“Are You Prepared!”

1. “Are You Prepared!” Medical Emergencies in the Dental Office Presented by: Keith M. Schneider, MS, DMD Tuesday, July 16, 2013 Tuesday, July 23, 2013

2. Overview • Improve your ability to plan for, manage and handle office medical emergencies as part of the dental team.  • Discuss the importance of a thorough health history in dealing with medical emergencies • Cover background information on emergencies • Necessary office emergency equipment • Scenarios of medical emergency situations and how to handle them

3. In Office Emergencies • Other emergencies can happen in the dental office • Not covered in this lecture

4. Our 10 Objectives • Describe emergency preventive procedures and preparedness in the dental office. • Explain the importance of obtaining a pretreatment health history from each patient. • Describe the procedure for obtaining a blood pressure, pulse, respirations, and temperature. • Demonstrate the initial sequence of patient assessment in an emergency. • Identify how stress and anxiety can lead to medical emergencies.

5. Our 10 Objectives • Recognize the signs or symptoms of impending or developing emergencies. • List the general steps to be taken when a medical emergency arises in a dental office. • Identify the type of emergency when given a patient situation and describe the necessary emergency care. • Identify the contents of an emergency kit. • Describe the medicolegal implications of medical emergencies.

6. Case Scenerio • During root canal therapy, a 68-year-old male patient becomes pale, perspires profusely, and clutches his chest.  He appears confused, seizes briefly, and is now unresponsive to verbal stimuli.  He is not breathing and no pulse can be felt in the carotid artery.  • Do you know how to handle this situation?

7. Medical emergencies can occur at any time in the dental office.  • They can happen to anyone • the anxious patient in the reception room • the elderly diabetic who was told to skip breakfast prior to coming to her appointment • the receptionist with a seizure disorder • the dentist experiencing prolonged chest discomfort • In a survey of 4,000 dental offices, 75 percent said they had treated medical emergencies in the last ten years. • It is estimated that the average dentist will have to deal with one or two life-threatening medical emergencies in their office during their career.

8. Knowing how to handle medical emergencies will make the dental provider more confident in his or her ability to handle all aspects of the job. • The best way to handle an emergency is to be prepared in advance. • Whether the medical emergency occurs years in the future or this afternoon, preparation is the key.  • All health care providers should be prepared to recognize and handle medical emergencies in the office.

9. Staff should be trained and frequently updated in first aid and cardiopulmonary resuscitation procedures.  • A written emergency plan should be available, and all staff members should be thoroughly familiar with it and their responsibilities in an emergency. • This includes training of office personnel in handling emergencies, development and posting of office emergency guidelines, and maintenance of an emergency kit or “crash cart,” fully equipped and ready for immediate use.

10. Introduction • Relatively rare • Most not life-threatening • Can become serious • Most are treated in office • Know when to refer for help

11. Introduction • Increasing # of older patients • Therapeutic advances • Longer appointments • Surgery is more often stress provoking • Increasing variety of drugs administered

12. Introduction • Preparation/Practice • Team • Patients • Action Plan • Supplies/Medication • Prevention • Recognition/Classification • History/signs/symptoms • Treatment • EMS – Activate when necessary

13. Preparation

14. Preparation • Doctor’s training – BLS, ACLS, CE • Auxiliary staff • Establish a system • Support • Staff – at least 2 in office at all times • 911 • Fire department • Local Urgent Care • Practice • Annual BLS • Periodic Emergency Drills • Preassigned Responsibilities

15. Avoiding Emergencies Adequate preparation of the patient and staff. The following are suggested guidelines: • Medical history – Update every 4-6 month • Obtain physician consultation when necessary. • Patients to take their normal medications on the day of their appointment.  • Review when confirming appointments • i.e. around meal times for diabetics; Angina patients bring nitroglycerin tabs; asthma patients bring inhaler.

16. Avoiding Emergencies • Staff member training • Monitor and interpret vital signs.  • Vitals at initial visit as a “baseline reading” • Subsequent visits for “high risk” patients • Basic first aid procedures and basic life support (CPR). • Each staff member should know and practice their particular function in an emergency • Emergency telephone numbers should be posted at each phone. • Should be aware of signs of stress and how to alleviate them

17. Avoiding Emergencies • Office personnel should be aware of the signs and symptoms indicating an emergency.  • An emergency kit readily available • each staff member should know where it is located. • All staff should be aware of their legal responsibilities when responding to an office emergency. • Remember—the “best handled” medical emergency will always be the one that never happened.

18. Emergency manuals • Develop an emergency manual • Keep it simple • Commercial manuals are available • Staff designations • Phone numbers to EMS • Address and directions to office • Special instructions to EMS

19. Emergency manuals • Review protocol – twice a year • Practice using equipment • Use outdate drugs to practice • Practice airways

20. When to call – 911! • Condition is life-threatening • Patient not responding to Treatment • Patient’s response is not appropriate • When in doubt – SHOUT!

21. Emergency Plan

22. Preparation Equipment • Dental Chair • Trendelenburg position • Operatory with adequate space • CPR board

23. Preparation Equipment • Respiratory assistance: • Oral / nasal airways • Tonsil suction • High-volume suction • Ambu bag (Air Mask Bag Unit) • Clear face masks

24. Preparation Equipment • BP Cuff and stethoscope • Oxygen Tank – (size E Portable with low flow regulator) • Syringes – IM (3cc), SubQ (TB syringe) • Automated External Defibrillator (AED)

25. Oxygen and Airway • Oxygen source – fixed / removable • Cannula • Readily accepted by patient – comfortable • Maximum delivery – 6L/M (higher is painful) • Non-rebreathing mask • Better than a rebreathing mask • Set O2 at 10L/M or maximum flow • Able to deliver 100% O2

26. Oral-pharyngeal Airways • Prevent tongue from obstructing airway • Proper size – important • Measure corner of mouth to the earlobe • Insert upside down and rotate at soft palate

27. Pocket Mask • Always use with O/P airway if possible • Easy technique • Set O2 to maximum level • Rate – 12/minute (every 5 seconds)

28. Bag-Valve-Mask • Gold standard • Use a O/P airway also • Delivers 100% O2 • Difficult with small hands • Rate – 12/minute • Gently squeeze bag – assist patient breathing

29. Preparation Equipment • Administration of Medications: • Syringes – needles • Tourniquets • Intravenous solutions • Indwelling catheters • Intravenous tubing

30. Preparation Equipment • Commercial Emergency Kits • Self assembled: “Crash carts” • Choose agents likely to use • Organize in easy to use manner • Labeled – name and situation used • Checked frequently for completeness • Expiration of medications

31. Preparation – Monitors • Stethoscope • Sphygmomanometers ( BP Cuff) • Detachable cuffs for varying sized arms • Proper size = 20% larger than the diameter of arm • Three sizes – standard, larger adult, pediatric

32. Preparation – Supplies & Equipment • Emergency Kits – commercial available/high price • Self assembled: • Choose agents likely to use • Organize - easy to use manner • Labeled – name and situation used • Checked frequently for completeness • Expiration of medications

33. Emergency Drugs Oral Preparations • Antihistamine: • Diphenhydramine (Benadryl) • Antihypoglycemic: • Candy, fruit, sugar,Glutose • Vasodilator: • Nitroglycerine • Nitrostat

34. Emergency Drugs Inhaled preparations • Oxygen • Brochodilator: • Allupent, Epinephrine bitartrate (Medihaler-Epi) • Albuteral (Proventil/Ventolin) • Respiratory stimulant – Aromatic Ammonia

35. Emergency Drugs Parenteral preparations • Analgesic • Morphine • Anticonvulsant – Diazepam • Valium • Antihistamine – Diphenhydramine • Benadryl

36. Emergency Drugs Parenteral preparations • Antihypoglycemic – 50% dextrose in water • Corticosteroid: • Dexamethasone (Decadron) • Methyprednisolone (Solu-Medrol) • Hydrocortisone (Solu-Cortef)

37. Emergency Drugs Parenteral preparations • Narcotic antagonist – Naloxone (Narcan) • Flumazenil (Romazicon) • Sympathomimetic – Epinephrine • Vagolytic - Atropine

38. PREVENTION

39. Prevention • Know who’s at risk • Medical history • Predict future problems • Prevent crisis in present • Physical exam – vital signs • Obtain consults - written • Alter treatment

40. Prevention • Office Visit - thorough history and physical • Chief Complaint • Medical History • Surgical History • Family History • Social History • Medications • Allergies • Vital signs • Alter treatment • i.e. stress reduction protocols

41. Medical History Form • Thorough • Easy to complete • Easily updated and dated • Easy to recall updated information • Patient’s signature – medical/legal

42. Medical History Form – Limitations • Unable to quickly recover information • Incorrect / inaccurate information • Patient mistakes re: medications • Daily maintenance medications are overlooked • Non-tablet form of medication • Alternative medications/vitamins

43. Surgical History • Hospitalizations & operations • Supports the medical history • Cross check • Complications with procedures or anesthesia

44. Family History • Genetic predispositions • Underlying health conditions that may surface as patient gets older

45. Social History • Smoking • ETOH • Drug use

46. Medications • Dosage/indications • Prescription • Non-prescription (Vitamins/supplements) • Recreational

47. Allergies • Pre-existing allergic conditions • Environmental allergies • Drug interactions

48. History that Matters

49. History that Matters

50. History that Matters