13 Management of Medical Emergencies

Abstract

Medical emergencies do not discriminate. They may occur at any time to anyone. They happen every day and may vary widely in their severity. As their name suggests, emergencies occur unexpectedly and bring about stress to the entire dental health care team. Preparation and practice are the keys to better manage medical emergencies. Understanding why medical emergencies happen, how best to prepare for them, and how to manage them efficiently as a team will help alleviate stress placed on the team during a real crisis. This chapter provides important information for the dental practitioner to aid in the diagnosis and treatment of common medical emergencies encountered in dental practices utilizing the commonly employed principles of prevention, organization, recognition, and stabilization. There is a critical window of time from when the medical emergency first begins until the emergency medical personnel arrive at the office to provide support. It is this important period of time that the dental health care team must be prepared for. They must understand how to manage the patient. The information is provided in a concise and clear manner that facilitates retention of key concepts which may be useful in a medical emergency

Introduction

This chapter provides important information for the dental practitioner to aid in the diagnosis and treatment of common medical emergencies encountered in dental practices utilizing commonly employed principles of prevention, organization, recognition, and stabilization.

There are four medical emergencies that occur most commonly in a dental practice setting. These are as follows:

  • Syncope (most common).

  • Allergy.

  • Angina.

  • Postural (orthostatic) hypotension.

These four emergencies constitute nearly 75% of all office-based medical emergencies.

Why Medical Emergencies Occur and How to Avoid Them

  • Fear: Recognize that most patients do not enjoy visiting the dentist.

  • Stress: Investigate strategies that will reduce patient stress (behavioral, pharmacologic).

  • Allergies: Investigate adverse drug reactions and avoid using or prescribing these meds.

  • Drug interactions: Develop a deeper understanding of commonly used medications in the dental office.

  • Medically compromised patient:

    • Consult, when needed, with the patient’s physician to develop best practices in managing these difficult patients.

    • Consider shorter morning appointments when patients might be feeling better.

How can the Dental Provider Prevent Medical Emergencies?

  • Prevention:

    • Obtain a complete medical history.

    • Record and review patient’s vital signs.

    • Evaluate the current status of each of the patient’s medical comorbidities.

    • Contact the patient’s primary physician to further explore the current status of each of the patient’s medical conditions.

  • By evaluating the current status of each medical condition, the practitioner not only becomes more confident in managing the patient’s dental problems but also takes steps for preventing medical emergencies in the dental office.

  • A complete medical history is the foundation of investigating a patient’s current health status.

  • Record vital signs:

    • Blood pressure (BP).

    • Heart rate.

    • Respiratory rate.

    • Temperature.

    • BP should be recorded at each patient visit.

  • A review of the patient’s health history ought to be performed at each clinic visit to inquire about any changes in medical conditions, new diagnoses, medication changes, or new allergies.

    • Any updates should be noted in the patient’s health record.

Vital Signs

  • When recording vital signs, it is important to have the necessary equipment available.

    • BP cuff (sphygmomanometer) and stethoscope to record BP.

    • Finger palpation and a watch with a second hand to record heart rate.

    • Thermometer or temperature probe to record temperature.

Blood Pressure—Clinical Limitations

  • It is important that each dental office have a clearly written and consistently enforced policy for dealing with elevated patient BPs.

  • Patients with significantly elevated BP are at increased risk of a stroke or cardiac event.

  • Blood pressure ≥ 180/110:

    • Defer elective treatment.

    • Patient should be referred to his/her physician as soon as possible for evaluation and management.

    • If the patient is symptomatic (headache, dizziness, confusion), 911 should be called, emergency medical response should be activated, and the patient should be transported via ambulance to the nearest emergency room or stroke center.

  • Blood pressure ≥ 160/100 but < 180/110

    • May proceed cautiously with emergency/non-elective dental treatment if patient’s elevated blood pressure is asymptomatic.

    • Consider monitoring BP during the procedure with automated noninvasive BP monitor set at regular (5- or 10-minute intervals).

    • Refer patient to his/her physician for appointment within 1 month.

  • Blood pressure ≥ 140/90 but < 160/100

    • Proceed with dental treatment, but encourage patient to see his/her physician for evaluation.

  • Blood pressure < 120/80

    • No contraindications to elective dental treatment.

  • Many patients have complex medical conditions and may be undergoing management with several medical doctors.

    • These patients pose challenges to dental providers, such as:

      • Potential for drug interactions if they are on several medications.

      • Patients may be elderly or more fragile and less likely to tolerate stress.

      • Carry a higher risk of undergoing a medical emergency.

  • Dental providers should be prepared to cancel treatment or postpone treatment based on uncontrolled systemic diseases (BP too high, blood sugar too high or low) even if the patient insists that he/she is okay.

  • The dental provider is ultimately responsible for managing the patient during dental treatment.

  • If the dental provider is not comfortable, treatment should be canceled or postponed.

Stress Reduction to Prevent Medical Emergencies

  • Alleviating patient fears is instrumental in preventing common medical emergencies in the dental office.

  • Taking time to establish good rapport with patients is a worthwhile investment of time. This decreases patient anxiety as the patient feels more comfortable.

  • Appropriate appointment times.

  • Good communication with the patient before, during, and after the appointment/procedure.

  • Profound local anesthesia/pain control.

Scheduling Appointments to Minimize Risk

  • Certain patients may feel better at certain times of the day.

  • Diabetic patients do better with morning appointments.

  • Cardiac patients often feel better in the late morning/early afternoon.

Pain Control

  • Administering profound local anesthesia in appropriate doses is critical for treatment success and helps minimize anxiety and discomfort during procedures.

  • The proper use of effective sedation techniques can help patients tolerate dental procedures, but not every patient is a good candidate for sedation.

  • Certain medical and emotional conditions can interfere with the ability of sedation techniques to be provided in a safe and effective manner.

  • A clinician needs to be trained, licensed, and/or permitted to employ certain sedation techniques.

  • Manage postoperative pain with appropriate prescriptions.

  • Consider nitrous oxide or other sedation techniques, if appropriate.

Cardiopulmonary Resuscitation

  • The first step when initiating cardiopulmonary resuscitation (CPR) is to establish unresponsiveness.

  • ABCDs of CPR.

  • Airway:

    • Head tilt.

    • Jaw thrust (if neck trauma suspected).

  • Breathing:

    • Look for chest rise.

    • Listen for breath sounds.

    • Feel for chest rise.

    • If respirations are absent/inadequate, then provide rescue breathing.

      • Bag valve mask (BVM).

    • Ventilation rate: 1 breath every 5 to 6 seconds (10 to 12 breaths per minute).

  • Circulation:

    • Check pulse.

    • If pulse is absent, then initiate chest compressions.

      • Compression-to-ventilation ratio is 30:2 (rate of 100 compressions per minute).

  • Defibrillation:

    • Automated external defibrillator (AED).

Algorithms for the Management of Medical Emergencies

ACUTE ADRENAL INSUFFICIENCY

Pathophysiology

  • The adrenal glands are located on top of the kidneys and produce corticosteroids and catecholamines.

  • Corticosteroids provide resistance to stress, maintain vascular reactivity, increase plasma glucose, and control metabolism of carbohydrates, proteins, and fats.

  • When exogenous corticosteroids are prescribed (e.g., prednisone), the glands begin decreasing output, become suppressed, and lose much of their ability to respond to stress.

  • When the patient is exposed to a stressful situation such as surgery, the adrenal glands are unable to provide adequate corticosteroids to maintain vascular reactivity, and the BP falls.

Diagnosis

  • Weakness, fatigue, and hypotension induced by surgical stress.

  • Other symptoms include pallor, diaphoresis, nausea, tachycardia, and loss of consciousness.

Position

  • Trendelenburg (supine, but with feet elevated above head).

Treatment

  • The patient should be placed in the Trendelenburg position, intravenous fluids rapidly administered, and hydrocortisone given to augment the inadequate cortisol production of the adrenal glands.

  • Sequence of treatment:

    • Terminate the procedure, activate Emergency Medical Services (EMS)—call 911.

    • Airway, breathing, circulation (ABCs).

    • Intravenous (IV) access if not already available.

      • Give rapid infusion of 5% dextrose with normal saline.

    • Hydrocortisone 100 mg IV or dexamethasone 4 mg IV.

    • Transport to a medical facility or an emergency room.

ACUTE CORONARY SYNDROME—ANGINA PECTORIS

Pathophysiology

  • Angina is a crushing pain in the chest caused by blockage of the coronary arteries.

  • The pain can radiate to areas such as the shoulder, neck, arms, or the mandible.

  • In stable angina, the atheroma retains a relatively stable fibrous cap that prevents the accumulation of blood clot around it.

  • The decreased lumen size leads to pain during times of exertion.

  • In unstable angina, the atheroma may have a ruptured cap that attracts the accumulation of blood.

  • Eventually, a blood clot forms at the site and the blood vessel becomes temporarily occluded at unpredictable time intervals.

  • The occlusion of the artery reduces the blood flow, and therefore oxygen supply to the heart muscle which results in unpredictable angina or chest pain even during rest.

  • Symptoms of both stable and unstable angina occur only when a coronary artery experiences occlusion of 70% or greater of its luminal area.

  • Progressive occlusion of the coronary arteries leads to the “acute coronary syndrome.”

  • Angina is frequently the initial clinical manifestation of this syndrome.

  • However, the occlusion may ultimately result in a myocardial infarction (MI).

  • Hence, there is a continuum in the treatment approach (“ONAM”—oxygen, nitroglycerin, aspirin, morphine).

Diagnosis

  • Vice-like, heavy, squeezing chest pain.

  • Pain may radiate to shoulder, neck, arms, or jaw (mandible).

Position

  • Semi-seated (semi-upright sitting position), loosen tight clothing for patient comfort.

Treatment

  • The first steps in treatment consist of administering oxygen (O2) as well sublingual nitroglycerin to dilate the coronary arteries, increase oxygen delivery, and improve blood flow.

  • This helps decrease cardiac demand while increasing plasma oxygen supply to prevent infarction (death) of the myocardium (heart muscle).

  • Sequence of treatment:

    • Terminate the procedure, pack surgical site, assure patient.

    • Activate EMS—call 911.

    • Administer O2 via nasal mask or cannula at 4–5 L/minute of flow.

    • Constantly monitor vital signs.

    • Administer sublingual nitroglycerin (1–2 sprays or 1 tablet).

      • Repeat at 5-minute intervals for up to two doses.

    • If pain persists after 10 min of onset, assume that MI has occurred, administer morphine sulfate 1.5–3.0 mg/5 minutes, and treat as MI with a dose of aspirin 160–325 mg as well as additional morphine as needed.

    • Transport to hospital.

ACUTE CORONARY SYNDROME—MYOCARDIAL INFARCTION

Pathophysiology

  • The acute coronary syndrome develops because of fatty deposits (atherosclerotic plaques) within the coronary artery walls.

  • Eventually, this deposit may lose its capsular cover and a blood clot may form which permanently and completely occludes the artery.

  • Subsequent ischemia leads to death or necrosis of the area of the myocardium supplied by the artery.

Diagnosis

  • Usually heavy, squeezing chest pain that does not respond to nitroglycerin.

  • Twenty percent of MI patients have no pain but exhibit nausea, vomiting, weakness, anxiety, and cardiac dysrhythmia.

  • Hypotension is often seen in these patients.

Position

  • Semi-reclined, loosen tight clothing for patient comfort.

Treatment

  • Treatment of the acute coronary syndrome follows the acronym “ONAM” and begins, just like the treatment of presumed angina, with the administration of oxygen and nitroglycerin.

  • These measures are followed by the administration of aspirin and morphine.

  • The morphine provides pain relief, a feeling of euphoria, and vasodilation, which diminishes the volume of blood returning to the compromised heart.

  • Nitroglycerin and oxygen dilate the coronary arteries and increase oxygen delivery, respectively, thereby reducing the area of tissue necrosis.

  • The aspirin helps in preventing the platelets from aggregating, which could cause further clotting and coronary blockage.

  • Sequence of treatment:

    • Activate EMS—call 911.

    • Administer O2 by face mask.

    • Start IV.

    • Constant monitoring of vital signs.

    • If nitroglycerin has not been given already, give one dose sublingually (spray or tablet) with second dose in 5 minutes, and a third dose in another 5 minutes.

    • Morphine sulfate 1.5–3 mg increments every (q) 5 minutes.

    • Aspirin 160–325 mg tablet, chew and swallow (½ to 1 tablet).

    • Monitor for bradycardia, hypotension, dysrhythmia, and be prepared to treat.

    • Transfer to hospital.

ALLERGIC REACTION TO DRUGS

Pathophysiology

  • When an allergen enters the body, certain white blood cells (plasma cells) make antibodies that attach to mast cells.

  • Allergens can be virtually any foreign substance, from pollen or grass to the latex in medical gloves.

  • When the same allergen enters the body again, the allergen becomes attached to two adjacent antibodies on a mast cell, and inflammatory chemicals such as histamine are released to induce profound vasodilation and bronchoconstriction.

  • Mild reactions usually manifest as a skin reaction without other systemic signs or symptoms.

  • Anaphylaxis is the most severe of allergic reactions and results from the uncontrolled release of histamine.

  • Severe reactions (anaphylaxis) manifest with all signs and symptoms of allergic reaction with skin rash, watery eyes and nose, abdominal cramps, wheezing, tachycardia, and hypotension.

  • Bronchoconstriction and vasodilation in anaphylaxis may trigger life-threatening dyspnea and hypotension, respectively.

Diagnosis

  • Rash, itching, hives, swelling, sneezing, coughing, wheezing, nausea, light-headedness, and hypotension.

Position

  • Horizontal (supine) or slight Trendelenburg.

Treatment

  • The first and life-saving step in management of a severe allergic response is giving epinephrine.

    • Epinephrine’s beta-2 (β2) activity dilates the constricted bronchioles.

    • Its beta-2 (β2) activity constricts blood vessels and helps control hypotension.

  • Additional treatment includes administering antihistamines such as diphenhydramine (Benadryl®) to combat some of the histamine-induced components of the allergic reaction, including rashes and itching.

  • In addition, a potent steroid (such as dexamethasone) is given to counteract other effects like swelling of the airway, throat, lips, and eyelids.

  • Sequence of treatment for mild reaction (e.g., rash) usually seen > 1 hour after drug is administered:

    • Benadryl® 50–100 mg IV.

    • Follow with Benadryl® 50 mg by mouth (PO) four times daily (qid) for 2 days.

  • Sequence of treatment for severe reaction (e.g., anaphylaxis)

    • Activate EMS—call 911.

    • Maintain chest-rising breaths with AMBU®-bag hand ventilation and, if possible, establish a fixed airway using endotracheal intubation or a laryngeal mask.

    • Administer O2 at a flow of 4–5 L/minute.

    • Provide IV fluid if possible.

      • One liter (L) of lactated Ringer’s (LR) solution is best, though normal saline or other electrolyte solutions may also suffice.

    • Administer epinephrine 1:1000 concentration, 0.3–0.5 mg subcutaneous (SQ), intramuscular (IM) [tuberculin syringe] at 10–20 min intervals.

    • May also opt for epinephrine 1:10,000 titrated to patient response with increments of 0.2–0.5 mg IV (2–5 mL) repeated at 2–5 minute intervals as needed.

    • Benadryl® 50 mg IV: follow with Benadryl® oral dose (50 mg) for 2 days as mentioned above for mild reactions.

    • Dexamethasone 4–8 mg IV or IM.

    • Be prepared to treat:

      • Upper airway obstruction with intubation; in rare cases cricothyrotomy must be considered.

      • Hypotension.

      • Seizures.

    • Transfer to hospital and observe as an inpatient for 24 hours.

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Dec 8, 2021 | Posted by in General Dentistry | Comments Off on 13 Management of Medical Emergencies

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