Many thanks to my sponsor:
Medical Histories and
Medical Emergencies
in the Dental Office:
“Vital Signs” for the Dental Team
Central Ohio Dental Forum
March 10, 2016
Cindy Kleiman, RDH, BS
Oral Care Consultant and Speaker
Team Member Duties
Member #1: Stay with the patient
Member #2: Call 911, bring emergency kit and AED
Member #3: DOCUMENT
H
Every team member
must be ready…
Any one of us
may be the patient!
Emergency Management
New CPR Guidelines 2010
P Position
C Circulation
A Airway
B Breathing
D Definitive Care
Diagnosis
Drugs
Defibrillation (for CPR)
H
Have an automatic
blood pressure cuff
on hand for emergencies.
1
Basic Emergency Kit
Injectables:
Epinephrine
Histamine blocker
Non-injectables:
Oral Histamine Blocker
Vasodilator
Aspirin (Baby)
Anti-hypoglycemic (Sugar)
Bronchodilator
Ammonia Inhalant
Equipment:
O2, BP Cuff, Barrier Mask, AED
Instructions should be
written out
in the emergency kit.
H
EVERYONE participates
in monthly monitoring.
Do your Homework!
Angina Pectoris
Indigestion is similar to the pain of
angina or MI and should not be
ignored. Seek medical assistance if
chest pain persists for 2 minutes or
longer, if episode is the first.
A
transient chest pain caused by
insufficient supply of oxygenated
blood to the heart
 Often brought on by exertion or
emotion
 Relieved by rest or nitroglycerin
H
H
2
Medical History Interview

How frequently do you suffer angina attacks?

How long do the attacks last?

What precipitates your attacks?

How quickly does nitroglycerin relieve your
attacks?
When was your last attack?
* Phone patients day prior to treatment
requesting them to bring their nitroglycerin

P Comfortable, usually upright
C
Usually not needed
A
B
D Nitroglycerin
Oxygen
H
No prior history of chest pain

Patient with history of angina

Pain more intense than usual

Nitroglycerin x 3 fails to alleviate pain

Nitroglycerin resolves pain… then pain returns
H
Myocardial Infarction
Consider Myocardial Infarction
if…

Angina Pectoris
Management
Symptoms
 Pain
 Severe to intolerable
 Crushing, choking
 Radiates: L arm,
hand, shoulders,
neck, jaw




H




Nausea, weakness,
dizziness
Palpitations
Cold perspiration
Sense of impending
doom
Restlessness
Acute distress
Skin
 Cool, pale, moist
Heart rate
 Bradycardia to
tachycardia
H
Myocardial Infarction
Management
Women’s Signs and Symptoms






Signs
P
C
A
B
D
Shortness of Breath
Weakness
Unusual fatigue
Indigestion
Disturbed Sleep
50% of women have no chest pain
Comfortable
As Needed
 Call 911
 Nitrous Oxide
 Oxygen
 Nitroglycerin
H
 Aspirin (4 Baby, chewed)
H
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Cardiac Arrest:
Basic Life Support - CPR
P
C
A
B
D
Position
Circulation
Airway
Breathing
Defibrillation
If your facility doesn’t have one,
purchase an AED.
It could save your life!
H
Diabetes Mellitus
Hypoglycemia
Have an instructor review
how to perform CPR
in a dental chair.
Hypoglycemia occurs when the body's
blood sugar, or glucose, is abnormally low.
The term insulin shock is used to describe
severe hypoglycemia that may result in
unconsciousness.
H
Diabetic Emergency:
Hypoglycemia
Causes
Medical History Interview
Signs and Symptoms

Too much insulin

Shaking

Too little food

Sweating

Anxiety

Palpitations

Restlessness

Mental Confusion
H

Do you use oral medication or insulin?

How well controlled is your diabetes?

What was your last blood sugar and how
long ago was it taken?
(Fasting: 80-110 normal)

What is your A1C reading?
H
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Dental Treatment Guidelines
For Diabetic Patients
Stanley F Malamed “Medical Emergencies in the Dental Office”
7th Edition
2015
H

When did you last eat and when are you due
for your next snack or meal?

Do you have a sugar source readily
available; if so, could you please get it out?

Are you feeling okay at this time for
treatment? (If they are unsure, ask them to
please check their blood sugar before you
proceed.)

What signs do you exhibit with a low blood
sugar?
H
Hypoglycemia Management
Hypoglycemia Management
Conscious
Unconscious
P Comfortable
C
As Needed
A
B
D Administer “sugar”
P Supine
C
A
B
D Call 911
 Absorbable sugar (gel)
―Under lips, canine to canine ?
 Sugar IV by EMS
 Glucose gel
 Fruit juices (Orange preferred by many)
 Hard candy
 Soft drinks (non-diet)
As Needed
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Final Word
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The Asthma Attack
Constriction of the airways and formation of
thick mucus makes it progressively more
difficult to inhale and exhale
All insulin diabetic patients should
monitor their blood glucose levels
at the end of each dental
appointment prior to driving.

This leads to one or more of the following symptoms





H
Tightness in the chest
Shortness of breath
A chronic or recurring cough
Wheezing, particularly when trying to exhale
Anxiety
H
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Medical History Interview
Asthma Attack
Management
 What brings on an attack?
 How often do you get an attack and how long
does it typically last?
 What drugs do you use to prevent acute
episodes?
 What is the usual number of doses needed?
 Have you ever been hospitalized for your
asthma?
 Do you have your inhaler with you?
 When was your last attack?
*Call asthmatic patients prior to day of treatment,
requesting them to bring bronchodilator
P Upright
C
A
Usually not needed
B
D Inhaler
Oxygen
Epinephrine if critical
H
H
Asthma Attack Management
Syncope: Predisposing Factors
Non-psychogenic Factors
Psychogenic Factors
Summon EMS if…
Patient requests



Episode is continuing with
2 doses of bronchodilator
(Status Asthmaticus)


Fright/Anxiety
Extraction
Injections
Pain, especially of a sudden
and unexpected nature
The sight of blood or of
surgical or other dental
instruments (such as a local
anesthetic syringe)

Sitting upright or standing

Hunger

Exhaustion

Hot, humid, crowded
environment

Male sex

Age between 16 and 35 years
H
H
Syncope Management
Recovery
P Supine, slight elevation of legs
C
A
As needed
B
D

May continue to be light-headed, weak, pale
May be disoriented/confused
Pulse & blood pressure should return to
normal
Takes 24 hours to completely recover

Discharge in custody of responsible adult



 Ammonia inhalant
 Oxygen
H
H
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Allergic Reactions
Allergy Facts
 The faster the onset of signs and symptoms after
exposure to the allergen, the more severe the
reaction
 Allergy involving only skin is NOT life-threatening
and requires milder, less aggressive management
 Allergy involving difficulty with breathing IS
life-threatening, requiring immediate, aggressive
management
What to look for:
 Sneezing, coughing, or wheezing
 Shortness of breath
 Tightness and swelling in the throat,
face, tongue, or chest
 Itching, burning, or rash
 Dizziness and weakness
 Nausea and vomiting
H
H
Allergy Management
Delayed Onset Skin Reaction
P
C
A
B
D
Comfortable
Be sure to have
oral Benadryl
(diphenhydramine)
in your kit.
Usually not needed
Oral histamine blocker
Continue for 2-3 days prn
H
Usual Progression of Anaphylaxis
Anaphylaxis
Skin
A severe, and sometimes fatal, allergic
reaction characterized by respiratory
distress and hypotension, leading to
cardiovascular collapse
Eyes, nose, GI
Respiratory System
Cardiovascular System
H
H
7
Anaphylaxis Management
Anaphylaxis Management
D
P Based upon primary complaint:
 “Can’t breathe” – upright
 “Feel faint” – supine, feet elevated
C
As Needed
A
Call 911
Oxygen
Epinephrine
−Every 5 minutes or until EMS arrives
−Multiple doses usually required
Histamine blocker IM
B
H
H
All new and temporary
employees should be
oriented on
emergency procedures
and equipment.
All team members
should practice with
an EpiPen trainer.
Why Epinephrine?
Seizure
Reverses 2 components of anaphylaxis which
lead to death

An event of altered brain function
caused by abnormal or excessive
electrical discharges in the brain

Most seizures cause sudden
changes in behavior or motor
function
Bronchospasm – epinephrine is
bronchodilator
 Hypotension – epinephrine is vasopressor
(BP↑)

Works quickly

IM top of thigh (EpiPen†), works in 1-2
minutes
H
H
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Causes of Seizures

Epileptic patients

Cerebral anoxia

CVA (stroke, ‘brain attack’)
Tumor
Previous head injury
Idiopathic




Stress induces seizures


Tonic-Clonic Generalized Seizure
Prodromal Phase

Can be several minutes to an hour

May have an aura
Neonatal injury

Ictal Phase (The Actual Seizure)

Tonic rigidity (10-20 seconds)

Evolves into clonic contraction relaxations
(2-5 minutes)
H
H
Post-Ictal
Tonic-Clonic Generalized Seizure
 Tonic-clonic movements stop
 Respiration returns to normal
 Consciousness gradually returns
 Is self-limiting
 Lasts not more than 2 - 5 minutes
 Usually does not require IV
anticonvulsant therapy
 Patient may be disorientated/confused
 Sphincter relaxation may cause
incontinence
 Usually does not result in injury
H
Medical History Interview
H
Tonic-Clonic Seizure Management
P – Supine





Protect victim:
Rescuer 1: arms – gently!
Rescuer 2: legs – gently!
What type of seizure do you have?
How often do you have seizures?
What is your aura?
How long do your seizures last?
Did you take your medicine today?
C
A
B
As needed
D – Call 911
Remove “pillow” or “donut” from headrest of chair
H
Do not put anything into the mouth
H
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Post-Ictal Phase
Medical Emergency Kits, AED, BP
ABC as needed
 Patient is disoriented, sleeping
 Position


Health First
 www.healthfirst.com

Core Medical – CLAM Drug Kit
 www.clammedical.com

Physio-Control AED
 www.physio-control.com
 [email protected]

Omron 7 Series
 BP652 [N]
 Turn on side, if possible
― Aids in airway maintenance
 Dental Chair
― Maintain supine, maintain airway as needed
H
H
Thank you!
Cindy Kleiman, RDH, BS
Oral Care Consultant and Speaker
480-342-9655
www.cindyspeaking.com
[email protected]
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