Transcript management of medical emergencies in the dental office

Management Of Medical Emergencies In
The Dental Office
Fady Faddoul, DDS, MSD,FICD
Professor and Vice-Chairman
Department of Comprehensive Care
Director, Advanced Education in General Dentistry
Case Western Reserve University
School Dental Medicine
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Management of Medical Emergencies
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Medical emergencies can and do happen
Advances in medicine
 Longer lifespan
 Multiple medications
 Medically compromised
 Longer appointments
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Incidence
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A survey done in the 90’s showed that, over
a 10 year period, 90% of dentists have
encountered at least one medical
emergencies.
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Types
TYPE OF EMERGENCY
NUMBER
PERCENT
Altered Consciousness
17,782
59
Cardiovascular
4,280
14
Allergy
2,887
9.5
Respiratory
2,718
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Seizures
1,595
5
999
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Diabetes-Related
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Management of Medical Emergencies
Basic Life Support
 Advanced Life Support
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Management of Medical Emergencies
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Emergency situations
Managed properly most emergencies are resolved satisfactorily
Mismanaged even benign emergencies can turn disastrous
 Recognize
 Position
 Stabilize
 Diagnose
 Treat
 Refer
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Management Of Medical Emergencies
1.
2.
3.
4.
5.
6.
Recognition
Prevention
Preparation
Basic life support (BLS)
Cardiopulmonary resuscitation (CPR)
Specific medical emergencies
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Prevention

IS THE BEST
TREATMENT
Know your patient
Never treat a STANGER
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Prevention
90% of life-threatening situations can be
prevented
 10% will occur in spite of all preventive
efforts (sudden unexpected death)
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Prevention
Medical History
 Physical Evaluation
 Vital Signs
 Dialogue History
 Determination of Medical Risk
 Stress Reduction
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Prevention
MEDICAL HISTORY
 Review
 Update
 Medication
 Medical consultation
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Prevention
PHYSICAL EVALUATION
 Length of time since last evaluation
 Vital signs
 Visual inspection of patients
 Referral to physician
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Prevention
VITAL SIGNS
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Blood pressure
Pulse rate
Respiratory rate
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Temperature
Height
Weight
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Prevention
DIALOGUE
HISTORY
 Putting it all together
 Check accuracy of
medical history
 Recognize anxiety
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Prevention
DETERMINATION OF MEDICAL RISK.
 Ability of patient to safely tolerate dental
treatment.
 Does patient represent increased medical
risk?
 Can patient be managed in the dental
office?
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Determination Of Medical Risk
American Society of
Anesthesiology
Physical Status Classification
System
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ASA I
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A patient without
systemic disease
A normal healthy
patient
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Can tolerate stress involved
In dental treatment
No added risk of serious
Complications
Treatment modification
Usually not necessary
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ASA II
A patient with mild systemic
disease
Example:
-Well-controlled diabetic
-Well-controlled asthma
-ASA I with anxiety
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Represent minimal risk
during dental treatment
Routine dental treatment
With minor modifications
-Short early appointments
-Antibiotic prophylaxis
-Sedation
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ASA III
A patient with severe systemic
disease that limits activity but is
not incapacitating
Example:
- a stable angina
- 6 mos. Post - MI
- 6 mos. Post - CVA
- COPD
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Elective Dental Treatment
is not Contraindicated
Treatment Modification is
Required
- Reduce Stress
- Sedation
- Short Appointments
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ASA IV
A patient with incapacitating
systemic disease that is a
constant threat to life
Example:
- Unstable angina
- M I within 6 months
- CVA within 6 months
- BP greater than 200/115
- Uncontrolled diabetic
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Elective dental care
should be postponed
Emergency dental care
only
Rx only to control
pain and infection
 Other treatment in
hospital
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(I&D, extraction)
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ASA V
A morbid patient not
expected to survive
Example:
- End stage renal disease
- End stage hepatic disease
- Terminal cancer
- End stage infectious disease
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Elective treatment
definitely
contraindicated
Emergency care only
to relieve pain
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Prevention
STRESS REDUCTION
 Premedication
 Sedation
 Pain control (intra and post-op)
 Early appointments
 Short appointments
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Preparation
Team Effort
 BLS for all office personnel
 CPR for all office personnel
 Emergency drills
 Emergency phone numbers (911)
 Emergency equipment
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BASIC LIFE SUPPORT
(BLS)
CARDIOPULMONARY
RESUCITATION
(CPR)
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SBE Prophylaxis
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In 2012, the guidelines were updated and now premedication is needed for
fewer conditions.
The conditions for which premedication is necessary includes:
 artificial heart valves
 a history of infective endocarditis
 a cardiac transplant that develops a heart valve problem
 the following congenital (present from birth) heart conditions:
*unrepaired or incompletely repaired cyanotic congenital heart disease,
including those with palliative shunts and conduits
*a completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
six months after the procedure
*any repaired congenital heart defect with residual defect at the site or
adjacent to the site of a prosthetic patch or a prosthetic device
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SBE Prophylaxis
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Patients who previously needed antibiotic
prophylactic but no longer need them include:
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mitral valve prolapse
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rheumatic heart disease
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bicuspid valve disease
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calcified aortic stenosis
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congenital (present from birth) heart
conditions such as ventricular septal defect,
atrial septal defect and hypertrophic
cardiomyopathy
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SBE Prophylaxis
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Procedures needing prophylaxis:
 All dental procedures that involve manipulation
of gingival tissue or the periapical region of
teeth or perforation of the oral mucosa.
 procedures that do not require prophylaxis are
radiographs, placement of removable
prosthesis, and placement orthodontic bracket.
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Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
AMOXCICILIN
Adults 2 grams
Children 50 mg/kg (not to exceed adult dosage)
Orally 1 hour before procedure
No repeat dose
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Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
Allergic to Penecillin
Adult
Children
Clindamycin
600 mg
20 mg/kg
Cefalexin or Cfadroxil
2 gr.
50 mg/kg
Azithromycin or Clanthromycin
500 mg
15mg/kg
ORALLY 1 HOUR BEFORE PROCEDURE
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Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
Unable to take Oral Medication
Adults:
Children:
Ampicillin
2 gr IM or IV
50 mg/kg IM or IV
Within 30 minutes of procedure
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Management of Medical Emergencies
Antibiotic Prophylaxis
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Amoxicillin vs. Penecillin
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Both equally effective against Streptococus viridan
Amoxicillin is better absorbed from the GI tract, and
provides higher and more sustained serum level
2 gr. Provides as effective coverage as 3 gr. With less
GI adverse effects.
2nd dosage not required due to prolonged serum level
above the inhibitory period for most oral Streptococci.
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Management of Medical Emergencies
Antibiotic Prophylaxis
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ERYTHROMYCIN
No longer recommended due to GI side
effects. Practitioners who have used it
successfully in the past, may continue to
use it following the previously published
regimen.
2 gr. 2 hours before procedure
1 gr. 6 hours later
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Management of Medical Emergencies
Antibiotic Prophylaxis
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Patient already taking antibiotic used for prophylaxis:
1.
Select an antibiotic from a different class, rather than
increasing the dosage
2.
Delay treatment if possible 9 to 14 days after
completion of antibiotic to allow usual flora to
reestablish
Example: Amoxicillin, go to Clindamycin.
No Cephalosporin due to cross resistance
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Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylaxis for dental patients with
TOTAL JOINT REPLACEMENT
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Management of Medical Emergencies
Antibiotic Prophylaxis
The most crucial period is up to 2 years
following a joint replacement
 Prophylaxis not recommended for dental
patients with: Pins, Plates, and Screws.
 Prophylaxis is not routinely indicated for
most dental patients with total joint
replacement
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Management of Medical Emergencies
Antibiotic Prophylaxis
Patients at potential increased risk of total joint
infection
 Immunocompromized/Suppressed patients
 Other Patients:
 Insulin Dependent diabetics
st
 1 2 years following joint replacement
 Previous prosthetic joint infection
 Malnourishement
 Hemophilia
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Management of Medical Emergencies
Antibiotic Prophylaxis
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Procedures and regimens are the same as
discussed earlier for SBE prophylaxis.
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A cephlosporin is preferable to Amoxicillin
due to its affinity to cynovial fluids
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