Transcript Monitors and Records

Monitors and Records
TSBDE Rules and Regulations
110.3 (f) Clinical Requirements
Patient Evaluation
Healthy or medically stable patient
(ASA I, II)
– Review of history, PE, medications
Significant health disability
(ASA III, IV)
– Documentation of medical consult regarding
potential procedure risks
Pre-Procedure Preparation:
Informed Consent
The patient and/or guardian must be
advised of the procedure associated
with the delivery of the enteral
conscious sedation
(h) Monitoring and Documentation
Pre-procedure: patients who have been
administered enteral conscious sedation
must be monitored during waiting
periods prior to operative procedures
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Alertness
Responsiveness
Breathing
Skin color
Monitoring:
During the Procedure
Direct Supervision
Oxygenation
– Color of mucosa, skin or blood must be
continuously evaluated. O2 saturation must
be continuously evaluated by pulse oximetry
Ventilation
– Chest excursions
– Precordial stethoscope
Monitoring:
During the Procedure
Circulation
– Initial blood pressure and pulse
– There after as appropriate (10 minutes)
Time oriented anesthetic record
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Vital signs
Individual administering drugs
Assistants in the room
Name of drug
Dosage administered
Time of administration
Pulse Oximetry
Ventilation vs. Oxygenation
Arterial vs. venous
– SpO2—arterial oxygen saturation
HbO2 vs. Hb; absorption of infra-red and red
light
– Ratio of oxygenated hemoglobin to total
hemoglobin (%)
Use of supplemental O2
Limits and alarms
Recovery and Discharge
Positive pressure O2 and suction
immediately available
Direct continuous supervision until O2
and circulation stable and patient
appropriately responsive for DC
Document O2 circulation, activity, skin
color, and level of consciousness
appropriate and stable for DC
Written Postoperative
Instructions: DC criteria
CV function satisfactory
Airway patency
Patient easily arousable
Protective reflexes intact
Hydration adequate
Patient can talk if applicable
Patient can sit unaided if applicable
Written Postoperative
Instructions: DC criteria
Patient can ambulate if applicable
Very young and disabled—return to
presedation baseline
Responsible individual available
Any unusual reactions documented and
assisted
Dentist must determine that the
patient is appropriate for DC
OFFICE EMERGENCIES
Medical Emergencies…
Goal is to recognize and treat minor
emergencies to prevent a major lifethreatening emergency, and initiate
treatment of the life-threatening
emergencies awaiting transport to an
acute care facility
Prevention…
Patient’s baseline
– Vital signs
– Psychological baseline
Important to get vital signs at each
appointment to establish a solid baseline
Any variations in baseline before sedation
need to be evaluated
This established baseline gives an accurate
record to base any intra-operative changes
Prevention/Warning Signs…
Physical Signs
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Bradycardia
Tachycardia
Irregular pulse rate
Irregular respiratory rate
Abnormal temperature
Prevention…
Mentation Signs
– Inappropriate alterations in cognitive function
Sensation Signs
– Inappropriate
Psychological Signs
– Acute changes
– Apprehension
– Agitation
Emergency Equipment…
Oxygen
Suction
– Back-up suction
Airway management equipment
Drugs
AED ?
Office Emergency Drug Kit…
Commercial vs. “Home Made” Kits
Primary or critical drugs
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Vasopressor—Epinephrine
Histamine blocker—Benadryl
Bronchodilator—Albuterol
Carbohydrate—Cake frosting
Antiplatelet—ASA
Office Emergency Drug Kit:
Primary or Critical Drugs
Anticonvulsant—Benzodiazepine
Opioid antagonist—Naloxone
Benzodiazepine antagonist—Flumazenil
Ammonia capsules ????
Complications/Emergencies
Recognition and
Management
Syncope:
Transient Cerebral Hypoxia
Signs and Symptoms:
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Clammy-sweaty, pale appearance
C/O nausea/vomiting
Rapid pulse
Nervousness
Loss of consciousness
Dilated pupils
Syncope: Management
Supine position with feet elevated
ABC’s
Spirits of Ammonia?
Cold compresses to neck and face
Monitor vital signs: BP, HR, SpO2
Syncope: Outcome
Signs and symptoms resolved
Return of normal state of consciousness
Return of vital signs to near baseline
levels
Orthostatic Hypotension…
Cause: syncopal episode secondary to
supinevertical position change
Management: same as syncope,
reposition pt slowly after stable
Outcome: signs and symptoms resolve,
pt returns to normal state of
consciousness and return to baseline
vitals
Allergic Reactions…
History, History, History
Slow / delayed reactions (mild)
Immediate / rapid onset(Anaphylaxis)
Slow / Delayed Reaction…
Signs and Symptoms: one hour or days
after offending drug allergen
administered
– Urticaria
– Pruritus
Slow / Delayed Allergic Rxn
Management…
Identify and eliminate the cause
Document vital signs (BP, HR, Resp)
Treatment of skin lesions:
– Systemic: diphenhydramine (Benadryl)
50mg IV, IM initially. If lesions persist may
need po 5-7 days of Benadryl 25-50mg q 68o
Slow / Delayed Allergic Rxn
Management…
Treatment of skin lesions
– Topical: corticosteroid preparations (Lidex,
Kenalog Synalar)
Medical consultation with physician or
allergist prior to any further treatment
Immediate Rxn (Anaphylaxis)
Identification of offending agent and
management of signs and symptoms.
Signs and symptoms
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Urticaria, Pruritis, rhinitis
Erythema
Hypotension and bronchoconstriction
Swelling of lips, eyelids, cheeks
Constriction of pharynx or larynx with
stridor/hoarseness
Anaphylaxis Management…
Head down position
ABC’s with supplemental O2
Triad of Drugs:
– Epinephrine-IV 1:1,000 Adults 0.3ml; Child,
0.01mg/kg
– Antihistamine—diphenhydramine 50mg IM
– Corticosteroid--Solu-Medrol 125mg IV or
Decadron 8mg IV
Anaphylaxis Management…
Activate the EMS
Must have stable vital signs for 1 hour
prior to DC from acute care facility or
office. Medical consultation
recommended
Rx diphenhydramine 50mg q 6-8
Severe Hypoglycemia
(Insulin Shock)
Normal B.S.: 80-120mg/dl
– Acute hypoglycemia B.S. < 50mg/dl
Signs and Symptoms
– Adrenergic symptoms: sweating,
nervousness, tremulousness, faintness,
palpitations
– CNS manifestations:Visual
disturbances,stupor, coma, Sz
Severe Hypoglycemia
Management
If possible, sugar by mouth
If oral route not possible:
– IV dextrose 50%(500mg/cc); 50cc infused
over 2-3 minutes
Activate EMS
Seizures…
The most dramatic finding in medicine
Belief that trained assistance is
necessary
Partial seizures
– Simple partial Sz—”spells”
– Complex partial
Grand Mal
– Generalized tonic-clonic (90%)
Seizures…
Petit Mal
– Brief lapse of consciousness
5-10 seconds
No tonic clonic movement
Cyclic blinking
Seizure prevention
– Therapeutic blood levels
Seizures…
Management
– Prevention of injury
– Maintenance of adequate ventilation
– Usually self limiting and not requiring
intervention
– ABC’s
Cerebrovascular Accident…
“Brain Attack”
Causes
– Hemorrhagic
– Occlusive
Signs and symptoms
– Variable—violent to HA, dizziness, vertigo, loss of
consciousness
Management
– ABC’s
– Transport to hospital
Chest Pain…
Angina Pectoris
– History, History, History
– Location of pain
Substernalradiating pain
Treatment
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Termination of procedure
Position—upright
ABC’s
Vasodilators and oxygen
EMS
Acute Myocardial Infarct…
Mangement
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ABC’s vs. ABCD
Activate EMS
Oxygen
Nitroglycerin
ASA
AED
Automatic
External
Defibrillation
Relationship Between Survival
and Defib Time
With each passing minute, survival rate
drops 10%
Out of hospital survival rates without
defibrillation < 2 minutes: 8%
Survival rates with defibrillation
<
2 min: 30-89%
FEATURES OF AED’s
Monophasic defibrillators deliver 200-360
Joules in ONE direction
Biphasic defibrillators deliver 150 Joules of
energy in TWO directions (Double pass
through the heart)
Biphasic defibrillators are smaller, lighter,
less expensive, and less demanding of
batteries, with fewer maintenance
requirements
FEATURES OF AED’S
Biphasic waveform shocks combined
with impedance adjustment or
compensation provides equivalent
defibrillation success at lower energy
levels than those of monophasic shocks
Laboratory studies have verified and
clinical human studies are supporting
RESTRICTIONS
CONTRAINDICATION
Not recommended in children under 8
years and/or 90 pounds
Not used unless adult patient has NO
pulse
Not to be used in moving vehicle
AED’s ON THE MARKET
Heartstream Forerunner (Agilent
Technologies)
Physiolcontrol 500 (Medtronics)
SurvivaLink Quickstart (SurvivaLink)
Laerdal HeartStart 911 (Laerdal)
Respiratory Distress…
Apnea—absence of respiratory
movement
Hyperventilation
– Tachypnea
– Treatment
Hypoventilation—PaCO2 > 45 torr
Hypoxia—deficiency of O2
Airway Obstruction…
Partial vs. complete obstruction
– Partial—coughing, wheezing—should allow
the coughing to continue
– Partial with weak cough reflex—crowing
sound, prolonged inspiration
In the conscious patient there is a good
chance that the object well be
swallowed or coughed up
Asthmatic…
Mangaement
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Termination of procedure
Position—upright
Calming of the patient
ABC’s
Definitive care—administration of
bronchodilator
Management of Airway
Position—supine
Head tilt-chin lift
Jaw-thrust maneuver
Artificial ventilation
Airway Obstruction
Most common cause: tongue and/or
epiglottis
Opening the Airway
Jaw thrust
Head tilt–chin lift
The Oropharyngeal Airway
Malposition of
Oropharyngeal Airway
Too short
Nasopharyngeal Airway
Insertion technique
Bag-Mask Ventilation
Key—ventilation volume: “enough to produce
obvious chest rise”
1-Person:
difficult, less effective
2-Person:
easier, more effective
Cricoid Pressure
Thyroid
Cartilage
Cricoid
Equipment for Intubation
Laryngoscope with
several blades
Tracheal tubes
Malleable stylet
10-mL syringe
Magill forceps
Water-soluble lubricant
Suction unit, catheters, and tubing
Aligning Axes of Upper Airway
A
Mouth
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B
B
Pharynx
C
C
Trachea
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
Visualization of Vocal Cords
Anatomy
Vallecula
Tongue
Epiglottis
Vocal
cord
Glottic
opening
Arytenoid
cartilage
Esophageal-Tracheal
Combitube
A = esophageal obturator; ventilation into trachea through side openings = B
E
C = tracheal tube; ventilation through open end if proximal end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
Distal End
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth
A
C
H
Proximal End
D
B
F
G
Esophageal-Tracheal Combitube
Inserted in Esophagus
A
H
D
A = esophageal obturator; ventilation into
trachea through side openings = B
D = pharyngeal cuff (inflated)
F = inflated esophageal/tracheal cuff
H = teeth markers; insert until marker lines at
level of teeth
D
B
F
Laryngeal Mask Airway (LMA)
The LMA is an adjunctive airway that consists of a
tube with a cuffed mask-like projection at distal
end.
LMA Introduced Through Mouth
Into Pharynx
Anatomic Detail
Cricothyroid Membrane With Horizontal
Cricothyrotomy Incision
CNS Depressant Drug Overdose…
Position—supine
ABC,s
Administration of O2
– Positive pressure
Administration of antagonist
– BZD—flumazenil
0.2 mg repeat q 5 minutes (adult)
0.1 mg or 3ug/kg (child)
– Opioid—Naloxone
0.4 mg IM/IV (adult)
0.01 mg/kg IM/IV (child)