Transcript Drug Related emergencies - West Liberty University

R. John Brewer NREMT-P
Dental Education Inc.
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The administration of drugs is common in the
practice of dentistry and oral surgery.
The majority of the drugs used in dentistry
can be divided into four categories.
1. Local anesthetics
2. Analgesics
3. Antibiotics
4. CNS Depressants
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Important part of the dental treatment plan
when potentially painful procedures are
considered.
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Prescribed for relief of preexisting pain or
alleviation of potential post-operative pain.
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Used in the management of infections
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Prescribed for all phases of the dental
treatment for the prevention and
management of dentistry related fears.
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Whenever a drug is administered, a rational
purpose should exist for its use.
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Indiscriminate administration of drugs is one
of the major reasons the number of incidents
of serious or life threatening emergencies in
the medical and dental office have increased.
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It is estimated well over 100,000 patients
have died in hospitals due to adverse drug
reactions.
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It is estimated that over 2 million patients
have suffered serious but non fatal adverse
drug reactions.
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Toxicology is the study of the harmful effects
of chemicals on biological systems. These
effects range from minor to serious, or even
cause death.
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Whenever a drug is administered, two types
of reactions may be noted.
Desirable drug reaction
undesirable drug reaction
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General principles of toxicology
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No drug ever exerts a single action.
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No useful drug is entirely devoid of toxicity.
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The potential toxicity of the drug rests in the
hand of the user.
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Our goal is to give the correct drug in the
correct dose, via the correct route to the
correct patient at the correct time for the
correct reason.
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It is very important you know about the drugs
that you have in the office or prescribe to the
patient.
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Most Adverse drug reactions do not pose a
threat to the patients life.
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There are three responses to drugs that are
life threatening:
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Overdose reaction
Allergic reaction
Idiosyncrasy reaction
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A condition that results from exposure to
toxic amounts of a substance that does not
cause adverse effects when given in smaller
amounts .
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Defined as a hypersensitive response to an
allergen to which the individual has been
previously exposed, and now has developed
antibodies.
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Allergic reaction is possible with any drug or
substance.
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The drugs and substances most likely to
cause allergic reactions.
Aspirin
Penicillin
Bisulfites
Latex
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An individuals unique hypersensitivity to a
particular drug, food, or other substance.
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Management is to position the patient, ABC’S
are vital.
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The major cause of drug related emergency
situations in the dental office is the
“administration” of local anesthetics.
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Although true Adverse reactions occur ,most
reactions are related to the injection(seeing
the needle)
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Syncope and hyperventilation are the most
common “drug related” emergencies.
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These episodes usually result from emotional
stress receiving the local, not from the drug
itself.
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Locals is the most widely used drugs , are the
safest, and most effective drugs for the
prevention, and management of pain.
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It is important to stress again that most
adverse drug reactions to locals are a result of
the administration, not the drug.
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The next most common adverse drug
reaction is the toxic reaction. This is
produced by a relative overdose secondary to
accidental intravascular injection.
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True documented allergic reactions to locals
is extremely rare.
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Prescribed to treat established active
infections
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Should only be used when indicated due to
resistant bacteria strains and allergies.
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Pain relieving drugs make up a significant
portion of scripts written by dentists.
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Two categories of analgesics
mild- non opioid
strong opioid
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Mild- asa, ibuprofen, Tylenol
Strong- Opioid- codeine, demerol, diludid,
vicodin oxycontin
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Adverse drug reactions to the mild analgesics
are GI upset, nausea, constipation, itching
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Adverse drug reactions to the opioids are
nausea, vomiting, and orthostatic
hypotension, respiratory depression,
respiratory arrest.
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Aspirin, Tylenol and Codeine remain the most
commonly prescribed drugs.
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The use of these drugs for all phases of dental
care has increased significantly over the
years.
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The most common drugs prescribed is the
benzodiazepines.
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An overdose of a local is related to the blood
level of the local in the myocardium and
Central nervous system.
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There are several factors which influence the
rate at which blood levels increase or for
which blood levels remain elevated. These
factors could be drug or patient related.
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Normal distribution curve.
This is where the majority of patients
responds appropriate with “normal dose”,
However some are less responsive, and some
become more responsive to the local.
Age
Due to absorption, metabolism, and excretion
drug doses should be decreased for patients
under 6 years and over 65 years.
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- Weight > Lean body weight more of the drug the
patient can tolerate.
***A lack of consideration of body weight is one
of the major causes of overdose reactions.
Pathological process
Presence of Pre-existing disease may alter
bodies ability to transform a drug into a
biologically inactive substance.
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Patients with CHF demonstrate blood levels
of locals 2x those found in healthy patients
receiving the same dose.
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Patients with chronic lung disease are at
increased risk for local overdose. CO2
retention results in the decrease of the
seizure threshold for local anesthesia. If a
patient has a PCO2 of 65-81 their seizure
threshold is lowered by approx 53%.
Genetics
It is been reported that there are certain
individuals that possess genetic deficiencies
that alter their response to certain drugs.
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Attitude
It has been shown that the seizure threshold for
locals is lowered in patients who are overly
stressed.
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Vasoactivity
Locals that are more lipid soluble and more
highly protein bound are retained longer,
therefore having a slower absorption rate.
This increases the margin of safety.
The greater the degree of vasodilatation, the
more rapid the local is absorbed.
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Dosage :
The larger the dose the higher the peak blood
level.
Route of Administration:
Inadvertent intravascular is the factor that
causes most overdoses.
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Rate of Injection
The rate of injection is vital in the cause or
prevention, of overdose reactions to all
drugs.
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Local Anesthetic overdose reactions can
result from the combination of inadvertent
intravascular injection, combined with too
rapid a rate of ingestion.
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Both 100% preventable
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The more vascular the area, the faster the
absorption rate will be.
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The addition of a vasoconstrictor to a local
results in a decrease rate of systemic
absorption of the drug.
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Low to moderate overdose
Confusion
Talkativeness
Apprehension
Excitedness
Slurred speech
Generalized stutter
Muscular twitching, tremor to face,and
extremities
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Nystagmus
Elevated blood pressure
Elevated heart rate
Elevated respiratory rate
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headache
Feeling lightheaded
dizziness
Blurred vision
Ringing in ears
Numbness of tongue
Flushed or chilled feeling
Drowsiness
Disorientation and loss of consciousness
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Management is based on its severity.
-again most cases are mild in nature requiring
little or no treatment. Most local overdoses
again are self limiting.
Rarely should you go beyond just
administering a little 02.
Over treatment has the potential to become
a problem.
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It is imperative when administering a local,
that the patient remain under continual
observation, during and after administration
of the local.
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Again mild local reactions, will begin in 5-10
minutes following injection.
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Terminate procedure
Position of comfort
ABC’s
02 administration
Vital signs
Iv access
Administration of anti-convulsant.
EMS
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If signs symptoms appear immediately
(seconds to 1 minute)intravascular injection is
the most likely cause.
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Clinical findings are going to be much more
severe and rapid.
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Patient may immediately become
unconscious, and have seizures.
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Position patient supine - remove syringe
911
ABC’s
02 administration
Protect patient
Vital signs
IV therapy/ anticonvulsant
Manage the postictal patient
Anxiety after injection
Tremors of limbs
Diaphoresis
Headache
Tachycardia/ Bradycardia
Elevated blood pressure
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Terminate procedure
Position – semi sitting
ABC’s
Reassurance of the patient
Vital signs every 5 minutes
911
If hypertensive administer vasodilator(NTG)
esmolol
Transfer to hospital
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Whenever CNS-depressant drugs are
administered, the possibility exists that an
exaggerated degree of CNS depression may
develop.
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There have been several deaths both Adult
and Pediatric due to this.
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The clinical efficacy of a drug is dependent on
its absorption into the cardiovascular system
and its blood levels in different target
organs.(Brain)
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Only the inhalation and IV routes of drug
administration permit titration of the drug to
a precise clinical effect.
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Drug absorption via oral or IM is erratic.
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The use of a CNS depressant to obtain deep
sedation via a route of administration in
which titration is not possible is an invitation
to overdose and cannot be recommended.
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Recent administration
Decreased level of consciousness
Unconscious
Respiratory depression
Loss of motor coordination
Slurred speech
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Terminate dental procedure
Place Supine
ABC’s
911
Oxygen administration
Vitals
IV therapy
Reversal agents
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Over sedation and respiratory depression are
the primary clinical findings. However they
may have :
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Altered level of consciousness
Constricted pupils
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RECOGNIZE THE PROBLEM!!!!!
Discontinue treatment
Position
ABC’s
Oxygen
Vitals
IV therapy
Reversal agent
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A majority of the overdoses involve the
administration of more than one drug.
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Whenever more than one CNS depressant
drug is administered, the doses of both drugs
must be reduced to prevent exaggerated,
undesirable effects.
A reminder that locals are CNS depressants
themselves.
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When administering locals in conjunction
with CNS depressants, the dose of the local
anesthetic should be minimized.
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Ensuring a cooperative patient who
maintains protective reflexes is the primary
goal of sedation.
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Be prepared for emergencies
Individualize drug dosages
Recognize and expect adverse drug effects
Common Factors to those offices that had
deaths:
-Improper preoperative evaluation
- lack of knowledge of drug pharmacology
- lack of adequate monitoring.
The monitoring process should include
 -(CNS) direct verbal contact with patient
-Respiratory system
(Capn0graphy)
Pulse OX
Cardiovascular system
continuous monitoring of vital signs.
EKG
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Case #1
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Death of a 28 lb. pediatric patient. Patient
was given 7.5cc of local.
Case #2
Robert Pauley 73 y/o gentleman undergoing IV
sedation, at some point stops breathing,
cardiac arrest.
No vitals
No Pulse ox
No Reversal drugs given
Wrong ACLS drugs given
Suite filed/ Plaintiff’s family $1,135,000
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Dec. 2007
Georgetta Watson 46 y/o female
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Root Canal
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No history was taken prior to doing
procedure
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Patient monitored with pulse oximeter
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Pulse ox decreasing
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Irregular breathing pattern noted.
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Eventually EMS contacted
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EMS arrives finds patient in cardiac arrest.
Transported to hospital pronounced DEAD.
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Reports indicate a combination of 2 sedation
drugs were given in excessive amounts.
No patient history is documented
Patient was not placed on a monitor no
documentation of vital signs being recorded
No CPR being performed
Staff did not have BLS training.
NO record of staff training
MD’s license suspended 8/08
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Aug. 13,2008 8.5 million dollar awarded to
family in wrongful death lawsuit.
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This patient went into cardiac arrest 40
minutes after given a combination of 2
sedation drugs.
The patient received the following:
- 7mg versed iv push
- 75mg Demerol iv push
-.7mg atropine
- 6mg decadron
1 carpule 2% lidocaine 1: 100,000
3 carpules 3% mepivacaine
Oct. 15, 2007
Henry Dillow age 25 has 4 wisdom teeth
removed. Dead x3 days after surgery from
necrotizing fasciitis.
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John Coleman was a 47 y/o male patient
Needed multiple extractions.
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Given 2mg halcion.
Patient did not respond well to drug.
Staff restrained patient do DMD could finish
procedure.
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Following procedure patient given
flumazenil. Apparently at that point patient
went into cardiac arrest.
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EMS transported patient to hospital, anoxic
brain death, taken off ventilator the next day
and pronounced dead.
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Wife files suit against office stating the
following:
Office not prepared to handle emergency
Patient was over sedated
Delay in 911 call
In addition “DOCS” also being sued since they
did the training.
This patient had a history of obesity, diabetic,
and colon cancer.
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A patient in Wheeling, was administered 17
tablets of 0.25 mg halcion, for total dose of
4.25mg. A reminder an overdose can occur
at 2 mg.