Midaz 3 mg• Segni vitali stabili .

V V,paz di FP

• Per impianti multipli• Maschio,76 y,79 kg,cm 174

• ASA 4;cardiomiopatia dilat,(ma FE migliorata fino al 50%),COPD, gastrite cronica

• farmaci:Bisoprolol,valsartan 40,atorvastatin ,furosemide,lansoprazol venlafaxin,clonazepam

• Premed:triazolam 0.5 mg,30’ prima • Induz;midaz 1,no fent• Chir dur:115 min• Segni vitali stabili,no problemi

Quando il paziente è un collega..

• Cirrosi con ipertensione portale ,ipopiastrinemia(splenomegalia),forte fumatore......

• Candidato ad impianti multipli...

•?•(clinica....)

Protocollo di sedazione per i paz.ad alto rischio...buono per tutti???

• Riconoscere il rischio• Consulto medico completo prima del trattamento:MMG??Specialista?• Appuntamento nel momento del giorno quando il loro stress è minimo• Durante i primi gg della settimana quando l’ufficio è aperto per le

emergenze ed è disponibile il curante e lo specialista• Monitoraggio dei segni vitali preop,intraop,postop • Regime sedativo con minime alterazioni fisiologiche• Controllo adeguato del dolore durante e dopo il trattamento• La durata del trattamento non deve superare i limiti di tolleranza del

paziente• Follow up del dolore postop e controllo dell’ansia • Controllare con :

– Telefonata più tardi il giorno stesso/ sera Telefonata il giorno seguente

Prevenzione:Riduzione dello stress• Richiesta di consultazione;Medico curante,cardiologo...• Scelta dell’ora,meglio la mattina presto per i paz ansiosi ,dopo una notte di sonno....• Minimizzare il tempo di attesa, a meno che non si sfrutti per la sedazione...• Segni vitali preop e postop

• Premedicazione:– la notte prima

dell’appuntamento;ipnotico/sedativo:diazepam,triazolam,flurazepam,zolpidem,zaleplon...;prescrivere!!!

– all’appuntamento ,almeno mezz’ora prima( 1 h...)

Sedazione durante intervento;iatrosedazione,farmacosedazione controllo del doloreDurata del trattamentoControllo del dolore ;intraop postop :prescrizione:analgesici,antibiotici,ansiolitici se necessari,

Riduzione dello stress

ansia

dolore

Ambiente

Durata

attesa

STRESS

Sedazione:la notte prima,il giorno stesso,approccio psicologico,ecc,ecc

Analgesia;oppioidi,N2O,A.L.

Musica,relax,TV,distrazione,

minimizz

are

Avere le cose giuste

Attrezzature e farmaci

Farmaci essenziali • Ossigeno;bombola da 5 lt,come minimo,200 atm,con va e

vieni ,mascherina facciale ,occhialini nasali– 3 maschere facciali adulti,piccola,media ,grande

Adrenalina,fiale da 1 mg :FASTJECT 2 ml,siringa preriempita,iniett(77 £):330 microgr o 165 microgrVideo prodotto dall'Allergopharma che illustra come usare l'adrenalina auto iniettabile (Fastjekt) in caso di shock anafilattico.

• Nitroglicerina:cp sublinguali 0.3-0.4 mg,Carvasin 5 mg ,Natispray• Antistaminico:clorfeniramina(trimeton) fiale 10

mg,Prometazina(farganesse 50 mg)• Albuterolo,salbutamolo(Ventolin)• Aspirina;cp 160-325 mg

Farmaci essenziali farmaco indicazioni Dose iniziale(adulti)

ossigeno sempre Inalazione 100% Bombol,maschere,ambu

adrenalina anafilassi 0,1 mg ev;0.5 mg i.m. Fiale,penna

Asma che non risponde al salbutamolo

0,1 mg ev;0.2—0.5 mg i.m.

Arresto cardiaco 1 mg ev

Fastjekt anafilassi Siringa preriempita 330 0pp 165 microgr ,im.

Nitroglicerina(Trinitrina 0.3,carvasin 5 mg)

Dolore anginoso 0.3-0.4 mg,sublinguale Cp,fiale

Natispray,sublinguale)

Clorfeniramina/Trimeton)

Reaz.allergica 10 mg ev,i.m. fiale

Salbutamol(ventolin) broncospasmo 2 puff,spray inalatorio bombolette

aspirina Infarto miocardico 160-325 mg,p.os cp

Fonte di carboidrati ipoglicemia Succo di frutta ,100-150 ml:;caramelle,zollette di zucchero....

bottiglia

Altri farmaci per emergenzafarmaco indicazione Dose iniziale adultoatropina Bradicardia

significativa,attacco vaso vagale

0.5 mg ev,im

efedrina Ipotensione significativa 5-10 mg iv,10-25 mg imidrocortisone Insuff.surrenalica 100-200 mg iv o im

anafilassi 100-200 mg iv o im

Morfina o protossido d’azoto(N2O)Buprenorfina

Dolore anginoso che non risponde all NTG

2 mg ev,3-5 mg imInalazione al 30-35% con O20.15-0.3 mg subling o im o ev

Lorazepam(Tavor) Crisi epilettica ,attacchi di panico

4 mg i.m o ev lentaCp per os 1 mg

Midazolam Crisi epilettica 5 mg i.m. o evranitidina Anafilassi,allergia 50 mg ev o 150 mg p.osOndansetron(zofran) Nausea,vomito 4 mg,iv o im

Maschera con reservoir

• http://youtu.be/nEbsKfLl1n4

• Acquisti materiale consumabile;doctorshop,doctorpoint

autorizzazione acquisto FU-3.doc

SIAD Ozzano Emilia via Libertà 17 www.siad.com

• ALLEGATO 3 – DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE (ai sensi dell’art. 46 del D.P.R. 28/12/2000, n. 445)• • • Il/la sottoscritto/a……………………………………………………………………………..• • • Responsabile dell’Ente di Soccorso/Studio Medico…………………………………………..• • • con sede in……………………………………………………………………………………….• • • Partita IVA/C.F…………………………………………………………………………………• • • • Consapevole delle sanzioni penali, nel caso di dichiarazioni non veritiere, di formazione o uso di atti falsi, richiamate dall’art. 76 del DPR n. 445/2000• • • DICHIARA• • di essere soggetto autorizzato al rifornimento all’ingrosso di gas medicinali e di impiegare gli stessi sotto la propria sola responsabilità.• • • • • In fede• • ………………………………………………..• • Luogo, Data ………………….,……………….•

• buongiorno,• non possiamo vendere medicinali a studi medici che non abbiano sottoscritto

l’allegato che Le inoltro...• • Riesce ad inoltrare ai due medici il modulo, facendomelo poi avere via e-mail o

via fax allo 051 796026?• Grazie mille• • Massimiliano Lucchina• Servizio Vendita• • SIAD S.p.A. | I-40064 Ozzano dell'Emilia (BO) - Via della Libertà, 17• Tel. +39 051 799399 | Fax +39 051 796026• massimiliano_lucchina@siad.eu | www.siad.com

Bombola di ossigeno

• 5 litri,200 atm=1000 litri• Se usate 6 lt/min ce n’è per 166 min......• Guardate la pressione;quando è ,per es, a 80

atm,significa che ci sono ancora 400 lt...• A 20-30 atm è meglio sostituire con una altra

piena.

La valigetta degli orrori set di rianimazione completo di: bombola ricaricabile di ossigeno da 0,5 LT in acciaio, riduttore con manometro ed erogatore, pallone rianimatore, maschera rianimazione, 2 cannule di Guedel, pinza tiralingua, apribocca elicoidale, tubo atossico, in contenitore plastico antiurto.

FARMACI UTILI NELLO STUDIO ODONToIATRICODI maria/Niso,Roma

• ADRENALINA fiale da i mg • Anexate fiale da o,5mg (c’è anche da 1 mg)• Aspirina compresse effervescenti • Atropina fiale da 0,5 mg• Bentelan 4mg• Carvasin compresse sublinguale• Catapresan fiale• Emagel 500 1• Flebocortid da 500mg (almeno 2) o Solu-medrol 500mg (almeno 2)• Lasix fiale• Midazolam o ipnovel fiale da 5 mg• Nifedicor gocce• Ranidil fiale• Sol fisiologica in fiale da 10 cc e per fleboclisi ,250 o 500 ml • Tranex fiale• Trimeton fiale e/o Farganesse fiale• Valium o simili in gocce• Ventolin o Broncovaleas puff

Diluenti dei cortisonici

• Il bentelan contiene:Fenolo, sodio cloruro, sodio metabisolfito, sodio edetato, acqua p.p.i.

• SOLDESAM SOL. INIETTABILE e SOLDESAM FORTE SOL. INIETTABILE: fenolo, sodio citrato biidrato, acido citrico anidro, acqua per preparazioni iniettabili

• Solucortef;sodio fosfato,alcool benzilico • Flebocortid ; una fiala di polvere contiene: sodio fosfato,

Metile–p–idrossibenzoato, Propile–p–idrossibenzoato.• Una fiala di solvente contiene: sodio cloruro, acqua per

preparazioni iniettabili.

Plasma expander

• Le gelatine hanno più reazioni allergiche degli amidi;quindi preferirei come plasmaexpander il Voluven o similari.....,;comunque visto che l’uso sarà eccezionale,la differenza probabilmente non esiste.....

Precauzioni d’uso ;effetti collaterali

• NTG:paziente semisdraiato o supino(ipotensione!!!)

• Albuterol(Ventolin);tachicardia,ipertensione• Aspirina:masticare prima di deglutire

Altro materiale per emergenza( e non solo)

• Stetoscopio• Apparecchio misuratore di pressione• Siringhe;2,5,5,10 ml• Aghi monouso:22g,20 g• Fleboclisi 250-500 ml,plastica,pvc• deflussori• Cateteri e v 22 g,20 g. • Defibrillatore automatico(AED)• Pulsossimetro(+NIBP....)• Cannule di Guedel/mayo• Maschera laringea?• Tubo endotracheale,laringoscopio???• Misuratore di glicemia?

Approximate FiO2 delivered by nasal cannula

• Flow rate lt/min approx FiO2

• 1 0.24• 2 0.28• 3 0.32• 4 0.36• 5 0.40

Approximate FiO2 delivered by face mask

• Flow rate lt/min approx FiO2

• 5-6 0.40• 6-7 0.50• 7-8 0.60• A minimum flow of 5-6 lt/min necessary to prevent

rebreathing

Applicare la maschera di anestesia al paziente

The 3 reservoirs of low flow O2 therapy

Pharynx

Mask

Reservoir bag

Approximate FiO2 delivered by face mask with reservoir

• Flow rate lt/min approx FiO2

• 6 0.60• 7 0.70• 8 0.80• 9 >0.80• 10 >0.80

La curva di dissociazione dell’ossiemoglobina

Maschera anestetica(trasparente) applicata al paziente e connessione al circuito di anestesia

Maschera da ossigenoterapia;aperture laterali

Cannule nasali per ossigenoterapia

Allora:sequenza di intervento con ossigeno

• Prevenzione(paziente in RS):occhialini,flusso 1-2 lt/min

• Soccorso(paziente in RS):maschera morbida :flusso 5-6 lt/min

• Emergenza(paziente in RS problematico o apnea);va e vieni(Unità respiratoria manuale,URM):6-8 lt/min,guardare pallone se RS ; se non :assistere manualmente !!!

Mobiletto con farmaci e materiale di emergenza

Un vecchio monitor con ECG,PA,pulsossimetro con saturimetria

Mobiletto per farmaci e cose varie,bombola di ossigeno,defibrillatore automatico

Fissaggio (non ottimale) del catetete ev,rubinetto a tre vie con connettori per farmaci dalle pompa

siringa

Cannula brevettata a 2 vie per somministrazione di ossigeno e campionamento della CO2 espirata

setto che separa le due vie

Curva della CO2 espirata(etCO2)

IL CARRELLO DELLE EMERGENZE(CRASH CART)

Il

Contenuto e composizione del carrello delle emergenze

• Minimum Crash Cart Supplies and Drugs • (Based on 2010 ACLS Protocols) • This list is based on the 2011 American Heart Association

Advanced Cardiovascular Life Support Provider Manual and does not include Adult Immediate Post-Cardiac Arrest Care.

• Disclaimer:This list was created to show the basic supplies and equipment required for emergency treatment in an ambulatory surgery center while waiting for EMS to arrive and must be reviewed by the anesthesia and medical staff at your facility and approved by the Medical Executive Committee and Governing Board.

Minimum Crash Cart Supplies and Drugs (Based on 2010 ACLS Protocols

• Defibrillator/EKG monitor with external pacing capabilities • or • AED (automated external defibrillator) • Adult Electrode defibrillator pads • Portable suction machine • suction canister • suction tubing • Suction Catheters • Yankauer Suction Tip • Clipboard, code worksheets, ACLS algorithms • Electrode pads/ Defibrillator Pads • Trach Tray; Cuffed Tracheostomy Tubes: Shiley • Adult Cricothyrotomy Kit • Cardiac backboard • Ambu bag with adult mask • Portable 02 tanks • Adult Face Mask non-rebreather • Nasal Cannula • Nebulizer Kit • Airway Patency: • Nasopharyngeal Airways, assorted sizes • or • Oropharyngeal Airways: assorted sizes • Airway Management: • Advanced: • Laryngoscope handle and assorted blades • C-Batteries for laryngoscope • Endotracheal Tubes:Assorted sizes, Cuffed and uncuffed • Stylet • LMA (laryngeal mask airway) - assorted sizes • or • Esophageal-tracheal tube • or • laryngeal tube

• MEDICATIONS

• NAME DOSE ROUTE • Adenosine 6 mg/2ml IV • Albuterol Inhaler 3ml INH • Aspirin 325mg PO • Atropine syringe 1mg/10ml IV • Atropine 0.4mg/ml IV • Amiodarone 150mg/3ml IV • Calcium Chloride 10% syringe IV • Diphenhydramine 50mg/ml IV • Dextrose 50%W 25gm/50 ml IV • Dopamine 400 mg/5ml IV • Epinephrine 1:1,000 amp/ autoinjector IV • Epinephrine 1:10,000 syringe IV • Furosemide 40mg/4ml IV • Hydrocortisone 100mg/ 2ml IV • Lidocaine 2%syringe 100 mg IV • Mag Sulfate 50% syringe IV or IM • Methylprednisolone 125 mg IV • Morphine sulfate Narcotic Cabinet IV • Narcan 0.4mg/ml IV • Nitroglycerine 0.4mg SL • Procainamide 100mg/ml IV • Sodium Bicarb 8.4% 50mEq IV • Sotalol 100mg IV Sterile Water 10ml IV • 0.9% Na chloride 10ml IV • Vasopressin 10units/ml IV • Lidocaine 4% 2gm 500ml IV • IV catheters, tape, alcohol wipes, tourniquets, tongue blades • IO Needles • IV Tubing- primary and piggyback • IV solutions: Lactated Ringers, Normal Saline • Needles, syring

Inizio della laringoscopia

Inizio della laringoscopia;vista frontale

Inserimento della lama del laringoscopia lungo il dorso della lingua mantenendo un leggero sollevamento verso l’alto

Avanzamento della lama del laringoscopio

Avvicinamento alla base della lingua e sollevamento della lama a 45o

Inserimento della lama del laringoscopio nella vallecula,davanti all’epiglottide;effetto fulcro e

visualizzazione della glottide

Avvicinamento alla base della lingua e sollevamento della lama a 45o

Visione laringoscopica diretta :lingua spostata a sinistra

Visione ingrandita laringoscopica

Un catetere endovenoso

IMG_5312.JPG

<iframe src="http://player.vimeo.co

Come è fatta la maschera laringea

Maschera laringea(LMA) in sede

Palloncino spia e condotto per gonfiaggio cuffia

lingua epiglottide

trachea

esofagoAria/O2/anestetico

respirazione

Come si inserisce la maschera laringea

Come si prepara e inserisce la maschera laringea

Basic airway management explanation and practice you tube

• http://youtu.be/I4vyltWT8TU• http://youtu.be/_1x1mOGoYyc• http://youtu.be/4YDg-Ppo81c

http://youtu.be/kzHj5LWtdIo

Training e pratica

•BLS•ACLS

Essere preparati per le emergenze:• Storia clinica del

paziente;anamnesi con aggiornamento ad ogni visita

• Identificazione del paziente a “rischio” ;presenza dell’anestesista o spostamento in altra sede:casa di cura,day surg,Hosp...

• Quando si conferma un appuntamento ricordare ai paz. di prendere le loro medicine!

• Staff preparato per CPR• Piano di emergenza scritto• numero tel di emergenza ad ogni postazione• Kit di emergenza pronto e tutti sanno dove è • Verifica routinaria del contenuto e scadenze

The health history should include information regarding the patient’s past and present health status.

ASA classification of physical status

Estimated Energy Requirements for Various Activities

NYHA

NYHA Classification - The Stages of Heart Failure

In order to determine the best course of of therapy, physicians often assess the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient's quality of life.

Class

Patient Symptoms

Class I (Mild)

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).

Class II (Mild)

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Class III (Moderate)

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Class IV (Severe)

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

NYHA Classification - The Stages of Heart Failure

• In order to determine the best course of of therapy, physicians often assess the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient's quality of life.

• Class Patient Symptoms• Class I (Mild) No limitation of physical activity. Ordinary physical activity

does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).• Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but

ordinary physical activity results in fatigue, palpitation, or dyspnea.• Class III (Moderate) Marked limitation of physical activity. Comfortable at

rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.• Class IV (Severe) Unable to carry out any physical activity without discomfort.

Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

• Class Functional Capacity: How a patient with cardiac disease feels during physical activity• I Patients with cardiac disease but resulting in no limitation of physical activity. Ordinary physical activity does not cause undue fatigue,

palpitation, dyspnea or anginal pain.• II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity

results in fatigue, palpitation, dyspnea or anginal pain.• III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity

causes fatigue, palpitation, dyspnea or anginal pain.• IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the

anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases.

• Class Objective Assessment• A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.• B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at

rest.• C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-

ordinary activity. Comfortable only at rest.• D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

• For Example:• A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe obstruction of the left main coronary

artery is classified:• Function Capacity I, Objective Assessment D• A patient with severe anginal syndrome but angiographically normal coronary arteries is classified:• Functional Capacity IV, Objective Assessment A

Segni vitali

• Prima di ogni trattamento dovrebbero essere misurati i segni vitali:PA,FC,respirazione e temperatura....

Inserire fot Omron

IMG_6728.JPG

Riconoscere una emergenza • Segni e sintomi di emergenza incipiente:– Dolore toracico– Cute pallida– Sudorazione– Vomito(nausea)– RESPIRAZIONE IRREGOLARE– SENSAZIONI STRANE O INSOLITE– Modificazioni delle frequenza e/ o della pressione

Procedure iniziali nell’emergenza• Interrompere la procedura • Chiamare aiuto• Chiamare il kit di emergenza • Valutare lo stato di coscienza:se incosciente,abbassare la poltrona

;trendelemburg• Somministrare O2;se cosciente,occhialini,se incosciente ma

respira maschera ,se incosciente e non respira pallone e maschera

Algoritmo di base

• PABCD• Posizionare• A airway• B: breathing• C:circulation• D:definitivo o diagnosi

Valutare le vie aereeaprire la bocca

estendere il capo e sostenere il mentoimpiegare l’aspirazione se necessario

Valutare la respirazionese non respira,dai due respiri con ossigeno 100%

se in apnea,inserisci la cannula orofaringea chiama per l’AED

Valutare la circolazionecerca il polso;carotide,(radiale)

in assenza di polso,preparati per CPR:mettere il paziente in piano,meglio al suolo ,iniziare MCE

applicare l’AED se c’è il polso,valutare la frequenza e la forza

Distress

• Respiratorio:broncospasmo,asma• Toracico;dolore;angina,MI• Psicologico;agitazione,convulsioni• Prevenire il distress:– Ambiente accogliente,tranquillo,,rilassato– Minimizzare la paura,il freddo– Mantenere PA e FC e respirazione nei limiti.....– Non interrompere la terapia !!!

Valutare il paz. e la situazione:• Controllare i segni vitali del paziente;PA,FC,respirazione,colore..• Non tentare di trasportare il paziente da soli!!!• Chiama immediatamente il 118 se:

– Arresto cardiaco– Arresto respiratorio– incoscienza> 1 min– Stato confusionale prolungato– Dolore toracico > 5 min non alleviato dal venitrin– Difficoltà respiratoria– Convulsioni– Ipotensione grave o tachicardia(???)

• Tratta il paziente in emergenza finchè non arriva il soccorso• Tieni pronta la cartella e quanto fatto finora per la squadra di soccorso• Compila la scheda delle emergenze in studio

What types of emergencies can be expected in the dental office?

Ostruzione delle vie aeree• Segni e sintomi:

– Sensazione di soffocamento,improvvisa;afferrare la gola(segno universale)– Stridore– Tosse violenta– Dispnea,spasmi– Cianosi

• Trattamento:– Tosse forzata– Compressione addominale– Percussione dorsale con paziente curvo in avanti – Ossigenazione – Ispezione delle prime vie aeree:– laringoscopio,pinza di Magill,aspiratore– Chiamare aiuto– Trasferimento in ospedale per broncoscopia in urgenza. How to Perform the Heimlich Maneuver You tube

http://youtu.be/kJDpr05zmB4

• How to Perform the Heimlich Maneuver• Edited by Bob Robertson, Rob S, Nicole

Willson, Travis Derouin and 37 others• Google/wikihow

Airway obstruction management

Asma,broncospasmo• Segni e sintomi:

– Sensazione di soffocamento– Sensazione di peso sul torace– stridore– Tosse– Dispnea– Cianosi

• Trattamento:– Posizionare il paz.seduto,braccia in avanti– Ossigeno– Spray con salbutamol 2 puff;ripeti dopo 5 min se inefficace– Chiamare aiuto– Valutare i segni vitali e riferire al personale di emergenza

• http://youtu.be/kff3co6xwik

• http://youtu.be/EK8nzKzdnIM• http://youtu.be/wlygTaY4ioc

Arresto cardiaco

• Segni e sintomi:• Non risponde• Non respira• Non ha polso• Trattamento:

– Mettere il paz supino;tavola sotto il torace o stendere sul pavimento;

– Chiamare aiuto– Attaccare AED e seguire le istruzioni– Iniziare CPR– Ossigenare ;ventilazione con pallone e maschera

• http://youtu.be/I-eFjl2G9vg

Angina

• Segni e sintomi:– Dolore o sensazione di oppressione sottosternale ,irradiato

alle spalle,dorso,epigastrio,collo,mandibola…..– sollievo con NTG...si spera....

• Trattamento:– Seduto – NTG sublinguale ogni 5 min:Natispray sublinguale – Ossigeno– Chiamare aiuto– Valutare i segni vitali e riferire al personale di emergenza

Infarto miocardico• Segni e sintomi:

– Dolore o sensazione di oppressione sottosternale ,irradiato alle spalle,dorso,epigastrio,collo,mandibola…..

– Mancato sollievo con NTG – Dispnea,sincope,diaforesi,morte improvvisa

• Trattamento:– Seduto – NTG sublinguale ogni 5 min– Ossigeno– Aspirina 165-325 mg.– Analgesico:morfina???buprenorfina??N2O??– Chiamare aiuto– Posizionare AED – Valutare i segni vitali e riferire al personale di emergenza

– MONA:Morfina,ossigeno,nitroglicerina,aspirina

Puntata ipertensiva • Segni e sintomi:

– Cefalea,vertigini,ronzii– Disturbi della vista– Cardiopalmo(tachicardia)– (dispnea)– Epistassi

• Trattamento:– Nifedipina(nifedicor).5-15 gtt sublingualiOpp– Clonidina(catapresan) mezza/1 fiala im o ev lentaOpp– Furosemide(Lasix) 1/ 2 fl im o ev lenta– Ossigenoterapia(occhialini)

Aritmie

• Senza ECG...• ipocinetiche/ipercinetiche

Allergia

– Limitata ad un sistema o generalizzata– Faringe e prime vie aeree;edema angioneurotico– Tratto respiratorio;asma,broncospasmo,stridore– Cute;orticaria,prurito– Anafilassi;tutti i precedenti+collasso cardiocircolatorio

– Segni e sintomi– Prurito,arrossamento,pomfi,edema labbra,mucose bocca,faringe…..– Distress respiratorio,asma,– Ipotensione,polso piccolo,frequente,pallore– Ossigeno– Chiamare aiuto– Valutare i segni vitali e riferire al personale di emergenza

anafilassi

• Posizione supina• Ossigenazione• Adrenalina i.m 0.5mg• Liquidi ev– Antistaminico: trimeton 10 mg im.– Cortisone

• Chiamare aiuto• In caso di arresto,CPR

Sincope vasovagale,svenimento• Segni e sintomi

– Svenimento– Nausea – Debolezza– Pallore– Cute fredda e sudata– Polso rallentato,ma prima tachi– Ipotensione– Discomfort addominale– Midriasi– sbadiglio

• Trattamento– Posizione supina– Elevare gli arti inf– Ossigeno– Monitorizzare – Atropina 0.5 mg i.m. o iv

Fattori scatenanti psicogeni:paura,ansia,stress emotivo,cattive notizie,dolore,specie se improvviso ed inaspettato,vista del sangue,strumenti chirurgici,siringhe...

Fattori scatenanti non psicogeni:Stazione erettaFame da salto del pasto o da dietaEsaurimento,stanchezzaCattive condizioni fisicheAmbiente caldo-umidoAffollamentoSesso maschileGiovani:16-35 anni

Pathophysiology:Stress

Catecholamines release

Decreased peripheral vascular resistance & ↑ blood flow to peripheral muscles

↓ venous return

↓ circulatory blood vol. & drop in arterial B.P.

Activation of Compensatory mechanisms

Reflex bradycardia develops (< 50)

Significant drop in cardiac output associated with fall in B.P below the critical level

Cerebral ischemia & loss of consciousness

Assess consciousness (loss of response to sensory stimulation)Activate office emergency system

P- Position patient supine with feet elevated slightly

A→B→C – Assess & open airway (head tilt &chin lift); assess airway patency& breathing; assess circulation (palpation of carotid pulse)

D – Definitive care:Administer O2

Monitor vital signs

Perform additional procedures: Administer aromatic ammonia

Administer atropine if bradycardia persistsDo not panic!

Post syncopal recovery- delayed recovery-

Postpone dental treatment Activate EMSDetermine precipitating factors

POSTURAL HYPOTENSIONPredisposing factors:• Administration and ingestion of drugs e.g. antihypertensives like sodium

depleting diuretics, calcium channel blockers &ganglion blocking agents, sedatives and narcotics, histamine blockers, levo dopa

• Prolonged period of recumbency or convalescence• Inadequate postural reflex• Late stage pregnancy• Advanced age• Venous defects in legs (e.g. varicose veins)• Recovery from sympathectomy• Addisson’s disease• Physical exhaustion and starvation• Chronic postural hypotension (Shy – Drager syndrome)

Clinical manifestations:• Precipitous drops in blood pressure and lose consciousness whenever they

stand or sit upright • Do not exhibit any prodromal signs and symptoms• May become lightheaded, or develop blurred vision• Clinical signs and symptoms - precipitating drugs• Blood pressure during syncopal period is quite low• Un like vasodepressor syncope , heart rate during postural hypotension

remain at the baseline level or somewhat higher• Consciousness returns rapidly once the patient is returned to the supine

position

Pathophysiology:When patient moves into an upright position

SBP drops and approaches 60 mm Hg in one minute

DBP also drops

Slight changes in heart rate and not at all

Cerebral blood flow drops below the critical level

May lose consciousness

Once the patient is placed into supine position, reestablishment of cerebral blood flow occurs

P- Position patient supine with feet elevated slightly

A→B→C – Assess & open airway (head tilt &chin lift); assess airway patency& breathing; assess circulation (palpation of carotid pulse)

D – Definitive care:Administer O2

Monitor vital signs

Patient recovers consciousness- slowly reposition chair delayed recovery -

activate EMS

Continue BLS as needed and discharge patient

iperventilazione

• Segni e sintomi– Dispnea– Respirazione rapida– Svenimento– Parestesia delle estremità– Palpitazioni

• Trattamento– Calmare– Incoraggiare respirazione lenta– Rebreathing( rirespirazione in un sacchetto di carta)

Epilessia(convulsioni)• Segni e sintomi:

– Incoscienza improvvisa– Apnea transitoria– Cianosi(nella fase tonica)– Movimenti involontari degli arti– Assenza???

• Trattamento:– Assumere decubito laterale– Proteggere dai danni,lasciare spazio,spostare dai pericoli – Monitoraggio dei segni vitali– Ossigeno– Midazolam 5 mg im o iv,– Buccolam 10 mg – MAD???per via nasale

http://youtu.be/7sJMaSOoH88

http://youtu.be/7sJMaSOoH88

ipoglicemia• Segni e sintomi:• Senso di fame

– Parola strascicata,incoerente– Comportamento alterato– Polso rapido– Apprensione,ansia,irrequietezza,aggressività– Disorientamento,perdita di coscienza– Tremori– sudorazione

• Trattamento:– Succo di frutta,caramella,zuccherino pos.– Se è avvenuta perdita di coscienza,glucosio ev.– Nel dubbio tra iper e ipoglicemia,meglio somministrare glucosio comunque!

– destrostick

Riconoscere l’ictus

• Sorridi!o mostra i denti!• Alza entrambe le braccia e tienile alzate!• Dicci una frase semplice

–Alterazioni improvvise!!!!!

cefalea

Perdita vistaImprovvisa confusione

ROSIER scale (Recognition of Stroke In the Emergency Room)

• Appendix G: ROSIER scale• Recognition of Stroke in the Emergency Room (ROSIER)18• Assessment Date: ___________________ Time: ___________________• Symptom onset Date: ___________________ Time: ___________________• GCS E=___ M=___ V=___ BP= ____ / ____ *BG= __________ • *If BG < 3.5 mmol/L, treat urgently and reassess once blood glucose normal

• Has there been loss of consciousness or syncope? Y (-1) ?N (0) • Has there been seizure activity? Y (-1) ?N (0) • Is there a NEW ACUTE onset (or on awakening from sleep)• I. Asymmetric facial weakness Y (+1) ?N (0) • II. Asymmetric arm weakness Y (+1) ?N (0) • III. Asymmetric leg weakness Y (+1) ?N (0) • IV. Speech disturbance Y (+1) ?N (0) • V. Visual field defect Y (+1) ?N (0) ?• Total Score ________ (-2 to +5)• Provisional diagnosis• ?Stroke ?Non-stroke (specify) __________________________• Note: Stroke is unlikely, but not completely excluded if total scores are ≤0.• ROSIER (95% CI) CPSS (95% CI) FAST (95% CI) LAPSS (95% CI)• Sensitivity 93 (89-97) 85 (80-90) 82 (76-88) 59 (52-66)• Specificity 83 (77-89) 79 (73-85) 83 (77-89) 85 (80-90)• Positive Predictive Value 90 (85-95) 88 (83-93) 89 (84-94) 87 (82-92)• Negative Predictive Value 88 (83-93) 75 (68-82) 73 (66-80) 55 (48-62)

Perdita di coscienza e convulsioniStroke Unit

Interferenza con un pacemaker cardiaco

• pacing activity of both pacemakers and the dual chamber ICD ‑was inhibited by

• 1)a battery operated composite curing light at between 2 ‑and 10 cm from the leads.

• 2)The use of an ultrasonic scaler(ablatore) interfered with the pacing activity of the dual chamber pacemaker between 17 ‑and 23 cm from the leads, the single chamber pacemaker at ‑15 cm from the leads and both ICDs at 7 cm from the leads.

• 3) ultrasonic cleaning system, • Roedig JJ, Shah J, Elayi CS, Miller CS. Interference of cardiac pacemaker and

implantable cardioverter defibrillator activity during electronic dental devices use. J ‑Am Dent Assoc 2010;141:521 6.‑

• It has been estimated that one or two life threatening emergencies will occur in the lifetime practice of a general dentist. 

•   Obtaining a health history and a set of vital signs is the first step in identifying the patient likely to develop a medical emergency.  With proper training, thorough preparation, and regular practice, the staff of the dental office will be able to provide appropriate medical care should the need arise.

Summary.

FONTI DI INFORMAZIONE ED AGGIORNAMENTO

ADA courses

• DT DENTAL OFFICE EMERGENCIES• You will receive 2 unit(s) of continuing education credit

upon successful completion of this course. The registration fee is only $76.00

• DESCRIPTION:• This course discusses how the dental office team can

prepare itself to handle medical emergencies.• AUTHOR:• American Dental Association, Continuing Education and

the Council on Dental Practice and Product Development and Sales.

LEARNING OBJECTIVES:

• Upon completion of this course, participants should be able to do the following:– Describe why it’s important to have a dental office emergency plan.– Identify what types of emergency training are important for dental office

staff.– Identify ways in which dental office staff can prepare for medical

emergencies– Identify the steps involved in taking a good health history.– Identify some ways to help alleviate patient anxiety.– Identify some of the symptoms that may indicate an impending emergency.– Identify some components in a dental office emergency kit.– Discuss the importance of recordkeeping in the event of a dental office

emergency.– Describe some of the legal aspects of dental office emergencies.

ADA

• Medical Emergencies in Dentistry: Prevention and Preparation

• Pamela Sparks Stein, DMD• Dr. Stein is on the faculty full-time at the University of

Kentucky College of Medicine and College of Dentistry in both the Dept. of Anatomy and Neurobiology and the Dept. of Restorative Dentistry. She authored the award-winning “Dental Emergency Protocol Manual” and In-Office Emergency Protocol Software Program. Contact her at pam.stein@uky.edu

FINE

Some (simple)calculation:• O2 flow :6 lt/min

• Mask (dead) space:50 ml• Pharynx (dead) space:50 ml• TV:500 ml• RR:20/min,I/E ratio ½• Insp time:1 sec• O2 flow/sec= 100 ml • In the next inspiration( 1 sec) the patient will get 500 ml,of which

50 ml(mask)+ 50 ml (pharynx) + 100 ml (O2 flow in 1 sec) of pure Oxygen:

• Then 200 ml of FiO2 =1 and 300 ml of FiO2= 0.21:Total 260 ml of O2= FinspO2=260/500=0.52 FiO2

Some working variables

• Higher O2 flows may increase FiO2• Lower TV increase FiO2• Larger TV decrease FiO2• Faster RR decrease FiO2• Lower RR increase FiO2• L’equazione completa è un integrale………..

Vt 250 ml,mask

• O2 flow :6 lt/min• Mask (dead) space:50 ml• Pharynx (dead) space:50 ml• TV:250 ml• RR:20/min,I/E ratio ½• Insp time:1 sec• O2 flow/sec= 100 ml • In the next inspiration( 1 sec) the patient will get 250 ml,of

which 50 ml(mask)+ 50 ml (pharynx) + 100 ml (O2 flow in 1 sec) of pure Oxygen:

• Then 200 ml of FiO2= 1 and 50 ml of FiO2 = 0.21:Total 210 ml of O2= FinspO2=210/250=0.84 FiO2

VT 500 ml,nasal cannula• O2 flow :6 lt/min

• Nasal cannula:no (dead) space• Pharynx (dead) space:50 ml• TV:500 ml• RR:20/min,I/E ratio ½• Insp time:1 sec• O2 flow/sec= 100 ml • In the next inspiration( 1 sec) the patient will get 500 ml,of

which 0 from cannula+ 50 ml (pharynx) + 100 ml (O2 flow in 1 sec) of pure Oxygen:

• Then 150 ml of FiO2 = 1 and 350 ml of FiO2 = 0.21:Total 150 +73,5 ml of O2= FinspO2=223/500=0.44 FiO2

Anticoagulazione e chirurgia dentaria • Chest. 2008 Jun;133(6 Suppl):299S-339S.

The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J; American College of Chest Physicians. McMaster University, Hamilton, Ontario, Canada.

• Abstract• This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are

receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S-131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices. The key recommendations in this article include the following: in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C). In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C) . In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and co-administering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

• • Arch Intern Med. 2003 Apr 28;163(8):901-8.

Perioperative management of patients receiving oral anticoagulants: a systematic review.Dunn AS, Turpie AGCONCLUSIONS:• Most patients can undergo dental procedures, arthrocentesis, cataract surgery, and diagnostic endoscopy without alteration of their regimen. • For other invasive and surgical procedures, oral anticoagulation needs to be withheld, and the decision whether to pursue an aggressive strategy of perioperative administration of intravenous heparin or subcutaneous low-molecular-weight heparin should be individualized. • The current literature is substantially limited in its ability to help choose an optimal strategy. Further and more rigorous studies are needed to better inform this decision.• Comment in• Dental procedures can be undertaken without alteration of oral anticoagulant regimen. [Evid Based Dent. 2005]• Oral anticoagulant and dental procedures. [Arch Intern Med. 2003]• Perioperative management of patients receiving oral anticoagulants. [Arch Intern Med. 2003]• The perioperative management of warfarin therapy. [Arch Intern Med. 2003]• J Oral Sci. 2007 Dec;49(4):253-8.• Dental management of patients receiving anticoagulation or antiplatelet treatment.• Pototski M1, Amenábar JM.• Author information• • • Abstract• Antiplatelet and anticoagulant agents have been extensively researched and developed as potential therapies in the prevention and management of arterial and venous thrombosis. On the other hand, antiplatelet and anticoagulant drugs have also been associated with an increase in the bleeding time and risk of

postoperative hemorrhage. Because of this, some dentists still recommend the patient to stop the therapy for at least 3 days before any oral surgical procedure. However, stopping the use of these drugs exposes the patient to vascular problems, with the potential for significant morbidity. This article reviews the main antiplatelet and anticoagulant drugs in use today and explains the dental management of patients on these drugs, when subjected to minor oral surgery procedures. It can be concluded that the optimal INR value for dental surgical procedures is 2.5 because it minimizes the risk of either hemorrhage or thromboembolism. Nevertheless, minor oral surgical procedures, such as biopsies, tooth extraction and periodontal surgery, can safely be done with an INR lower than 4.0.

• PMID: 18195506 [PubMed - indexed for MEDLINE] Free full text• Anticoagulant, Antiplatelet Medications and Dental Procedures• • • Patient Version Dentist Version• Do you take medications like aspirin, warfarin (Coumadin, Jantoven, Marfarin), clopidogril (Plavix), or ticlopidine (Ticlid) to prevent heart attack or stroke, resulting from a blood clot?• These medications make it more difficult for your blood to clot and because of this, you may have trouble with bleeding after certain dental procedures. It may take longer than you would expect for any bleeding to stop. In light of this, you might consider reducing your dosage or stop taking the medications entirely

before receiving dental care. However, it is generally agreed that anticoagulant drug regimens should not be altered prior to dental treatment.1-5 If you stop taking, or take less of, the anticoagulant medication, you increase your chance for blood clot development, which could result in thromboembolism, stroke or heart attack. The risks of stopping or reducing this medication routine outweigh the consequences of prolonged bleeding, which can be controlled with local measures. For example, you may be asked to bite down on sponges treated with a liquid that helps control bleeding.

• Some patients who are taking these anticoagulant medications have additional medical problems that increase the risk of prolonged bleeding after dental treatment. 1 If you have one of these conditions, your dentist may want to refer you to a hospital dental clinic. These medical conditions include:• liver impairment or alcoholism• kidney failure• certain blood disorders.• Talk to your doctor or dentist if you are curious about these medications and how they may affect your dental treatment.• References• 1. United Kingdom National Health Service. Surgical management of the primary care dental patient on antiplatelet medication. National Electronic Library of Medicines. Accessed April 27, 2011.• 2. Douketis JD, Berger PB, Dunn AS. The perioperative management of antithrombotic therapy American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition) . Accessed April 27, 2011.• 3. Grines CL, et al. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents . Circulation 2007;115:813-8. Accessed April 27, 2011.• 4. Nematullah A, Alabousi A, Blanas N, Douketis JD, Sutherland SE. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis . Journal of the Canadian Dental Association 2009;75(1):41-41i. Accessed May 2, 2011.• 5. Armstrong MJ, Gronseth G, Anderson DC, Biller J, Cucchiara B, Dafer R. Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease . Report of the Guideline Development Subcommittee of the American Academy of Neurology.

Neurology 2013;80:2065-9. Accessed May 29, 2013.

The Nature and Frequency of Medical Emergencies Among Patients in a Dental School Setting

Patrick L. Ander, Robin L. Comeau, Michael Hatton, Mirdza E. Neiders.

.J.Dental Education,2010;74;390-396.

• University at Buffalo School of Dental Medicine• Direct correspondence and requests for reprints to Dr. Patrick L. Anders, University at Buffalo School

of Dental Medicine, 355 Squire Hall, Buffalo, NY 14214; 716-829-2241 phone; 716-829-3554 fax; planders@buffalo.edu.

• Received July 23, 2009.• Accepted January 6, 2010.• As health care improves and life expectancy increases, dentists and dental students are treating a growing number of elderly and medically compromised patients, increasing the likelihood of a medical emergency during treatment. Previous studies examining emergencies in a dental setting have relied upon self-reports and are therefore subject to biases in reporting. The purpose of this study was to examine data generated from documentation of CODE-5 medical emergency events at the University at Buffalo School of Dental Medicine over an eight-and-a-half-year period. The incidence of emergencies was found to be 164 events per million patient visits, which is lower than reported in previous studies. Most emergencies involved suspected cardiovascular events, syncope, complications related to local anesthesia, and hypoglycemia. Twenty percent of emergencies involved people who were in the building for reasons other than to receive dental care, underscoring the need for an operational CODE-5 system whenever a building is occupied. We suggest strategies to reduce the incidence of medical emergencies and increase ability to manage those that do occur

Emerg Med J 2008;25:296-300 Prehospital careA state-wide survey of medical emergency management in dental practices:

incidence of emergencies and training experienceM P Müller, M Hänsel, S N Stehr, S Weber, T Koch

• +• Author Affiliations• Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, University of

Technology, Dresden, Germany• Dr M P Müller, Department of Anaesthesiology and Intensive Care Medicine, Carl Gustav Carus University Hospital,

University of Technology, 01307 Dresden, Germany; mp-mueller@web.de

• Accepted 18 November 2007• Abstract• Background: Only a few data exist about the occurrence of emergencies in dental practice and the training experience

of dental practice teams in life support. This study evaluates the incidence of emergencies in dental practices, the attitude of dentists towards emergency management and their training experience.

• Methods: Anonymous questionnaires were sent to all 2998 dentists listed in the Saxony State Dental Council Register in January 2005.

• Results: 620 questionnaires were returned. 77% of the responders expressed an interest in emergency management and 84% stated that they owned an emergency bag. In the 12-month study period, 57% of the dentists reported up to 3 emergencies and 36% of the dentists reported up to 10 emergencies. Vasovagal syncope was the most frequent emergency (1238 cases). As two cardiac arrests occurred, it is estimated that one sudden cardiac arrest occurs per 638 960 patients in dental practice. 42 severe life-threatening events were reported in all 1 277 920 treated patients. 567 dentists (92%) took part in emergency training following graduation (23% participated once and 68% more than once).

• Conclusion: Medical emergencies are not rare in dental practice, although most of them are not life-threatening. Improvement of competence in emergency management should include repeated participation in life support courses, standardisation of courses and offering courses designed to meet the needs of dentists.

• Self-reported preparedness for medical emergencies among dentists in two hospitals in Benin City• PI Ugbodaga, O Ehigiator, AO Ehizele

• Abstract

• Context: Medical emergencies have been known to occur in dental offices and can lead to loss of life if not well managed.Objective: The objective of this study was to assess self-reported preparedness by practicing dentists for management of medical emergencies in Benin City, Nigeria.Methods: A self-administered questionnaire was completed by dentist in a teaching and general hospital in Benin City.Results: Majority of respondent (86.6%) reported to have received either theoretical or practical or both training in medical emergency at undergraduate level. While only 46.7% have had training post graduation.Only 6.7% of respondent have certification in both basic life support and advanced trauma life support, while only 20% participated in emergency drills in the last six months prior to this study. Non availability of emergency kit was reported by 43.3% of the respondent. No respondent knew of the availability of a complete emergency kit. Only adrenaline, oral glucose, diazepam, oxygen and AMBU bag were reported to be availableby 36.7%, 16.7%, 33.3%, 33.3% and 23.3% of the respondents respectively. Only 40% of the respondents felt competent to perform mouth-to-mouth resuscitation.Conclusion: Preparedness for management of medical emergencies was found to be inadequate among the surveyed dentists. The need for improvement of the training of practicing dentists in the management ofmedical emergencies at the undergraduate, postgraduate, and continuing education levels as well as the need for organization of the dental workplace to handle such emergencies cannot be overemphasized.

• Keywords: Medical emergency, preparedness, Competence, Dentists

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trans position of great arteries, tetralogy of fallot• Surgically constructed systemic pulmonary shunts

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