6/3/20141 management of medical emergencies in the dental office fady faddoul, dds, msd,ficd...

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Management Of Medical Emergencies In The Dental Office

Fady Faddoul, DDS, MSD,FICDFady Faddoul, DDS, MSD,FICDProfessor and Vice-ChairmanProfessor and Vice-Chairman

Department of Comprehensive CareDepartment of Comprehensive CareDirector, Advanced Education in General DentistryDirector, Advanced Education in General Dentistry

Case Western Reserve University Case Western Reserve University School Dental Medicine School Dental Medicine

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Management of Medical Emergencies

Medical emergencies can and do happenMedical emergencies can and do happen

Advances in medicineAdvances in medicine Longer lifespanLonger lifespan Multiple medicationsMultiple medications Medically compromisedMedically compromised Longer appointmentsLonger appointments

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Incidence

A survey done in the 90’sA survey done in the 90’s showed that, over showed that, over a 10 year period, 90% of dentists have a 10 year period, 90% of dentists have encountered at least one medical encountered at least one medical emergencies.emergencies.

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Types

TYPE OF EMERGENCYTYPE OF EMERGENCY NUMBERNUMBER PERCENTPERCENT

Altered ConsciousnessAltered Consciousness 17,78217,782 5959

CardiovascularCardiovascular 4,2804,280 1414

AllergyAllergy 2,8872,887 9.59.5

RespiratoryRespiratory 2,7182,718 99

SeizuresSeizures 1,5951,595 55

Diabetes-RelatedDiabetes-Related 999999 33


Basic Life SupportBasic Life Support Advanced Life SupportAdvanced Life Support

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Emergency situationsEmergency situations Managed properly most emergencies are resolved satisfactorilyManaged properly most emergencies are resolved satisfactorily Mismanaged even benign emergencies can turn disastrousMismanaged even benign emergencies can turn disastrous

RecognizeRecognize PositionPosition StabilizeStabilize DiagnoseDiagnose

TreatTreat ReferRefer

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Management Of Medical Emergencies

1.1. RecognitionRecognition

2.2. PreventionPrevention

3.3. PreparationPreparation

4.4. Basic life support (BLS)Basic life support (BLS)

5.5. Cardiopulmonary resuscitation (CPR)Cardiopulmonary resuscitation (CPR)

6.6. Specific medical emergenciesSpecific medical emergencies

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Prevention

IS THE BEST IS THE BEST TREATMENTTREATMENT

Know your patientKnow your patient

Never treat a STANGERNever treat a STANGER

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Prevention

90% of life-threatening situations can be 90% of life-threatening situations can be preventedprevented

10% will occur in spite of all preventive 10% will occur in spite of all preventive efforts (sudden unexpected death)efforts (sudden unexpected death)

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Prevention

Medical HistoryMedical History Physical EvaluationPhysical Evaluation Vital SignsVital Signs Dialogue HistoryDialogue History Determination of Medical RiskDetermination of Medical Risk Stress ReductionStress Reduction

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Prevention

MEDICAL HISTORYMEDICAL HISTORY ReviewReview UpdateUpdate MedicationMedication Medical consultationMedical consultation

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Prevention

PHYSICAL EVALUATIONPHYSICAL EVALUATION Length of time since last evaluationLength of time since last evaluation Vital signsVital signs Visual inspection of patientsVisual inspection of patients Referral to physicianReferral to physician

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Prevention

VITAL SIGNS

Blood pressureBlood pressure Pulse ratePulse rate Respiratory rateRespiratory rate

TemperatureTemperature HeightHeight WeightWeight

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Prevention

DIALOGUE DIALOGUE

HISTORY HISTORY Putting it all togetherPutting it all together Check accuracy of Check accuracy of

medical historymedical history Recognize anxietyRecognize anxiety

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Prevention

DETERMINATION OF MEDICAL RISK.DETERMINATION OF MEDICAL RISK. Ability of patient to safely tolerate dental Ability of patient to safely tolerate dental

treatment.treatment. Does patient represent increased medical Does patient represent increased medical

risk?risk? Can patient be managed in the dental Can patient be managed in the dental

office?office?

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Determination Of Medical Risk

American Society ofAmerican Society ofAnesthesiology Anesthesiology

Physical Status ClassificationPhysical Status ClassificationSystem System

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ASA I

A patient without A patient without systemic diseasesystemic disease

A normal healthy A normal healthy patientpatient

Can tolerate stress involved Can tolerate stress involved

In dental treatmentIn dental treatment No added risk of seriousNo added risk of serious

ComplicationsComplications Treatment modification Treatment modification

Usually not necessaryUsually not necessary

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ASA II

A patient with mild systemic A patient with mild systemic diseasedisease

Example:Example:

-Well-controlled diabetic-Well-controlled diabetic

-Well-controlled asthma-Well-controlled asthma

-ASA I with anxiety-ASA I with anxiety

Represent minimal risk Represent minimal risk during dental treatmentduring dental treatment

Routine dental treatmentRoutine dental treatment

With minor modificationsWith minor modifications

-Short early appointments-Short early appointments

-Antibiotic prophylaxis-Antibiotic prophylaxis

-Sedation-Sedation

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ASA III

A patient with severe systemic A patient with severe systemic disease that limits activity but is disease that limits activity but is not incapacitatingnot incapacitating

Example:Example:

- a stable angina- a stable angina

- 6 mos. Post - MI- 6 mos. Post - MI

- 6 mos. Post - CVA- 6 mos. Post - CVA

- COPD- COPD

Elective Dental Treatment Elective Dental Treatment is not Contraindicatedis not Contraindicated

Treatment Modification is Treatment Modification is RequiredRequired

- Reduce Stress- Reduce Stress

- Sedation- Sedation

- Short Appointments- Short Appointments

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ASA IV

A patient with incapacitating A patient with incapacitating systemic disease that is a systemic disease that is a constant threat to lifeconstant threat to life

Example: Example:

- Unstable angina- Unstable angina

- M I within 6 months- M I within 6 months

- CVA within 6 months- CVA within 6 months

- BP greater than 200/115- BP greater than 200/115

- Uncontrolled diabetic- Uncontrolled diabetic

Elective dental care Elective dental care should be postponedshould be postponed

Emergency dental care Emergency dental care onlyonly Rx only to control Rx only to control

pain and infectionpain and infection Other treatment in Other treatment in

hospitalhospital (I&D, extraction)(I&D, extraction)

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ASA V

A morbid patient not A morbid patient not expected to surviveexpected to survive

Example: Example: - End stage renal disease- End stage renal disease

- End stage hepatic disease- End stage hepatic disease

- Terminal cancer- Terminal cancer

- End stage infectious disease- End stage infectious disease

Elective treatment Elective treatment definitely definitely contraindicatedcontraindicated

Emergency care only Emergency care only to relieve painto relieve pain

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Prevention

STRESS REDUCTIONSTRESS REDUCTION PremedicationPremedication SedationSedation Pain control (intra and post-op)Pain control (intra and post-op) Early appointmentsEarly appointments Short appointmentsShort appointments

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Preparation

Team EffortTeam Effort BLS for all office personnelBLS for all office personnel CPR for all office personnelCPR for all office personnel Emergency drillsEmergency drills Emergency phone numbers (911)Emergency phone numbers (911) Emergency equipmentEmergency equipment

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BASIC LIFE SUPPORT(BLS)

CARDIOPULMONARY RESUCITATION

(CPR)

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SBE Prophylaxis In 2012, the guidelines were updated and now premedication is needed for In 2012, the guidelines were updated and now premedication is needed for

fewer conditions. fewer conditions. The conditions for which premedication is necessary includes: The conditions for which premedication is necessary includes:

artificial heart valves artificial heart valves a history of infective endocarditis a history of infective endocarditis a cardiac transplant that develops a heart valve problema cardiac transplant that develops a heart valve problem the following congenital (present from birth) heart conditions:the following congenital (present from birth) heart conditions:*unrepaired or incompletely repaired cyanotic congenital heart disease, *unrepaired or incompletely repaired cyanotic congenital heart disease,

including those with palliative shunts and conduitsincluding those with palliative shunts and conduits*a completely repaired congenital heart defect with prosthetic material or *a completely repaired congenital heart defect with prosthetic material or

device, whether placed by surgery or by catheter intervention, during the device, whether placed by surgery or by catheter intervention, during the first six months after the procedurefirst six months after the procedure

*any repaired congenital heart defect with residual defect at the site or *any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic deviceadjacent to the site of a prosthetic patch or a prosthetic device

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SBE Prophylaxis

Patients who previously needed antibiotic Patients who previously needed antibiotic prophylactic but no longer need them include:prophylactic but no longer need them include: mitral valve prolapsemitral valve prolapse rheumatic heart diseaserheumatic heart disease bicuspid valve diseasebicuspid valve disease calcified aortic stenosiscalcified aortic stenosis congenital (present from birth) heart congenital (present from birth) heart

conditions such as ventricular septal defect, atrial conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathyseptal defect and hypertrophic cardiomyopathy

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SBE Prophylaxis

Procedures needing prophylaxis:Procedures needing prophylaxis: All dental procedures All dental procedures that involve manipulation that involve manipulation

of gingival tissue or the periapical region of of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. teeth or perforation of the oral mucosa.

procedures that do not require prophylaxis are procedures that do not require prophylaxis are radiographs, placement of removable radiographs, placement of removable prosthesis, and placement orthodontic bracket. prosthesis, and placement orthodontic bracket.

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Management of Medical EmergenciesAntibiotic Prophylaxis

Prophylactic Regimen for Dental ProceduresProphylactic Regimen for Dental Procedures

AMOXCICILINAMOXCICILIN

Adults 2 gramsAdults 2 grams

Children 50 mg/kg (not to exceed adult dosage)Children 50 mg/kg (not to exceed adult dosage)

Orally 1 hour before procedureOrally 1 hour before procedure

No repeat doseNo repeat dose

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Prophylactic Regimen for Dental ProceduresProphylactic Regimen for Dental ProceduresAllergic to PenecillinAllergic to Penecillin

AdultAdult ChildrenChildren

ClindamycinClindamycin 600 mg600 mg 20 mg/kg20 mg/kg

Cefalexin or CfadroxilCefalexin or Cfadroxil 2 gr.2 gr. 50 mg/kg50 mg/kg

Azithromycin or ClanthromycinAzithromycin or Clanthromycin 500 mg500 mg 15mg/kg15mg/kg

ORALLY 1 HOUR BEFORE PROCEDURE

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Prophylactic Regimen for Dental ProceduresProphylactic Regimen for Dental Procedures

Unable to take Oral MedicationUnable to take Oral Medication

AmpicillinAmpicillin

Adults:Adults: 2 gr IM or IV2 gr IM or IV

Children:Children: 50 mg/kg IM or IV50 mg/kg IM or IV

Within 30 minutes of procedureWithin 30 minutes of procedure

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Amoxicillin vs. PenecillinAmoxicillin vs. Penecillin Both equally effective against Streptococus viridanBoth equally effective against Streptococus viridan Amoxicillin is better absorbed from the GI tract, and Amoxicillin is better absorbed from the GI tract, and

provides higher and more sustained serum levelprovides higher and more sustained serum level 2 gr. Provides as effective coverage as 3 gr. With less 2 gr. Provides as effective coverage as 3 gr. With less

GI adverse effects.GI adverse effects. 22nd nd dosage not required due to prolonged serum level dosage not required due to prolonged serum level

above the inhibitory period for most oral Streptococci.above the inhibitory period for most oral Streptococci.

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ERYTHROMYCINERYTHROMYCINNo longer recommended due to GI side No longer recommended due to GI side

effects. Practitioners who have used it effects. Practitioners who have used it successfully in the past, may continue to successfully in the past, may continue to use it following the previously published use it following the previously published regimen.regimen.

2 gr. 2 hours before procedure2 gr. 2 hours before procedure1 gr. 6 hours later1 gr. 6 hours later

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Patient already taking antibiotic used for prophylaxis:Patient already taking antibiotic used for prophylaxis:1.1. Select an antibiotic from a different class, rather than Select an antibiotic from a different class, rather than

increasing the dosageincreasing the dosage2.2. Delay treatment if possible 9 to 14 days after Delay treatment if possible 9 to 14 days after

completion of antibiotic to allow usual flora to completion of antibiotic to allow usual flora to reestablishreestablish

Example: Amoxicillin, go to Clindamycin.Example: Amoxicillin, go to Clindamycin.No Cephalosporin due to cross No Cephalosporin due to cross

resistanceresistance

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Prophylaxis for dental patients with Prophylaxis for dental patients with

TOTAL JOINT REPLACEMENTTOTAL JOINT REPLACEMENT

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The most crucial period is up to 2 years The most crucial period is up to 2 years following a joint replacementfollowing a joint replacement

Prophylaxis not recommended for dental Prophylaxis not recommended for dental patients with: Pins, Plates, and Screws.patients with: Pins, Plates, and Screws.

Prophylaxis is not routinely indicated for Prophylaxis is not routinely indicated for most dental patients with total joint most dental patients with total joint replacementreplacement

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Patients at potential increased risk of total joint Patients at potential increased risk of total joint infectioninfection

Immunocompromized/Suppressed patientsImmunocompromized/Suppressed patients Other Patients:Other Patients:

Insulin Dependent diabeticsInsulin Dependent diabetics 11stst 2 years following joint replacement 2 years following joint replacement Previous prosthetic joint infectionPrevious prosthetic joint infection MalnourishementMalnourishement HemophiliaHemophilia

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Procedures and regimens are the same as Procedures and regimens are the same as discussed earlier for SBE prophylaxis.discussed earlier for SBE prophylaxis.

A cephlosporin is preferable to Amoxicillin A cephlosporin is preferable to Amoxicillin due to its affinity to cynovial fluidsdue to its affinity to cynovial fluids

6/3/20141 management of medical emergencies in the dental office fady faddoul, dds, msd,ficd...

Documents

specific medical emergencies

physician slide

anxiety slide

stanger slide

benign emergencies

diabetesrelated9993

prevention dialoguehistory

dental treatment