9/28/2018 - Bosack · ASA physical status classification 28 Definition I Normal, healthy patient II A patient with mild systemic disease No functional limitation ... Root apex locators

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Medical Emergencies

Compromised Dental Patients2018 update

Robert Bosack, DDS

• Start with the understanding that most patients come in healthy.• Dental guilt – “you did something to cause the problem”• Patients are “sicker”• life-style choices / inadequate medical care

• Start with the understanding that most patients come in healthy.• Dental guilt – “you did something to cause the problem”• Patients are “sicker”• life-style choices / inadequate medical care

Expectationsof dental professionals

1. Identify and understand patient disease2. Identify and understand medications3. Determine if patient is stable4. Stratify risk of procedure in light of co-morbidity,

consult as needed5. Identify need for and implement Tx modifications6. Predict and prepare for medical emergencies

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Flaws of medical training in dental schools

1. Depending on medical clearance without asking theright questions or understanding the implications ofthe recommendations

2. MD does not understand dental procedure forwhich they are providing clearance

3. DDS cannot shift responsibility to MD for theiractions

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• Survey emailed to 20,000 DDS / 530 responses (2.8%)• Most emergencies could have happened anywhere• Top 3 emergencies

1. Syncope (40%)2. Epinephrine reaction (37%)3. Postural hypotension (34%)

• 95% had medical emergency kits• Oxygen (95%)• Epi auto-injectors (83%)• AED (75%)

• Survey emailed to 20,000 DDS / 530 responses (2.8%)• Most emergencies could have happened anywhere• Top 3 emergencies

1. Syncope (40%)2. Epinephrine reaction (37%)3. Postural hypotension (34%)

• 95% had medical emergency kits• Oxygen (95%)• Epi auto-injectors (83%)• AED (75%)

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“medical clearance”

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ObesityCOPD120 pack-yearsSOB at restType 1 DMLiver / Kidney transplantOSA without CPAPHTNLegs wrappedOrthostatic intolerance

ObesityCOPD120 pack-yearsSOB at restType 1 DMLiver / Kidney transplantOSA without CPAPHTNLegs wrappedOrthostatic intolerance

≠ “mother may I ?”≠ “can I use epinephrine ?”≠ “mother may I ?”≠ “can I use epinephrine ?”

• “is your patient medically optimized”• Do you have any concerns…. ?”• “is your patient medically optimized”• Do you have any concerns…. ?”

NO

YES

Should you call911 ??

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Have you rehearsed this lately ?

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Will you be nervous ?Should you be nervous ?Will you be nervous ?Should you be nervous ?

When should you call ?When should you call ?

Who will come ?• Police• EMT – Basic• EMT – Intermediate• EMT – Paramedic

Who will come ?• Police• EMT – Basic• EMT – Intermediate• EMT – Paramedic

What should you say ?Calls are recordedKeep records

What should you say ?Calls are recordedKeep records

Why might you delay calling?Why might you delay calling?

Maybe things will get betterEmbarrassmentLegal worries – “dental guilt”“911 Penalty”

The call to 911

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Indications for the calllist is NOT complete

• Difficulty in breathing – short of breath– Asthma, unresponsive to bronchodilators– Allergic reaction, rapidly progressing

• Chest pain (not responding to NTG?)• Loss of consciousness (syncope?)– Inability to converse

• Sudden, severe headache or dizziness• Stroke

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Wouldn’t it have been better ifwe knew – ahead of time! –

that the patient was prone tosyncope ?

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Syncope – fight or flight, gone awry

Syncope

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1 second 13 secondsHow long will this last?

Syncope: Treatment• Recognize, stop, protect• Supine / Trendelenburg• O2• Ammonia vaporole ?• Monitor duration of recovery• If worried – 911, check history for hints– Primary seizure disorder– Local anesthetic overdose– Stroke– Allergy– MI

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Syncopeprobably not worrisome

• Sudden, full recovery, otherwise healthyteens• Feels bad, then pass out, no pain• 1% of all ER visits, 35% admission – no further

Dx, $500M

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Syncopecould be worrisome !• Elderly• Occurs when supine• No warning• Any underlying CV disease– Arrhythmia – no warning– Medications

• Prolonged recovery or seizure• Any pain / shortness of breath

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Continue to treat after syncope?

• Use your own judgment• Try to finish as case indicates• Was patient in pain ?• Poor anesthesia ?• Poor rapport ?• Wait 24 hours ????

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Have a PlanHave a Plan

“Emergency”Serious

UnexpectedSudden

DangerousImmediate action

Rare

Threshold for use of the term?

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“Emergency”Serious

UnexpectedSudden

DangerousImmediate action

Rare

Simple, easy to follow, visible, structured, habitual team response

Most “emergencies” shouldbe preventable !

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Because you can pick yourpatients!!!

Because you can pick yourpatients!!!

Just bad luckJust bad luck

OR, did you do something to provoke it !!!OR, did you do something to provoke it !!!

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Patients are sicker !

And scope is increasing !!23

Can your patient tolerate your plannedtreatment?• What are you going to do– Impressions– Use a vasoconstrictor• Crown prep with local anesthetic• Painful RCT• Extraction with flap

• How sick is your patient?– Resilience• Can they tolerate pain ? fight or flight?• Status of coronary arteries

– Reserve• Can you climb a flight of stairs?

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The medical evaluation• Patient fills out form + dialogue

• Detect undiagnosed or poorly controlled disease• Medical consultation prn• Assign ASA status• Refer to MD, refer to OMFS

• Prevent (avoid) medical emergencies• MI, asthma attack, seizure, hypoglycemia

• Develop a tx plan consistent with patient’smedical status

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Suspicion clinches diagnosis• ASA status -• Height / weight / BMI• Airway Risk Factors = DiseaseRisk Factors = Disease

Smoke, drink, sedentary lifestyle, poor dietary choices, obesity, older than stated ageSmoke, drink, sedentary lifestyle, poor dietary choices, obesity, older than stated age

• DM : CAD• HTN : CAD• Obesity : HTN, DM• Smoke : COPD, Cancer

• DM : CAD• HTN : CAD• Obesity : HTN, DM• Smoke : COPD, Cancer

ASA physical status classification

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Definition

I Normal, healthy patient

II A patient with mild systemic diseaseNo functional limitation

III A patient with severe systemic diseaseFunctionally limited

IV A patient with severe system diseaseConstant threat to life

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I

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RiskDisconnectPractice drift

RiskDisconnectPractice drift

Cardiovascular System• Diseases– Hypertension– Blood Thinner– Prosthetic Valves– Pacemakers / defibrillators – CIED’s– Recent MI / stents

• Risk Assessment• Emergencies

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Hypertension• BP > 120 / 80 mmHg– Damages blood vessels– Damages heart muscle and valves– Can exacerbate bleeding

• LIMIT IS 180/110 mmHg• Take BP on all patients

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Worry about• Increase myocardial demand• Plaque rupture• Hemorrhagic stroke• Prolonged bleeding

Worry about• Increase myocardial demand• Plaque rupture• Hemorrhagic stroke• Prolonged bleeding

Bleeding

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Blood Vessel Damage Vasoconstriction Platelet Plug Clot Formation

Causes:• Biologic variation• Poor technique• Patient on blood thinners• Antiplatelet drugs• Warfarin• Direct Acting Oral Anticoagulants

Prior clotRisk of clot

Brain (stroke)Heart (MI)Lungs (PE)

A-fibProsthetic valves

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Blood “Thinners”1. Antiplatelet drugs– Aspirin– P2Y12 inhibitors

• Clopidogrel (Plavix™)• Prasugrel (Effient™)• Ticogrelor (Brilique™)

2. Warfarin– INR measures,

• Slow drug !!3. DOAC

– Can’t measure, no reversal– Thrombin inhibitors

• Dabigatran (Pradaxa™)– Xa inhibitors

• Rivaroxaban (Xarelto™)• Apixaban (Eliquis™)• Edoxaban (Savaysa™, Lixiana™)• Betroxaban (Bevyxxa™)

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Management concepts:1. Risk of clot > risk of bleeding2. Do NOT stop or ask to stop these drugs

• Unless very high risk of unaccessable bleeding3. INR should be “therapeutic” – must know on day

• 2 – 3 for all situations• 2.5 – 3.3 for prosthetic mitral valves, recent clot ?

Surgicel Nu-Knit888-596-7973 – Medex Supply $1100 or $7.66 each

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Prosthetic Valves, etc.premedication guidelines

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Some indications:1. Prosthetic cardiac valves2. Hx of endocarditis3. Cardiac transplant with regurg.4. Unrepaired or unsatisfactorily

repaired cyanotic heart defects

For dental procedures that cause bleeding.

https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis

2 grams amoxicillin2 grams cephalexin600mg clindamycin500mg azithromycin

Pacemaker - defibrillator

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Questions:1. Is your MD satisfied with the functioning of the device ?2. Do you follow up with your pacemaker clinic ?

Avoid:1. Electrosurgery / electrocautery

The following devices should be OK, check product literature1. Ultrasonic scalers2. Pulp tester3. Root apex locators4. Curing lights

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Coronary Artery Disease

• Hardening, narrowing or dysfunction of coronary vessels• Decreased flow, decreased blood supply

– Stenotic – fixed lesion• Fairly steady course

– Thrombotic – acute• Variable, unpredictable

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Atherosclerosis

monocytes) Treatment• Diet, exercise, no smoke – no drink – no salt• Vasodilators• Stents

• Bare metal (early (1 mo.)) risk of re-thrombosis• Tend to close back up earlier

• Drug eluting• Prolonged risk of re-thrombosis• Last much longer without closing up

• BYPASS surgery

Recent MI (60 days)Recent stent (1 year)

• Consult mandatory• Cardiac damage– Muscle or electrical system

• Stent can be thrombogenic for first year– Avoid elective surgery ?

• Do not stop blood thinners

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American Heart AssociationRisk Assessment

• Major predictors – cancel all– Unstable coronary syndromes– Decompensated heart failure– Arrhythmia –• Fast heart rhythms• Symptomatic ventricular rhythms

– Severe valvular disease• Aortic and mitral

– Recent pacemaker

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AHA “risk assessment”• Intermediate predictors– Mild chest pain– Prior MI– Compensated HF– Diabetes– Renal insufficiency

• Functional capacity– 1 flight of stairs ? - then OK

• Nature of surgery– Dental is minor– Major implant work IS NOT MINOR

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Chest pain /MI• You won’t be able to tell the difference unless sudden death• Angina– Stable (fixed plaque)– Unstable (random emboli)

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Management1. Stop2. Reposition to semi-recumbent3. 100% oxygen (NRB)4. Vital signs5. Chew ASA, do not swallow

1. Avoid with ASA allergy2. 160 – 325mg

6. Call 911 – give NTG if patient uses it

Management1. Stop2. Reposition to semi-recumbent3. 100% oxygen (NRB)4. Vital signs5. Chew ASA, do not swallow

1. Avoid with ASA allergy2. 160 – 325mg

6. Call 911 – give NTG if patient uses it

DO NOT GIVE NTG• if systolic BP < 90mmHg• If patient takes Viagra, etc.

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BLS update – 2016, adult• Scene safety• Unresponsive – call for help + AED• Patient on back, flat firm surface• Carotid pulse check– Signs of circulation, signs of breathing

• 30 /2– 2” to 2.4”, 100-120/min– Ventilate to chest rise

• AED

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Scene safetyUnresponsive –

Carotid pulse check

30 /2

Ventilate to chest riseAED –

BLS update – 2016, 1 –

Defibrillation• Necessary for survival from SCA• Chances of success 10% for each minute of

delay• 350,000 deaths per year from SCA• SCA - #1 killer, 70% outside the hospital• Response time 5 – 10 minutes?• AED can save up to 200,000 lives/year

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Chest pain in young adultsnew onset or “checked off on history form”

• Frequent trigger for ER visits (8 million)• 1% of ACS patients are < 40 yrs

– Underlying process could be benign or life threatening– Thorough evaluation and risk stratification

• WHEN IN DOUBT, send it out !• Most common cause of acute chest pain in young

adults– Chest wall pain – costochondritis– Anxiety disorders (panic attacks)– GERD

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Chest pain in young adultsnew onset or “checked off on history form”

• Frequent trigger for ER visits (8 million)• 1% of ACS patients are < 40 yrs

– Underlying process could be benign or life threatening– Thorough evaluation and risk stratification

• WHEN IN DOUBT, send it out !• Most common cause of acute chest pain in young

adults– Chest wall pain – costochondritis– Anxiety disorders (panic attacks)– GERD

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Could be1. Cardiac origin• Acute pericarditis• Myocarditis• Mitral valve prolapse (young females)• Aortic dissection

2. Hypertrophic cardiomyopathy (1/500)3. Respiratory – pneumothorax / pulmonary embolism4. Cocaine• Platelet aggregation, coronary vasoconstriction

and increased myocardial oxygen demand

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Breathing difficultyShort of breathAir hungerDyspnea

• Asthma– Avoid tx with recent exacerbation

• Heart attack – “soft” symptoms• Foreign body aspiration–Must account for all instruments–Must refer with loss down the throat• Stomach• Trachea

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Asthma“stepwise” classification and management

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Intermittent Persistent

Mild Mild Moderate SEVERE

Sx frequency < 2 / week > 2/week Daily Continuous

Exacerbations > 2 week> 1 night-time/month Frequent

Night-time Sx < 2 / month > 2 / month > 1 night / week Frequent

FEV1 > 80% > 80% 60 – 80% < 60%

β adrenergic Short acting Short acting Short + long acting Short + long acting

Steroids Inhaled Inhaled Inhaled + Oral

LeukotrieneInhibitors YES YES YES

Cromolyn prn prn

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Breathing Disorders - Asthma:Treatment

• Terminate the procedure• Remove / remediate trigger– Stress, dust, eugenol, monomer

• Give oxygen– Will not reverse spasm

• Call for help• 2 + puffs albuterol inhaler

• IM EPINEPHRINE !

Epinephrine InjectionWith deteriorating condition, failure ofmultiple puffs of inhale and help notimmediately available, 0.3cc (0.3mg) of a1/1,000 epinephrine solution (half thedose for children) and call 911

With deteriorating condition, failure ofmultiple puffs of inhale and help notimmediately available, 0.3cc (0.3mg) of a1/1,000 epinephrine solution (half thedose for children) and call 911

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ADA News 10/16Dr. Larry Sangrik

• Epi-pens– Designed for use by laymen– Can be self-administered– Cost is sky-rocketing

• 2 faults– Device is all or nothing– Dose is fixed at 0.3 or 0.15mg

• Unnecessary financial burden

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Ampule – break, filter needle to aspirate, then change needle and inject.Ampule – break, filter needle to aspirate, then change needle and inject.

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The IM injectionThe IM injection

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Vasoconstrictorslowers pH, burns, delays onset3% plain for mandibular blocks

• Epinephrine– α = β

• Tachycardia• Peripheral vasoconstriction• No change in BP• Better choice for hypertensive patients

• Levonordefrin– α > β

• HTN• Less cardiac stimulation• Better choice for “cardiac” patients

• No interaction with MAOI’s• Possible interaction (HTN) with TCA’s• Definite interaction with non-selective β blockers

– hypertension + bradycardia

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MAOI• Isocarboxazid (Marplan™)• Phenelzine (Nardil™)TCA• Amitriptyline (Elavil™)• Imipramine (Tofranil™)• Doxepin (Sinequan™)• Desipramine (Norpramin™)Non-selective β blockers• Propranolol (Inderal™)• Nadolol (Corgard™)• Labelolol (Normodyne™)

MAOI• Isocarboxazid (Marplan™)• Phenelzine (Nardil™)TCA• Amitriptyline (Elavil™)• Imipramine (Tofranil™)• Doxepin (Sinequan™)• Desipramine (Norpramin™)Non-selective β blockers• Propranolol (Inderal™)• Nadolol (Corgard™)• Labelolol (Normodyne™)

α = peripheral vasoconstrictionβ = central vasodilation and cardiac stimulationα = peripheral vasoconstrictionβ = central vasodilation and cardiac stimulation

Intra-arterial injection

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Intravenous injection

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Sympathetic stimulation

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Sympathetic blockade• Infraorbital nerve– Runny nose– Painful nasal mucosa– Spontaneous resolution in days

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Left Oculosympathetic palsy (blockade)following left mandibular block with articaine

1. Ptosis – drooping of the upper eyelid – loss of symp to superior tarsal muscle2. Upside-down ptosis – slight elevation of the lower lid3. Miosis4. Enopthalmos – impression that the eye is sunk back5. Injected (bloodshot) conjunctiva

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injection into parotid capsulevs. stroke

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Close eyes / SmileClose eyes / Smile Raise eyebrows / SmileRaise eyebrows / Smile

Forehead sparing withcentral lesionForehead sparing withcentral lesion

Forehead notspared withperipheral lesion

Forehead notspared withperipheral lesion

Ocular complicationsmaxillary infiltration & mandibular blocks

• Amaurosis fugax• Mydriasis / miosis• Ptosis• Diplopia• Lateral rectus palsy

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Broken Needle3 bends and they break, every time

• Never bend needle• In and out in a straight line• Never bury needle to the hub• Smaller gauges are easier to break– avoid use of a 30g needle for a mandibular blocks

• Keep calm• Keep patient still, grasp with hemostat• Retrieval is mandatory

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Diabetes Mellitus• Type I– Autoimmune – NO insulin

• Type II– Insulin resistance / deficiency

• A1C

– 3 month “look back” on sugar control

• Blood sugar should be 60-110dl/mg• If too high, patient pretty sick• If too low– Bizarre behavior, belligerent, confused– When in doubt, give your diabetic patient SUGAR !!

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A1c Glucose11 310

10 275

9 240

8 205

7 170

6 135

5 100

psychiatric diseasesubstance abuse

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What to look for….

• Ensure ongoing successful medication and therapycompliance– Engaged ?– “Steady-Eddie” medication• No overdose or withdrawal

• Continue all drugs into perioperative period– Drug interaction?

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“Suspected” substance abusemanagement concerns

• Refuse treatment– With any acute drug exposure– Signs of agitation, withdrawal, skittishness– “soft calls”– “Suspicion clinches diagnosis”

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How old is too old?Does old = sick ?

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Less reserve, NOT noticed at rest !Less reserve, NOT noticed at rest !

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When the source of a fuel cannot be removed from theimmediate area, soaked with water or covered with a water-soluble jelly, the open flow of oxygen or nitrous oxide/oxygenmixtures to the patient should be stopped for 1 minute priorto the use of a potential ignition source and intraoral suctionshould be used to clear the ambient atmosphere of oxidizer-enriched exhaled gas.

When the source of a fuel cannot be removed from theimmediate area, soaked with water or covered with a water-soluble jelly, the open flow of oxygen or nitrous oxide/oxygenmixtures to the patient should be stopped for 1 minute priorto the use of a potential ignition source and intraoral suctionshould be used to clear the ambient atmosphere of oxidizer-enriched exhaled gas.

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• Unexpected patient movement• Sounds – snap / pop• Sights – smoke, discoloration• Smell – burning• Feel - heat

• Unexpected patient movement• Sounds – snap / pop• Sights – smoke, discoloration• Smell – burning• Feel - heat

• Remove burning material from patient• Stop ALL gas• Pat out, pour water• AIRWAY, BREATHING• CO2 extinguisher

• Remove burning material from patient• Stop ALL gas• Pat out, pour water• AIRWAY, BREATHING• CO2 extinguisher

• Fire drills• Time out• Allow alcohol products to dry• Coat hair with water soluble jelly• Open face draping• Stop flow of O2 and N2O for 1 minute before

potential ignition sources

PREVENT

DIAGNOSE

MANAGE

Seizuresabnormal, sudden, excessive, episodic and synchronous neuronal discharge

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• Ensure good control (can drive a car) and compliance with medication• Avoid triggers• Protect from injury - don’t just do something, stand there.

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Angioedema from ACE inhibitors

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• Captopril (Capoten)• Enalapril (Vasotec)• Lisinopril (Zestril, Prinivil)• Ramipril (Altace)• Fosinopril (Monopril)• Quinapril (Accupril)• Benazepril (Lotensin)• Trandolapril (Mavik)

Allergy

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Hives (rash)ItchAngioedema

Watery eyesRunny nose

WheezingThroat swellingDifficulty breathing

Cramping, nausea, diarrhea

Benadryl 25-50mg PO

Albuterol Inhaler

IM EPI 0.3mg

911

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Allergy: Treatment• Mild – refer to ER– Anti-histamine – to block histamine receptors

– Can stop progression, will not reverse symptoms• Diphenhydramine (Benedryl™)– 25-75mg p.o.,– β agonist for bronchoconstriction

• Early and often

• Severe – call EMS– Epinephrine 0.3mg IM,– Lasts only 5 minutes, usually need repeat dose– Monitor airway, VS

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1. O2 source and delivery mask2. Sugar3. Benadryl4. EPINEPHRINE 1:1,000 vial5. Albuterol Inhaler6. Nitroglycerin (0.4mg tablets or spray)7. Aspirin 160 – 325mg, chew - swallow

1. O2 source and delivery mask2. Sugar3. Benadryl4. EPINEPHRINE 1:1,000 vial5. Albuterol Inhaler6. Nitroglycerin (0.4mg tablets or spray)7. Aspirin 160 – 325mg, chew - swallow

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Glucose $2.50, Diphenhydramine $15 (200Ct)

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Thank you for your attention

Robert C. Bosack, DDS

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