Transcript Lecture 3 LRC

MEDICAL EMERGENCIES
Lecture 3
Objectives
Recognize Medical Emergencies
Explain protocol to handle medical emergencies
Be able to follow emergency management protocol
Describe how to manage the patient experiencing a
medical emergency
Discuss Angina Pectoris, Myocardial Infarction, Heart
Failure and Acute Pulmonary Edema
Objectives
List specific signs and symptoms associated with CVA
Explain the steps needed to prepare an office for a patient experiencing
CVA
Describe the procedure for the management of dental patient
experiencing Myocardial Infarction, Cardiac Arrest, Acute Pulmonary
Edema and Heart Failure in the dental setting
Objectives
List signs and symptoms associated with pacemaker and ICD
malfunction
Explain the special precautions that should be taken to prevent a
patient from experiencing a pacemaker or ICS malfunction
Introduction
Coronary artery disease (CAD): also called coronary
heart disease: most often the cause of chest pain
originating in the heart.
Results in the greatest number of deaths per year.
A medical history is critical prior to the initiation of any
dental treatment.
RDH should be able to identify risk factors for CAD.
Chances of survival increases if emergency procedures
are activated at the onset of symptoms.
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Risk factors for CAD
Atherosclerotic heart disease = CAD
Atherosclerosis is a slow, complex inflammatory arterial
disease that starts in childhood and progresses with
age.
Major risk factor in the development of all forms of
cardiovascular disease and is most likely the cause of
myocardial ischemia.
Starts when the inner lining of an artery is injured or
damaged by: high cholesterol, tobacco, diabetes, high
BP, infectious microorganisms.
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Coronary artery disease (CAD)
Atherosclerosis characterized by a buildup of yellowish
plaques on the inner walls of arteries.
The plaque is composed of cholesterol, lipids, platelets,
calcium, and cellular debris.
As the plaque size increases, it starts to restrict blood
flow and oxygen to the heart and brain.
Closing off an artery or occlusion of an artery can
result in silent ischemic episodes, angina pectoris,
acute myocardial infarction (AMI), or strokes.
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Atherosclerosis
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Risk factors for CAD: Gender
Historically considered to affect males more than females
However, CAD and stroke is the leading cause of death
among women in the US.
Diabetes, high cholesterol- increased risk of CAD in women
more than in men.
Post-menopausal women higher risk for CAD than premenopausal women.
Hormone replacement therapy may reduce risk.
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Risk factors for CAD: Age
Increasing age in men and women increases the risk
of developing CAD.
New onset CAD occurs after 65 yrs of age.
Modifying risk factors or the prevention of
developing risk factors directed to the age groups
between 65-75.
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Heredity Including Race
Family history of premature CAD, high blood pressure, high
cholesterol.
Patients with a family history of premature heart disease is at a
higher risk.
African Americans have the highest CAD mortality rates.
Non-Hispanic whites have the 2nd highest mortality rates followed
by Hispanics, Native Americans, and Asians.
African American women have a higher CAD mortality rate
compared to non-Hispanic women.
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Tobacco Use
Smokers 2-4 times more like to develop CAD than non-smokers.
Smoking is a major independent risk factor for sudden cardiac death in
patients with CAD.
Smoking accelerates the development of coronary plaques and
promotes plaque rupture and coronary thrombosis.
Tobacco cessation quickly and significantly reduces the risk for a heart
attack.
Cigarette smoking is the most preventable cause of death in the US.
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Hypertension
Individuals over the age of 50 with a systolic BP greater than 140 mmHg is a
more important risk factor in the development of cardiovascular disease than
diastolic blood pressure.
Dental professionals will encounter patients who have undiagnosed or
uncontrolled BP. Referral to a MD may be necessary prior to treatment.
Always take and record BP and vitals at every appointment.
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Hypercholesterolemia
High Cholesterol – waxy, fat-like substance made in the
liver.
Found in foods derived from animals including meat, dairy,
eggs, cheese, and milk.
A small amount of cholesterol is needed to help digest fat.
Cholesterol attaches to a lipoprotein and is carried
throughout the bloodstream.
Too much cholesterol results in atherosclerosis and CAD.
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Lipoproteins
Low-density lipoprotein (LDL): cause atherosclerosis. Optimal levels
are less than 100 mg/dL. 160-189mg/dL are considered high
High-density lipoproteins (HDL): help rid the body of LDLs. High levels
of HDLs prevent CAD.
Triglycerides: another form of fat found in the bloodstream. Increased
levels of 150-200mg/dL or > may increase the risk for CAD
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Diabetes
Most common complication of diabetes type I and II is cardiovascular disease due
to atherosclerosis and hypertension.
Atherosclerosis in diabetics is accelerated and more severe.
Macroangiopathy: is the damage done to the large blood vessels in diabetics as a
result of atherosclerosis.
Microvascular damage due to hyperglycemia diminshes vascular function making
the consequences of atherosclerosis and hypertension more difficult to withstand.
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Macroangiopathy: narrowing of the arteries
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Obesity and Physical Activity
Obesity and lack of physical exercise negatively impact CAD due to their
effect on major risk factors.
Obesity often results in Type 2 Diabetes.
Weigh control, diet, and exercise can reduce hypertension and
hypercholesterolemia
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Angina Pectoris
Chest pain due to angina is one of the more common medical
emergencies in the dental office.
Angina due to inadequate supply and/or increased demand for
oxygen to the myocardium (myocardial ischemia).
Clinicians should be aware of the patient’s whose medical hx indicate
past incidences of angina.
CAD, presenting as angina or AMI, is the leading cause of sudden death
in the US.
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Angina Pectoris
As plaque deposits increase in size they restrict the opening of
the artery= atherosclerosis
Occlusion of the artery can result in an infarction
Common medical emergency in dental office
Forms of Angina
Stable
Unstable
Variant (Prinzmetal’s)
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Signs and Symptoms of
Stable Angina
Generalized chest discomfort: pressure, burning, heaviness,
squeezing, or choking**
Radiates from thoracic area to left shoulder, down the arm, and to the
neck, lower jaw, or tongue.
Patient may present symptoms such as diaphoresis or a cold sweat,
nausea and pallor.
Attacks can vary in intensity; lasting from 1 to 15 minutes.
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Stable Angina
AKA typical, chronic, classic, exertional
Usually related to CAD and is the most common form of angina.
Usually induced by physical activity or stress and symptoms are worse
in cold weather or after a large meal.
May radiate to shoulders, arms, neck, mandible, or epigastric.**
Pain associated with a pressing feeling, crushing, burning, or
squeezing.**
Usually discomfort in left area of chest lasting from 1-15 minutes.
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Stable Angina
Stable angina responds to rest and nitroglycerine within 10 to 15 minutes.
Angina considered stable if there has been no change in frequency, etiology,
or duration of symptoms in last 60 days.
Can receive dental care – appointments should be short and minimally
stressful.
Medications for angina: calcium channel blockers, nitrates,
and beta-adrenergic blocking agents.
Regular exercise reduces frequency of symptoms and
increases functional capacity of the heart
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Signs and Symptoms of
Stable Angina
In acute anginal episodes, pts may be apprehensive
and may press their fist to their sternum called the
Levine sign.
Pts may have an increase in HR and BP.
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Levine sign
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Prevention of an Anginal Episode
A complete, comprehensive medical history to identify patients who may be at
risk for or have CAD.
Patients with unstable angina (UA) should only get Tx if ok by physician.
Do not use vasoconstrictors.
Patients with stable angina can be tx in the office, but the emotional,
environmental, and physical stresses of the dental appt may cause an anginal
episode.
Modify dental tx to reduce stress: shorter appt times and end tx when pt starts
to show signs of fatigue, stress, or anxiety.
Schedule patients for late morning or afternoon appts.
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Prevention
Local anesthetics containing a vasoconstrictor on a pt with stable angina
is generally not contraindicated; but the max dosage of epi for a
cardiac-risk pt is .04mg. Which amounts to approx 2 cartridges of
anesthesia containing 1:100,000 epi.
Pts treated with b-adrenergic blockers for management of angina
should not be given vasoconstrictors.
Pts with unstable angina should NOT receive local anesthetics with
vasoconstrictors.
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Prevention
Angina pts may benefit from supplemental oxygen at a flow rate of
3-5 L/min via nasal cannula.
Minimizes the risk of inadequate oxygenation of the myocardium
during treatment.
Have pts bring their own nitroglycerin spray or tablets to the dental
appt.
Better to use pts Rx because the dosage will be correct for the pt.
Medical ER kit should contain nitroglycerin (nitrolingual spray)
preferred because it is more stable than tablets.
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Treatment of Angina
Terminate treatment
Semi-supine or upright position
Assess ABC’s
Administer oxygen, 3-6L/minute
Monitor vital signs
Administer sublingual or transmucosal nitroglycerine – dilates coronary
blood vessels resulting in decreased cardiac workload
Treatment of Angina
Use patient’s own medication if current
Will feel tingling sensation on tongue if fresh
Administer one table every 5 minutes up to 3 doses – usually alleviates
symptoms in 2-4 minutes
Nitro contraindicated in hypotensive patients
Treatment of Angina
Following administration of nitroglycerine, patient may experience
tachycardia, flushing, pounding in head, hypotension.
Nitroglycerine is not effective if it is expired or if patient is experiencing
an acute heart attack.
If pts pain is more severe than previously experienced, EMS should be
called immediately.
If pt has no known history of angina and chest pain lasts for 2 minutes
or longer, call 911 immediately.
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Figure 10.3 Nitroglycerin
Figure 10.2 Anginal patient with nasal cannula to deliver oxygen
Figure 10.4 Blockage of coronary arteries
Heart Attack
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Acute Myocardial Infarction (AMI)
Necrosis of a portion of the myocardium due to total
or partial occlusion of a coronary artery.
Occlusion caused by atherosclerosis, thrombus, or a
coronary spasm.
May form rapidly or over a period of time.
MI can lead to cardiac arrest: when the heart fails to
beat.
Providing basic life support prior to EMS arriving could
save a life.
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Acute Myocardial Infarction (AMI)
Cardiac dysrhythmia may occur after MI and is a
high risk for death
Dysrhythmia may present as:
◦ Bradycardia: slow heart rate
◦ Ventricular tachycardia – rapid contraction with
inadequate ventricular filling
◦ Ventricular fibrillation – disorganized, irregular
contraction of ventricles
◦ Asystole – absence of heart contractions
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Signs and Symptoms of AMI
Classic symptom: chest pain lasting 20 minutes or
longer**
Pressure, tightness, heaviness, burning, squeezing,
crushing sensation in middle of chest and/or lower 1/3 of
epigastrium
Pain may radiate down arms, shoulders, jaw, or back.**
Pt may also experience weakness, dyspnea, diaphoresis
and an irregular pulse.
If pain is intense, pt may have nausea and vomiting.
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Signs and Symptoms of AMI
Pts may feel a sense of impending doom, clutching their fist to their
chest (Levine Sign).
Women show different symptoms: indigestion, back pain,
breathlessness, back pain, deep throbbing in left or right bicep or
forarm.**
Diabetics suffer silent MIs.
The elderly show signs of shortness of breath, dizziness, pulmonary
edema, and/or an altered mental status or an arrhythmia.
Always important to treat chest pain as cardiac related until a cardiac
cause can be ruled out.
Pg.105, Table 10.4
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Treatment of AMI **
Stop hygiene treatment, alert staff and dentist, call EMS.
Place patient in a comfortable position.
Monitor vitals
Administer high-flow oxygen and BLS.
Patient can take one nitroglycerin tablet every 3-5 minutes, no more
than 3 doses in a 15 minute time period.
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Treatment of AMI
Initiate fibrinolysis: breaking down of fibrin, part of a process designed to
dissolve a clot or prevent a clot from forming.
Administer aspirin chewed 325 mg. – antithrombotic effect – clinical effect
reached in 20 minutes.
Aspirin should be chewed to enter bloodstream quicker. Make sure the
patient is not allergic to aspirin.
Manage pain to prevent cardiogenic shock with nitrous oxide, if available.
If cardiac arrest occurs, perform CPR with AED.
According to the AHA, the immediate initiation of CPR and use of AED
within the first 3-5 minutes, pts have the highest chance for survival.
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Figure 10.5 Baby aspirin for anticoagulation
Heart Failure
Occurs when heart muscle is impaired and no longer
pumps sufficient blood to body tissues and organs
Can result from almost any kind of CVD
Congestive heart failure now called heart failure by the
American Heart Association due to the broad
spectrum of the disease
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Heart Failure
MI and hypertension most frequent etiology
Can be associated with other underlying factors
Initially presents during exertion
As disease progresses symptoms occur even when at rest
Heart Failure
3 cardinal symptoms of HF: dyspnea, edema, and fatigue; though not
necessarily diagnostic of HF.
Symptoms of HF initially start during exertion, as disease progresses
shortness of breath and fatigue are present even when pt is at rest.
Physiological and/or psychological stress with dental tx can exacerbate
symptoms.
Could lead to life-threatening acute pulmonary edema.
Very important for clinician to recognize signs and symptoms, know how to
modify and manage dental tx, and be prepared to respond to a medical
emergency.
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Clinical Manifestations
of Heart Failure
Left ventricular HF
Right ventricular HF
Both left and right ventricular HF
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Figure 11.2 Left-side and right-side heart failure
The Heart
Left atrium collects newly oxygenated blood from the lungs and the left
ventricle pumps the oxygen-rich blood out to the body.
Right atrium collects oxygen-poor blood from the body, the right ventricle
pumps it to the lungs where the blood picks up oxygen and gets rid of carbon
dioxide.
Heart failure can be classified according to the side of the heart that is
affected.
Long term heart failure usually involves both sides.
Pg. 115, figure 11.2 and pg.114, figure 11.1
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Signs and Symptoms of
Left Heart Failure
Cardiac asthma – wheezing due to congestion of bronchial mucosa
Pale and cool to touch
Diaphoresis
Increased BP
Pulse rapid and thready – may alternate between strong and weak
LV failure usually occurs before RV failure.
Signs and Symptoms of
Left Heart Failure
Heart failure patients with moderate to severe breathing difficulty are
classified as ASA III or IV.
Often require supplemental oxygen via nasal cannula.
Dental tx must be modified: shorter appt times, placing the pt in an
upright position during treatment, a standing prophy.
LV pts may also cough due to congestion in the lungs; a dry,
nonproductive, chronic cough occurring with dyspnea and during
exertion or lying in a supine position.
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Signs and Symptoms of
Right Heart Failure
Usually develops after left heart failure.
Causing the effect of increased fluid pressure ultimately damages the right
side of the heart.
RV failure results in the inability of the heart to pump oxygen-poor blood
from the systemic venous circulation to the lungs for oxygenation.
Results in congestion in systemic venous system.
RV pts feel: fatigue and weakness.
Classic symptom – peripheral edema.
Pitting edema in lower legs and ankles, a depression that remains in the
tissue for a few seconds after release of pressure to the area.
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Signs and Symptoms of
Right Heart Failure
Reduction in renal blood flow resulting in a decrease in the
excretion of sodium, so causes the retention of fluids.
◦ During the day patient’s activity increases degree of HF –
less urine production
◦ At night – less active – renal and cardiac function may
improve
◦ Nocturia may result – increased urination at night
Distended external jugular veins while lying or sitting.
Normally the jugular veins are collapsed while standing
or sitting.
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Signs and Symptoms of
Right Heart Failure
In RV heart failure, engorgement of the liver and spleen occurs.
As the disease progresses, edema in the abdomen becomes evident.
Congestion in the gastrointestinal tract can cause nausea, vomiting
and anorexia.
Edema in the central nervous system can manifest clinically with pt
experiencing headaches, insomnia, and irritability.
Pg 117, Table 11.1
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Signs and Symptoms of Later Stages of Heart
Failure
Mental confusion, anxiety, and restlessness due to the
lack of O2 to brain.
Cardiac cachexia: malnutrition and wasting of tissues;
may be evident in end-stage HF.
Cyanosis of the skin and mucous membranes, especially
in the nail beds and lips; also a sign of late-stage HF.
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Treatment of Heart Failure
Changes in lifestyle can lessen the symptoms of HF and
prevent the disease from progressing.
◦ Smoking cessation, exercise, weight loss, diet low in
fat and sodium, limited caffeine and alcohol, and
stress reduction.
◦ Drug therapy differentiated between systolic and
diastolic dysfunction.
◦ Diastolic dysfunction: the underlying cause of impaired
diastolic function determined prior to drug therapy.
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Treatment of Heart Failure
Drug therapy
◦ ACE inhibitors
◦ Diurectics
◦ Vasodilators
◦ Beta blockers
◦ Calcium channel blockers
Management of Heart Failure
Patient in Dental Setting
Questions
◦ Heart failure
◦ Swelling in feet or ankles
◦ Shortness of breath
◦ Weight gain – 3 pounds over 7 days with edema red flag –
postpone treatment
Management of Heart Failure
Patient in Dental Setting
Physical characteristics observed
◦ Cyanosis
◦ Jugular veins
Vital signs prior to treatment and throughout appointment
Management of Heart Failure
Patient in Dental Setting
ASA IV (dyspnea, orthopnea, and fatigue at all times) require
medical consultation
◦ Elective treatment should be postponed until symptoms
controlled
Acute Pulmonary Edema
Most dramatic life-threatening symptom of HF.
Acute pulmonary edema is the result of a swift and abrupt
accumulation of fluid in the alveolar spaces in the lungs inhibiting
lung expansion and results in the decreased ability for the lungs to
oxygenate the blood.
Precipitating events
◦ Stress
◦ Infection
◦ Failure to take medications as prescribed
◦ Meal high in sodium
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Signs and Symptoms of Acute
Pulmonary Edema
Gasping for air
Rapid pulse
Cool, moist skin
Cyanotic lips and nail beds
Anxiety
Dyspnea with cough that may produce frothy, blood tinged sputum
Loud coarse lung sounds
Treatment of Acute Pulmonary
Edema in the Dental Setting
Life threatening
Contact EMS
Terminate all treatment
Reduce patient anxiety to reduce cardiac and respiratory workload
Position patient comfortably – probably upright to aid in breathing
ABC’s
Treatment of Acute Pulmonary
Edema in the Dental Setting
O2 10 L/minute or more
Monitor vital signs every 5 minutes
Nitroglycerine 2-3 tablets or sprays every 5 -10 minutes
◦ Do not use if systolic BP below 100 mmHg
If consciousness lost, place in supine position and
administer CPR
Treatment of Acute Pulmonary Edema in the Dental
Setting
Maintaining the airway and breathing is the primary concern.
Clinician can perform a bloodless phlebotomy using BP cuffs placed 6 inches
below the groin and one 4 inches below the shoulder.
One BP cuff should be removed every 5-10 minutes and reapplied to the
other free extremity.
Cuff should be tight enough to reduce blood flow but loose enough to feel
the arterial pulse.
This tx can temporarily remove blood from circulation, allowing the heart to
pump the remaining blood more effectively.
Resulting in reduced pulmonary congestion and improved breathing.
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Figure 11.3 Bloodless phlebotomy
Managing acute pulmonary edema
Nitroglycerin can be given for a rapid treatment of pulmonary edema
and heart failure.
Morphine may be administered for patients experiencing apprehension
and anxiety; increase in vasodilation, decrease in cardiac and respiratory
work load.
Pts with hypoxia with cyanosis, mental confusion, or delirium, the use of
opioids is an absolute contraindication.
In the dental office, staff would be only administering oxygen and
allowing pt to sit upright to reduce respiratory distress.
Cardiac Pacemaker
Composed of pulse generator and leads
Generator contains electronic circuitry that powers device
Figure 12.1 Pacemaker
Figure 12.2 Area of pacemaker
Cardiac Pacemaker
Used for arrhythmias
Usually bradycardia leading to low cardiac output
Pacemaker monitors heart rate
Implantable
Cardiac Defibrillator
Similar device to pacemaker
Used to treat harmful tachyarrhythmias (200 BPM) which
usually originate in ventricles
Pacemaker or
ICD Malfunction
All patients with pacemaker or ICD should have medical consultation
prior to dental treatment
Small chance of infective endocarditis
Rarely is premedication recommended
Greater risk of malfunction with electromagnetic interference
Pacemaker or
ICD Malfunction
Possible etiologies of malfunction
◦ Cellular phones
◦ MRI
Should be informed by physician
Should carry a card
Pacemaker or ICD
Malfunction in Dental Office
Safe procedures
◦ Radiographs
◦ Handpieces
◦ Curing lights
◦ Sonic and piezoelectric scaler
Possibly unsafe procedures
◦ Older ferromagnetic ultrasonic scalers
◦ Magnetostrictive ultrasonic scalers
◦ TENS
Pacemaker or ICD
Malfunction in Dental Office
Possibly unsafe procedures
 Older ferromagnetic ultrasonic scalers
 Magnetostrictive ultrasonic scalers
 TENS Units
 Ultrasonic baths
 Electrosurgical units
 Sonic toothbrushes –
 Vasoconstrictors in local anesthetics, use with caution
Pacemaker or ICD Malfunction
Electrical interference is interpreted by pacemaker or ICD as electrical
activity and may inhibit function.
Situation is temporary and does not cause permanent damage to the
pacemaker.
Extent of the malfunction depends on the strength, duration, and type
of interference.
Pacemakers and ICDs are protected from interference by shielding the
circuitry inside a stainless steel or titanium case, signal filtering,
interference rejection circuits, noise reversion functions and
programmable parameters.
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Figure 12.3 Magnetostrictive ultrasonic scaler contraindicated
in pacemaker and ICD patients
Figure 12.4 Ultrasonic bath contraindicated in close proximity
to pacemaker and ICD patients
Figure 12.5 Use of lead apron with pacemaker and ICD patients
Figure 12.6 Appropriate distance of sonic toothbrush with pacemaker
with ICD patients
Signs and Symptoms of
Pacemaker Malfunction
Lightheadedness
Dizziness
Dyspnea
Moist, pale skin
Weakness
Bradycardia or tachycardia
Chest pain
Swelling of extremities
Signs and Symptoms
of ICD Malfunction
Inappropriate defibrillation
Twitching
Biting
Sudden movements
Treatment of Pacemaker or ICD
Malfunction
Turn off interference
Assess level of consciousness
If conscious
◦ Monitor vital signs
◦ Monitor pulse rate to determine if it has reverted to normal rhythm
◦ If rhythm is not normal – contact EMS for transport to ED
Treatment of Pacemaker or ICD
Malfunction
If unconscious
◦ Treat for syncope
◦ Monitor vital signs
◦ If consciousness not regained – contact EMS for transport to ED
Dallas!
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