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Medical Emergencies in the Dental Office, Medical Emergencies in LIFE!
Mel Hawkins, DDS, BScD AN, FADSA, DADBA
DISCLOSURE
Mel Hawkins
has no relevant financial relationship with any company or organization to disclose with respect to this continuing dental education program
The Ontario Dental Association’s
152nd Annual Spring Meeting
May 10th, 2019
Almost Always Almost Never
Reality of Dental Emergencies“With Great Power comes
Great Responsibility”
How can we as health
professionals, who are
supposed to have higher
skills, be expected to treat an
emergency situation in the
office or in life when they
NEVER (well, almost never)
occur?
What today is NOT:
A myriad of different emergency
situations involving as many
different medical scenarios which
you and I may never have heard of
let alone memorized, which drug
to use, where to give it, IV? IM? IL?
dose in mg., how often must you
repeat it? side effects? Then,
which drugs can combat the side
effects? etc…etc…
Are we facing an . . . .
INCONVENIENCE?
URGENCY?
EMERGENCY?
RARITY?
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Inconveniences
Syncope 15,407
Mild Allergy 2,583
Postural Hypotension 2,475
Bronchospasm (asthma) 1,392
Hyperventilation 1,326
Epinephrine Reaction 913
“Emergency” n=30,608
Martin & Ellis JADA 112:499-501, Malamed JADA 124:4-53 >30,000 events
Syncope 15,407
Postural Hypotension 2,475
Syncope 15,407
Postural Hypotension 2,475
Syncope 15,407
Postural Hypotension 2,475
Urgencies
Syncope 15,407
Angina 2,552
Seizure 1,595
Bronchospasm (asthma) 1,392
Epinephrine Reaction 913
Insulin Shock (conscious) 890
“Emergency” n=30,608
Martin & Ellis JADA 112:499-501, Malamed JADA 124:4-53 >30,000 events
Syncope 15,407
Angina 2,552
Seizure 1,595
Bronchospasm (asthma) 1,392
Myocardial Infarction 289
Local Anaesthetic Overdose 204
“Emergency” n=30,608
C.V.A. 68
Emergencies
Martin & Ellis JADA 112:499-501, Malamed JADA 124:4-53 >30,000 events
Rarity (“Non” Events)
Acute Pulmonary Edema 141
Diabetic Coma 105
Adrenal Insufficiency 25
Thyroid Storm 4
Martin & Ellis JADA 112:499-501, 1986, Malamed S JADA 124:4-53, 1993
“Emergency” n=30,608
Martin & Ellis JADA 112:499-501, Malamed JADA 124:4-53 >30,000 events
“What’s Really Important?”
Syncope 15,407
Angina 2,552
Myocardial Infarction 289
Cardiac Arrest ???
Asthma, Severe Allergy
Bronchospasm1,392
“What’s Really Important?”
SUMMARY:
Sycope occurs more times than all the other conditions
COMBINED i.e. > 50%
CONCLUSION:
If you can treat syncope by Position, A. B. C.’s and O2 +
sugar, then you can treat over 50 % of
unconscious victims or patients AND...
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“What’s Really Important?”
FURTHERMORE:
By knowing this syncope protocol a health
professional or member of the public or both can
initiate treatment of the other 50 % of
emergencies
WITHOUT MAKING or NEEDING A DIAGNOSIS
Supportive care and CPR or BLS fundamentals
including (rarely) chest compressions will maintain
life until consciousness returns or EMS arrives.
Everything Else Has Time!
Diabetic Coma/Insulin Shock Sugar
Epilepsy/Seizure/ConvulsionsAirway
Protect
Hyperventilation - O2 Sat? 100%
Mild Allergy Itchiness/Rash Wait
Local Anaesthetic/Epinephrine Blockers
2
Protocols,
Age/Risk
Pharmaco-
dynamics
Defib,
Drugs
and
Diagnosis
WHAT TODAY IS:
Airway +
a few good
adjuncts,
Oxygen,
Vasocon-
strictors
1 3
▪ Protocols,
▪ Age/Risk
▪ Pharmacodynamics
1
Emergency Protocol
IT DEPENDS on:
• What,
• When, and
• Where the problem is!
Is 911 a false sense of security?
Emergency Protocols
911 is a solution.YES
What to do in the
meantime???Problem
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Communication
• Front Desk
• Office Manager
“What is your Emergency?”
The 3 U’s
Unconscious
Unresponsive
Unable to find
a pulse
RESPONSIBILITIES
Attending person 911“I HAVE AN UNRESPONSIVE CHILD
WITHOUT A PULSE”.
123 Home Street.
Hawkins residence.
Front door.
“I will meet you there”
RESPONSIBILITIES
Front Desk 911“WE HAVE A PATIENT IN CARDIAC ARREST
WITH CPR IN PROGRESS”
91 Rylander Blvd.
Dr. Hawkins office.
Front parking lot.
“I will meet you there”
All the staff must know the location of:
• Portable oxygen with masks/cannulas
• Bag-Valve-Mask with airways
• Automatic External Defibrillator
• Emergency drug kit
• Portable suction
• Emergency lighting source
Staff Training
• Current BLS training
• Task designation: 2 groups,
action + support
• Mock simulations:
shorter time (15 min.)
higher frequency (2 mo.)
repetition, repetition, repetition
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Staff Training
Recommendation:
Can you discover, privately,
without embarrassment who is
and who may not be prepared
for an assigned duty before
an event, not during.
Every 2 Months:Syncope
for 15 Minutes:Syncope
Mock Simulations 2019
Syncope Algorithm
Position, ABC’s
Time, Time, Time
Always!
O2 by nasal
cannula
4 litres/minute
+ Glucose
Syncope Algorithm
But the Nasal Cannula
is an open and therefore a dilutable
system
So how much
enriched % oxygen
can actually be
administered?
Syncope Algorithm
Room air has ~ 21 % oxygen
The percentage O2 approximates:
20 + 4 X litre flow of O2 = % oxygen received
3 litres/min = 32 %
4 litres/min = 36 %
5 litres/min = 40 %
6 litres/min = 44 %
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Medical Consultation
B-r-r-r-ing
B-r-r-r-ing
B-r-r-r-ing
B-r-r-r-ing
MUST HAVE A GAME PLAN!
1. Dental treatment risk/benefit
2. Contemplated medications in
mg. or g.
MD scrawling: BP is 240/120
but “OK for dental treatment”
is NOT a mandate!
RESPONSIBILITY? OURS!
EMERGENCY KITS
Acme Dental / Medical Kit
Ready
made?
Self
assembled?
IN OLD
DAYS:
nice
suitcase
and color
coded
micro-
print
SENIOR CITIZEN
“AVER-AGE” PATIENT
PEDIATRIC
CONSIDERATIONS
Pharmacodynamics: Age/RiskPhysical Classifications - ASA
ASA I – normal, healthy
ASA II – mild systemic disease
ASA III – severe multiple systems, medication
ASA IV – severe disease, threat to life
ASA V – won’t survive without operation
ASA VI – brain dead, alive organ transplant
E – operation modification e.g. ASA III-E
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The Senior Citizen
Although inaccurate, a “senior” in our society is usually < or = 65 years old
A “bad day” will usually happen because of an attack of a pre-existing condition
Senior’s Considerations
• Physiology
• Age of 65 is arbitrary.
How often do we see a 65 year old
who looks 50 and vice versa?
Hepatic metabolism and renal
clearance can be reduced by 50%
in patients over the age of 65.Becker DE Mod Curric Moder Sed, Miami Valley Hosp. Dayton OH
Senior’s Considerations
Fear Factors:• Loss of independence
• Institutionalization and isolation
• Disability
• Death
Senior’s Considerations
•C.N.S:
• Loss of Neurons
•C.V.S:
• Systolic B.P. with age
• Rate due to parasympathetic
activity
Senior’s Considerations
• Pulmonary:
• Loss of alveolar septa
• elasticity of lungs
• Impact of smoking
Senior’s Considerations
COMMUNICATION
DIFFICULTIES
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The “Aver-age” Patient
ASA I or II are generally very
safe sedation patients.
ASA III is a judgment call.
A “heart” patient is safer with
sedation than without it.
A “bad day” will usually
happen because of lack of
attention to the rules - doses,
lack of good L.A. or “point of
no return” feelings.
Why does
Morbidity –
Mortality
“target”
CHILDREN?
Although inaccurate, a
“child” in our society
is usually defined as
≤ 12 years old.
A “bad day” will
usually happen
because of lack of
respect of their
airway...
Children
Pediatric Considerations
High
MYOCARDIAL
O2 Consumption
High BRAIN
O2 Consumption
The 2 MOST
IMPORTANT
Physiological
Considerations in
PEDIATRIC
RESCUE are:
C.V.S / C.N.S:
Pediatric Considerations
C.N.S:
The CPR / BLS guideline of:
“3 – 6 minutes until permanent brain
damage begins” is for the adult
without an O2 debt and does NOT
apply in pediatric life.”
IT’S MORE IN THE ORDER OF
1 MINUTE!
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Pediatric Considerations
Drug (local anaesthetic) impact:
• Unpredictable
• Blood Brain Barrier is immature
• Metabolism due to immature liver
Pediatric Considerations
COMMUNICATION
DIFFICULTIES
??
??
?
?Questions
▪ Airway,
▪ A Few Good Adjuncts,
▪ Oxygen and
▪ Vasoconstrictors
2
MANAGEMENT OF AIRWAY
Actions & Armamentarium
•
Airway Obstructions:The ConsciousVictim
Airway
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I like to put EVERYTHING in my mouth…my toes…your toes,
everything!
Airway
• Know Each Patient’s Airway
• Always Maintain Patency
• Head Position
• Clear Debris
• Use Throat Partitions
• Use Rubber Dam When Possible
It would be ideal to be able
to use emergency
armamentaria in day-to-day
dentistry too, for cost
efficiency, familiarity and for
practice!
Equipment Management Adjuncts
Airway -“Mouth Rester”… not a prop
Disposable Laryngoscope
“A tongue depressor
with a light on it”
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Magill Forceps
Serated, circular tips,
double lumen
➔
Disposable “long saliva ejector”
…with a screen tip that
doesn’t
come off
•
Airway Obstructions:The UnconsciousVictim
AirwayOral Pharyngeal Airway
Size? Angle of Mandible to Corner of Mouth
Airway closed Airway open
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Old and New Ideas
CRICOTHYROTOMY
CRICOTHYROTOMY What is it?
A mechanical opening of the airway at the
1st tracheal ring – the cricothyroid membrane
Done below a blockage of the plugged
(food) OR constricted laryngeal vocal cords
(laryngospasm) due to an irritant, resulting
in little or no air exchange to the lungs
Accompanied by panic, inability to speak
and strained, contracted accessory neck
muscles
Follows multiple, unsuccessful Heimlich
manoevers
CRICOTHYROTOMY Where is it?
At the 1st tracheal ring – the cricothyroid
membrane
Done below the Adam’s Apple, just above the
1st tracheal cartilage)
If respiratory effort is still present, an ingress of
air will follow
This allows time to try to physically remove the
obstruction
If not, a bag to tracheal tube or opening(?) must
somehow do AR part of CPR.
CricothyroidMembrane Puncture
for Tracheal Access
CRICOTHYROTOMY Obstructions?
Seaweed
Food bolus
Laryngospasm with coughing
air is being exchanged – leave them alone
Laryngospasm without air exchange ( cannot
cough).
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CRICOTHYROTOMY Actions?
Trocar needle within a 13 ga. Or 10 ga. Metal
tube inserted inward and downward
Horizontal scalpel incision. Reverse blunt end
inserted at 90 degrees
Broken Bic® pen
Fishing knife
If not available, a “mouth to opening” must
somehow do the AR portion of BLS/CPR.
Cricothyrotomy
What you really need to
know about old and new
ideas of cricothyrotomy
is…
MANAGEMENT OF BREATHING
Actions & Armamentarium
Oxygen Sources
•Portable tanks
(Stem & Wrenches)
•Central tanks
• Regulators and Components
• Flow meters
Flow meter:
0-15 litres/min Full:
2000
PSI
Nasal Cannula - Disposable
O2
4 l/min
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Non-rebreathing Mask (NRB)
O2
6-10 l/min Bag-valve-mask
Systems (B.V.M.)
Bag Valve Mask (BVM)
Inflatable Mask
(use 10 cc. syringe – air)
One way valve- once
sealed no need to lift
edge of mask for
exhalation
Supplemental O2 with
reservoir at 10-15
liters/minute
2-3 l. bag
Can be
used IF
breathing
Transparent mask –
can see regurgitation
These 3
fingers pull up
These 2 digits
press
Demand Valve
NOT Recommended
??
??
?
?Questions
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MANAGEMENT OF CIRCULATION
Actions & Armamentarium
Vasoconstrictor Considerations
VASOCONSTRICTOR
“ISSUES”or
Truths, Lies and
Consequences
A. Use is based on vasoconstrictivealpha receptor agonists
1. Delays absorption, reducing toxicity and prolonging duration
No Advantage With Concentrations > 1:200,000
2. Reduces haemorrhage at surgical site
(CONCENTRATION IS ADVANTAGEOUS IN THIS CASE)
Vasoconstrictor Considerations
Vasoconstrictor Considerations
Deep
Arteries
Adrenergic alpha receptor functions and vascular distribution
Vasoconstriction
2Vasodilation +Bronchial dilation
1 Cardio-tropic
Veins and
Submucosal
Arteries
2
With most heart conditions, the most
serious medical-dental risk for dental
treatment is the vasoconstrictor.
or FalseTrue
Vasoconstrictors
A. Epinephrine is not safe
for the hypertensive
patient
True or False?
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Selecting a Vasopressor
• Epinephrine for Hypertensive Patients
• Levonordefrin if Tachycardia is Concern
• Both Increase Myocardial Oxygen Demand
Epinephrine Heart Rate
Levonordefrin Blood Pressure
Vasoconstrictors
B. When anaesthetizing
children – do not use
epinephrine. Use a plain
non-epi containing
solution
True or False?
Parents are
responsible
for lip /
tongue biting
Dentists are responsible for
safety!
Vasoconstrictors
Why?
Epinephrine delays
absorption, reduces
toxicity and safely
allows for 1 ½ X
maximum dose!
75 mg
400 mg
300 mg
300 mg
300 mg
No Vasoconstrictor
150mgBupiva 0.5%
600 mgPrilocaine 4%
500 mgMepiva 3%
500 mgLidocaine 2%
500 mgArticaine 4%
VasoconstrictorDRUG
“MRD” or Maximum Recommended Doses
* For healthy 70 Kg adult –must adjust for age and weight
Hawkins, M - various sources, 2017
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Maximum Doses
78 mg/kg (up to 500
mg)Prilocaine 4%
9*7 mg/kg (up to 400
mg)Mepivac 3%
13 ? 10 ?7 mg/kg (up to 500
mg)Lidocaine 2%
102 mg/kg ( up to 200
mg)Bupiva .5%
77 mg/kg (up to 500
mg)Articaine 4%
Drug Maximum Dose # “Carps”
Hawkins, JM: various sources compiled 2012Hawkins, M - various sources, 2017
Vasoconstrictors
C. Epinephrine and
antidepressants do not
interact (except POSSIBLY
with tricyclics?)
True or False?
ANTIDEPRESSANTS
CLASS: MONOAMINE OXIDASE INHIBITOR
GENERIC NAME TRADE NAME
Phenelzine sulfate Nardil®
Tranyleypromine sulfate Parnate®
Local Anaesthetic/Vasoconstrictor Precautions:None, since both epinephrine and neocobefrin are
metabolized by COMT, not MAO
ANTIDEPRESSANTS
CLASS: TRICYCLICS
GENERIC NAME TRADE NAME
Maprotiline hydrochloride Ludiomil® Novo-Maprotilinel®
Trimipramine maleateApo-Trimip® NovoTripramine® NuTrimipramine® Rhotrimine®, Surmontil®
Local Anaesthetic/Vasoconstrictor Precautions:Use with caution; epinephrine and levonordefin have been
shown to have an increased pressor response in combination with tricyclics. Clinically may only be seen in higher doses.
ANTIDEPRESSANTS
CLASS: SELECTIVE SEROTONIN REUPTAKE INHIBITORS
GENERIC NAME TRADE NAME
Fluoxetine hydrochloride Prozac®
Fluvoxamine maleate Luvox®
Paroxentine hydrochloride Paxil®
Sertratine Zoloft®
Local Anaesthetic/Vasoconstrictor Precautions: No interactions reported with vasoconstrictors
ANTIDEPRESSANTS
CLASS: MISCELLANEOUS
GENERIC NAME TRADE NAME
Nefazadone hydrochloride Serzone®
Venlafaxine hydrochloride Effexor®
Buspirone hydrochloride BuSpar®
Local Anaesthetic/Vasoconstrictor Precautions:No precautions appear necessary
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Vasoconstrictors
D. Non-selective -blocked
patients are a relative
precaution only. All
other -blocker
categories are fine
True or False?
Vasoconstrictor Considerations
Deep
Arteries
Adrenergic alpha receptor functions and
non-selective blockade (e.g. Inderal®)
Vasoconstriction
2 Vasodilation +Bronchial dilation
1 Cardio-tropic
Veins and
Submucosal
Arteries
2
BETA-ADRENERGIC SympathomimeticsBLOCKERS epinephrine
(a) Cardioselective
Atenolol Tenormin®
Metoprolol Betaloc® Lopressor®
(b) Noncardioselective
Nandolol Corgard®
Propranolol Inderal®
Sotalol Sotacor®
(c) Noncardioselective and alpha blocker
Labetalol Trandate®
“alright” 1 blocked only
“beware” 1,2 both blocked
“cool”all blocked
43 year old female, Candace, 1 hour hygiene appt.
Propranolol 40 mg. b.i.d. for migraine headaches, but no
CVD, BP 128/86 HR 88
IV sedation - 4 mg. midazolam with RN Nancy
Local anesthesia: 4% articaine
1:100K epi 6.8 ml. – 4 cartridges
Q 2 minutes: 152/94 92
Q 3 168/98 78
Q 4 190/104 64
Q 5 minutes: 158/98 78
Case Report
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Case Report
1. IF ANY SYMPTOM ➔ Activate EMS
2. Position, ABC’s, O2
3. Lower Blood Pressure – Nitroglycerine
spray + support
4. ASA? NO!
ER protocol, Miami Valley Hosp Becker DE Dayton OH
NOW WHAT?
Managing Beta Blocked Patients
No issue with cardioselective agents,
(a) category BUT
Propranolol and others in the non-
selective, (b) category
WHAT TO DEFINITELY DO!
1. Look it up on line
2. Wait 5 minutes after each cartridge and
reassess vitals
Managing Beta Blocked Patients
WHAT TO POSSIBLY DO?
3. Avoid using a vasopressor if (b)
category
4. Consult physician regarding
discontinuing (b) beta blocker or
changing it to a cardioselective (a)
beta blocker
Hypertension Algorithm
Syncope Protocol
Reassess BP / Perfusion
Nitroglycerin Nifedipine
EMS transport if symptomatic
Vasoconstrictor Summary:
A. Epinephrine is safe for the hypertensive
patient
B. When anesthetizing children - use
epinephrine. It delays absorption,
reducing toxicity
C. Non-selective -blocked patients are a
relative precaution only
D. Epinephrine and antidepressants do not
interact (tricyclics?)
??
??
?
?Questions
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Looking at the “Drug”
Local
Anaesthetic
DOSAGES
Any “%” solution
needs to be expressed
as:
mg/cc (ml)
POSOLOGY
In 2 % lidocaine, for example:
2 %, add 0 = 20 mg /cca cartridge of 1.8 cc
= 36 mg
POSOLOGY Maximum Doses
78 mg/kg (up to 500 mg)Prilocaine 4%
9*
7 mg/kg (up to 400 mg)Mepivac 3%
13 ? 10 ?7 mg/kg (up to 500 mg)Lidocaine 2%
102 mg/kg ( up to 200 mg)Bupiva .5%
77 mg/kg (up to 500 mg)Articaine 4%
Drug Maximum Dose # “Carps”
Hawkins, JM: various sources compiled 2017
* For healthy 70 Kg adult –must adjust for age and weight
75 mg
400 mg
300 mg
300 mg
300 mg
No Vasoconstrictor
150mgBupiva 0.5%
600 mgPrilocaine 4%
500 mgMepiva 3%
500 mgLidocaine 2%
500 mgArticaine 4%
VasoconstrictorDRUG
“MRD” or Maximum Recommended DosesFactors:
Physiology of a child affects the M.R.D.
3% mepivacaine PLAIN
Adult: 7 mg./kg = 490 mg. = 9 cartridges
Age 12-18 yrs: 6 mg./kg = 330 mg. = 6
Age 6-12 yrs: 5 mg./kg = 200 mg = 3.5
Age < 6 yrs: 4 mg./kg = 100 mg = < 2
Hawkins, JM: various sources compiled 2012Hawkins, JM: various sources compiled 2017
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Factors:
Physiology of a child affects the M.R.D.
2% lidocaine 1:100,000 epi
Adult: 7 mg./kg = 490 mg. = 13 cartridges
Age 12-18 yrs: 6 mg./kg = 330 mg. = 8.5
Age 6-12 yrs: 5 mg./kg = 200 mg = 5.5
Age < 6 yrs: 4 mg./kg = 100 mg = 3
Hawkins, JM: various sources compiled 2012Hawkins, JM: various sources compiled 2017
Scenario:
1. Good child J
2. Financial
3. L.A. is just
“water”
4. Bell curveDr. Norman Treiger, DDS, MD Montefiore Hospital, the Bronx, NY
CASE REPORT
Case: @ 55 lb 7 y.o. (25 k.g.)
Administered:
11 CART 2% LIDO 1:100,000 EPI
or
@ 400 mg!
How …..
Does This Happen???
Dr. Norman Treiger, DDS, MD Montefiore Hospital, the Bronx, NY
Factors:
1. Size: 1/3 of adult2. Physiology of a child vs. adult3. M.R.Dose = 133 mg.
or no more than ~ 3.5 cartridges!
4. BUT adjust for physiology to 4 mg./kg. So…M.R.D. = 100 mg. or < 3 cartridges
Dr. Norman Treiger, DDS, MD Montefiore Hospital, the Bronx, NY
RESULTS:
Patient died
No dentist or assistant CPR (BLS) certificationNo resuscitative equipment, including no oxygenDefense: Medicaid case. “Had to do as
much dentistry as possible”
Involuntary manslaughter, jail term
Dr. Norman Treiger, DDS, MD Montefiore Hospital, the Bronx, NY
Toronto, ON
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Miami, Florida Airport
The 3 R’s:
Racketball…
Readiness?..
and
Rescue
Attempt…
VictimMust BeOn “Firm”Surface ???
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Resusitation: FloorResusci-Anne (n = 50)
Hawkins, M JODA. Jul/Aug Vol 6:28
Dental Chair ResusitationResusci-Anne (n = 50)
Hawkins, M JODA. Jul/Aug Vol 6:28
Defibrillation,
Drugs and
Diagnosis
3
Defibrillation
3
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A.E.Ds
One-Touch
$1245.00CPR Savers and First
Aid Supply®
AED + ECG
Simple but
Sophisticated
$1999.00CPR Savers and
First Aid
Supply®
A.E.D. State Standards and Philosophy
• If you are regulated to have
one, then get one!
•FL, NY, TX (future) ?
Automatic External Defibrillators or A.E.D.s
• Increasingly common placement in
malls, airports, golf courses,
exercise facilities and office
buildings
• They DO save lives when used by
trained individuals
Roccia WD, Modic PE, Cuddy MA: Automated external defibrillators use
among the general population. J Dent Educ 67:1355-1361
D
Automatic External Defibrillators or A.E.D.s
• How adequately do untrained persons
perform in an emergency?
• Does lack of training influence patient
outcomes?
• Can a lay person successfully operate
an AED to deliver the shock needed in v-
fib or pulseless v-tach?
Roccia WD, Modic PE, Cuddy MA: Automated external defibrillators
use among the general population. J Dent Educ 67:1355-1361
D
Automatic External Defibrillators or A.E.D.s
FAILURE RATES:
General population: 80%
1st year dental students: 60%
3rd year dentsl students: 30%
Dental professionals/RN’s: 20%
Anaesthesiologists/OMFS: 10%
REASONS for FAILURE (n=50):
Failure to remove chest covering clothing: 52.4%
Incorrect placement of pads 28.6%
Operator touching patient
or not saying, “CLEAR, CLEAR, CLEAR” 14.3%
Roccia WD, Modic PE, Cuddy MA: Automated external defibrillators use among the
general population. J Dent Educ 67:1355-1361
D
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Let’s Do
Drugs
3
What do you need?
DO NOT
even THINK of using a
drug you know nothing
about!
Guidelines
Emergency MedicationsResponsible Auxiliary:
• Check kit every two months (on mock simulation day) to assure drugs are not expired or broken. Replace as needed.
• Review correct method for preparation in emergency periodically.
OXYGEN
Epinephrine
Various injectors available for anaphylaxis
(severe allergy; bee stings, peanuts) and
bronchospasm
CHILD / ADULT:
Packs of 1 or 2 vary in price
child: 0.15 mg.
adult: 0.3 mg.
*until you can draw up from an amp.
Epinephrine
Equi-potent doses: (1ml 1:1000 amps)
by route of administration:
• SC - 0.5 mg
• IM - 0.3 mg.
• IL - 0.2 mg.
• IV - 0.1 mg. - must dilute 1:10,000
If patient has air exchange: ß-2 inhaler: albuterol
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Epinephrine
EPIPEN®* for anaphylaxis (severe allergy;
bee stings, peanuts) and bronchospasm
CHILD / ADULT: EpiPen 2-Pak®:
child: 0.15 mg….. $279.06
adult: 0.3 mg…. $ 279.06
*until you can draw up from an amp.
Nitroglycerin
Action is unclear: SL administration vasodilation result in a reduced venous return, or preload reduction, lowering myocardial O2
consumption.
Indications: Ischemic chest pain - 1 tab Q5M x 3
Symptomatic hypertensive episodes
• Dose: 0.3-0.6 SL mg. tabs / 0.4-0.8 SL spray
Warning: do not give another “nitro” if SBP < 90
$9.00 / 100
Expiration date
must be
“Sharpied” to
8-10 weeks from
“today’s
seal breaking”
$32.00
Nitrolingual®
Pumpspraybut . . .
. . . expiry date IS the expiry
date
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153 154
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ASA
Giving the maximum
as a 325 mg. tablet
is OK but…
325 mg. = peak effect
It’s best via 4X baby
ASA (81 mg.) chewed,
aside from, and over and
above prophylactic
use
ASA (for MI)
325 mg. = peak effect
Action: Keeps # of platelets
from increasing, which could
lead to further coronary
artery blockage
or if cerebral blockage,
STROKE!
ASA (for MI)Solbutamol-Bronchodilator
Salbutamol - β2 agonist
Inhaler: Inhale 1 to 2 puffs of
Salbutamol up to 4 times daily.
More than 8 inhalations per day is
not recommended.
Salbutamol -Ventolin® -
β2 agonist
Diphenhydramine
• Action and effect based on blocking
histamine release
• Indications / Dose: (50mg/ml amp or SDV)
• pruritus / urticaria / nausea
• 50mg IM followed by 50mg TID P.O.
• medical follow up to anaphylaxis
• THINK FIRST! Can they get a ride?
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Glucose Source
ALL dental offices have a
massive sugar availability in
house!
?
?
??
?Questions
Diagnosis DependentTreatments
Syncope
• Sudden, transient loss of
consciousness
• Common immediately pre- or post
injection
• Most common procedure – extraction
• Often recovery before advanced
treatment can be implemented
Syncope Profile - Prevalence
• Male » Female
• Never in children
• Average age? 35 years old
• Scenario:
Male, 35 y.o., anxious,
“macho” guy,
“needlephobic”
Syncope Signs/Symptoms
• Pallor
• Nausea
• Disorientation
• Loss of Consciousness
• Blood pressure
• Pulse thready, may arrest 30-45 sec.
• Low blood sugar
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29
Syncope Causes
• Anxiety, Pain
• Sit up too fast
• Inject too fast
• Intraosseous injections
• Hypoglycemia (prolonged NPO)
Syncope Algorithm
Position, ABC’s
Time, Time, Time
Always!O2 by nasal
cannula
4 litres/minute
+ Glucose
Nausea /Vomiting
…associated with syncope
Hyperventilation
Signs / Symptoms:
• Rapid, shallow breaths, “air hunger”
• Impaired inspiration / expiration
• Sense of panic
• Disorientation
• O2 saturation = 100%
Hyperventilation
Showtime?
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Hyperventilation Treatment
• Rebreathe from paper bag?
• Do nothing and leave room?
*Nobody has ever died from a
100% oxygen saturation!
Angina
• Pallor, chest pain in “waves”
• “Indigestion?”
• Denial
• Midsternal pain, left arm, left mandible
• Nausea, diaphoresis
• Rapid, shallow breathing,
• Rx 1 nitroglycerine tablet or 2 sprays
Myocardial Infarction
• Female: “weight on chest” /
indigestion?
• mild shortness of breath (SOB), nausea
• Male: chest pain, sharp, severe, left arm
• SOB, BP (pain)
• Panic, fear, but denial
• Rapid, shallow breathing
Angina / MI Algorithm
Syncope Protocol
Nitroglycerin q. 5 min x 3
Assume MI / Call EMS
Cardiac Arrest
• Marked hypotension
• Rapid, shallow breathing LOC
• Apnea cyanosis = respiratory
arrest
• Fibrillation = no pulse
• AED gives diagnosis and action
Cardiac Arrest Algorithm
Syncope Protocol
CPR
100% Oxygen
➔ 1 - 2 mg epinephrine
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Asthma
Asthma and Severe Allergy
Signs/Symptoms
Bronchospasm Algorithm
ABC’s & Position
Oxygen
B-2 inhaler
BUT if not exchanging air:
epinephrine 0.3 mg
Seizures / Convulsions
DEFINITIONS:
•Seizure: “Fibrillation of the CNS”
•Convulsion: “Fibrillation of the CNS”
with Motor Nerve activity added
Protect Patient,Protect Yourselves!
Syncope ProtocolFollowing Seizure
Seizure Algorithm
If status seizure: EMS/PPV
Seizure Algorithm
Not practical
Flumazenil
Anexate®
Romazicon®
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• Primary assessment is in front of you or in the history
• Activate EMS, 911
• Assign, Designate
In The Dental Office or
Witnessed at home
It is still A, B, C
• Primary assessment
• Call for HELP, get to a phone even if it’s youthat has to leave
• No medical history, no relatives, no knowledgeable friends
Unexplained, Unwitnessed,
Unconscious
Cardiac arrest NOW
C, A, B
IN LIFE…triple “U”
• Look for MEDIC ALERT bracelet or
necklace
• Read allergies, medical conditions
• Phone emergency hot line # on MEDICAL ALERT tag,
• Quote victim’s ID #
• Medical history will be given 24 / 7 by phone
QUESTIONS?
Pregnancy
Local Anesthetic News:
Dental Treatment Safety with Local Anesthetics during Pregnancy 572
Cover Story:
Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A,
JADA 146(8) Aug 2015
JADA ® AUG. 2015 146(8)
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189 190
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33
Pregnancy SafetyLocal Anaesthetics
➢ A prospective, comparative observational
study by the Israeli Teratology Information
Services (TIS), 1999 – 2005
➢ 210 pregnant patients were exposed to
dental treatment including local
anaesthetics - 112 (53%) in 1st trimester
vs. control group = 794 pregnant patients
who were not exposed to any dental
treatment or local anaesthetics
Hagai A et al, Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment:
A prospective comparative cohort study, JADA 146(8), Aug 2015
Pregnancy SafetyLocal Anaesthetics
The rate of major
anomalies was not
significant between the
two groups.
There was no difference in
the rate of miscarriages,
gestational age at
delivery, or birth weight.
Hagai A et al, Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment:
A prospective comparative cohort study, JADA 146(8), Aug 2015
Pregnancy SafetyLocal Anaesthetics
Safest local anaesthetics during pregnancy
and breast-feeding:
➢ Lidocaine and prilocaine (Citanest ® brand)???
are B (FDA 2012)
➢ All others, even mepivacaine plain (Carbocaine®
brand, Carestream Dental) are C (FDA 2012)
➢ Risk of methemoglobinemia with topicals
(especially esters: benzocaine, tetracaine)
➢ Epinephrine is OK
Pregnancy SafetyLocal Anaesthetics
Donaldson M & Goodchild JH, Pregnancy, breast-feeding and
drugs used in dentistry, J Am Dent Assoc, 143(8), August 2012
Pregnancy SafetyLocal Anaesthetics
Donaldson M & Goodchild JH, Pregnancy, breast-feeding and
drugs used in dentistry, J Am Dent Assoc, 143(8), August 2012
Epinephrine is a catecholamine,
which normally is present in the
body, with no clear evidence of
increased risk of malformation
when used during pregnancy with
local anaesthetics
Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A, ADA 146(8) Aug 2015
Pregnancy SafetyLocal Anaesthetics
Donaldson M & Goodchild JH, Pregnancy, breast-feeding and
drugs used in dentistry, J Am Dent Assoc, 143(8), August 2012
In Canada and adopting an ADA position paper:
Epinephrine is safe, including these
Local anaesthetics that contain epinephrine:
0.5% bupivacaine, Marcaine® 1:200K epi
2% lidocaine, Xylocaine ® 1:100K epi
3% mepivacaine, Carbocaine ®
In fact there is no evidence of increased risk of
malformation with the use of ANY local
anaesthetic.Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A ADA 146(8) Aug 2015
ADA Updated reaffirmation published Feb 6 2019
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34
Pregnancy SafetyLocal Anaesthetics
Donaldson M & Goodchild JH, Pregnancy, breast-feeding and
drugs used in dentistry, J Am Dent Assoc, 143(8), August 2012
2% lidocaine, 1:100,000 epinephrine
...is the ONLY local anaesthetic +
epinephrine composition that is
OK’d on all NIH, ADA and FDA
guideline lists
Hagai, A, Diav-Citrin, O, Shechtman, S, Ornoy, A ADA 146(8) Aug 2015
ADA Updated reaffirmation published Feb 6 2019
Pregnancy SafetyLocal Anaesthetics
143(8), August 2012
Conclusions:
The use of local
anaesthetics as
well as dental
treatment during
pregnancy, does
not represent a
teratogenic risk.
Hagai A et al, Pregnancy outcome after in utero exposure to local anesthetics as part of
dental treatment: A prospective comparative cohort study, JADA 146(8), Aug 2015
Pregnancy SafetyLocal Anaesthetics
Despite the reassuring considerations…
Dentists are still reluctant to perform dental
treatment for pregnant patients and
Women are still reluctant to receive dental
treatment during pregnan
Hagai A et al, Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment:
A prospective comparative cohort study, JADA 146(8) , Aug 2015
QUESTIONS?
Toronto, Ontario Canada
Friday, May 10th, 2019
Medical Emergencies in the
Dental Office, Medical Emergencies in Life !
Mel Hawkins, DDS BScD AN
Dentist/Dentist Anesthesiologist
Toronto, ON Canada
The Ontario Dental Association’s
152nd Annual Spring Meeting
1 2 3
Product
Issues
Dentist
Issues
CONSULTING DILEMMAS
Patient
Issues
199 200
201 202
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35
CASE REPORT
PRODUCT
COMPLAINT:
3% MEPIVACAINE (PLAIN)Common local anesthetic administered
COMPLAINT:7 patients 'stroke-like' reactions to
3% mepivacaine (plain)DOCTOR’S INTERVIEW
INFORMATION
Background
•Dentist with 34 years
experience
•Practices general dentistry
•High need for exodontia
•Holistic component to
practice
“Nobody’s
going to die
on my
watch”
“This last
patient might
sue me” “I know stroke
when I see it”“It must be the
mepivacaine”
Quotes
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36
EMS 911CALLED 7 TIMES
in past year
due to
"stroke-like
symptoms"
Common History: “Hypertension”
• Dentist did not define her personal interpretation of hypertension
• No baseline vital signs on record
• No intra operative vital signs taken
• Multiple tooth extractions common
• 3% mepivacaine plain used for these stated “hypertension” case histories
Patient Signs & Symptoms
Anxiety,
anxiousness,
restlessness
DIFFERENTIAL
DIAGNOSIS
?
?
?
?
?
ALLERGY TO 3% MEPIVACAINE?
ALLERGY?
• No scientific evidence of allergy
• No itching, urticaria or airway
compromise
• No documented Ag-Ab in
literature
• Mepivacaine molecule is a non-
allergen
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Option
A
Option
A
“COULD IT BE THE
PRESERVATIVE IN THE LOCAL
ANESTHETIC?"
PRESERVATIVE?
3% mepivacaine does
NOT contain a
preservative
ALLERGY TO LATEX?
LATEX ALLERGY?
Doctor states it is a
latex-free office
MYOCARDIAL EVENT?
MYOCARDIAL?
• No scientific evidence
• No angina
• No signs or symptoms of
infarction
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PATIENT SELF-MEDICATION?
SELF-MEDICATED?
Unknown
IATROGENIC?
IATROGENIC?
•Dental office environment
•Dentist treatment?
•Other in-office factors during
procedure
•Was the local anaesthetic
ineffective?
CEREBRAL VASCULAR ACCIDENT - STROKE?
•Headache, dizziness, impaired
vision, mental clouding
•Hemiplegia, unilateral weakness
•Nausea, diaphoresis
•Facial “Bells Palsy” appearance
•Speech impairment
•Fear
SIGNS, SYMPTOMS OF STROKE
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39
• No scientific evidence, symptoms
not consistent with stroke
• No vital signs available
• Assumption: paramedics/ER took
vitals
• Doctor does not know actual
systolic/diastolic/rate results
• Doctor did not accompany to ER
CVA - STROKE?
WHAT’S
YOUR DIAGNOSIS, DOCTOR?
Toronto, Ontario Canada
Friday, May 10th, 2019
Medical Emergencies in the
Dental Office, Medical Emergencies in Life !
Mel Hawkins, DDS BScD AN
Dentist/Dentist Anesthesiologist
Toronto, ON Canada
The Ontario Dental Association’s
152nd Annual Spring Meeting
1 2 3
Product
Issues
Dentist
Issues
CONSULTING DILEMMAS
Patient
Issues
CASE REPORT
Patient
Issue:
First appointment:
Product titrated slowly
IV 30 mg. 0.1% midazolam
Versed® brand in 1 ½ hours
Second appointment approach?
BACKGROUNDINFORMATION
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40
Dentist student with no IV
training getting case
experience during 95 hour
MCMS Program
CASE FACTS - CLINICAL
Hawkins JM, Director Mod Curr Moder Sed,
U of A Fac Med Dent, 2011
•Male 32 y.o. 6’ 145 lbs. ASA “1”
•Personal drug history held
back?
•Baseline vital signs on record:
BP 128/88, P. 110
PATIENT HISTORY
PRE OP:
• Anxiety, anxiousness, restlessness
• Pupils not really constricted but not
assessed initially
PER OP:
•
PATIENT SIGNS & SYMPTOMS –1st APPOINTMENT
30 mg. midazolam over 1 ½ h.
• Intra operative vital signs stable
• Pulse oximeter within normal
limits throughout
“When are
you going to
start?”“Are you going
to give me any
drugs soon?”“I’m not
asleep”“This sucks”
Quotes:
SECOND APPOINTMENT Dilemma –
PATIENT DRUG TOLERANCE?
• Based on last appointment tolerance i.e.
total dose, dentist/student asks
permission to “push” 3 mg. midazolam
IV
• Request denied, 1 mg. given slowly IV
• Patient goes to level 4-5 very difficult
to wake
PATIENT SIGNS, SYMPTOMS –2nd APPOINTMENT
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DIFFERENTIAL
DIAGNOSIS
?
?
?
?
?
SYNCOPE?
•Symptoms not consistent with
vasovagal syncope
•No panic attack
•No hyperventilation
•Not needle phobic
•Hypoglycemia could be a factor
SYNCOPE ?Option
A
Option
A
MIDAZOLAM
OVERDOSE?
Were other drugs possibly
on board?
What drugs could they be?
MIDAZOLAM O.D?
Only 1 mg...after a previous
appointment with 30 mg.?
ALLERGIC REACTION TO MIDAZOLAM?
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42
ALLERGIC REACTION ?
• No evidence of allergy
• No itching, urticaria or airway
compromise
• No documented Ag-Ab in
literature
• Midazolam molecule is not a
known allergen
CEREBRAL VASCULAR ACCIDENT (CVA)?
No evidence of common
symptoms
CVA – STROKE?
MYOCARDIAL EVENT?
• No scientific evidence
• No angina
• No signs or symptoms of
infarction
MYOCARDIAL SOURCE?
IATROGENIC?
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249 250
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43
•Dental office environment
•Other in-office factors during
procedure
Unknown
IATROGENIC ?Option
A
Option
A
PATIENT SELF-
MEDICATION
SELF-MEDICATION?
SELF-MEDICATION “I’m afraid of not getting
enough”
Unknown but
Highly Suspect!
SELF-MEDICATION?
becomes a
Primary Diagnosis
SHOULD EMS HAVE BEEN CALLED?
MANAGEMENT
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Always! Syncope Protocol
Position, ABC’s
Time, Time, Time
Always!
O2 by nasal
cannula
4 litres/minute
+ Glucose
• Male 32 y.o. 6’ 145 lbs. (too tall for his
weight-cocaine?) ASA “1” ?
• Personal drug history held back?
• Baseline vital signs on record:
BP 128/88, (not sycope-too high and not
cardiac-too low) P. 110 (cocaine?)
• Pupils constricted (narcotic?) but
unnoticed
MANAGEMENT – IT’S EASIER TO GO BACK…
• Call EMS? Support? Wait?
• Reverse midazolam with 0.1 – 0.2 mg.
flumazenil?
• “Guess” at a self administered narcotic
and give 0.4 mg. Narcan® ?
• All of the above?
• Would you treat him again?
NOW WHAT?
• Call EMS? Support? Wait?
• Reverse midazolam with 0.1 – 0.2 mg.
flumazenil?
• “Guess” at a self administered narcotic
and give 0.4 mg. Narcan® ?
• All of the above?
• Would you treat him again?
WHAT EVOLVED?
FINAL OBSERVATIONS
• You just never know!
• Don’t assume anything
• Always titrate any medication slowly
• Treat each appointment like it is the first
appointment.
• Students now not permitted to see
previous appointment sedation record
• Don’t be surprised to be surprised!
FINAL OBSERVATIONS
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• Liability claims experience
repeatedly characterized by poor
record keeping
• Dentists often do not attend CDE
programs
• Abandonment and lack of follow up
is most incriminating
FINAL OBSERVATIONS FINAL OBSERVATIONS
•Court almost always empathizes
with patient, facts aside
•Plaintiff’s lawyer knows the
dentist has liability insurance
•Company is hardly ever targeted
Final Observations
•Never offer financial
compensation directly to a
patient - viewed as admission of
guilt
•Bring in a “friendly” expert
•Legal release mandatory
ANY
LAST
QUES-
TIONS
?
Toronto, Ontario Canada
Friday, May 10th, 2019
Medical Emergencies in the
Dental Office, Medical Emergencies in Life !
Mel Hawkins, DDS BScD AN
Dentist/Dentist Anesthesiologist
Toronto, ON Canada
The Ontario Dental Association’s
152nd Annual Spring Meeting
265 266
267 268
269