16. Behavior in emergency situations in the maxillofacial and oral surgery. Flashcards
1
Q
Syncope, and its main characteristics
A
- Transient loss of consciousness and postural tone=>
- Spontaneous recovery without neurological deficit
2
Q
Most common cause of unconsciousness in a dental office setting
A
Vasovagal syncope
3
Q
Psychogenic and non-psychogenic causes of vasovagal syncope
A
- Psychogenic=>
* Fright
* Anxiety - Non-psychogenic=>
* Prolonged standing and dehydration
4
Q
What surgeon should consider when a patient experiences syncope
A
- Usually a benign, self-limiting event=>
- Rule out other more serious etiologies of unconsciousness
5
Q
Cardiac causes of syncope
A
Obstructive outflow diseases such as aortic stenosis
6
Q
Neurogenic causes of syncope
A
Seizures, transient ischemic attack, migraines
7
Q
How orthostatic hypotension can lead to syncope
A
- Patients with depleted intravascular volume=>
- Side effect of drugs=> antidepressants and antihypertensives
- Patients with autonomic instability=>
- Diabetes mellitus
8
Q
Hypoglycemia relation to syncope
A
Rare cause of syncope
9
Q
Patients in which vasovagal or vasodepressor syncope generally the etiology
A
Young, healthy patients
10
Q
Stages of syncope and the symptoms
A
- Presyncopal Stage:
* Blood pressure and heart rate drop - Syncope Stage:
* Irregular breathing
* Pulse thready, blood pressure can drop to extremely low levels
* Unconsciousness can last from seconds to several minutes after placement in the supine position - Postsyncope Stage:
* Rapid recovery
* Pallor, nausea, disorientation may persist
11
Q
Management steps for syncope in an emergency situation
A
- Stop the procedure immediately
- Trendelenburg position and administer oxygen
- If unconsciousness =>,basic life support protocol: call for help, assess airway, breathing, and circulation
- Chin lift or jaw thrust to open the airway.
- If breathing and circulation present=> crush an ampule of ammonia under the patient’s nose to hasten recovery
- Call emergency medical services if unconsciousness lasts beyond 10-15 minutes.
Failure to lay the syncopal patient flat can result in brain damage or death.
12
Q
Most frequent triggers for asthma
A
- Viral or bacterial respiratory infections
- Exposure to cold, allergens, irritants=>
- Smoke, and exercise
- Emotional distress and medications=>
- Aspirin, NSAIDs
13
Q
How oral and maxillofacial surgeon prepares for an asthmatic emergency
A
- Careful history and conducting a physical examination=>
- Extent of the patient’s asthma
- Baseline peak flow rate
- Usage of inhaled agents
- History of emergency care or intubation
14
Q
Measures that can help prevent asthma attacks during dental procedures
A
- Reduce emotional distress in fearful patients.
- Anesthetic drugs such as opioids and barbiturates cautiously=> as they can induce bronchospasm=>
- Histamine release
15
Q
How a typical asthma attack presents
A
- Chest congestion or tightness
- Nonproductive cough
- Inspiratory and expiratory wheezing
16
Q
Signs of a severe asthma attack
A
- Increased dyspnea
- Use of accessory respiratory muscles
- Hypoxia is a late sign=>
- Immediate treatment.
17
Q
Steps taken if a patient is suspected of having an asthma attack during a surgical procedure
A
- Stop the surgical procedure immediately
- Administer oxygen and a beta-2 agonist like albuterol via a metered dose inhaler (MDI).
- No response to bronchodilators=>
- Medical emergency (status asthmaticus) and alert EMS
- Subcutaneous epinephrine and parenteral glucocorticoids for severe attacks
18
Q
Recommended dosage for albuterol during an asthma attack
A
- Six puffs of albuterol MDI (90 µg/puff)
- Can be repeated every 20 minutes as needed
19
Q
Status asthmaticus, and how it is managed
A
- Severe asthma attack that does not respond to bronchodilators
- Requires immediate EMS intervention=>
- Subcutaneous epinephrine and parenteral glucocorticoids
20
Q
How epinephrine administered during a severe asthma attack
A
- Subcutaneously at a dose of 0.3 ml of 1:1000 dilution
- Every 20-30 minutes for up to three doses
21
Q
Role of glucocorticoids in managing severe asthma attacks
A
- Relieve airway inflammation
- Benefits after 3-6 hours, early
- 125 mg of methylprednisolone
22
Q
Complications that can occur in diabetic patients in the surgical office setting
A
- Hypoglycemia
- Diabetic ketoacidosis
- Hyperosmolar non-ketotic coma
23
Q
Why hypoglycemia particularly concerning in the outpatient setting
A
- Acute condition requiring immediate attention=>
- Severe complications
24
Q
How hypoglycemia defined in adults and children
A
- Blood glucose levels less than 50 mg/dl in adults
- Less than 40 mg/dl in children
25
Relationship between intensive glucose control therapy and hypoglycemia in diabetes management
* Helps prevent microvascular complications of diabetes mellitus=>
* But increases the incidence of symptomatic hypoglycemia
26
Normal physiological response to hypoglycemia
* CNS response=> release of glucagon, cortisol, and epinephrine=>
* Increase glycogenolysis and gluconeogenesis
* Inhibit insulin-dependent glucose uptake
* Process can be disrupted by drugs or disease states=> impaired recovery from hypoglycemia
## Footnote
The brain relies on a continuous glucose supply as it cannot store glucose.
27
How diabetes and certain medications impair the body's response to hypoglycemia
* E.g exogenous insulin and beta-blockers can impair the counter-regulatory response to hypoglycemia=>
* Reduce the body's ability to recover from low blood glucose levels
28
Why diabetic patients undergoing surgery at increased risk for hypoglycemia
* Patients to fast (NPO status), necessitating adjustments in insulin or oral hypoglycemic doses
* Surgeries can alter eating habits=>
* Increased risk of hypoglycemia
29
Initial symptoms of hypoglycemia
* Sweating, anxiety, palpitations
* Hunger, and tremor=>
* Blood glucose levels below 60 mg/dl
* Mild cognitive dysfunction around 50-55 mg/dl.
30
How hypoglycemia affects older patients compared to younger patients
* More likely to experience cognitive impairment
* Less likely to exhibit other warning symptoms of hypoglycemia
31
Severe symptoms that can occur with progressive hypoglycemia
* Severe neurologic symptoms include lethargy and obtundation at 45-50 mg/dl
* Coma can occur at 30 mg/dl
* Convulsions and death below 20 mg/dl
32
Initial steps taken to manage hypoglycemia in a surgical office setting
* Obtain an initial blood glucose level to document hypoglycemia
* Do not delay glucose administration if clinical suspicion is high
33
Appropriate treatment for a conscious patient experiencing hypoglycemia
* Oral glucose via glucose=>
* Tablets, fluids, candy, or food
* Reasonable initial dose is 20 g of glucose
34
Done if patient is unable or unwilling to take oral glucose
* Intravenous dextrose=>
* Initial dose of 25 g
* Unconscious patients,=> dextrose while managing airway, breathing, and circulation
35
Glucagon used in managing hypoglycemia, and its limitations
* Administered intravenously (1 mg doses),
* Subcutaneously
* Intramuscularly (1-2 mg)
* Effective except in cases of hypoglycemia secondary to ethanol due to depleted glycogen stores
36
What clinicians should be aware of regarding the treatment of hypoglycemia with glucose or glucagon
* Raise plasma glucose concentrations only transiently
* Monitoring of the patient's glucose concentration and clinical status essential after treatment
37
Monitoring required for a conscious patient who only needed oral carbohydrates to treat hypoglycemia
* One hour before allowing them to leave the office=>
* To ensure stable blood glucose levels and recovery
38
Monitoring required for an initially unresponsive patient treated for hypoglycemia
* Monitor vital signs and blood glucose levels at least every five minutes=>
* Until medical assistance arrive
39
Why offices that provide medications, especially parenteral ones, should be prepared for anaphylaxis
* Life-threatening medical emergency occuring unexpectedly
40
Anaphylaxis and how does it occurs
* Type I hypersensitivity reaction=> antigen binds to IgE antibodies on mast cells and basophils=>
* Systemic release of immunologic mediators
41
Common clinical presentations of anaphylaxis
* Urticaria (hives) and/or angioedema (swelling)
* Respiratory compromise and cardiovascular collapse=>
* Usual causes of death in anaphylaxis
42
Common causes of anaphylaxis in a surgical practice
* Drugs such as penicillin and aspirin
* Exposure to latex
43
Conditions that must be differentiated from anaphylaxis
* Vasodepressor syncope
* Local anesthetic overdose
* Panic attack, cardiac arrest, foreign body aspiration
44
How initial signs and symptoms of anaphylaxis be managed
* Procedure stopped immediately
* Airway, breathing, circulation, and consciousness level assessed,
* Epinephrine should be administered without delay
45
Role of epinephrine in managing anaphylaxis, and how it should be administered
* Intramuscularly or subcutaneously at a 1:1000 dilution (0.2–0.5 ml in adults or 0.01 mg/kg in children)
* Injected into the lateral thigh, upper arm, or sublingually=.
* Dose repeatable every 5 minutes as needed
46
Position patient placed in during anaphylaxis and why
* Trendelenburg position (lying flat with feet elevated)
* Maximize cerebral blood flow
47
Additional treatments that should be considered after initial epinephrine administration in anaphylaxis
* Antihistamines (such as diphenhydramine) intramuscularly or intravenously at 1–2 mg/kg (up to 50 mg).
* Albuterol for bronchospasm
* Corticosteroids (such as hydrocortisone prevent recurrent or protracted anaphylaxis
48
Why its important for all patients with anaphylaxis to be taken to an emergency department
Can recur
49
Seizures
* Excessive activation of neurons=>
* Abnormal neurological functioning
50
Two main classifications of seizures
* Partial=>
* Simple partial (consciousness maintained) and complex partial (consciousness lost)
* Generalized seizures=>
* Involve activity in both cerebral hemispheres
* Absence, myoclonic, and tonic-clonic (grand mal) seizures
51
Differentiates primary from secondary seizures
* Primary seizures =>no known etiology
* Secondary seizures=> injury or illness affecting CNS
52
How a seizure managed in a medical office setting
* Confirm it is a seizure and not syncope
* Patient should be reclined to a supine position to minimize injury
* Basic life support initiated=>
* Airway is clear and administering oxygen
* Objects should be moved away
* Pulse should be checked to rule out cerebral hypoxia
## Footnote
Tonic-clonic seizures last less than 2 minutes and do not require anticonvulsants, but postictal monitoring and support are crucial
53
Status epilepticus and why is it considered a true medical emergency
* Seizures lasting longer than 5–10 minutes
* or frequent seizures without a return to baseline between ictal states=>
* Significant morbidity and mortality
54
Initial treatment steps taken for a patient experiencing status epilepticus
* Call EMS immediately
* Basic life support, and secure intravenous access.
* Ampule of 50% dextrose IV to rule out hypoglycemia
* First-line treatment=> benzodiazepines- lorazepam (0.02–0.03 mg/kg IV),
55
Second-line treatment options if benzodiazepines do not terminate a seizure
* Phenytoin (20 mg/kg IV infusion at 25–50 mg/min)
* Phosphenytoin (15–20 mg/kg IV infusion at 100–150 mg/min) intramuscularly
* Monitor vital signs closely due to potential hypotensive effects
