General Medicine Flashcards
(21 cards)
Syncope
- definition
- aetiology
- clinical presentation
- dental mgmt
Definition: transient self-limiting loss-of-consciousness.
Aetiology: Transient global cerebral hypoperfusion - from vasovagal, orthostatic, cardiac dysrhythmias or cardiac disease
Clinical presentation: Spontaneous loss of consciousness followed by rapid recovery
Presyncope - lightheaded, sweaty, nauseous, blurred vision.
Dental management:
Feeling faint → Stop dental tx
Tilt chair back to horizontal position if in chair. Raise pt’s legs, head lower than heart
Measure heart rate. BP if lost consciousness
If consciousness not regained, call 000, start basic life support DRSABC
Coronary Ischaemia
- definition
- aetiology
- clinical presentation
- dental mgmt
Definition: Lack of blood supply to heart
Aetiology:
Angina
Temporary MI resulting frm demand for more blood flow
Typically crushing central chest pain, radiating to left arm, neck of jaw
Atypical pain or shortness of breath or light-headedness
Acute myocardial infarction
Suspect if chest pain unrelieved by GTN (glyceryl trinitrate)
Pt with history of angina says this is ‘Worst pain ever’ / first ever episode of chest pain
Management:
If chest pain occurs in pt w Hx of angina:
Stop dental treatment
Measure BP, HR, pulse oximetry
Assess consciousness by talking to pt
To relieve symptoms: ask pt sit down (bcs possible hypotention), give glyceryl trinitrate (spray/tablet) every 5min
If pain >10min after 2 doses GTN, give 3rd dose and proceed as severe/new chest pain
Even if recover, Do not proceed w dental tx. Refer for medical evaluation even if seems well.
New chest pain
Call 000
Aspirin 300mg orally
Measure BP, HR, pulse oximetry
If SaO2 <90% start supplemental O2.
Provide reassurance until assistance arrives
If pt LOC, start basic life support. Use AED if available
Maintain until regain consciousness or assistance arrives
Cardiac arrest
- definition
- aetiology
- clinical presentation
- dental mgmt
Definition: heart stopped
Pt suddenly LOC, no pulse or respiration
Aetiology:
Ventricular Tachycardia
Ventricular Fibrillation
Asystole
Management
Stop dental tx
Call 000
Start basic life support, CPR, AED if available
Maintain tx until pt regains consciousness/assistance arrives
Acute Asthma
- definition
- aetiology
- clinical presentation
- dental mgmt
Definition: Inflamed/narrowed airway → breathing difficulty
Episodes of asthma can be fatal
Past history - pts need to bring their medication
Assessment of severity
Severe: use of accessory muscles of neck during inspiration; unable to complete sentences in one breath bcs of dyspnoea
Wheezing is poor indicator
Life-threatening: reduced consciousness/collapse, exhaustion, cyanosis
Management:
Stop dental tx. Sit pt upright
Mild/moderate asthma attack:
4 puffs salbutamol inhaler via spacer, 1 puff at a time
4 breaths in and out of spacer after puff
4 min
If no improvement, repeat
If still no improvement, → severe
Severe asthma attack
Call 000
Start supplemental O2 and airway support if needed
Salbutamol inhaler via spacer
>6yo: 12 puffs
<6yo: 6 puffs
1 puff - 4 breaths in spacer
Reassess within minutes
While waiting for assistance:
Repeat salbutamol dose as needed, at least every 20min
If life-threatening, give salbutamol continuously
Monitor pt
Inhaled or Swallowed objects
Prevention:
Rubber dam
Careful and unrushed approach
High volume suction or instruments to retrieve
Floss, gause or rotating pt’s head
Obstruction of airway
Partial
Wheeze, stridor (noisy inspiration), laboured breathing, coughing spasms,
cyanosis
Complete
Inability to breathe, speak, cry, cough
Bulging of neck veins
LOC
Cyanosis
Management
Conscious with signs of airway obstruction:
Call 000
Reassure, breathe deeply, try to dislodge obj by coughing
If ineffective, up to 5 back blows
If ineffective up to 5 chest thrusts
Alternate until obstruction relieved or assistance arrives
LOC:
000
Remove object if possible
CPR
Stroke
Transient ischaemic attack (blood supply cut off)
Signs:
Transient LOC
Difficulty moving one side of the body
Confusion
Difficulty in speaking
Management
Stop dental treatment
000
Measure BP, HR, pulse oximetry
Start supplemental oxygen if SaO2 <90%
Maintain airway
Monitor vital signs, start basic life support if required
No aspirin - difficult to identify if stroke is haemorrhagic or ischaemic
Seizures
Patients w epilepsy can have seizures
Generalised vs partial
Aura, sudden spasm of muscles causing rigidity, jerky movements, LOC assoc w noisy breathing, salivation and incontinence
Aetiology: Epilepsy, Syncope, hypoglycaemia, stroke or cerebral hypoxia from other causes
Management
Stop dental treatment
Protect pt from falling, stabilise position
If possible, turn pt on side to reduce risk of aspiration
Don’t restrain unless to avoid injury
Wait until seizure stops
Assess consciousness
Maintain airway - remove vomit with high-volume suction. Do not place anything in pt’s mouth during seizure
LOC more than a few minutes or repeated seizures without recovery of consciousness btw attacks:
000
Maintain airway
Monitor pt until assistance arrives
Hypoglycaemic attack (diabetic pts)
Hypoglycaemic attack: Blood glucose < 3-5mmol/L
Aetiology: increase in insulin doses, forgotten meals, insufficient carbohydrates, excessive exercise in diabetic patients
Symptoms:
SNS - pale skin, sweating, shaking, palpitations, anxiousness
Impaired Brain function - hunger, confusion, coma, seizures
Management:
Stop dental treatment
If conscious and cooperative:
Give glucose 15g for adults
If not available, fast-acting glucose-containing food/drink (jellybeans, honey, sugar, fruit juice, soft drink)
If after 15min symptoms not improved, repeat
If 3 times needed, seek medical advice
If symptoms improved, eat longer-acting carbohydrate to prevent recurrence
Keep under observation until recovered. No driving home. Strongly advise medical review
If drowsy, uncooperative, unconscious
000
LOC → basic life support
Hyperglycemic attack: 000, basic life support
Diabetic pt general management
General dental management:
BGL monitoring - finger prick
HBA1c ideally <7%.
Oral manif: accelerated periodontal disease, gingival prolif, perio abscesses, xerostomia, poor healing, infection. Oral ulcerations. Fungal infections (candidiasis), numbness, burning & pain in oral tissues.
Short morning appts, ensure they’ve eaten, keep glucose source nearby
Stress good OH and regular checkups
Avoid surgery if poorly controlled
- Addisonian (adrenal) crisis
Insufficient cortisol hormone
Aetiology: occurs 6-12h after surgical stress in a pt on corticosteroids.
Symptoms: Lethargy, confusion, slurred speech
Management:
000
If rousable and can swallow: give them their own corticosteroid tablets
If unconscious and no immediate help, give hydrocortisone 200mg intramusc/IV
- Allergies
Aetiology:
Antibiotic hypersensitivity - esp beta-lactam antibodies
Latex allergy - wheals upon contact (urticaria). Can be life-threatening - clinical immunologist must be seen
Allergic rxn to LA: rare, it happens because of bisulphite stabilisers of adrenaline. Clinical immunologist
Food allergy
Symptoms
Wheals
Angioedema - acute oedema of subcutaneous tissue. Lips, eyelids, tongue
Anaphylactic rxn: IgE-mediated, bronchospasm, laryngeal oedema, abdominal cramps, diarrhoea, hypotension
Management
Mild urticaria/angioedema
Oral antihistamine
Extensive, or swelling involving eyelids, lips, tongue
Refer for urgent medical attention
Systemic corticosteroids may be indicated
Wth associated hypotension and evidence of anaphylaxis (swelling of throat, wheezing, dyspnoea)
000
Intramuscular injection adrenaline every 5min until pt responds
Suppremental O2 and airway support if needed
Basic life support and CPR if needed
Follow up with medical physician
General cardiovascular
What to note for tooth extraction
WHat to note for hypertension
For tooth extraction:
- Full Blood Assessment w platelet count (150k-450k/uL)
- Aspirin blocks platelet aggregation
- Abixavan inhibits clotting factor
- Local clotting measures: gelfoam (absorbent gelatin sponge), surgicel (oxidised cellulose, which is absorbent & helps blood clot), suturing, tranexamic acid (rinse when post-op bleeding, antifibrinolytic agent)
Hypertension:
- BP > 180/110Hg: avoid tx, or do in hospital
- Minimise adrenaline
- Slow changes in chair
- Avoid NSAIDs in diuretic/ACE inhibitor
Congestive Heart Failure
Inability of heart to pump enough blood for O2 reqs of body
Aetiology MI, valvular heart disease, cardiomyopathies
Dyspnoea, nocturia, peripheral oedema
Diagnosed by chest xray, ECG, echocardiogram
Treatment digoxin (NO ADRENALINE can cause arrythmia), enalopril (vasodilator ACE inhibitor), frusemide (diuretics)
Defer elective dental tx. Hospital care w cardiac monitoring if necessary
Ischaemic Heart Disease
Atherosclerotic Coronary Artery Disease (narrowing of arteries from plaque)
⇒ Angina Pectoris (chest pain from myocardial ischaemia), Myocardial infarction (necrosis of myocardial tissue) (defer if <6mths since last MI; NO Ab prophy for MI)
Treatment:
Lifestyle counselling, smoking/alcohol cessation, diet, salt restriction
- Pharmalogical: nitrates, Beta blockers, Ca channel blockers, K channel opener
If taking aspirin/platelet aggregation inhibitor can cause excessive bleeding
- Surgical: PCI (percutaneous coronary intervention), PTCA (percutaneous transmural coronary angioplasty [aka stent]), CABG (coronary artery bypass grafting) may need antibiotic prophylaxis
- If taking Warfarin INR must be <3.5
- Minimise adrenaline in LA/retraction cord
- No electrocautery/U/S for pacemaker/implanted defibrillator
Cardiac Arrhythmias
Any variation in normal heartbeat
Atrial tachycardias—-
* Regular (Sinus tachycardia) - secondary to a disease process
* Irregular (Atrial Fibrillation) - Causes: stress, fever, excessive alcohol, volume depletion, MI
Tx: treat underlying disorder, prevent thromboembolism w anticoagulants, control rate w pacemaker
Ventricular tachycardias—-
* Regular (Ventricular tachycardia) - sustained, life threatening, leads to VF
* Ventricular fibrillation: disordered contraction of ventricle, no cardiac output, leads to death
Venous thrombosis
Blood clot in lower extremities
Unilat leg pain and swelling, tenderness
Diagnosis ultrasound
Treatment anticoags, anti-thrombus stockings, foot exercises
Infective endocarditis
Oral petechiae (small bleeding spots)
Antibiotic prophylaxis in pts previous IE, w prosthetic cardiac valve, cardiac valvulopathy, rheumatic heart disease in Indigenous Australians
Required for invasive procedures - goes subgingival, extraction.
Prophylaxis with amoxicillin. For allergies/long-term penicillin therapy clindamycin
Reducing stress for CVD patients
- Open communication about fears and concerns
- Short morning appts
- Profound LA
- Adequate post-op pain control
- Post-procedure phone call
- Diazepam?
Sleep disordered breathing
- Normal snoring
- UARS
Normal Snoring - no abnormal ventilation
From anatomically narrowed upper airway + pharyngeal dilator muscle collapsibility
Vibration of ST through airway
Upper Airway Resistance Syndrome (UARS)
Midway btw snoring and OSA
Occurs with snoring and daytime sleepiness, sleep fragmentation with some increased ventilatory effort
Obstructive Sleep Apnoea
Loud snoring, excessive daytime sleepiness
Morning headache, tiredness poor concentration, memory.
Complete cessation of breathing/significantly decreased ventilation from airway obstruction during sleep
Diagnosis: lab sleep study
Untreated OSA → increased risk hypertension, stroke, arrhythmia, MI, diabetes
Central sleep apnoea
Cessation of breathing bcs of lack of CND respiratory drive
Management of OSA
General
Weight loss - regular aerobic exercise
Nasal decongestants
Measures to prevent supine posn
Avoid alcohol/sedatives near bedtime
Appliances
CPAP machine - continuous positive airway pressure
Oral appliances - mandibular advancement splint
Upper airway surgery
OSA
Obstructive Sleep Apnoea
Loud snoring, excessive daytime sleepiness
Morning headache, tiredness poor concentration, memory.
Complete cessation of breathing/significantly decreased ventilation from airway obstruction during sleep
Diagnosis: lab sleep study
Untreated OSA → increased risk hypertension, stroke, arrhythmia, MI, diabetes
Central sleep apnoea
Cessation of breathing bcs of lack of CND respiratory drive
Management of OSA
General
Weight loss - regular aerobic exercise
Nasal decongestants
Measures to prevent supine posn
Avoid alcohol/sedatives near bedtime
Appliances
CPAP machine - continuous positive airway pressure
Oral appliances - mandibular advancement splint
Upper airway surgery
Renal
Renal insufficiency vs renal failure
Chronic renal disease
Progressive and irreversible decline in renal function - reduced GFR
Oral: greater bleeding tendency, hypertension, anaemia ; halitosis, burning sensation, periodontitis
Osteodystrophy - bone weakened and sus to fractures care needed during dental extractions
Drug intolerance, increased susceptibility to infections
Tx: Lifestyle: reduced salt, correction of systemic complications. Dialysis, finally renal transplant.
Dialysis: every other day
Taking heparin anticoagulant
Avoid compression on arm with vascular access
Caurion w analgesia and ABs
Risk of adrenal crisis if treated with long-standing corticosteroids - morning appts. Consider need of supplementary steroids. Ab prophy?
DIGO from cyclosporin (immunosuppressant)
AGGRESSIVELY TREAT DENTAL INFECTIONS
