8. Medical Emergencies Flashcards
(169 cards)
1
Q
T/F All drugs (LA, antibiotics, sedatives, etc( have the potential to produce acute, life-threatening reactions
A
t- either through allergy or toxicity (OD)
2
Q
The main roles of the dentist in emergency situations are
A
- Prevention most important aspect in dealing with medical emergencies
- Stabilize the patient until EMS transfer
3
Q
Medical emergencies can be prevented how
A
- medical history and physical exam
- Medical consult (when indicated)
- Patient monitoring
4
Q
Medical history is typically obtained how
A
questionnaire
5
Q
Physical exam includes
A
- Baseline vitals (BP, Pulse, Respiration)
- Head and neck exam
- Observation of general appearance
6
Q
What information is requested for a medical consult
A
- Ask if the patient is in optimal condition for the planned procedure
- You are not asking for medical clearance
7
Q
Level of monitoring depends on what factors
A
- Procedure
- Underlying medical condition of the patient
- Behavior guidance technique used
8
Q
What level of monitoring is required for healthy patients treated with LA or minimal sedation
A
- General appearance of the patient
- Level of consciousness
- Level of comfort
- Muscle tone
- Color of skin/mucosa
- Respiratory pattern
- *This should always be monitored in every patient)
9
Q
Administration of LA in large doses can result in
A
CNS depression (esp. when combined with sedatives)
10
Q
When the intent is minimal sedation for adults the appropriate inital dose of one enteral drug is
A
no more than the max reccomended doe (MRD) that can be perscribed for unmonitored home use
11
Q
T/F Pre-op sedatives in kids under 12 prior to arrival at the office is not recommened
A
t- risk of respiratory obstruction
12
Q
MRD means
A
max recommended dose (FDA) for a drug
13
Q
Describe incremental dosing
A
administration of multiple doses of a drug until desired effect is achieved but does not exceed the MRD
14
Q
Describe supplemental dosing
A
A single additional dose of the initial dose of the drug (may be needed for prolonged procedures). Supplemental dose shouldn’t exceed 1/2 the initial dose and shouldn’t be given until the clinical half-life of the drug has passed. The total aggregate dose can’t exceed 1.5x the MRD on the day for treatment
15
Q
Why is there a narrower margin of safety in kid v.s adults
A
-Smaller degrees of respiration and CV reserve
16
Q
What two variables are measured with a pulse oximeter
A
- Pulse (Heart rate)
- Oxygen saturation (SaO2 or SpO2)
17
Q
How is Oxygenation measured with a pulse ox
A
- Light absorptive characteristics of hemo globin
- Red= Deoxy hemoglobin
- Infrared= Oxygenated hemoglobin
- Blood flow in arteries
18
Q
What are the consequences if the pule ox is too tight or too loose around the finger
A
Too tight
-Constricts circulation
Too loose
- Fall off
- Let other light in
19
Q
Paediatric probes are used for .
A
infants <1 y.o
20
Q
Is a paediatric probe is not available and the patient is 6 months old what can be used as a pulse ox
A
- Adult pulse ox on the large toe or thumb
- Ear probe (can be used on the cheek)
21
Q
The earlobe is susceptible to _ which is why you should do what before the application of an ear probe
A
vasoconstriction due to cold or hypovolaemia… rub the ear
22
Q
What can prevent an accurate reading by a pulse ox
A
Nail polish
- Colour can absorb light emitter by the pulse ox.
- Can turn the finger sideways
Henna
- Unable to measure SpO2 (blocks signal due to pigment)
- Can detect a pulse
Bright light
- Direct
- interferes with the light detector
Movement
- Can give erractic pulse waveform
- Issue with shivering which is common in recovery (not common in theatre)
Perfusion
-If blood flow to the finger changes (i.e result of peripheral vasoconstriction from cold or hypovolaemia) it can be seen on the monitor
Carbon Monoxide poisoning
- Patients involved in fires, inhaled smoke
- Significant amounts of Hb bond to CO (can’t detect this) and SpO2 is exaggerates as a result
23
Q
What is the clinically acceptable level of SpO2
A
95-100%
24
Q
Capnography measures
A
- End-tidal CO2 (EtCO2)
- Monitors ventilation
- Monitor expired CO2
25
Advantage of capnography over pulse ox
Pulse ox is not real time but capnography is therefor changes in ventilation are detected before detectable changes in hemoglobin oxygen saturation
26
Know this
Capnography uses infrared spectrometry to provide instantaneous and continuous record of CO2 con.
27
The two variables measured by capnography are
- Respiration rate
| - End-tidal CO2 conc.
28
Describe the four different phases of a capnograph
```
Phase I= Inspiratory blaseline
Phase II= Expiratory upstroke
-Large and rapid increase in CO2 conc.
Phase III=Expiratory Plateau
-Mostly dead space air to mostly alveolar air
Phase IV= Expieratory downstroke
-Rapid decline in CO2 conc.
-Return to phase I (inspiratory baseline)
```
29
What is the angle between phase II and III... phase III and IV
II and III= alpha
| III and IV= beta
30
The lines that form the beta angle meet at a point that represents
end-tidal CO2
31
Capnography looks like what if they patient isn't breathing or has an obstructed airway
flat baseline
32
Percordial/pretracheal stethoscope allows the dentist to hear
lung and heart sounds
33
Describe the difference in the data given by capnography and pulse ox verses percordial stethoscope (quanitative v.s qualitative)
capnograph and pulse ox= quanitative
| percordial stehoscope= qualitative
34
Snoring heard on percordial stetoscope means
airway blockage by tongue/tissues
35
Gurgling noises indicate
fluids in throut (suction to prevent aspiration/vomiting)
36
Wheezing means
bronchospasm
37
Obstruction sounds mean
poor patient position
38
No breath sounds mean
- Complete laryngospasm
- Complete bronchospasm
- Complete obstruction
39
What happens to heart rate, BP and respiration rate as you increase in age
- HR decreases
- BP increases
- Respiration rate decreases
40
The most commonly seen pediatric emergencies involve
loss of patent airway and respiratory depression and hypoxemia
41
The primary goal of BLS is
establish and maintain proper respiratory function
42
What is the primary emergency drug
oxygen
43
What is the minimum sized oxygen tank an office should have and why
E because the oxygen needs to be delivered minimally at 90% oxygen at a rate of 10 L/min for at least 1 hr
44
Delivery of O2 to a spontaneously breathing patient can be through
- Nasal cannula
- facemask
- Non-rebreather facemask
45
Which delivers the highest conc. of O2 to a breathing patient
- Nasal cannula
- facemask
- Non-rebreather facemask
non-rebreather facemask
46
What are the different methods of delivering O2 to a patient who isn't breathing
Postive pressure ventilation
- Mouth-to-mouth
- Mouth-to-mask
- Bag-valve- mask (amboo bag)
47
Which delivers a higher conc. of O2 mouth to mask or bag-valve-mask
amboo bag (100 % v.s 16%)
48
Child rescue breathing = _breaths per minute requiring 1 breath every _ seconds
12-20 breaths/min
| 3-5 sec
49
Adult rescue breathing = _breaths per minute requiring 1 breath every _ seconds
10-12 breaths/min
| 5-6 sec
50
What is required for bag-valve-mask ventilation
- tight mask fit
| - open airway
51
Exhalation is (active/passive) with the amboo bag
passive
52
How does a oropharyngeal or nasopharyngeal airway help open an obstructed airway
keeps tongue forward
53
Why can't u use a naso/oropharyngeal airway in a concious patient
induces gagging and vomitting
54
OPA (oropharyneal airway) is measured from what two points
corner of mouth to angle of jaw
55
NPA is measured how
from the nose to the ear?
56
What is the ideal suction to use during sedation and high
high volume suction (Yankauer)can suction mouth and pharynx without damaging tissues
57
Most medical emergencies in dental office (do/don't) require use of drugs
don't
58
Where are the two common sites for IM injections
deltoid and vastus lateralis (anterolateral portion of the thigh)
59
T/F IM injection can't be done through patient clothes
F IT CAN
60
DURING IM INJECTION NEEDLE IS HELD AT _ DEGREE ANGLE
90
61
What are the two landmarks for the vastuslateralis injection
- Greater trochanter of the femur
- Lateral femoral condyle
- Inject in the middle third at the anterior lateral aspect
62
What is the second most important emergency drug
epinephrine
63
Epinephrine is used in what emergency situations
- Anaphylaxis
- Asthma (doesn't respond to albuterol)
- Cardiac arrest
64
T/F Epi is only administered if a patient is experiencing a medical emergency
t
65
Actions of Epi
- Sympathomimetic
- Stimulates both alpha and beta receptors
- Increases heart beat
- Increases BP
- Relaxes bronchial smooth muscle
- Anti-histamine
66
Epi is supplied in two different concentrations what are they
- 1:1000 (1mg/mL) in 1 mL ampule
| - 1:10,000 (0.1 mg/mL) in 10 mL syringe
67
What is the conc. of epinephrine in a dose of adult and child epiPen
```
Adult= 0.3 mg
Child= 0.15 mg
```
68
EpiPen is injected where
anterolateral aspect of the thigh ONLY
69
Max dose for child and adult of Epinephrine
Child
-0.01 mg/kg up to 0.3mg/dose
Adult
-0.3 mg/dose
70
T/F If you administer epiPen and after 5 mins and the patient isn't responding you can't give more epinephrine because you are at the max dose
f- give again
71
Side effects of epi
- HTN
- Tachycardia
- Cardiac arryhthmia
- Chest pain
- Anxiety
- Headache
72
Albuterol is also called
proventil or ventolin
73
When is albuterol used
acute asthmatic attack (bronchospasm)
74
Albuterol is a _ receptor agonist
beta 2 adrenergic
75
Dose of albuterol
2 puffs wach simultaneously with a deep inspiration (repeat as needed)
76
Side effects of albuterol
tachycardia and anxiety
77
When is nitroglycerin used
-Chest pain (stable or unstable angina pectoralis ir evolving MI)
78
Nitroglycerin is a vaso(dilator/constrictor) and smooth muscle _
dilator and relaxant
79
How is nitroglycerin supplied
sublingually either in spray or tablets
80
Dose of nitroglycerin
- 1 spray or 1 tab (0.4mg) every 5 mins
- or until chest pain subsides
- or systolic BP is below 100 mm Hg
- Max is 3 sprays**
81
Side effects of nitroglycerin
- Hypotension
| - Headache
82
When should aspirin be used as emergency medicine in the dental office
-Suspected MI (use chewable tabs- work faster)
83
MOA of aspirin
inhibits thromboxane synthetase
| -Antiplatelet agent
84
Dose of aspirin
325 mg
85
Side effects of aspirin
dyspepsia (indigestion)
86
When is diphenhydramine used
- Allergic reactions of slower onset or less severity
| - Adjunct to epi in severe allergy
87
Action of diphenhydramine
-Histamine H1 receptor antagonist that blocks the response of H1 to histamine
88
How is diphenhydramine supplied
50 mg in a 1 mL (or 1 cc) vial (IM)
| -Thus in 1 cc there is 52 mg of benadryl
89
Dosage of diphenhydramine
1-2 mg/kg IM (up to 50 mg)
90
Side effects of benadryl
sedation and xerostomia
91
Midazolam is used as an emergency medicine for
sustained grand mal seizures
92
Dose for versed for grand mal seizure is
- (kids) 0.15 mg/kg IM to max of 10 mg for initial dose
- (Adult) over 50 kg-- admin. 10 mg
- May give supplemental doses is seizure isn't resolved in 5-10 mins
93
Side effects of versed
- sedation
| - depression
94
Commercially available glucose is not significantly absorbed when? But is signigicantly absorbed when?
Not when applied in oral vestibules but ARE effective when swallowed
95
Ammonia inhalants are used when
arouse patient unconcious secondary to suspected syncope
96
Corticosteroids can be used for what emergency
- acute adrenal insufficiency
| - adjunct in allergy management
97
Examples of corticosteroids for use are
- Methylprednisolone (solu-medrol)
| - Hydrocortisone (solu-Cortef)
98
what is another name for Flumazenil
Romazicon
99
Flumazenil should be given (IM/IV) Narcan?
IV... IM or IV
100
What are the things you should look for in an unconcious patient
- position
- circulation (pulse)
- airway
- Breathing
- Definitive therapy
101
If there is no pulse and the patient is unconscious, what should you do
30 chest compressions (one rescuer) at a rate of 100/minute and give 2 breaths and repeat
102
If an unconscious patient has a pulse what should you do
open airway and determine if they are breathing
103
If there is no pulse and the patient is unconscious, and there are 2 rescuers, what should you do
15 chest compressions at a rate of 100/minute with 2 breaths
104
If the patient lost conciousness or hypotension how should they be positioned
- lay flat on back with feet raised slightly above the heart
- Minimizes work of heart, increases pooled blood from extremities to vital organs (i.e brain)
105
How should a patient who is conscious and involved in respiratory distress or chest pain be positioned
-Sitting or semi-reclined
106
Compression depths for adults, children and infants
- Adults- at least 2 inches (5 cm)
- Children At least 1/4 AP diameter (~2 inches)
- Infants At least 1.4 AP diameter (1.5 inches or 4 cm)
107
Compression rate for adults, children and infants
all are at least 100/min
108
T/F the chest should completely recoil between compressions
t
109
Interruptions should be limited to
<10 seconds
110
How do you open the patient's airway
head tilt- chin lift
111
What is the compression-to-ventilation ration for adults, children and infants for 1 and 2 rescuers
- Adult= 30: 2 (1 or 2 rescuers)
- Child= 30:2 (1 rescuer) 15:2 (2 rescuers)
- Infant= 30:2 (1 rescuer) 15:2 (2 rescuers)
112
T/F compressions should continue before and after defibrilation shock
t
113
Treatment for mild or delayed allergic reaction
Diphenhydramine
- Child= 10-25 mg qid
- Adult- 25-50 mg quid
114
Treatment for sudden onset anaphylaxis
- Oxygen and epinephrine
| - 0.01 mg/kg every 5 min until recovery or help arrives
115
Treatment for acute asthmatic attack
- Sit patient upright
- Oxygen
- Albuterol
- Epi if unresponsive to albuterol (0.01 mg/kg every 15 min as needed)
116
Treatment for LA toxicity
- Oxygen
- CPR if needed
- Call emergency
117
Treatment for LA reaction to vasoconstrictor
- Oxygen
- CPR
- Call for emergency help
118
Treatment for overdose (benzo)
- Flumazenil (0.01-0.02 mg/kg) max= 0.2 mg. May repear at 1 min intervals tnot to exceed cumulative dose of 0.05mg/kg or 1 mg, whichever is lower
- Oxygen
- CPR if needed
119
Treatment for narcotic overdose
- CPR if needed
- O2
- Naloxone (0.1 mg/kg up to 2 mg) may be repeated to maintain reversal
120
Treatment for a seizure
- Recline and position to prevent injury
- Open airway
- Give benzo (midazolam or diazepam)
- Child up to 5 yrs (0.2-0.5mg every 2-5 min with max at 5 mg)
- Child 5 yrs and up 1 mg every 2-5 min with max 10 mg
121
Treatment for syncope
- Reline with feet up
- Ammonial inhales
- O2
- Cold towel on back of neck
122
What is the most common cause of loss of conciousness in the dental office
syncope
123
Syncope is (more/less) common in kids compared to young adults
less
124
What typically triggers syncope
-maladaptive stress (triggered by anxiety)
125
What are the early signs and symptoms of syncope (or presyncope)
- Dizzy or light headed
| - May lose normal skin color in face and lips
126
T/F is pre-syncope is recognized early enough syncope can be prevented
t
127
Management of pre-syncope
- Position patient supine, lowering head and raising legs above head
- Should increase BP and promote an increase in cerebral blood flow
128
Administration of O2 is appropriate for any emergency visit involving
a decrease in brain perfusion
129
Consequences of syncope
- Decrease in heart rate and BP
- Decrease in blood flow to brain and loss of conciousness
- Breathing becomes irregular, pupils dilate and convulsive movements may be noted
- Muscles relax and airway may become obstructed
130
Any unconscious patient should receive
BLS
131
Failure to open airway and maintain ventilation in syncope patient usually leads to
convulsive movements subsequent to cerebral hypoxemia
132
Loss of conciousness from syncope usually resolved quickly is
placed in supone with legs elevated
133
Although conciousness may be regained quickly after syncopy recovery of _ and _ can be slow
HR and BP
134
When should you seek medical assistance for a syncope patient
if recovery is delayed beyond 5 mins or is incomplete after 15-20 mins
135
When is drug therapy indicated for syncope... what is the drug of choice and why
it isn't unless HR and BP remain depressed after positioning
-The drug of choice to increase HR and cardiac output is atropine
136
T/F There is no increased risk of repeat syncope after the episode
F- there is (patient should be escorted home)
137
An allergic reaction is a type _ hypersensitivity reaction
I
138
Primary agents in the dental office that elicit allergic reactions are
- penicillins
- ester type LA (topical LA)
- Sulfite antioxidants in LA containing vasoconstrictors
139
Anaphylaxis is primarily mediated by the release of _ from what cells
histamine... mast cells
140
The body systems primarily involved in clinical allergic reactions are
- skin **Most common**
- respiratory system (2nd most common)
- CVS
141
Histamine results in
- inflammation
| - vascular effects (vasodilation)
142
The more rapid the allergic reaction onset the (more/less) severe
more
143
Edema in the face and neck as a result of an allergic reaction is dangerous because
airway obstruction
144
What is the primary respiratory issue involved with anaphylaxis
bronchial smooth muscle constriction --> respiratory distress caused by airway obstruction
145
Principle recognizable sign of allergic reaction is.... which is caused by
wheezing (due to bronchoconstriction)
146
Smooth muscle contraction caused by allergic reactions can lead to what GI issues
abdominal cramps
- nausea
- vomiting
147
What are the CVS effects of an allergic reaction
- hypotension
- vasodilitation (result of histamine)
- Reflex tachycardia
- Arrhythmia
- Eventually.... cardiac arrest
148
What is the max initial IM dose of Epi
0.3 mg
149
You can administer _ number of ampules of 1:1000 epi
1
150
If the patient weights 65 lbs or less which epi-pen is used
jr
151
Why is epi used for allergic reactions
it counteracts most of the effects of histamine
- Bronchodilitation
- Increases BP
- Counters skin rash and urticaria
152
Epinephrine is not as effective at reducing what effect of histamine
edema
153
Oxygen should always be administered when
respiratory symptoms are present
154
Supplemental treatment for severe allergic reactions include
-corticosteroid and anti-histamines
155
Max dose of diphenhydramine is
50 mg
156
What are the four phases of grand mal seizures
- prodromal
- aura
- convulsive
- postictal
157
Describe the prodromal phase of grand mal seizures
- subtle changes that may occur over minutes to hrs.
| - not ususally clinically evident to DDS or pt
158
Describe the aura phase of grand mal seizures
- neurologic experience pt goes through immediately before the seizure
- Related to trigger areas of the brain in which the seizure activity begins
- Consist of a taste, smell, hallucination, motor activity or other symptoms
- often the same for the patient
159
The ictal phase is also called the
convulsive phase
160
Describe the convulsive stage of grand mal seizures
- loss of conciousness
- Tonic clonic movements
- Epileptic cry
- Clonic phase ususally lasts 1-3 minutes
161
Describe tonic clonic movements
```
Tonic= rigid skeletal muscle contractions
Clonic= rapid jerking of extremities
```
162
What causes the epileptic cry
tonic phase where the chest wall muscle contract and air is expelled through the larynx producing a vocalization called the epileptic cry
163
Describe the postictal phase of grand mal seizures
- Clonic phase ends
- Muscle relax and movement stops
- Significant CNS depression--> may lead to respiratory depression
164
Patient has amnesia beginning at what phase and ending at what phase during the grand mal seizure
prodromal phase throughout entire seizure
165
Describe management of seizures
- Gentle restraint (prevent self-injury)
| - Ensure adequate ventilation, supportive care in postictal phase (especially airway management)
166
T/F Single seizures often require drug therapy
F- many are self-limiting
167
What is status epilepticus
- Ictal phase lasts longer than 5 minutes
| - OR if the seizutes continue to develop with little time between them
168
Status epilepticus can be life threatening because uncontrolled muscle contraction can result in
- Hyperthermia
- Increased O2 consumption
- Tachycardia
- Hypertension
- Impaired ventilation
- Cardiac arrhythmias
169
Treamtnet of status epilepticus
- Midazolam or diazepam (IV perfered but can do IM if access isn't available
- 0.15mg/kg IM to max of 10 mg for initial dose
- Ensure airway patency after administration
- Activate EMS
